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A new public health service?
Public Health (1989), I03, 151 152
Public Health The Journal of The Society of Community Medicine (Formerly the Society o f Medical Officers o f Health) Volume 103
Number 3
May 1989
A N e w Public H e a l t h Service? Unlike the precipitate rate o f change due to politically inspired reforms o f the National Health Service, such as the introduction o f General Managers and the proposed Internal Market, the restructuring o f the Public Health Services is being undertaken slowly and carefully following prolonged consultation. The Committee o f Enquiry established in January 1986 was presented with so much evidence that it was unable to complete its task before the original deadline o f December 1986. Indeed its report was not published until January 1988. During 1988 the report was discussed widely, and was generally welcomed. Even so, it was not until nearly a year after its publication, when this general approval was evident, that the circular (HC (88)64) giving effect to its recommendations was issued. This allows District Health Authorities until 30th June 1989 to put their proposals for implementing the recommendations to the Regional Health Authorities, and Regional Health Authorities until 31 st December to report to the DHSS. After such a prolonged period o f gestation one would expect well considered and sound proposals to emerge. Undoubtedly the majority o f districts which accept the spirit as well as the letter o f the instruction, will make sound proposals for their future service. But there will be a need for firm guidance, and possibly some political pressure to ensure that all districts make adequate provision. In 1984/5 a number o f Districts took the opportunity to 'save' the money to pay the General Manager's salary by not replacing a retiring District Medical Officer or Community Medicine Specialist. These same authorities have sought to cut expenditure on Public Health Services such as Family Planning and Child Health in order to help finance the shortfall in central funding o f pay awards and so keep hospitals solvent. It is such districts, which currently lack adequate Public Health advice, and do not appreciate their need for it, which are most likely to take minimal actions in response to the circular. They are the ones which will seek to exploit the option o f sharing a Consultant responsible for Infectious Disease control with one or more other Districts, an option intended to meet the needs o f cities where one Local Authority is served by two or more Health Authorities. Alternatively they may ask their microbiologist to take this on in addition to his existing duties. How such an appointment will be reconciled with the requirement in paragraph 14 o f the circular that the © The Society of Community Medicine, 1989
152
Editorial
consultant appointed will be a full member o f the department o f Public Health may test the ingenuity of the General Managers. The damage to the service, which resulted from loss o f personnel through early retirement during successive reorganisations and from years o f stringency during which public health budgets were cut in order to help fund clinical services has been severe. It will not be easy to repair. Even if recruitment improves, training enough good future Directors o f Public Health will take several years. In the meantime, the number o f properly trained and experienced Community Physicians is an important constraint. Those authorities which understand the importance of Public Health and have retained strong departments of Community Medicine will naturally continue to attract all the best applicants. Authorities which have neglected the speciality and reduced staffing will find it hard to attract good applicants. Those who are reluctantly seeking to appoint a Director o f Public Health because the D H S S requires them to do so should not be surprised if candidates are as reluctant to apply to them as they are to make an appointment. It follows that the ' G o o d ' Authorities will tend to get better and the 'Poor' ones to get relatively worse, unless the DHSS and Regional Health Authorities between them are able to devise and apply some remedy. At the very least, it will be necessary to ensure that the new posts as Directors of Public Health, and other key posts are sufficiently attractive to stimulate a redistribution o f talent. Building is always slower and more difficult than destruction, but this must not be allowed to deter authorities which have run their departments down from rebuilding them. The additional task o f compiling an annual report on the health o f the population will increase the need for staff to support the Director of Public Health. As they enhanced the influence of the former Medical Officers of Health, so the Annual Reports o f Directors o f Public Health will enable the latter to disseminate information and advice both to their authorities and, via the local press, to the Public. No authority should be permitted to so deprive their Director o f Public Health o f support staff that he has to devote most o f his time to writing his report. He must be supported by at least one other Community Physician and have sufficient support staff to collect and collate and present the data he needs both for his annual report and for his role as advisor on the Public Health implications o f the options under consideration when management decisions are being taken either by the Manager or by the Authority. Is it too much to hope, that the new Directors will, in the course of a decade, build up departments as effective and efficient as those o f the better local authorities prior to 1974? Perhaps when the hospitals have opted out o f Health Authority control as envisaged in the Government's latest proposals District Health Authorities may become less preoccupied with hospital management and rediscover the interest in Public Health which the more progressive of the County Borough Councils showed in the 1960s. J.S.R.
Public Health The Journal of The Society of Community Medicine (Formerly the Society o f Medical Officers o f Health) Volume 103
Number 3
May 1989
A N e w Public H e a l t h Service? Unlike the precipitate rate o f change due to politically inspired reforms o f the National Health Service, such as the introduction o f General Managers and the proposed Internal Market, the restructuring o f the Public Health Services is being undertaken slowly and carefully following prolonged consultation. The Committee o f Enquiry established in January 1986 was presented with so much evidence that it was unable to complete its task before the original deadline o f December 1986. Indeed its report was not published until January 1988. During 1988 the report was discussed widely, and was generally welcomed. Even so, it was not until nearly a year after its publication, when this general approval was evident, that the circular (HC (88)64) giving effect to its recommendations was issued. This allows District Health Authorities until 30th June 1989 to put their proposals for implementing the recommendations to the Regional Health Authorities, and Regional Health Authorities until 31 st December to report to the DHSS. After such a prolonged period o f gestation one would expect well considered and sound proposals to emerge. Undoubtedly the majority o f districts which accept the spirit as well as the letter o f the instruction, will make sound proposals for their future service. But there will be a need for firm guidance, and possibly some political pressure to ensure that all districts make adequate provision. In 1984/5 a number o f Districts took the opportunity to 'save' the money to pay the General Manager's salary by not replacing a retiring District Medical Officer or Community Medicine Specialist. These same authorities have sought to cut expenditure on Public Health Services such as Family Planning and Child Health in order to help finance the shortfall in central funding o f pay awards and so keep hospitals solvent. It is such districts, which currently lack adequate Public Health advice, and do not appreciate their need for it, which are most likely to take minimal actions in response to the circular. They are the ones which will seek to exploit the option o f sharing a Consultant responsible for Infectious Disease control with one or more other Districts, an option intended to meet the needs o f cities where one Local Authority is served by two or more Health Authorities. Alternatively they may ask their microbiologist to take this on in addition to his existing duties. How such an appointment will be reconciled with the requirement in paragraph 14 o f the circular that the © The Society of Community Medicine, 1989
152
Editorial
consultant appointed will be a full member o f the department o f Public Health may test the ingenuity of the General Managers. The damage to the service, which resulted from loss o f personnel through early retirement during successive reorganisations and from years o f stringency during which public health budgets were cut in order to help fund clinical services has been severe. It will not be easy to repair. Even if recruitment improves, training enough good future Directors o f Public Health will take several years. In the meantime, the number o f properly trained and experienced Community Physicians is an important constraint. Those authorities which understand the importance of Public Health and have retained strong departments of Community Medicine will naturally continue to attract all the best applicants. Authorities which have neglected the speciality and reduced staffing will find it hard to attract good applicants. Those who are reluctantly seeking to appoint a Director o f Public Health because the D H S S requires them to do so should not be surprised if candidates are as reluctant to apply to them as they are to make an appointment. It follows that the ' G o o d ' Authorities will tend to get better and the 'Poor' ones to get relatively worse, unless the DHSS and Regional Health Authorities between them are able to devise and apply some remedy. At the very least, it will be necessary to ensure that the new posts as Directors of Public Health, and other key posts are sufficiently attractive to stimulate a redistribution o f talent. Building is always slower and more difficult than destruction, but this must not be allowed to deter authorities which have run their departments down from rebuilding them. The additional task o f compiling an annual report on the health o f the population will increase the need for staff to support the Director of Public Health. As they enhanced the influence of the former Medical Officers of Health, so the Annual Reports o f Directors o f Public Health will enable the latter to disseminate information and advice both to their authorities and, via the local press, to the Public. No authority should be permitted to so deprive their Director o f Public Health o f support staff that he has to devote most o f his time to writing his report. He must be supported by at least one other Community Physician and have sufficient support staff to collect and collate and present the data he needs both for his annual report and for his role as advisor on the Public Health implications o f the options under consideration when management decisions are being taken either by the Manager or by the Authority. Is it too much to hope, that the new Directors will, in the course of a decade, build up departments as effective and efficient as those o f the better local authorities prior to 1974? Perhaps when the hospitals have opted out o f Health Authority control as envisaged in the Government's latest proposals District Health Authorities may become less preoccupied with hospital management and rediscover the interest in Public Health which the more progressive of the County Borough Councils showed in the 1960s. J.S.R.