Public health post-2013 Contents

4Enabling public health teams to work effectively

Access to data

Summary

97.In its evidence to our inquiry, PHE acknowledges that there have been problems with data, but say that they are beginning to be addressed:

I completely agree that at the moment directors of public health do not have good enough access to the data that they need to do their jobs. It is variable across the country. Again, it is one of the things that varies, but nevertheless there is a problem. It is in two categories. The first is getting access to data on healthcare activity for their population. The second is in getting access to operational data about the public health services that they commission – things like vaccination and screening services.

[Professor John Newton, Chief Knowledge Officer, Public Health England, Q316]

Concerns have been raised to the Committee about access to the following data (this list is not exhaustive)

Mortality data, Local level cancer statistics, Data on screening rate, Data on immunisation rates– practice level data, Pseudonymised NHS numbers, Data from STEIS – NHS incident reporting system, HES data – access has been granted in some cases but this has been a long drawn out process, and

concerns have been raised that in future Public Health teams will have to pay to access this data.

98.A full list of the data public health professionals have told us they need but currently lack access to is contained at Annex 1.48

99.In some cases, data is beginning to flow, but public health professionals report that it has taken nearly three years of campaigning to get it.49 When data does come through, there is often a significant time lag, and an inability to link it to other data sets.50 In some cases, local solutions have been found, but they have involved very time consuming work-arounds.51

100.Professor Newton, Chief Information Officer at PHE, told us that PHE would like to see more support from the Health and Social Care Information Centre (now known as NHS Digital) in providing access to local government for data, and in particular he told us that the policy that data linkage can only happen centrally—at NHS Digital—needs to be revisited and reviewed.52 He went on to explain that the information strategy published in 2012 was clear that all data linkage must take place within the NHS Digital.53 However, in Professor Newton’s view, NHS Digital “is not yet set up to be able to deliver those services”:

“The situation we have is that the information – the data – is in one place, and

the people who have the capacity and capability to use it are in another”.

[Professor John Newton, Chief Knowledge Officer, Public Health England, Q325]

101.The policy of data linkage only happening centrally also causes problems for local area public health teams who want direct access to their local data to be able to carry out ad hoc studies.

Conclusions and recommendations

102.Our inquiry has identified numerous problems with access to data for public health professionals, which is creating barriers to effective joint working. We are pleased to note that efforts are now ongoing within Public Health England to address these problems.

103.Public health teams need to be able to access data in patients’ interests. We were told by PHE’s chief knowledge officer that a change in policy was needed to remove the current restriction that all linkage of health and social care data can only take place centrally, within NHS Digital (HSCIC). We recommend that the Department of Health review these barriers.

104.Some areas have managed to access the data they need, and others have not. Some areas also lack the capacity to analyse their data. A co-ordinated national support programme is needed to ensure that until data is easily available to local authorities, all areas at least understand what data they are able to access, and how they can do so.

105.PHE identified two types of data public health specialists are having difficulty in accessing—access to population healthcare data, and access to operational data about the services they commission. Annex 1 to this report contains a compilation of the concerns public health professionals have raised to this inquiry regarding access to data, and we ask PHE and NHS Digital to provide a response to us on each point raised. We will revisit this issue to check progress in six months’ time.

The public health workforce

The public health workforce - both the specialist workforce and the wider workforce - is essential to delivering improved outcomes. Barriers to workforce mobility must be removed, and the Government should review regulation for public health spcialists.

106.A well-motivated, skilled and multidisciplinary workforce is needed to improve and protect the public’s health. The workforce has been described to us as a core public health workforce of between 30,000 and 40,000 staff, including public health specialists and practitioners such as health visitors and school nurses whose primary role is to improve and protect public health; and a much wider workforce of around 15 million who have the potential to influence health through their roles such as staff working in the NHS, fire service, and wider local government services.54

Sources: Centre for Workforce Intelligence, Mapping the core public health workforce, October 2014, Written evidence submitted by the Public Health System Group (PHP0065), Written evidence submitted by Public Health England (PHP0099)

107.During the inquiry we heard from a diverse mix of this workforce, from those in leadership position to those in frontline delivery roles. Most were supportive of the move of public health to local government,55 although some of those in frontline service delivery were less enthusiastic.56

108.We heard of the importance of the Director of Public Health role as a leader, advocate and facilitator in local systems and we were told that 85% of Director of Public Health posts now have substantive postholders, similar to the figures before the 2013 transition to local authorities.57 Health Education England told us that specialist public health training continues to be a popular choice amongst applicants from a range of backgrounds, including medicine.58

109.The Centre for Workforce Intelligence has mapped the core and wider public health workforce through various reports since 2012.59 Unfortunately, the commitment in the Department of Health Public Health Workforce Strategy in 2013 to develop a minimum dataset for the public health workforce has not yet been implemented and there is no directly comparable data covering the period of transition to assess how the workforce is changing over time. The 2016 update to the DH strategy suggests that data collection may be tested in 2016, and the Health Education England witness referred to a workforce database being introduced in 2017.60

110.The broadly optimistic view presented by both PHE and HEE does not reflect the results of the ADPH survey of the impact of spending cuts presented to us which show that 30% of councils have reduced or are planning to reduce their spending on advice to CCGs and/or within the council.61

111.The loss of advice on healthcare planning was identified as a threat to the effectiveness of commissioning.

We are a very large trust with 19 different commissioners and five vanguards, and you can imagine that we have to spend an awful lot of time trying to join all that up. One of the stark things, to pick up some of the points that have been made, is that we have not seen a public health specialist in those commissioning discussions anywhere. That perhaps says something about the capacity

within healthcare public health for the NHS, and that is a weakness of the current arrangements.

[Public health specialist, provider trust, informal session]

112.Beyond public health specialists, many of the witnesses to our inquiry referred to the virtues of engaging a wider range of people in efforts to improve public health—a significant benefit of the move of public health to local authorities. Shirley Cramer explained the potential of engaging the wider workforce:

….. In many local authorities where they are making some real headway in this area they have been doing this with lots of different groups— police services, ambulance services, leisure services, occupational therapists, a whole group of people. In order to do that, we need a number of things that need to happen nationally. It is going to happen locally in that that is where we will get the benefit, but there needs to be a national canvas, a national leadership and a national framework so that if people in the wider workforce want to have a role in public health in the future, or see their future in a career in public health, there are some progression pathways and flexibility for them to be supported to do

that. [Shirley Cramer CBE, Chief Executive, Royal Society for Public Health Q97]

Movement of staff across sectors

113.An issue of common concern to many of the organisations submitting evidence, including PHE, the Public Health Systems Group, ADPH and the Faculty of Public Health, was the importance of facilitating movement of staff across different organisations throughout their career to ensure they could gain the breadth of experience needed. At present there are significant regulatory blocks created by differences in terms and conditions between organisations that limit movement. The principal concern is the lack of ability to recognise continuity of service in moves between local government, civil service (PHE) and NHS which is important for a range of employment rights such as maternity and sickness, annual leave and redundancy entitlements. PHSG argues that this issue must be addressed so that “employers know that they are choosing between the best candidates and individuals do not feel constrained in their job choices.”62 These problems have been acknowledged by PHE In its recent workforce review, which recommends that PHE

continue to review what action can be taken at national and local level to remove barriers to mobility linked to terms and conditions of public health staff, and
in particular, work with NHS Employers, the NHS Staff Council, the LGA, DH and relevant unions to develop a plan for addressing continuity of service.63

Statutory regulation of all public health specialists

114.Public health specialists, including Directors of Public Health, come from a variety of professional backgrounds. Those with medical and dental qualifications are subject to statutory regulation including revalidation, whereas those from other backgrounds are covered by voluntary registration through the UK Public Health Register.

115.The UKPHR explains the essential difference between statutory and voluntary regulation on their website64:

“… the most important factor for effective regulation is that whoever employs the professionals or commissions their services takes the requirement to be regulated seriously and that they will only look to employ professionals who have demonstrated they have achieved the level of competency required to

be on a register.

The difference for statutory regulation is that the disciplinary procedures and sanctions of the regulator are underpinned by law. This means that if a professional is removed from the register it is illegal for them to continue to practise. A professional removed from a voluntary register would not appear on the register on enquiry and they may not practise where the employer requires its professional staff to be independently regulated.”

116.A commitment was made by the Department of Health in the 2013 workforce strategy to introduce statutory regulation for all public health specialists but in the update published in 2016 they have stated they will not be taking forward legislation.65 Professor John Ashton of the Faculty of Public Health Medicine gave the following articulation of the problem:

The next issue is about the registration of those who do not have a medical background. For reasons that are very difficult to understand, the Government have decided not to have a statutory regulation for those, and yet we think, from the point of view of public protection standards and equity, parity of esteem and so on, that it should be absolutely clear that the people who have been through a five-year postgraduate training, which is what they all do to become public health specialists, should be seen as being the same, should be treated the same and they should be required to do CPD and re-accreditation and all of that.

[Professor John Ashton CBE, President, Faculty of Public Health, Q59]

Conclusions and recommendations

117.We commend efforts to engage, mobilise and support the wider public health workforce, a group of some 15 million people from a diverse range of professional backgrounds who have the potential to improve public health through their day to day jobs.

118.Trends in the public health workforce can be adequately monitored only through the speedy introduction of the promised database. This is particularly important given the potential impact of reduced spending by councils on public health staffing.

119.Barriers to workforce mobility must be removed, and we are concerned that this issue has not been resolved three years after the transfer of public health responsibility to local authorities. We will review progress in six months.

120.Statutory regulation is intended to ensure public safety and confidence. We are disappointed that the Department of Health has changed its position on the regulation of public health professionals. As the Government develops its proposals for reform of professional regulation, it needs to ensure that it has a coherent, straightforward and evidence-based approach to the regulation of public health specialists. We recommend the Department of Health review its current policy in order to protect the public.

48 Acronyms used in diagram: STEIS - Strategic Executive Information System ; HES - Hospital Episode Statistics

49 Q134

50 Q134

51 Q134

52 Q318

53 Q318

54 Royal Society for Public Health (PHP0024) Section 3

55 Q108

56 See, for example, written evidence from Julie Hotchkiss (PHP0012) Ruth Speare (PHP0036) , Jeremy Wight (PHP0039)

57 Public Health England (PHP0099) para 11, figure 2

58 Q313

59 Centre for Workforce Intelligence, Public Health Projects, May 2016

60 Q314

61 ADPH, Impact of funding reductions on public health, February 2016

62 Public Health System Group (PHP0065) p4

63 Public Health England,Fit for the Future, May 2016

64 UK Public Health Register, About us - Frequently Asked Questions

65 Department of Health, Review of Public Health Workforce Strategy, April 2016

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30 August 2016