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Lord Hunt of Kings Heath: My Lords, one point on which we are all agreed is that public health is important to the way forward and to ensuring that the health of the nation overall improves. The key issue is at what level the principal public health authority should be based. The noble Earl, Lord Howe, clearly expressed the view that it should be based at the strategic health authority level. The Government disagree. We think that that is too remote a level. It would be remote from local government and from the local community.
Looking back over the past 20 or 30 years I am sure that no one could say with confidence that public health has been sufficiently integrated into the NHS decision-making structure for the pursuit of public health goals to receive the support and vigour that is required. One of the reasons for that is that public health has often been divorced from the critical primary care level. I am convinced that to give public health the dynamism, leadership and success that it needs, we need to make the essential link between the public health specialist and primary care.
One of the most successful ways of developing public health programmes is in the GP's surgery. One of the most successful interventions in relation to reducing smoking is the advice GPs and their staff give to members of the public. There are persuasive arguments for saying that the principal public health authority ought to be the primary care trust. That potential is surely to be found in local neighbourhoods and communities in the programmes being developed to lead, drive and improve health and reduce inequalities and in forging relationships with local authorities as much of the effort involved in public health concerns getting local agencies to work together.
I suggest that it is at the primary care trust level that one is likely to get the important links between the health service and local government. I believe that the strategic health authorities, which will have an average population of 1.5 million, would be too large for this purpose and would have to engage with too many different local authorities to be successful. At primary
care trust level one has much more chance of getting successful partnerships to work together across agency boundaries.The noble Baroness, Lady Cumberlege, raised two issues. First, she referred—as she did in Committee—to the King's Fund report. I do not disagree with her comments on the need for devolution and the need for politicians to step back from micro-managing the health service. However, I disagree with her suggestion that we should set up a national public corporation, as it were, to do that. I have grave doubts as to whether in reality that would divorce the health service from political influence. I believe that the devolution model that we are adopting is likely in the end to be much more effective. Surely no better indication of that is our desire to ensure that public health is placed at the lowest possible level of decision-making.
I agree with the noble Baroness, Lady Cumberlege, that the calibre of the directors of public health will be very important. I have already said in Committee—that has been confirmed—that the post of director of public health in primary care trusts is open to specialists in public health from a range of backgrounds as well as to consultants in public health medicine. To enable them to carry comparable responsibility across the 10 core areas of public health practice those specialists will need to have training, experience and qualifications comparable to those of consultants trained in public health medicine who will be on the GMC specialist register. Our ability to extend to another group of professionals the opportunity to be appointed directors of public health at the primary care trust level constitutes a great advance in the public health movement.
I agree with the noble Baroness that these are high calibre appointments. We need them to be robustly independent. We need them to provide leadership in public health. We need them to be public figures whom the public can rely upon in terms of their pronouncements and reports on public health. That is what we expect to happen. That role is much better conducted at the primary care trust level than at the strategic health authority level. I do not believe that simply having 28 directors of public health would give the strength, viability and public visibility that we will realise from appointing a director of public health in all primary care trusts.
On the parking of people, the explanation is simple. As we wish to ensure continuity of service, we decided that all staff who are currently employed in such situations would be assured of a further 12 months of employment, from 1st April this year to 30th March next year, in order to give time for the arrangements to bed down and for primary care trusts to appoint full public health teams. I accept that among public health professionals, this is a time of uncertainty. However, that is surely the best way to ensure that they are kept on the payroll and that primary care trusts are given the time that is needed to establish their full public health teams.
I was asked why we seek to retain performance management at the strategic health authority level while giving a strong role to directors of public health at the regional level. On performance management, that is consistent with the whole structure and relationship between strategic health authorities and primary care trusts. I have already said that I expect that performance management to be "light touch". However, it is appropriate that the performance management role is conducted at the strategic health authority level.
On public health networks, whichever way one cuts the cake, there will always have to be flexible arrangements to ensure that one has the right level of expertise. That would be the case even if one decided to follow the noble Earl, Lord Howe, and make strategic health authorities the principal public health body—there would still be a need to share specialties and to have flexible arrangements. As we have gone down the route of giving primary care trusts a public health lead, we have suggested—and will propose and develop—public health networks that take on board the point that was raised by the noble Baroness, Lady Masham. I refer to the point about ensuring that primary care trusts work together and that specialisms within public health are effectively covered. That brings us to the role of regional directors of public health. As a result of their professional competence and knowledge, they are best placed to enable public health networks to work effectively.
On the proposal that those bodies will be based in the nine government offices of the regions, surely that is a way of pulling together the work within central government and local government in relation to public health. Much of the work of the regional offices of government relating to local authorities can have an important influence on public health policies generally. In addition, those regional directors will be accountable to the Chief Medical Officer and will work closely with the four directors of health and social care within the Department of Health. We will secure co-ordination between the work of government as a whole in public health and in relation to health and social care at that critical regional level.
At the end of the day, there is a clear decision to be made: where should major public health responsibility be? The Government believe that that is best placed at the most local level possible—that is, with the primary care trust—where the impact of working with general practice and other primary healthcare practitioners will be a very powerful tool in relation to securing effective public health practice. However, that will have the safeguard of networks that pull together the work of primary care trusts and the performance management by those primary care trusts from strategic health authorities. It will also involve the professional mentoring role of regional directors of public health. That is a coherent set of arrangements and, crucially, it rests the key public health responsibility at the lowest possible level within the health service.
4.45 p.m.
Earl Howe: My Lords, once again, I am grateful to all noble Lords who took part in this important debate and in particular to the Minister for his reply.
Restructuring the NHS involves inevitable upheaval. Part of the Government's problem is that they are starting this upheaval from a rather shaky base. They began their period of office in 1997, so far as public health is concerned, very well. The White Paper, Saving Lives: Our Healthier Nation, contained much that was laudable. It followed the agenda set by the White Paper, The Health of the Nation, about which my noble friend Lady Cumberlege spoke with her usual authority.
To be fair, the Government have notched up some signal successes, such as the flu vaccination programme and the introduction of vaccinations for meningitis. However, when we look elsewhere—to the mushrooming of sexually transmitted diseases, the rise in HIV, the failure to maintain MMR vaccination rates, the rise in TB infections and the rise in malnutrition—their record is, frankly, pretty poor. Much of that failure, I am bound to say, rests at the centre. We need to realise what may ensue from upheaval to the health service. What we have had up to now, underpinning the delivery of public health, are functioning networks of key individuals. Those important relationships are now being disrupted and unpicked. Such disruption carries dangers of its own.
The King's Fund report, Public Health in the Balance, which was published recently, underlined the shortage of staff with public health skills in London. However, many of the messages in that report apply more widely. It states that fragmenting the teams that are based on health authorities and splitting them up into primary care trusts involves the risk of losing key specialist skills. The report found that there is a wealth of public health experience in London but also a high turnover of staff and a lack of appropriate qualifications. Strategic planning, including workforce planning, is vital if local needs are to be met.
Picking up those concerns, I heard what the Government said about why they had chosen to put in place a dual line of accountability for primary care trusts. I shall reflect carefully on the position that the Minister set out. I do not disagree that the performance management role should be performed by strategic health authorities. My suggestion merely was that strategic health authorities are well placed to do rather more—in other words, to take a strategic role. The overarching point that I was trying to make was that if one wants to upgrade public health, as we all do, one starts—surely to goodness—by defining one's objectives and the functions that need to be performed, and one then builds one's service around that. One does not do things in reverse—one does not start with a structure and then try to make public health fit into it.
I take some comfort from what the Minister said. I do not disagree with him that the public health agenda has not always been pursued at the level of primary care with the vigour that we could have
wished. There is much to be achieved through primary care trusts. There is a good case for centring much of the delivery effort at that level. However, issues such as the function of the surveillance of health promotion and health protection run much wider than primary care trusts and they need direction.The Minister and the noble Lord, Lord Turnberg, spoke about public health networks and commended the notion of flexibility. I say that flexibility is fine but that networks are inherently loose and vague. I agree with the noble Lord, Lord Clement-Jones, that they involve a great deal of energy and organisation. I still maintain that the accountabilities in the Government's model are not ideal. That aspect of these proposals, on its own, is one that we may live to regret. However, I believe that this has been a helpful debate. It is time to move on, and I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendment No. 4 not moved.]
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