Do Local Authorities need a Director of Public Health?
As local authorities start to get to grips with their new public health responsibilities there is the inevitable jostling for position and power in terms of where the public health teams sit.
In the non-statutory Public Health England guidance (produced jointly with the Local Government Assocation and the Faculty of Public Health) on appointment of directors of public health by local authorities there is a clear position that the Director of Public should have “accountability for acting as the lead officer in a local authority for heath” and “to enable them to carry out their role effectively there must be direct accountability between the DPH and and the local authority chief executive”. In most cases this is taken to mean that the Director of Public Health should have equal standing at the Executive Team as others such as the Director of Adult Social Care.
Some local authorities have not fallen obediently into line on this and have instead had the DPH reporting to the Director of Adult Services or even, as in Lancashire have had a none Faculty member take on the DPH role.
I think that some of the reasons why there has not been a consistent adherence to this model have been:
- Directors of Public Health being outmanouvered by other senior officers who understand the local authority environment better and have more credibility.
- A failure to demonstrate that DsPH responsibility equates to the statutory responsibilities and larger budgets of a Director of Adult Services or equivalent.
- Local Authorities already feeling confident that they have a good grip on strategies to address the health of the public with their existing top team – for example Lewisham where the head of Community Services manages the DPH.
While I have not been able to check this thoroughly there are roughly 26 Directors of Adult Social Care who include ‘health’ in there title (ADASS Members with Health in Job Title). This equates to approximately 5% of all Directors of Adult Social Care. Of these it is clear that some see themselves as the most senior champion for health in their local authority and in some cases probably manage the DPH – for example Derby.
Despite this I think that in the majority of cases most Directors of Public Health are in the top team reporting directly to the Chief Executive. But, as Mary Black in her good blog on the Faculty of Public Health website notes
“Those of us who are (on the top managment team) will need to demonstrate pretty fast that we deserve those seats and in some places we may well struggle to keep them. We have another 18 months, perhaps less, to prove our value.”
What is also interesting is that in addition to people like Mary who have a realistic and positive story to tell there are others who appear to have gone even further. So in my list of 26 Directors of Adult Social Care three of them are actually Directors of Public Health. Maggie Rae in Wiltshire, Richard Harling in Worcestershire and Paul Edmondson-Jones in York – whose job title is Deputy Chief Executive and Director of Public Health and Adult Social Services!
When we look at the structure chart for Wiltshire it is quite clear that Maggie is responsible for leading on Adult Social Care.
So, what we have here is a bit of a two way street. Some local authorities have clearly been impressed by the skills and experience of their Director of Public Heath and considered that these mean that they should also take on the Adult Social Care portfolio. While others have been more impressed by what the Adult Social Care profession has to offer and gone down that route.
Now, I don’t subscribe to the Association of Directors of Adult Social Care ebulletin so I have no idea if Sandie Keene their President is outraged by this colonisation of her territory.
I do subscribe to the Faculty of Public Health ebulletin and I know that John Ashton the Faculty President is not sanguine about Adult Social Care leading on Public Health.
“It is ludicrous to have the situation, as there has been in Lancashire, where a social worker is appointed Executive Director of Social Services and Public Health. We must be clear where we stand on issues such as this and draw lines in the sand. Social workers are most welcome to come to us and train as public health specialists and consultants”
FPH Bulletin – Issue 102 – August 2013
This is of course a serious debate
- Local Authorities are under the cosh from central government – they simply cannot afford large Executive Teams – its is inevitable that they will seek to rationalise and merge senior management roles.
- Local Authorities will need to focus on what difference they can actually make to the health and wellbeing of their citizens – in particular those who are the most vulnerable.
- The priorities they decide to focus on will play a significant part in determining what sort of person they feel should lead this at the most senior officer level.
There is therefore an urgent need to consider how best to ensure that local authorities and their partners are offered appropriately trained professionals who they can afford to pay.
If localism means anything then we need as a profession to consider how to support confident local authorities like Lancashire, Wiltshire and York to have the freedom to choose the best person for the job and not to be constrained by closed shops.
It is clear that for some local authorities the key issue is competence not the ‘FPH badge’ I suspect that this trend will continue. We therefore need to be developing a refreshed idea of what public health in local authorities might look like. Part of this must be through developing a shared dialogue with the other partner professions who have been working in local government and in many cases making it work well for the 40 or so years that Public Health has been in exile in the NHS.
What do you think?
Interesting post Mark. I don’t know enough about this debate to add much but it seems to me that the joining up of health & social care – that old vision yet to be achieved in most places – must mean that LA’s will collapse the posts, as they have done with all the other old LA categories such as housing, leisure, environmental health etc. In this light, John Ashton’s remarks look somewhat predictable & reactionary. I assume that he is not prepared, or feels able, to take on the adult care portfolio?
Mark – a really helpful contribution to the debate as public health becomes reacquainted with local government (having spent most of its history until 1974 in the bosom of local authorities). Critics of the new arrangements may care to consider whether public heallth ever enjoyed a golden age during its tenure in the NHS. Isn’t the key point here about DPH access to the LA CEx, top team and cabinet. Achievement will surely be measured by influence and impact on policies and how the money gets spent, not by the hierarchical position on the organisation chart. Also I think its worth emphasising that most LAs have executive director posts that cover a number of service areas, including social care and health, so the notion that DPHs are subordinate to social workers is way off the mark. I suspect most LAs will appoint the top jobs on the basis of the skills of the individual not their professional background per se.
Nelson Mandela described a good leader as being like a shepherd, skilfully allowing the most nimble sheep go out ahead but all the while providing protection and guidance to the flock from the back. I guess it shows you don’t have to be a sheep to lead a flock but you do have to understand the ways of the sheep. What matters in public health is perhaps not the job title of the person with the public health brief but the extent to which public health practitioners at all levels feel part of that person’s flock – understood, protected and supported to be nimble. FPH has a key role in helping to ensure that leaders, whatever their background, understand the ways of public health and that the profession remains as healthy and nimble as it can be.
I do agree , most LAs are downsizing MGM and their exec teams . It’s also a matter of politics and what the cabinet thinks about ph . Also other directors in local gov have important ph roles not just the dir Asc eg place , children , policy etc . Incidentally lancs cc explained their situation quite well I don’t think FPH comment was helpful . We need local government to fully realise their potential in leading ph , tribalism and professionalisation won’t help that goal . Lee Adams
Really interesting article. I’m interested in the lines of authority with these sorts of differences more than the background or expertise of the individual DPH. For me, it’s crucial that Public Health isn’t siloed either into its own or another directorate – it’s about infusing the whole authority with the perspective, and placing it within, say, Adult Services is misleading as it could have a positive role in transport, planning and education policies and more. I think a crucial part of this is making sure PH isn’t limited to its biggest spending priorities (substance misuse and sexual health) as some of its key contributions within LAs could be influencing and agenda-shaping as much as spending. (For better or worse, the situation is further complicated in Dorset, where I work, by the Public Health remit spanning Bournemouth and Poole Borough Councils, which are unitary councils, as well as Dorset County Council, which has six district councils under it.)
Interesting analysis Mark, and admiration for many DPHs finding their paths. Val.
Reblogged this on thepositivevoice.