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Chief Medical Officer – Annual Report – Could do Better

November 26, 2012

Its worth having a look at the recent report by the Chief Medical Officer for England. The CMO is the ‘professional head of all Directors of Public Health’ and is working in an environment that is very similar to the one that local DsPH will soon be in – a senior officer advising politicians.

While this report (her first) has some strengths regrettably it largely fails to provide a positive example to DsPH about how to engage with and influence local decision makers.

Here are some of the challenges

Social Determinants of Health

The  inspiration for this public health report is Sir John Simon – who was the second Chief Medical Officer from 1855 – 1876.

According to the UCLA website Simon was also first Medical Officer of Health for the City of London. In his first annual report in 1849 he called for municipal action to eradicate slums, build model dwellings for the poor, provide public wash-houses, take control of the water supply, suppress offensive trades, provide a municipal cemetery, complete the drainage system, and establish a permanent sanitary inspector. The website tells us that he used his considerable political influencing skills to achieve these changes – precisely the skills required by local DsPH and the CMO.

Regrettably this report does not convince that his legacy continues.

With its list of over 50 medical conditions this is a return to a style of public health reporting that local public health leaders have increasingly tried to get away from as they have sought to give clear messages about priorities and actions that will engage, motivate and energise none health sectors and organisations that can make the biggest difference to health and wellbeing.

This is a shame because hidden away within it are concerning figures that should form the basis of an assertive call to action.

Page 245 – Healthy Standard of Living – Percentage of children living in poverty

Page 246 – Percentage of Households in Fuel Poverty

These figures show respectively a failure to reduce levels of poverty and a worrying increase in the number of households in fuel poverty.

Some of the solutions here rest with government – and require more than pious calls  ‘for local authorities to actively promote the uptake of insulation’

Mental Health

The Governments Mental Health Strategy notes that this is the first government to give an equal weighting in policy terms to mental and physical health – regrettably this is not the case with regard to this report. In 300 pages there are 4 are devoted to mental health.

According to this report an estimated 6.1m people suffer from anxiety and depression in England. While it notes that currently just over 2% currently get access to IAPT services it draws no link between the relationship between housing insecurity, financial vulnerability and poor mental health.

This is a serious omission; by focussing on individual illnesses and diseases the CMO does not make a consistently strong link with ‘the causes of the causes’

Peoples social and economic circumstances affect their mental health and wellbeing. If people feel good about themselves and in control then they are more likely to be able to live healthily.

In presenting lists of data with no apparent order to them the report fails to give a clear message about where we should start from; particularly wth regard to the prevention agenda, and fails to empower local DsPH and Local Authority Cabinet Leads for Health with clear messages about pratice. She repeats the same mistake that JSNAs have been criticised for locally – lots of data and no clear view about priorities.

It is disapointing to include reference to the life course on pages 14 and 15 of the document and then to structure the report as a series of lists that ignores this framework.

No Assets

The report is a long list of deficits. At a local level many Directors of Public Health are seeking to develop a narrative that balances a description of need with the assets that exist in local communities. The CMO is in a unique position to provide a complementary view at a national level – and fails to do so.

With privileged access to cross government information on housing, volunteer involvement, investment in the voluntary and community sector, and with the Departments own Voluntary Sector Strategic Partner Programme to call on this would have been the place to show leadership and mandate innovation at a local level. None of this is referenced in the report.


I will comment on two of them.

Recommendation 2 – Physical Health and Mental Health and Wellbeing

The call for better data on resilience and wellbeing should go some way to addressing some of the deficits I have highlighted earlier with regard to mental health. To be frank this is urgent. The NHS is still driven by a narrow view of evidence based commissioning. If data does not exist then commissioners will continue to focus on areas where they can collect data – and as this report demonstrates that is predominantly siloed data about physical health conditions.

However, this recommendation calls for data being available at a national level. What the CMO needs to understand is that most commissioning now happens locally. She needs to be urging government agencies such as ONS, DH and other Government Departments to prioritise making information available to local authorities and CCGs that will help them commission more effectively to meet the needs of their populations.

Recommendation 4 Social Determinants

Frankly I struggle to follow this. The CMO highlights the challenges here –  low income, poverty, lack of access to education and training and her recommendation is…….build on the olympic legacy!

I find this staggering. At a time of economic crisis and government policies that impact particularly negatively on the poorest and most disadvantaged the key solution is to maximise the legacy of the Olympics!

As local authorities face the biggest cuts they have ever experienced I think this will be met with hollow laughter – talk about sending your Director of Public Health naked into the Health and Wellbeing Board!


Regrettably this report fails to recognise the challenges that local Directors of Public Health face, does not respond to the localist agenda and does not sufficiently reflect the developments in public health thinking with regard to the Marmot framework, co-production, assets and citizens voice.

What do you think?

2 Comments leave one →
  1. January 6, 2013 16:22

    I’ve only just found your blog, and hence only just read this post. As a busy Council leader and chair of the HWB, the fact that the CMOs annual report has hardly made the slightest impact in my awareness suggest that your analysis of the weakness of this report is spot on.

    But isn’t she in an impossible position with this Government? Haven’t they made it absolutely clear in almost everything they said that, in public health as with poverty and inequality, they have absolutely no support for action on the social causes of ill health and inequality, focussing exclusively on putting the whole weight on individual responsibility and choice?

    Mind you, an heroic public health report would see this as a spur to challenge the powerful through clear, well-marshalled and evidence based argument.

    • January 7, 2013 08:01

      Thanks Tim – I agree with your general points about this government. But if there was a time when public health professionals need to (in a subtle, strategic and nuanced way) use their statutory independence it is now, otherwise what is the point of having that independence?

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