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Local Government and a new Public Health

October 5, 2011

In an earlier post I touched in passing on the fact that the emphasis of current reforms seems to be more on the administrative issues associated with the move of public health to local government – finance, where DsPH will sit in the local authority that – sort of thing.

There seems to have been very little thought given to whether the public health function is actually fit for purpose or not. There is a cracking article by Richard Horton which touches on some of these issues. It’s on the Lancet website (www.thelancet.com Vol 378 September 17, 2011)  or if you are not registered – I have made it available here –  Future of Public Health Richard Horton.

The quote I really like from Richard Horton’s article is:

“Public health is the science of social justice, overcoming the forces that undermine the future security of families, communities, and peoples. Public health leadership in England is failing. It is time for those leaders to discover courage and purpose.”

This article is complemented by a series of papers commissioned by the excellent Healthy Communities Programme that was run by Local Government Improvement and Development (LGID). This programme has been the national leader in creating a forum for inclusive mature debate about the future of public health. There was a community of practice linked to this but it no longer exists in this form since the disappearance of this organisation.

The papers reflected a diversity of views about what public health should be in the future. Some continued to make an argument for the broad and technical role of the DPH while others focused more on the need to reinvent public health to capitalise on its new position in local government.

There are lots of papers and I have not read them all yet – but I would recommend those by David Hunter and Phil Coppard.

Some opinions.

I regret to say – with some notable exceptions I have met too many very well paid public health professionals who don’t seem to be comfortable with the principles that Richard Horton sets out above. There is a school of thought prevalent in the English public health mainstream that sees public health specialists primarily as skillful  technicians able to use a variety of sophisticated technical interventions that can reduce smoking, decrease obesity etc without worrying to much about improving peoples circumstances or life chances.

This apparent scientificity validates an approach that believes technical interventions can solve health inequalities and that unfair health outcomes have little to do with the distribution of wealth and power.

I think that the move into local government is going to expose this delusion pretty quickly for a number of reasons – here are my top 3.

Making a political stand for citizens – Local Government has spent over 100 years refining the way it works so that it can respond to the needs of its citizens. structures to respond to the needs of its citizens. At their best political leaders will put themselves on the line to defend the wellbeing of their electorate. Evidence? – Clay Cross and all the local authorities who took a stand over ratecapping.

Accountable for fair services – Councillors are acutely aware of the need to justify salaries of highly paid staff to their local electorate. One of the ways in which they defend the high salaries of their top staff is because they are responsible for large budgets, very big staff teams and are personally held to account when these services fail. There are many of examples of local authority directors who have had to take ‘the long walk’ when they have failed – particularly when this failure has affected the most vulnerable.

Making an impact – Leaders in Local Government have to be able to demonstrate that through their leadership they make a positive difference to local populations – if they are not able to do so then the question has to be – what added value do they bring and can their salary be justified.

The irony is that a good number of professions in local government probably owe their genesis to public health – for example local authority Directors of Housing Services. The challenge now is to demonstrate what added value Directors of Public Health bring given that many current local authority directors already work to a set of standards that they would argue improves health and wellbeing. Public Health needs to prove that it is as relevant now as it was at the start of the 20th Century, and frankly compared to some of the local authority big hitters (housing, social services, education) public health struggles to demonstrate impact at the moment.

So what offer can Public Health make in Local Government? Three possible actions.

Empower the politicians – Unlike Non Executive Directors in the NHS local councillors represent their electorate – this means they know that they have to go out into communities and engage and develop a shared sense of what a particular place should be like. Directors of Public Health have a tremendous opportunity to support and empower politicians in providing a strong and inclusive vision for their community. Part of this will of course be about empowering councillors to take the fight back to central government too.

 Managing Services – Directors of Public Health are in a great position to take responsibility for the delivery of large-scale services that impact on wellbeing. They can now play a key role in rebalancing commissioning placing a greater emphasis on services that are a prerequisite for wellbeing. Championing housing security (or even managing housing services!), ensuring that welfare rights services are available to all who need it (maybe leading commissioning of these) or championing the commissioning of careers services to improve social mobility. This is a tremendous opportunity – rather than fiddling about on the sidelines trying to persuade people to stop smoking when they are in problematic debt – or focussing on healthy eating in school when the number of young people who are Not in Education Employment or Training continues to rise.

Impact – In local government the DPH will be able to take direct responsibility for improving the wellbeing of whole populations. For example with regard to physical activity – they will no longer be constrained in just focussing on commissioning a few healthy walks programmes for people with long-term conditions – they can lead approaches that span transport, leisure, culture and health and spatial planning – creating powerful holistic cultural change that could improve all of our lives.

Moving into local government offers a real opportunity to create Public Health 2; “New Public Health”; call it what you will. There is a real opportunity and imperative to reshape public health so that it is ‘of local government’ and not ‘of the NHS’. But Directors of Public Health will need to have the ‘huevos’ for it, it’s about engaging wholeheartedly – and almost certainly discarding ambitions to be the clinical leads for public health in the NHS. Leave that for the clinical technicians!

6 Comments leave one →
  1. October 5, 2011 16:59

    Mark, thank you for this and for the making the Richard Horton article available. You lay out the challenges and the opportunities clearly, especially the possibility for DsPH to span services to create the major impact that has eluded LAs so far. Recently I have been doing a little work alongside an excellent public health consultant who would certainly be up for this. Just hope that the right people aren’t lost in the move. You mention the need for ‘huevos’, given the scale of the culture change that will be demanded of some, maybe ‘cojones’ will be needed as well!

  2. Sakthi Karunanithi permalink
    October 5, 2011 22:15

    Thanks for this thought provoking blog. I agree with everything that has been said except the last sentence – “and almost certainly discarding ambitions to be the clinical leads for public health in the NHS. Leave that for the clinical technicians!” – which does not make any sense based on what we know about the determinants of health.

    Health is not just determined by the socio-economic environment(s) and our lifestyles but also include some life saving clinical interventions and access to fair and high quality health and social care services, including responding to health emergencies using clinical & technical skills. The technical skills set to influence these determinants lie within the public health profession and we should not discard the scientific skills to protect health and influence fair and high quality health and social care services. Sadly, this is almost being forgotten or conveniently ignored (apart from a cursory mention that it will be a requirement for local authorities to provide public health support to clinical commissioning groups). In my view, it is a high risk strategy to completely wipe out public health skills from the NHS by moving them en-bloc to the local authorities.

    While local authorities are right in welcoming public health and scoping their impact, it is very important for them not to loose their focus on improving the whole range of health determinants, especially the contribution of health care services.

    Public health is both a science (technical) and art. We should keep it that way.

    • October 5, 2011 22:32

      Sakthi – thanks for your thoughtful and well argued response. I don’t want to decry the technical expertise at all – and when it is not quite so late at night – I will respond in more detail to your comments! All the best – Mark

  3. Nisreen Alwan permalink
    October 6, 2011 14:46

    Mark, thank you for this excellent blog.

    I think we have to acknowledge that some of “the very well paid public health professionals who don’t seem to be comfortable with the principles that Richard Horton sets out” in his article chose this career path with “ambitions to be the clinical leads for public health in the NHS”, and it is unfair on them to be told that they now have to do a different job than the one they have spent years developing their skills for. So may be the sloution is to explicitely split the current English Public Health workforce into the “New Public Health” as you refer to it, and the “clinical technicians”, although you may want to give the latter a fancier name!

    • October 6, 2011 15:45

      Nisreen – spot on! I agree with you (almost) completely. I think we would have a much stronger system if we accept that to make a real impact there is a need for a strong clinically focussed public health inside the health system and another one based in local government that has a different but complementary skill set. My personal view is that the world we are working in is too complex for one person – no matter how well trained – to have the capability and capacity to bridge these. I think that this problem arises in part because the public health resource as it is currently configured is so small relative to other functions such as adult social care, clinical care in hospitals – even primary care. On another note – I don’t completely agree with you re its unfair now to be asked to do a different job. While I have real sympathy for people who experience changes in their jobs or lose them through restructuring etc I do think that at the end of the day it is for our paymasters to decide if they want to fund us. It is for us – when our jobs are threatened to take this issue through our trade unions to bring pressure to bear – if we think the changes are unjustified. So I think that arguments about job role and security are essentially a trade union issue rather than a professional one the same rules apply here as to any worker who finds that their job has changed or vanished – ask the British Aerospace workers in Brough or the Careers Advisors who used to work for Connexions Services. Its time to organise and get on the streets! All the best – Mark

  4. October 6, 2011 16:09

    Mark,
    You raise some important points, but you are only looking on one side of the issue. I think it is important to educate the patient as well.
    http://www.foreignpolicy.com/articles/2011/10/03/wanted_smarter_patients#.ToowIt6Y4ZQ.twitter
    The article suggests that a way to leverage the improved technical skills is to educate the patients to take advantage of the expertise.

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