Government changes are jeopardising public health
BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i1662 (Published 29 March 2016) Cite this as: BMJ 2016;352:i1662
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A.
Having read the article, all the rapid responses to date (including my own previous ones), I beg the authors to put forward their "minimum requirements" in paras numbered 1. 2, 3.......
The Select Committee can, then, consider, accept or reject the representations. Here are my suggestions.
B.
1. Every local authority should have its own director of public health - not shared.
2. Every director of public health shall have the right, at his/her absolute discretion, to speak to the media, without let or hindrance. He (she) shall NOT be required or even requested, to be vetted by any other officer, nor by the Council, nor its Committees.
3. On all matters relating to the health of the population served by the DPH, the DPH shall have the right to address the appropriate Committee or the full Council.
4. The DPH shall be provided with adequate administraive, secretarial and finance expertise so that he/she can submit costed budgetary proposals to the Health Committee.
5. The DPH shall be judged on tbe basis of his performance for the use of the funds and personnel made available.
6. Any monies left unspent at the end if the financial year shall be returned to the Council for allocation elsewhere at the discretion of the Council.
C. I would welcome critcism of the suggestions set out above.
Competing interests: Member of the public, tax-payer. Interested in seeing that my taxes are well-spent, that the director of public health does his (her) job without interference, with adequate funds.
We welcome the important points made by Jeremy Wight and other authors in response to our editorial. Reduction of public health budgets, disempowerment of directors of public health and reported suspension of mandated services all serve to underline the seriousness of the situation facing public health in England and other parts of the British Isles [1,2]. In 2002, the Wanless report cautioned that securing good health for the whole population would require effective public health policy and widespread engagement with preventive measures [3]. Without a skilled workforce, embedded in the heart of local decision-making, and equipped with a budget to address determinants of poor health, public health in England will be the hobbled version of this vision: valuable expertise sidelined rather than harnessed to tackle the disease burden of an ageing population. A recent review of public health in Scotland recommended strengthening of the public health function, including the director of public health role, in order to meet growing health challenges such as obesity and poor mental health [2]. We hope that the current inquiry by the House of Commons Health Committee on public health in England will reach similar conclusions [4].
[1] Devakumar D, Mandeville KL, Hall J, et al. Government changes are jeopardising public health. BMJ 2016;352:i1662. BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.i1662
[2] The Scottish Government. Review of Public Health in Scotland: Strengthening the Function and re-focusing action for a healthier Scotland. 2016. Edinburgh: The Scottish Government.
[3] Wanless D. Securing Our Future Health: Taking A Long-Term View. 2002. London: HM Treasury.
[4] House of Commons Health Committee. Public health post-2013 - structures, organisation, funding and delivery inquiry. http://www.parliament.uk/business/committees/committees-a-z/commons-sele...
Competing interests: No competing interests
NHS health checks May as the authors say be mandated, but this has not stopped Devon County Council suspending the programme and cancelling all contracts, citing government spending cuts.
Competing interests: No competing interests
In their welcome editorial, Devakumar and colleagues repeat the mantra that 'public health budgets were initially ringfenced..' (on transfer from the NHS to local government). This was not strictly the case. Whilst it is true that the use of the Public Health Grant was ring fenced, wider local authority public health budgets were not. All local authorities spent money on public health prior to 2013, and given the huge pressures on their budgets at the time of the transition, it was inevitable that the PH Grant would be used to pay for programmes previously funded out of mainstream local authority budgets. As a result, overall public health spend was reducing significantly even before the recent ill judged reductions in the PH Grant. For example in Sheffield, within two years, one third of the public health grant had been diverted to pay for programmes previously funded by the Council. To make matters worse, in some cases no proper consideration of the relative cost effectiveness of programmes lost and programmes preserved was undertaken, with less cost effective, previously council funded programmes taking priority over more cost effective, previously NHS funded ones. Moreover, while Public Health England monitored the use of the PH Grant, it appeared to take no interest in the wider expenditure on public health.
Devakumar and colleagues also refer to the diminished public health workforce. Along with the widespread loss of senior specialist public health posts across many local authorities, the position of the Director of Public Health has been in many cases significantly degraded, despite the best efforts of the profession's leaders at the time of the transition. Prior to 2013, the DPH was of right an executive director of the PCT, the highest decision making body on health and public health matters in a locality. Now, many of them are third tier officers, divorced from strategic decision making. Small wonder that morale is low, many posts vacant, and those that are advertised are at times attracting no medical applicants and in at least one case, no applicants at all. It is very regrettable that the huge potential for public health that was afforded by the transfer to local government is being lost in the implementation.
Competing interests: Consultant Clinical Adviser, NICE Non-executive director, Chesterfield Hospitals formerly Director of Public Health, Sheffield
Thank you for pointing out that Chief Medical Officers pointed out, years ago, that public health BUDGETS were being raided and that the PUBLIC HEALTH FUNCTION neededto be strengthened.
It should be clear to the readers that: a) the ministers did not listen to their own CMO. b) the raiders did not care, the councillors did not care, the public never noticed. The readers will also recall that a director of public health announced in the Rapid Responses, that She Had herself given ip part of Her allocatio to another section of her Council.
I reiterate that
1.the directors of public health should be given a ring-fenced budget, based on tneir own projected expenditure on specifc public health functions.
2. the directors' role should be strengthened by making them directly ( without an intermediary) accountable able to the relevant committees and the Council.
3. the directors should themselves make themselves known to their public by speaking to the press, the radio, the television.
I phoned one county council today, 6 April.The enquiries desk immediately gave me the name of the DPH. I phoned two district councils. The enquiries desk did not know that they had a DPH.
Competing interests: Member of the public.
Devakumar and colleagues are right to highlight many of the major public health challenges facing this country as well as identifying the need for a stronger and more capable public health workforce.(1) In the past senior public health figures including chief medical officers have also commented on raids to public health budgets and the need to strengthen the public health function.(2,3) We believe that an increased investment in ill health prevention through health promotion would have health and economic benefits, and result in for example, fewer treatment costs and lower welfare payments.
There is a developing consensus that public health action is needed to improve health and wellbeing, and relieve some of the burden on our overloaded NHS.(4-6) The case for action includes information about mortality, morbidity, and costs to individuals, the NHS and wider society. The case is further strengthened by evidence about effectiveness and cost-effectiveness. For example, tools are available to create health promoting schools and hospitals, and tackle the obesity crisis.
We are pleased to see that there has just been a review of public health in Scotland where the recommendations are very positive and include strengthening the roles of Directors of Public Health and developing a new public health strategy for Scotland.(7) In England, the Commons Health Committee is now reviewing public health, its delivery, effectiveness, workforce capacity, and spending. We hope that they will recommend similar actions to those proposed for Scotland.
Our major public health challenges including alcohol, obesity, mental health problems and health inequalities, do not simply require small scale didactic information campaigns and expensive NHS treatments. A long term positive health strategy is needed that includes creating environments that positively promote physical and mental health as well as addressing obesogenic and other risk factors.
To conclude, we make five clear recommendations:
1. A new long term public health strategy is needed that not only focuses on priorities including healthy eating, sensible drinking and mental health but also seeks to address inequalities.
2. There needs to be a paradigm shift in our thinking away from merely treating ill health and towards promoting positive health. Health promoting environments are needed including health promoting schools and hospitals.
3. Academics, practitioners and public health institutes need to be more vocal about the considerable past public health achievements and potential future successes.
4. Robust multi-disciplinary departments of public health need to be created that are able to lead and galvanise others (including doctors and nurses) into action.(8)
5. The role of Directors of Public Health needs to be strengthened if they are truly to become the masters of public health.(9,10)
References
1) Devakumar D et al. Government changes are jeopardising public health. BMJ 2016;352:i1662
2) Department of Health. The Report of the Chief Medical Officer’s Project to Strengthen the Public Health Function. London: Department of Health, 2001.
3) Department of Health. On the state of the public health: Annual report of the Chief Medical Officer 2005 London, Department of Health, 2006.
4) Wanless D. Securing our future health: taking a long-term view. Final report. 2002. http: //si.easp.es/derechosciudadania/wp-content/uploads/2009/10/4.Informe-Wanless.pdf.
5) Marmot M. Fair society, healthy lives: strategic review of health inequalities in England post-2010. 2010. www.instituteofhealthequity.org/projects/fair-society-healthy-lives-them....
6) NHS England, Public Health England, Monitor, Care Quality Commission, Health Education England. Five year forward view. 2014. www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf.
7) The Scottish Government. 2015 Review of Public Health in Scotland. Strengthening the Function and Re-Focussing Action for a Healthier Scotland. Edinburgh: The Scottish Government, 2016.
8) Watson M C and Lloyd J. Need for increased investment in public health BMJ 2016;352:i761. doi:10.1136/bmj.i761 pmid:26860902.
9) Watson M C and Lloyd J. Re: BMJ briefing: meet the new masters of public health BMJ Rapid Response 8th July 2013 http://www.bmj.com/content/346/bmj.f4242/rr/652995.
10) Vise R. BMJ briefing: meet the new masters of public health. BMJ 2013;346:f4242
Competing interests: No competing interests
I welcome this editorial from Devakumar et al as it accurately reflects the crisis that is developing as a result of the ill thought out Health and Social Care Act.
Much government policy pays lip service to prevention but this is not matched by real investment in public health interventions and staff who are able to lead on these.
We are having a similar experience in the Republic of Ireland where the recession has had a massive impact on staffing across the health service, but especially in Public Health. Since 2009 4 million euro has been taken out of local departments of Public Health through the non-replacement of posts, with 70 per cent of vacated posts since 2009 left unfilled.1
There are also issues with the Public Health consultant contract which is outdated. We do not have parity in pay or even job title with our other consultant colleagues, which further reinforces the perception of how low a priority Public Health is.
This is having a huge impact on our ability to deliver across all the domains of public health practice, an experience I am sure my UK colleagues are also facing.
It's time to get serious about prevention.
1. Restoring the position of Public Health. Irish Medical Times. March 31st 2016. http://www.imt.ie/news/2016/03/restoring-the-position-of-public-health.html
Competing interests: No competing interests
I welcome the article in general but I wish the authors had gone further and drawn some lessons from the history of public health.
1. During the first incarnation of the NHS (till 1974), it is perfectly true that public health was funded and managed separately from the GP services (managed by Executive Councils, which did have a public health doctor, a medical officer of health (MOH) as a member) and from the hospital services (managed by the hospital management committees, group hosp mgmt committees, boards of governors, regional hospital boards, where a medical officer of health was member). The MOH was liable to be, and was, publicly interrogated by the health committee of the council if the (elected) councillors were unhappy about any aspects of the hospital services used by the residents of the local authority.
In the current set-up, there is no such relationship between the local givernment and the local NHS management.
2. When, in 1974 the district community physicians were created, they too wore two hats - sometimes three. They had an office in the health service, plus an office in the town hall or district council offices for their "Proper Officer" functions. They might also have had an LEA function (as I did) for "statementing" for ascertainment for special educational needs.
You can see the public health physician's fingers in all the pies.
3. The district public health chap was monitored by the area officer. Sometimes, the Dept of Health and Social Security did try to convey its "views" down to the district but I am sure the man (or the woman) at the district did what the local situation demanded.
4. The district officer was always available to the press, the radio, the television, to answer questions about local health problems.
Today, at least in some areas, the local press does not even know the name of the director of public health. An invisible, inaudible director of public health can hardly influence the public.
5. The Faculty of Public Health did a great deal to influence the sugar debate. In addition, I would have thought, the directors of public health could, indeed should, try to stop the sale of sweeties through slot machines in shopping centres. Please visit Queensgate shopping centre in Peterborough.
6. The local directors of public health should have defined budgets for discharging defined responsibilities.
I would welcome the comments of the authors.
Competing interests: 1. Aged. 2. Tax-payer, wishing public health budget to be ring-fenced.
Dear Sir,
To help doctors dealing with the daily challenges of healthcare, I would like to bring to your attention a new Facebook group, Tea and Empathy. This is a national, informal, peer-to-peer network for healthcare professionals in the NHS. The aim is to foster an atmosphere of kindness and support where we can all offer an empathic ear to anyone struggling, signposting them on to further help if needed.
Originally intended for junior doctors, membership now stands at over 1000 and includes every level of doctor from undergraduate to consultant as well as some nurses. Discussion threads are wide-ranging, from individuals sharing their experiences of mental or physical health problems, mothers advising and supporting colleagues hoping to be able to continue breast-feeding when they return to work, sharing haikus, arranging walks with dogs to give but a few examples.
Any of your readers involved directly in healthcare are welcome to join the group.
Yours faithfully,
On behalf of Tea and Empathy
Phyllida M Roe
Competing interests: No competing interests
Re: Government changes are jeopardising public health
Author's description of the impact of government changes on public health was alarming to note. However, the evidence submitted by some of the public health leaders to the health select committee was not so alarming. Below is the summary of the qualitative review of this inquiry.
Impact of public health teams to Local authorities; feedback from select DPHs: Excerpts from the Health Select Committee
The Health Select Committee was questioning the Directors of Public Health on 01/03/2016. DPHs from London, Devon, Newcastle and Wolverhampton were the witnesses. Though there was a relative paucity of audience, the questioning went into depth on the challenges public health teams are facing since the time they moved into Local Authorities (LA). the DPHs felt that efficiency of public health function has improved in LA but were concerned about their scrutiny function due to the issues of both data sharing and relationships changes with the NHS and the NHS England. DPHs would like more regulatory powers bestowed on them.
Was it a good decision?
All the DPHs felt that moving public health to LA was an anticipated and good move but the transition still has not been complete but a continuous process. One of the DPHs felt that public health has more power and can make their own decisions unlike in the NHS. “We are the masters of our own destiny” was the verbatim.
However, it was felt that the relationship with GPs and the NHS has changed. When questioned further, it was further revealed that the Annual public health report is the only report that goes from LA without a Lead member's name on it.
“We have freedom to speak”, DPH, Devon County Council.
Is commissioning function better or worse?
All the directors felt that commissioning was better at LAs than in the PCTs, though both were not directly comparable. Commissioning in general was more detailed, better supported and offer value for money while the means of commissioning still remains the same e.g. PBR. Re tendering of School health services and integrated tariff for sexual health services were highlighted as the successes of this.
Are there any issues with the move?
Three main issues were pointed out in unison.
1. Not able to access screening, immunisation data at practice levels as LA need to be complaint with information governance to be considered as safe haven for patient level data.
2. Clinical governance issues as DPHs not able to access information on clinical incidents in a timely manner.
3. Not able to perform the scrutiny role because of the above said issues
How can public health function better?
The DPHs felt that better local regulatory powers, whether it’s about alcohol licensing or fast food outlets near schools would be beneficial to improve local public health.
PH to become a statuary consultant in planning processes, especially in private developments.
In summary, the DPHs felt that the efficiency of the public health function has improved in LA but were concerned about their scrutiny function due to the issues of both data sharing and relationships changes with NHS England. DPHs would like more regulatory powers bestowed on them. Only time will tell whether this perception will sustain given the funding issues.
Competing interests: No competing interests