Health reforms won’t work without major changes, say King’s Fund and BMABMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3243 (Published 26 May 2011) Cite this as: BMJ 2011;342:d3243
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I agree with Dr Bickler and his two colleagues that there is no clear
responsibility on any organisatioun for the health of the public in the
currently framed legislation.
I served in the real(old) public health, pre 1974. Then the local
authorities were responsible for public health. But, that was not enough
for the purpose. There was the Medical Officer of Health of those
authorities, with statutory responsibilities for the defined population.
No one succeeded in gagging the MOH. No one succeeded in rendering the MOH
impotent. Of course people tried - but failed.
After 1974, the "Proper Officer" retained some powers and exercised
those powers. He had the statotory right to be heard by the Council and he
exercised the right - much to the embarrassment of some councillors, some
officers - locaL and national.
The Public knew who the "Proper Officer" was.
No, Dr Bickler, if you want the public to be protected , then bring
back the MOH of the pre-1974 model.
Will the Faculty of Public Health consider this suggestion? After
consideration it can of course reject it and give reasons for the
JK Anand DPH FFPHM
Competing interests: Interest in public health as I am a member of the public
The proposed reorganization of the NHS has attracted a lot of
professional attention and public concern. Dramatic changes are also being
proposed to the public health system. We have a specific concern about the
planned changes in responsibility for public health. Our analysis of the
Health and Social Care Bill is that no organisation locally will have a
statutory responsibility to protect the public's health.
The NHS Act 2006 (Chapter 2, Section 24) gives a clear population
responsibility to the Primary Care Trust (PCT) to both protect and improve
the health of the population. This is an important underpinning to the
current public health system. Whilst partnership working, for example
between the NHS, Local Authorities and the Health Protection Agency is
crucial, it is quite clear that the "buck stops" with the PCT for ensuring
that the current NHS responsibilities for public health are dealt with.
This has proved important in complex situations, for example to ensure
adequate management responsibility is taken for health protection
incidents in healthcare facilities in which there are many different
organizational interests, or in mobilizing NHS resources to swab,
vaccinate and treat people in the community during a flu pandemic. It is
also important in maintaining a focus on public health programmes such as
TB control, and immunization and screening programmes which require a
population and coordinated approach across health organizations as well as
the clinical treatment of individuals.
The 2010 Bill abolishes PCTs and confers extra responsibilities on
Local Authorities (upper tier only in two tier local government areas). As
regards health improvement, a new section is added to the NHS Act that
each LA must take steps as it considers appropriate for improving the
health of the people in its area. In addition, the Secretary of State may
take such steps as he considers appropriate for improving the health of
the people of England.
These changes create two significant problems. First health
protection is excluded as a responsibility of any local health
organisation. Secondly, and as regards health improvement, the wording is
clear that LAs must take steps only if they deem them to be appropriate.
They have no obligation to do so. The Bill also includes clauses on GP
Commissioning Groups, but insofar as these relate to services to improve
health, they are about individual services, not for population health. GP
Commissioning Groups have no geographically defined public health
Our conclusion is that no local organisation will have a clear
responsibility for the health of local populations. The current general
duty on PCTs within the 2006 NHS Act to have a strategy to protect,
improve health and prevent ill health amongst the populations they serve
is replaced by permissive legislation on both LAs and the NHS to improve
health. This is backed up by a fail-safe for both organisations of "do it
if the Secretary of State says so". This is a significant loss of
responsibility and may have widespread implications.
It seems strange that despite the government's stated commitment to
public health and a desire to have a line of sight on it, a system is
being proposed in which the Secretary of State has no obligation to
protect and improve the health of local populations and that also removes
local obligations. Public health professional organizations have, in a
recent letter to the Prime Minister, proposed that local authorities
should be both responsible and accountable for protecting and improving
the health of their local populations, and they should be supported in
this endeavour by Public Health England (1). We support this view and
would hope it is included in the next version of the Bill after the
Dr Graham Bickler FFPH, Dr Sue Ibbotson FFPH and Dr Brian McCloskey
Competing interests: We are all employed by the Health Protection Agency