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How independent should Directors of Public Health be?

December 5, 2011

In Healthy Lives, Healthy People the Governments Strategy for public health in England it says:

“The Chief Medical Officer will have a central role in providing independent advice to the Secretary of State for Health and the Government on the populations health”.

It also states that the new QUANGO Public Health England will “maintain the principles and practice of Independent Scientific and Public Health Advice… and it will maintain a source of independent expert advice through a structure of Expert Committees”.

Finally in the Annex to the Strategy it also refers to the role of the Director of Public Health – producing an “authoritative independent annual report” on the health of their local populations.

What a lot of independence! – if we add in NICE – who are also tasked with providing independent advice there are plenty of ‘independent voices’ out there. To summarise thats the – CMO, Public Health England, Directors of Public Health and NICE.

Public Health puts a lot of store in its independence – on the basis that equitable systems need to have means to raise population health issues that might go against powerful sectional interests such as those of the state or the market.

In these increasingly unpleasant times – 25% of the population are now officially in fuel poverty – the issue of independence has never been more important.

One of the problems is working out what this independence is actually for and how to exercise it effectively. Here are two examples

Example 1 – the letter to the Telegraph

In October 2011 some 400 mainly public health professionals signed a Public Letter published in the Daily Telegraph lobbying the house of Lords – asking them to reject the Governments Health and Social Care Bill.

Lets be clear – if I had been asked to sign the letter – I would have been happy to do so – I fully support the sentiments expressed.

The public response from Andrew Lansley was swift and brutal:

“We are very disappointed that these individuals, who pride themselves in the use of evidence, should have fallen back into such generalised assertions for which there is not one shred of evidence…NHS staff and the general public are looking to senior leaders in public health to lead the implementation of the changes to secure better health results for all, not to rubbish them.”

Behind the scenes some of the signatories were challenged by their managers and warned about signing such public letters.

I have worked in both forms of government in this country – Local and National and I do think that there are issues about when and under what circumstances it is appropriate to go public.

In my opinion most professionals get a big bite of the cherry to influence practice through the management structures in their own organisations and because of this I think that they are right to be restricted in what they can say  outside of their organisation.

However, in these increasingly nasty times I know that organisations in all sectors are increasingly placing gags on all staff preventing them commenting on their organisations behaviour outside of work structures.

The only way that I can see that individuals can get around this – short of whistle blowing – is by signing up to a statement with another hat on – for example as a trade union member – rather than as an employee.

Now – what interests me is that none of the signatories to the letter signed it as members of their trade union – the Faculty of Public Health, Unison etc – but instead most signed it as employees of a range of (mainly) NHS organisations – as paid public health professionals.

Did their views represent their organisations views? Were the Chairs of the PCT Clusters asked first? I suspect in some cases they were but that in many cases they were not.

So is this an appropriate way for public health to exercise its professional independence?

My gut feeling is that it may have been better if they had signed the letters as members of the Faculty and other relevant unions rather than as employees of organisations.

This contrasts with the many letters signed by GPs – who, because they are by and large private sector small business people – can sign any letters they please in their paid capacity.

Example 2 – Director of Public Health Annual Report

The above example is pertinent because as Directors of Public Health move into Local Government a number have expressed their concern that they will lose their ability to be professionaly independent. At the moment many Directors of Public Health produce an annual report. The Health and Social Care Bill proposes that this independent Director of Public Health report will become a duty. I think that many DsPH are positive about this proposal.

I am aware that some Directors of Public Health currently insist on producing a public independent report that is not subject to any alteration by their PCT Chief Executive or Board. I am not sure that this is appropriate either. It seems to me – that in local government any report produced by local authorities must be owned by local politicians – in other words the cabinet or full council should have the right to change or veto content.

As far as public health is concerned this context is important – because the DPH should be using the report to influence the thinking of elected members and hopefully through this develop a consensus view of issues and priorities.

In the unlikely event of a disagreement between the DPH and the council cabinet there are a number of checks and balances which will include – the local authority scrutiny committee, Healthwatch and the Health and Wellbeing Board – the DPH should ensure that all are involved in drafting and commenting on the report.

The key issue is creating a platform for debate and dialogue – bringing together professional analysis with local realpolitik – to create opportunities for action.

It is essential that DsPH use this independent report to  build strong alliances with local authorities – because we can be sure that the Department of Health will be pulling the strings of Public Health England and we will continue to see the sort of behaviour by DH as described in example one.

So here are some actions we need to start to take:

  • The Faculty and the Association of Directors of Public Health need to provide more opportunities for the public health profession to work together through collective action.
  • In an increasingly politicised public health environment we need to consider carefully what independence actually means with regard the CMO, PHE and DsPH – and in particular when is this an individual and when is this a collective responsibility.
  • As PH moves into local government DsPH need to be supported in taking a nuanced and tactically astute approach to exercising their independence that builds collaboration and alliances within local government – particularly at an executive and elected member level.
  • Directors of Public Health need to look outside local government and consider how they can support – and I mean with money – genuinely independent voices that represent the interests of communities of geography and interest. Such as Community infrastructure organisations, Health Champions, Trade Unions, Citizens Advice Bureau and others.
We are in for a rough time over the next few years – and we will need to be well organised if we are to adequately respond to the needs of the people we claim to be most concerned about.

What do you think?

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