Public health—the frontline cuts beginBMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i272 (Published 20 January 2016) Cite this as: BMJ 2016;352:i272
All rapid responses
I feel sorry and sympathetic. It is as difficult to define "public health" as it is to define " national security".
That said, every local authority should advertise for a director of public health with a sharply defined remit, a sharply defined budget, named support staff, accountable to the director and to no one else. The director should have direct access to the media, on any matters he (she) wishes to discuss with the public, direct access to the full council, to ANY committee of the council that the director chooses to address.
Every year, the DIRECTOR should present to the Health Committee, the next year's planned activities and seek funds for the purpose.
This is how the OLD, OLD, REAL public health worked in the days of the Medical Officer of Health.
The population served knew who the MOH was. The Councillors had the right to haul the MOH over blazing coals.
And now? Even the local newspapers do not know the name of the Director of Public Health. I tried three newspapers in different parts of England a few months ago.
The solution lies with the public health personnel. Stay clear of jobs with local authorities which fail to give you the conditions set out above.
Competing interests: Member of the public
The transfer of public health responsibility at local level from the NHS to local government was one of the very few elements of the 2012 Health and Social Care Act that were relatively uncontroversial. This was no doubt partly because some public health practitioners looked on local government as a haven of stability in contrast to the chaotic changes being meted on the NHS, partly because of the promise of a ‘ring fenced’ public health budget, but primarily because the arguments for basing public health in local government were, and remain, strong. What is now happening to public health is therefore ironic as well as tragic.
The two key factors are the assault on public health budgets and the failure by local councils to appreciate the importance of specialist public health leadership. In fact the supposed ring fencing of the Grant was always a myth. This is because although councils have been required to give assurance that the Grant itself is used for public health purposes, that was never strictly defined, and nor was overall public health spend monitored. There has always been a wide range of activity that was paid for by local government that contributed to public health, expenditure on which could very legitimately be described as being for public health purposes. This meant that it was possible for councils to use the Public Health Grant to pay for activity that had previously been paid for by council budgets, and to disinvest from public health activities that had, prior to 2013, been paid for by the NHS in order to do so.
So since it was not the totality of public health spend that was ring fenced, only that element that transferred from the NHS in the form of the Public Health Grant, it was quite possible for councils to disinvest from public health activity. At a time of considerable pressure on local authority budgets it was perhaps inevitable that this should have happened. This has been widespread, though the overall extent has not been centrally monitored by Public Health England or any other agency, so far as I am aware.
This disinvestment at local level has of course been exacerbated by the cuts to the PH Grant, as highlighted by Iacobucci in his article. That this should be happening at a time when the importance of public health and prevention is being increasingly emphasised not only in the NHS five year forward view , but also in the NHS planning guidance for 2016/17, as well as, bizarrely, by Ministers themselves. The bringing together of health and social care budgets under the Better Care Fund should incentivise local councils to improve the health of their local populations, but at the moment they do not have the same financial incentive to invest in programmes that keep people well, as does the NHS. And while Primary Care Trusts were organisations whose only purpose was health, including promoting good health, and preventing and treating ill health, local government has a far wider range of responsibilities, the pursuit of some of which directly militate against the promotion of good health.
Meanwhile, the damage done by disinvestment is being compounded by the downgrading of the Director of Public Health role and failure of local government to value specialist public health leadership.
Prior to April 2013, Directors of Public Health were Executive Directors on PCT Boards, the highest level of decision making within the local NHS, and in that position had shared responsibility for the full NHS budget for the area, as well as full executive director responsibility for those elements of it that were spent on public health staff and programmes.
The importance of the role of the Director of Public Health was recognised throughout the transition process, and documented in the October 2012 guidance from the Department of Health.
Despite this recognition, the role of the Director of Public Health has been significantly downgraded in many areas as a result of the transition to Local Government. This has come about partly because the post has moved from being at the highest level of decision making (i.e. a full board member) in the PCT, to being in many cases at third tier in the management hierarchy in local government, but also because, as local councils are democratic organisations, final responsibility in them rests with the elected members, not with officers. Directors of Public Health have thus moved from having ultimate responsibility for Public Health in their areas, to being simply responsible for giving advice to elected members on public health matters, which may or may not be followed.
The advantage, of course, of being based in local government is that DsPH should have the ability to influence a wider range of factors that determine the health of the local population. The damage caused by loss of dedicated public health budgets would be much mitigated if there were strong public health influence on the totality of local government spend. But this is dependent both on Directors of Public Health being properly positioned and having the right level of influence within the council, but also on their being adequately supported by other public health consultants.
Unfortunately, whereas no NHS Provider Trust would seek to provide a clinical service that is not led by properly trained consultants, many councils appear to think that having public health led by a cadre of properly trained and accredited consultants is an expense they can do without. Where consultant posts have been disestablished, or left unfilled, not only is it more likely that decisions about how to use a diminishing public health resource will be ill-advised, but the scope for public health to have influence across the full breadth of the council’s activities will be constrained.
It is much to be hoped that the House of Commons’ Health Select Committee enquiry into the state of public health post 2013 recognises the parlous state it is in, and uses its influence to bring about changes that will enable the enormous potential of having public health based in local government to be realised.
Iacobucci G. Public health – the frontline cuts begin. BMJ 2016;352:i272
NHS England, Public Health England, Monitor, Care Quality Commission, Health Education England. Five year forward view. October 2014. www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf.
Competing interests: No competing interests
In 2014 we stated that a pressing imperative was to stop the raids on public health budgets and that a rapid review of the current public health capacity and future needs of local government was required (1). In the same year, NHS England’s Five Year Forward View recognised the enormous burden facing the NHS and emphasised the important roles that public health needed to play in the future (2). The report quite rightly stated that:
“The future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health.”
Iacobuccis investigation (3) recently reported in the BMJ is very timely as The Commons Health Committee is now reviewing public health: delivery; effectiveness; workforce capacity; and spending. The BMJ investigation that used freedom of information requests to find extensive cuts to front line services will add further weight to the evidence that has so far been assembled by the Committee.
We strongly believe that our current and future public health challenges require an “industrial scale” (4) upgrade both at national and local levels. However, we do not think that there should just be a focus on individual topics including: obesity; smoking; mental health; and alcohol. Over the years we should not be just “nudging” individuals from one risk factor to another. A more radical approach is needed, one that gets to the roots of the situation (5). A long term comprehensive strategy is required: that doesn’t just provide information but also seeks to tackle environmental factors.
Action is needed in many settings including schools, primary care, workplaces and communities. In the UK there are 220,000 doctors and 300,000 nurses – this in itself is a tremendous resource that could be used to promote health. In addition, teachers, environmental health officers, fire fighters and many more need to be galvanized into action. However without public health support this potential will not be realized. Unfortunately, we are aware of strong anecdotal information from within public health of budgets being raided, unfilled posts, declining numbers of staff, and poor morale.
This negative environment needs to be reversed; the improvements to health cannot be delivered without properly resourced and robust public health services. In order for services to be successful in all three domains of public health (health improvement, health protection and improving health services) they need to ensure they contain a diverse range of: specialist knowledge; skills; and experience. Medical and non-medical staff are needed.
The DPH leadership role is crucial to championing the health of our communities. However, in some areas the role has been downgraded as a result of the transition to local authorities. DPHs should be empowered so that they are more influential within their authorities and local communities.
To conclude, we strongly believe that the cuts must stop and there needs to be a major upgrade in investment in public health, as this will improve people’s health and wellbeing, tackle inequalities and relieve pressure on our overloaded NHS.
1) Watson M C and Lloyd J. Raiding the public health budget. Action is needed to tackle current public health threats BMJ 2014;348:g2721
2) NHS England, Public Health England, Monitor, Care Quality Commission, Health Education England. Five year forward view. October 2014. www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf.
3) Iacobucci G. Public health – the frontline cuts begin. BMJ 2016;352:i272
4) Middleton J. Health inequality is worsening as the cuts bite. 2014 [viewed 28 January 2016]. Available from: http://betterhealthforall.org/2014/10/07/health-inequality-is-worsening-...
5) Tones K and Tilford S. Health Promotion: effectiveness, efficiency and equity. Cheltenham: Nelson Thornes, 2001
Competing interests: No competing interests
My heart goes out today to Local Government colleagues who are expected to make piecemeal cuts in a chaotic national scramble. Expected to Prolong Active Life, they are like loyal Labradors whose ration of dog food is arbitrarily cut by a thoughtless master, over and over again. Isis was dependent on the Earl of Grantham, but his Lord valued him!
Today I received two well-meaning documents: 'Best start in life and beyond: Improving public health outcomes for children, young people and families'
(2016 https://www.gov.uk/government/publications/healthy-child-programme-0-to-... ) and
'Health matters: harmful drinking and alcohol dependence'
(2016 https://www.gov.uk/government/publications/health-matters-harmful-drinki... ).
In an era when commissioning for outcomes is supposed to be a priority, the Best start in Life identifies High Impact areas, such as "building resilience and supporting emotional wellbeing." Resilient children  make a good investment, because they may benefit for the rest of a long life. Similarly, adult harm from alcohol aggravates multiple problems  for years ahead: Health Matters confirms that "investment" in alcohol interventions can produce a high "return".
But depending on one fickle master in Westminster to invest in population health could waste so many opportunities for health gain. It could also leave loyal public servants gnawing in frustration at smaller and smaller bones.
By and large, the UK has democratic traditions, many channels of communication and free speech. Across this country we need to revive the lesson that public health is an emancipatory, participatory endeavour. Fundamental to public health leadership in Local Government is the capacity to mobilize bottom-up support for health.
 Iacobucci G. Public health – the frontline cuts begin. BMJ 2016;352:i272
 Caan W. Because you’re worth it. Perspectives in Public Health 2015; 135: 15.
 Caan W. Misfortunes never come singly. Perspectives in Public Health 2009; 129 :210-211.
 Caan W. Public health coming home. Journal of Public Health 2015 online (accessed 21 January 2016) http://jpubhealth.oxfordjournals.org/content/early/2015/08/05/pubmed.fdv...
Competing interests: A professional body once described my public health involvement as an 'Anarchist in a Cardigan'.