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.
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!