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A local government public health?

October 24, 2011

Supplementary

I missed the  Public Health Joint Statement 14 October 2011 produced by the LGA, Assoc of Public Health, NHS Confed, Faculty of Public Health etc. This is very relevant to the subject below and gives a useful bit of context. If anything it reinforces the points below – it is also worth having a look at Trevor Hopkins response to the blog in the comments below.

Original Blog

I am involved advising a couple of local authorities who like all unitaries are considering what public health might look like in the new world. As I have said in an earlier post – if we are to make the most of this transition we need to recognise that there will have to be a substantial cultural change in the way in which public health currently works. One of the challenges though is how radical can local authorities afford to be at this moment. They need to set the tone for the future, but not  destroy what is good or frighten off an already jittery public health profession.

One of the difficulties is knowing where to turn to for advice – the Faculty of Public Heath is in effect a craft guild whose primary concern is to protect the profession it has created – and there is nothing wrong with that. The problem arises when Local Government and National Government need independent advice. Advocating for the public health profession is not necessarily the same as advocating for a effective public health in local government terms. Of course the Department of Health has the same problem – it remains very reliant for advice on an embedded faculty function. This means that local authorities need to quickly come to a view themselves about what Public Health should look like.

Here are some of things that local authorities are considering at the moment.

Questions 1 and 2

Two of the questions a local authority councillor  needs answering when they are required to take on responsibility for a new service are:

  • what am I legally required to provide? and;
  • how much will it cost?

Once they are clear about this they can then work out whether they have any resource to deliver more than the statutory minimum and create a service that also reflects local priorities and need.

Of course these questions becomes much more pertinent when times are tough. For example – there is a statutory duty for local authorities to provide library services – which requires all local authorities to provide a comprehensive and effective library service, set in the context of local need.

However closure of a number of libraries to ensure better, more efficient services does not mean that local authorities are in breach of the Act – as the residents of Brent have recently found out. This subsidiarity of local government will be further strengthened by the Localism Bill which proposes a general power of competence – local authorities are free to do anything so long as they don’t break any laws. This is of course a double edged sword – they can respond to local needs and priorities – but it is all within the context of government policies – in particular funding regimes.

You can see where I am going with this. I have not been able to find anything that clearly states what local authority public health duties will be after public health departments have transferred over AND who MUST be employed to deliver on this duty and how MANY of such people there should be.

Frankly, in the world of publicly funded services there needs to be a clear argument why certain skill sets are required to deliver certain statutory functions and I have not seen those arguments presented – in public health. If there are no clear arguments to be presented then I think it is perfectly reasonable for a local authority cabinet lead to argue that they could purchase the same skill set for half or two thirds the price of a person with a Faculty of Public Health badge.

I would be really interested if someone can point me at the legislation and associated guidance that spells this out.

Question Three

“I thought you were a public health department – but you seem to be passporting a whole load of NHS treatment services over to us?”

I have been quite suprised to see that a large part existing public health budgets – in some cases 50% –  to be transferred over to local authorities is for NHS treatment services. Specifically drug treatment and STD services. I know that an element of these is for population level prevention measures but I think that the bulk of this is for treatment of individuals.

I think this is a mistake for two reasons.

First, expertise for the management of treatment services such as GUM  services rests inside the NHS and accountability for their performance should rest there too.

Second, the small public health function in local government needs the management headroom to bring added strategic impact to its work with local government. One obvious way to do this is to free up management time by getting rid of clinical responsibility for treatment services and refocussing this capacity to work more with local government.

If this does not happen there is a real danger that the new local government public health function while being based in the local authority will continue to be distracted/seduced by the pull towards NHS clinical responsibilities.

What do you think?

7 Comments leave one →
  1. mike pedler permalink
    October 25, 2011 08:44

    Mark

    I recently chaired an NHS sexual Health Network meeting. A big issue was future commissioning of these services – which in this area were seen by members as very good, with lots of investment in the last few years. No-one seemed to know how the commissioning would work in future, and the docs in particular seemed gloomy about losing hard-won services esp. for young people. Obviously they are reacting to the unknown as yet – but the results of your efforts to find out won’t have reassured them.

    Cheers

    Mike

    • October 25, 2011 09:35

      Thanks Mike – I suppose the issues for me are as follows. Is one of the reasons for the success that you saw due to local public health leadership of commissioning? Is it important that these services continue to be commissioned from within the NHS rather than from Local Government?

  2. Trevor Hopkins permalink
    October 27, 2011 10:09

    Hi Mark

    I entirely agree with your sentiments Mark – especially “that local authorities need to quickly come to a view themselves about what Public Health should look like”. My suggestion is that they are unlikely to for a number of reasons.

    Firstly, and importantly, most in the profession have failed to do this for themselves over the last 20 years. Despite a distinct lack of success in narrowing inequalities and increasingly poor outcomes in many of the areas they have been ‘targeting'(sic) and despite their supposed ‘independence’ they have not shown any enthusiasm to consider fundamentally alternative definitions or approaches to public health – and there are plenty around.

    Secondly, in medicalising’ society we have also medicalised Councils and Elected Members and damn the consequences. I’m revisiting Ivan Illich at the moment – boy did he get it right.

    Thirdly many aspects of Public Health are essentially ‘prejudiced’ in that the very terms ‘health’ and ‘wellbeing’ are contested concepts. Many Elected Members know this instinctively from their work in local communities. What public health wants for local individuals, families and communities may not necessarily be what they want for themselves – especially in the field of health improvement. This presents a real dilemma for elected politicians who rely on direct public support for their tenure.

    Finally this is compounded because the ‘dominant ideology’ of the current definition of public health means politicians lack both the concepts and language to describe public health in any other way than the ‘pathogenic’ model of risk, illness and health ‘domains’. My dictionary says: “Domain – A territory over which rule or control is exercised.”

    But we seem to be rushing headlong into trying to get different results by doing ‘more of the same’ (Einstein) or doing the same, but in a different and not necessarily more effective place. In a re-working of that old adage, ” Act on public health in haste – repent at leisure.”

    • October 27, 2011 11:35

      Trevor – lovely to hear from you! As you might expect – I agree with you completely. I think that your point about medicalisation and the dominance of a particular definition of public health are spot on. I am afraid that this is reinforced by the recent joint statement on the future of public health produced by the LGA, BMA, FPH, Assoc of Directors of Public Health, NHS Confed and Royal College of Midwives – I will put a link to this on the blog. This retains involvement of the Faculty in Appointment of Directors of Public Health, validates the specialist register, etc I do not think that any similar requirements apply to the appointment and training of Directors of Adult Services or Directors of Childrens Services. The one concession that is interesting is that the FPH will discuss how to ensure that existing local government staff who are performing PH functions are not disadvantaged.

      • Trevor Hopkins permalink
        October 27, 2011 14:21

        Oooh Mark I just love it when you ‘talk politics’ and I’m warming to this debate.

        It has been interesting to see the rise, in recent years, of the so called ‘evidenced based approach’ in public health ‘interventions’ on health improvement. This ‘psuedo science’ often turns out, on closer investigation, to be a bit of data analysis, some associational relationships and informed guesswork – fine, and often a good way to move forward, especially if we don’t know the answer – but don’t call it evidence with its connotations of the ‘natural sciences’.

        I leave the comment on the ‘professionalization’ (of Public Health) medicine to Ivan Illich from his excellent book ‘Limits to medicine – medical nemesis: the expropriation of health’ (1995 edition) page 255. Merely substitute the words Public Health for ‘medicine and medical’ and you have it.

        “The proposals that seek to counter iatrogenesis by eliminating the last vestages of empiricism from the encounter between patient and the medical system are latter day crusaders of an inquisitorial kind. They use the religion of scientism to devalue political judgement…By denying public recognition to entities that cannot be measured by science, the call for pure, orthodox, confirmed medical pratice shields this practice from all political evaluation.
        The religious preference given to scientific language over the language of the layman is one of the major bulwarks of professional privilege. The imposition of this specialized language upon the political discourse about medicine easily voids its effectiveness.”

  3. David Whyte permalink
    October 28, 2011 13:13

    The answer to question 2 in your post Mark “How much will it cost?” is easy and I am sure will be echoed by Directors of Finance across the land – they are likely to say it must cost no more than the sum distributed to local authorities for the purpose of providing public health functions (preferably less) – is this the shadow local authority allocation for 2012-13 expected from DH in December? That is how I have experienced these disaggregations in the past and whilst I’d like to see a viable different case put forward, I won’t hold my breath.

    I know of at least one Chief Executive who bitterly resents the attempt to “ring-fence” these allocations at a time when local government finance is under so much pressure and local authorities need all the flexibility they can muster to cope. Why should public health be any different say, to safeguarding children, or preventing winter deaths, libraries, leisure, and so on? Has the case been made?

    As for prescribed levels of staff then this will be no different for public health staff as for other local government functions. Very few services are defined in this way and there has always been inequity in provision between different areas because of it. Or perhaps instead of inequity this should read “adapted to local circumstances”.

    It seems to me that a better way of approaching this is by defining what a local area actually needs to get out of its public health system, what it can afford, and then matching the skills required to deliver this? One of the huge opportunities offered by Health and Wellbeing Boards is surely the opportunity to see how a public health agenda can be delivered better by a wider definition of the public health workforce (I go back to that category of the “wider public health workforce” given by the CMO in 2001).

    It may well be that those skills can be purchased for “half or two-thirds the price of a person with a Faculty of Public Health badge” but that is exactly the informed decision I expect local elected members to have to make. Of course within this there is a risk that widening definition in this way is used as a backdoor means of enforcing cuts masquerading as “efficiencies” but unless public health (particularly the “new” public health) has martialled its arguments about “what works?” (these don’t necessarily have to be all medicalised or “evidence-based” in the traditional sense but has public health actually done the ground work on promulgating this view?) – then that is a risk it has to run. Are we nearly there yet?

  4. November 22, 2011 14:29

    Reading your blog reminded me of this quote:
    “If you have come because you want to help us, you are wasting your time; if you have come because your liberation is tied up with ours then you are welcome”.
    Lila Watson
    Your comments on the new Vision for Volunteering and the difficulties facing voluntary organisations are well made but do not seem to me to fully recognise the positive aspects of the massive shift in thinking the vision represents away from a deficit model, (needing the intervention of professionals), to “a society where social action and reciprocity are the norm”.
    However, your own strap line, “taking control of our own health and wellbeing”, leads me to believe that you are in tune with this part of the vision. Let’s therefore focus on encouraging a shift in practice and attitude by DoH staff to accompany the new vision – not least an acceptance that ‘engaging with the community’ means more than formal meetings with voluntary sector organisations and attending public forums.
    There is a long, long road ahead but there is now just a bit more hope of moving forward in the right direction, towards stimulating informal care by linking up local people with common interests. They are the greatest assets we have and they are the only ones who can put mutual aid back into the DNA of communities.

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