The recent BMA survey of the public health profession provides a useful insight into the current concerns of public health professionals and into the general condition of public health as a profession.
The survey is worth reading. However, I think its message is quite different to the headline statements from the Faculty of Public Health and the BMA. They have chosen to focus on two areas of loss.
Loss of Independence and Loss of Medical Professionals.
“We are particularly concerned that over half of the people surveyed say they don’t have the freedom to speak out. That freedom has saved countless lives in the past when public heath leaders have spoken out, often going against the grain of popular opinion to do so.”
“This survey confirms what our members have been telling us for several years: public health specialists are very concerned that the new public health structures in England are a risk to people’s health. We know the system is working well in some places, but the number of professionals who are considering leaving the public health profession is one of many reasons for concern.”
John Ashton President of the Faculty of Public Health
John is supported here by Penelope Toff the BMA Public Health Committee Co-Chair
“Two thirds of doctors who responded are considering leaving the specialty and more than half of medical trainees are planning to move on.”
Lets have a look at these two questions in turn.
Q – “I have the professional independence I need to speak out on public health issues”
- Agree – 49.90%
- Neutral – 23.7%
- Disagree – 26.4%
Ok, it is possible from the above data to truthfully claim that less than 50% of public health professionals believe they have the professional independence to speak out, after all the figure is .1% below 50%.
But it is equally possible to say:
“Hooray! Twice as many public health professionals feel that they have the professional independence to speak out, compared to those who do not feel they can speak out”
Indeed if we were to put aside those who were neutral we could even claim that almost 2/3 of public health professionals who have an opinion about this feel that they do have the independence to speak out.
Q – Medics – have you considered leaving the profession in the past two years?
- Yes – frequently and or seriously – 25.7%
- Yes – it has crossed my mind – 34.7%
- No – 36.3%
So from these figures Melanie says 2/3 of medics have considered leaving the profession – presumably she has added together “frequently/seriously” and “its crossed my mind”.
Of course we don’t know how many people who said ‘yes’ have actually left the service and the single largest group are those who have never thought about leaving the service.
In the last 3 years it has ‘crossed my mind’ on a number of occasions that I might go and live on a canal boat, in a remote cottage, travel round the UK in a trawler etc – I have no intention of doing any of these things. (Yes, I know that some people reading this wish very sincerely that I had taken up one of these options.)
I think it is perfectly reasonable for people to indicate that leaving the profession has ‘crossed their mind’ and for them still to be generally happy and committed to their job.
More Survey Problems
Of course the survey has no base line either – so it is hard to know what public health professionals might have said when they were based in the NHS. I can still just about remember those happy days and there were plenty of public health professionals then who felt constrained by the bureaucratic and apolitical straightjacket of the NHS.
So we do not know what the variation is between present perceptions of independence and past perceptions when public health was in the NHS. That is of course what matters.
My favourite question has to be:
Q “In my local authority, the public health grant is not seen as a resource to be raided”
This is beauty! What a loaded question! This implies that some local authorities are being run by Highwaymen or Vikings – excellent! For those of us long in tooth I remember a constant complaint in the NHS was that there was no specific public health budget allocation at all – with any funds having to be fought for and protected every year.
For a good objective account of the current state of play in public health funding read the article by Gareth Iacobucci in the BMJ. In this there is a thoughtful response by John Middleton (Vice President of the Faculty of Public Health) who notes that:
“My (council) is no different (transferring money from the public health budget), although we are taking the opportunity to remould services in a more evidence based and public health focused approach … Its not wrong to apply public health funding to other areas, but some councils have just done it very crudely”
In the same article Duncan Selbie Chief Executive of Public Health England notes that:
“I welcome local government reviewing where the money has been spent. Local government is pretty advanced in looking at outcome based commissioning and of course they will be looking for more value….. the duty is to improve the public’s health, not to provide a public health service”
What is the real issue?
I think focusing on loss of independence and funding distracts from addressing a much more important and serious issue which I would suggest is something like this:
“How to develop a strong fit for purpose public health profession that is seen as relevant and useful to local government.” Importantly it also distracts from building on some of the strengths and positives that also come through this survey.
What the survey tells us
This is a profession in transition and as the introduction to the report on the survey notes – a divided one. It seems to me that non medical public health professionals and trainees in particular are generally more positive about how they view the future.
It also seem to me that there are quite large numbers often around 30% who are undecided about the present and future prospects for public health. In some ways this is fair enough – we are only one year into this transition.
There do seem to be as many concerns about Public Health England as there are about working with Local Government.
- This is a profession in transition, the Faculty in particular has to come to terms with a changing membership that is increasingly non-medical and recognise and represent their interests more.
- Public Health is still bedding into the new structures.
- Its not just about local government – if anything there are more fundamental concerns about Public Health England
- Trainees are generally positive about their future.
- Non Medics are positive about the future
- The independence of Directors of Public Health (whatever that means) is not under threat
- It is tough in public health – but that is no different to the experience of the rest of local government and the voluntary sector – there are common causes to be made.
It is really important to be working closely with local authorities to design a profession that works for them and not to try to impose the existing model onto them. It is particularly important build on and support those in the profession who are successfully establishing credible relationship within local authorities.
What do you think?
I was pleased to see the recent blog by David Buck at the Kings Fund “Health Inequalities we need a national conversation” calling for more collaboration and clarity between Public Health England, NHS England and the Department of Health. I share his frustration at the continued lack of co-ordination and leadership shown by these big (and comparatively well funded – compared to local authorities) national institutions.
I do however, take a different line.
First, I am really tired of the way national agencies and government launch into these national ‘conversations’. So was concerned to see (thanks to David drawing attention to it) that Public Health England have started one of these.
Remember the “NHS Listening Exercise”? What about Tony Blair’s “Big Conversation”? Or David Nicholson’s Call to Action? None grabbed me, maybe some of you reading this thought they were tremendous and made a real difference – if so please leave a comment!
Thus far I have been unimpressed by these attempts to establish a national dialogue with citizens and local players. They too often feel like a half hearted attempt to engage with the public and front line who already have quite enough to do with getting on with local challenges.
Having said that Public Health England do seem to have a more considered process which involves focussed interviews with Directors of Public Health, Councillors and local voluntary organisations.
Of course it is important to bring local voice and experience powerfully to national agencies. I just think that dialogue should be built around substantial long term relationships which recognise independence of view rather than fixed term conversations.
As a trustee of Citizens Advice I am impressed by the model that this organisation uses – but they are not unique – There is a long list of NGOs who provide evidence based challenge to policy – they include MIND, CPAG, Barnado’s, Disability Rights UK etc. Some of those get funding from government and its agencies to the irritation of right wing think tanks like the Institute of Economic Affairs who pejoratively brand these organisations “Sock Puppets” in their recent publication “The Sock Doctrine”.
One of the important services provided by Citizens Advice is to capture the evidence of need that emerges through front line delivery by its 350 or so member Citizens Advice Bureau across the country and interpret this, using it to bring suggestions for policy improvement and sometimes direct policy challenge. Through doing this they directly contribute to making policy better, society fairer and democracy stronger.
I think DH, PHE and NHSE in particular should look across the communities and people they serve and check that they are providing sufficient resource to advocacy organisations ranging from local government to the voluntary sector to ensure that they are exposed to continuous evidence based policy challenge. If they were to do this consistently and in a co-ordinated way they would not need one off ‘Big Conversations” instead they would be continuously exposed to powerful debate and dialogue from organisations who are directly connected to citizens and front line services.
Second, a little comment on David Bucks three national agencies and his suggested actions.
- NHSE – fully support his call for a greater focus on what primary care can do to tackle health inequalities – as I pointed out in an earlier blog the NHSE inequalities strategy is to put it politely – weak. I do think it is unfortunate though that the two areas that David focusses on are both to do with physical health – the role of of primary care in addressing poor mental health is crucial here.
- Public Health England – I am not convinced that David is right in calling for PHE to do more on health impact assessments of other government departments – for the reasons I outline above I think it would be better that PHE funds local government and NGOs to do this work – this will give much more independence and transparency to the challenge.
- Department of Health – I struggle to have expectations of the Department of Health. While I take David’s point on the Social Value Act I think that local commissioners just need to get on with it and guidance would probably better come from the sectors concerned.
We need to push government not rely on government departments giving us permission.
What do you think?
I have been involved as a trustee or committee member of various voluntary organisations for a long time. Well actually – for a very time.
I have become increasingly concerned that it is us in the voluntary sector who are too often unclear about the role and contribution of trustees. This is ironic because the voluntary contributions of trustees is one key element that makes the voluntary sector different and brings so much added value.
The dead hand of governance
I know that as the conversation turns to governance its time to switch off…. don’t stop reading just yet! I am going to try to avoid getting sucked into a piece on the bone dry world of corporate governance here.
I know they are not elected but being a trustee of a voluntary organisation – local or national – is just as political (with a small ‘p’) as being a councillor, MP or non exec on an NHS trust board but I don’t think this similarity is sufficiently understood or utilised within the sector.
It is too often the case that executive teams see trustees on voluntary bodies as a necessary evil – who will go through and check their work at board meetings – provide some useful support to key internal processes such as HR and Finance and sometimes bring a bit of internal testing on user experience and that – more or less – is it.
This is frankly not good enough. If we are to play to the strengths of the voluntary sector we need to expect that trustees will bring with them much more than this - here are three examples:
Specialist Technical Knowledge – When I was a trustee of a specialist CAB working in the mental health sector we always had at least one specialist NHS mental health worker on the board and often a current or ex service user of mental health services.
Environmental Analysis – another voluntary organisation that I am currently a trustee of has clearly worked hard to ensure that they have a wide range of trustees who have powerful connections and current experience of the wider social policy environment in which the organisation operates. The board spends little time on long discussions on finance, HR and programme implementation – the CE clearly understands that they have to do the bulk of this work and report on it to the board. Instead the CE uses the board to understand the environment, test ideas and develop strategies for action.
External Relationships – Trustees can bring real added value to developing relationships at the top of organisations. In many cases voluntary sector managers – even at Chief Executive level are compromised. I think that some of the challenges they face can include:
- Status – executives in a voluntary organisation may be at the top of their organisation but large funders – for example a local authority funding a local voluntary organisation – will see them as effectively a middle manager at best. They will often allocate a fairly junior manager – usually responsible for contracts to manage the relationship. This immediately reduces what should be a strategic relationship to a contractual service provider one.
- Conflict of interest – discussions about funding – particularly at a time of cuts – can be particularly difficult when these are led by managers whose staff (and indeed the manager) may be materially affected by the outcome of negotiations. This is particularly true when local funders will know that the final decision about financial viability and strategies to address deficits rests legally with the trustees not the manager.
Trustees are actually the custodians of an organisations values and vision – they should be in the best position to articulate these to leaders of other organisations – elected members, MPs, trust governors. They bring with them an experiential authority that comes from their willingness to take on unpaid positions of leadership on voluntary organisations boards. In my experience politicians and non executives understand, respect and value this role and welcome the opportunity to have this sort of dialogue and relationship.
It is through building these strategic relationships that foundations are laid for long term practical joint action and sometimes even funding!
What do you think?
NHSE in their recent report “Promoting Equality and Tackling Health Inequalities” note that “inequalities in both health outcome and service experience have endured over time despite substantial investment in healthcare” I think that the reasons are fairly well established – the root causes of health inequalities are fundamentally to do with the social determinants of health – and as the NHSE report says only…
“15 to 20% of the life expectancy gap can be directly influenced by healthcare interventions”
As a CCG non exec I know that there are front line GPs who have a long history of working hard to improve the health and wellbeing of the communities they serve. They are frustrated by the limited range of interventions they can offer – many of which assume that people are in good housing, have stable incomes and have had access to a good education.
We know that there is no magic wand here, many of the people experiencing the greatest health inequalities are under the cosh, even more so at the moment as they are hit from all sides by government policies.
Yet there is more that we can do. There are tremendous long standing examples of good practice which are built around peoples own relationships and communities, they build on their strengths as well as addressing their needs.
One of the best examples in my view are neighbourhood organisations (sometimes referred to as community anchors) that:
- Provide a range of services and therefore respond holistically to peoples needs
- Have a history and experience of working with people as assets – as volunteers, employees, trustees
- Are independent and accountable to local communities
The relationship that these organisations have with some of the most excluded communities is so much more coherent than the transactional one that health service providers find themselves forced to adopt.
The example that is often cited is Bromley by Bow Healthy Living Centre, but there are plenty of other longstanding neighbourhood based community organisations. Many of these are members of Locality – which is the umbrella body for these. Locality was formed through a merger of the British Association of Settlements and Local Action Centres (BASSAC) and the Development Trust Assocation.
…and yet these organisations rarely appear on the radar of health and wellbeing boards and Clinical Commissioning Groups as agencies that are a key part of the solution to addressing health inequalities.
At Leeds Metropolitan University Health Together we did a piece of work with a small number of Locality Members. working with them to capture their views about how local commissioning can better support them in their work. The full report “Strengthening the Voice of neighbourhoods” is available here – its not very long!
Some of the issues that emerged from this work and subsequent discussions at the 2013 Locality Convention included:
The tyranny of public health evidence – There is very narrow view of the evidence which ignores peoples experience as a whole and focusses too much on measurement of clinical conditions and the evidence for clinical solutions. We at Leeds Metropolitan University recently organised a national conference on this topic – and there is more information including speakers videos here.
The commissioning delusion – there is an assumption that most health services need to be commissioned at ‘place level’ (local authority or CCG) rather than at neighbourhood level. I know that many Local Authorities have ambitions to push budgets out to neighbourhoods through Area Committees, Area Panels etc but in my experience they have struggled to gain interest and the amount of funding they have available is usually trivial.
There are a number of options here, some of these are spelled out in ideas from the project we did with Locality members which include:
- A greater focus on the contribution of neighbourhood structures – not just area committees and panels – but the role of Parish and Town Councils
- A need for more work at a national level to support good practice guidance on neighbourhood led commissioning
- A great emphasis on joint/integrated commissioning across CCGs and Local Government
- More visits to and presentations from grass roots community organisations by health and wellbeing boards and other governance structures.
There are real possibilities to be generated through formal alliances between General Practitioners and their local community neighbourhood organisation – usually a Locality Member or a neighbourhood based health living centre. As well as providing the opportunity to tailor services directly to particular communities it also starts to develop a service model which may help the sustainability of not just small community based organisations but also of independent primary care.
All of these ideas have a fit with continued government interest in Whole Place and Community Budgets. The always excellent House of Commons Library has a useful summary report on these here.
What do you think?