- Email: [email protected]
Public health in England: an option for the way forward?
Viewpoint
Public health in England: an option for the way forward? Martin McKee, Louise Hurst, Robert W Aldridge, Rosalind Raine, Jennifer S Mindell, Ingrid Wolfe, Walter W Holland Lancet 2011; 378: 536–39 Published Online February 28, 2011 DOI:10.1016/S01406736(11)60241-9 See Comment page 468 European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London, UK (Prof M McKee DSc, I Wolfe MSc); Department of Epidemiology & Public Health, University College London, London, UK (L Hurst MSc, R W Aldridge MSc, Prof R Raine PhD, J S Mindell PhD); and LSE Health, London School of Economics and Political Science, London, UK (Prof W W Holland MD) Correspondence to: Prof Martin McKee, European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London WC1H 9SH, UK [email protected]
Introduction It was clear as soon as it was announced that UK Health Secretary Andrew Lansley’s unexpected decision to subject the National Health Service (NHS) in England to revolutionary change1 would have profound consequences for public health.2 The White Paper, Healthy lives, healthy people,3 proposes that the public health function currently based in Primary Care Trusts be fragmented (figure). Some elements will move to the Department of Health, to a division called Public Health England, while others will move into local government. Health-care planning elements might move to proposed Commissioning Consortia and the NHS Commissioning Board, although this is not explicit.4
The problems with the current proposals First, placing Public Health England within the Department of Health sits uneasily with the claim to be “liberating the NHS...from political control”,2 and will strip those transferred of their independent voice as advocates for the health of the population. Independent public health advice is crucial to build public trust. It has taken many years for public health professionals to regain that trust after the bovine spongiform encephalopathy affair,5 and as illustrated by the government’s difficulty in convincing many parents of the safety of the measles–mumps–rubella vaccine.6 Second, the decision to divide the public health function between the Department of Health and local government will fragment the workforce rather than create a “uniting
Department of Health
Public health budget
Public Health England (within Department of Health)
Public health grant
NHS budget
Funds to commission specific public health services
NHS commissioning architecture (Commissioning Board and Consortia)
GPs Providers
Local Authorities
force”.2 It also clouds accountability because the Secretary of State retains wide-ranging powers to “require a local authority to exercise any of the public health functions of the Secretary of State (relating to the protection of the public in the authority’s area) by taking such steps as may be prescribed”.3 Third, although public health budgets transferred to local government are ring-fenced, it is already clear that cash-strapped local authorities might redesignate many of their existing activities as public health, citing the slogan “public health is everyone’s business” in a way that was never contemplated. The Local Government Group recently published a briefing paper arguing against ring-fencing and forced transfer of staff from Primary Care Trusts.7 While the Secretary of State retains powers to address this point, the resources required to maintain scrutiny are lacking. Moving local public health functions outside the NHS risks them being overlooked to a much greater extent than when they were within the NHS,8 and—crucially— local government is not gaining any of the additional regulatory powers it would need to address the determinants of population health. Fourth, even if Directors of Public Health have sufficient status and political support locally, those employed by small local authorities, as in London, will have inadequate technical support to function effectively. Suggestions that senior staff be pooled among neighbouring authorities might work where authorities have the same political complexion, but this situation will be rare and vulnerable to changes in political control. It also adds to the blurring of accountability. Fifth, the proposals include absorption of the Health Protection Agency, currently an arms-length body, into the Department of Health. As well as loss of independence, this move creates practical difficulties such as those that arise from the substantial trading activities of the Health Protection Agency (eg, microbiological testing under contract that sustains highly specialist capacity). The suggestion has been made that these difficulties could be overcome by hiving off these activities,8 but any arrangements that would be compatible with European Union competition law could result in loss of crucial expertise within the Health Protection Agency. Finally, the scale of disruption risks loss of substantial expertise.9 Minimising such disruption is essential to maximise performance in this time of austerity, when a strong public health function is needed more than ever.10
Health and Wellbeing Boards
Building on achievement Figure: Government proposals for the public health function in England Blue arrows=funding flows; red arrows=cross-membership of boards. NHS=National Health Service. GPs=general practitioners. 3
536
It is essential not to lose sight of the enormous achievements of public health in England in the past decade. The government justifies its reforms by citing www.thelancet.com Vol 378 August 6, 2011
Viewpoint
what it sees as past failures. Its criticisms levelled at the NHS have been discredited,11 while those of public health for failing to narrow health inequalities are better laid at the door of the Treasury and the Department of Health, as noted by the Public Accounts Committee.12 Coalition ministers have said less about: the implementation of smoke-free legislation, initially opposed by ministers in the previous government, which is already associated with fewer hospital admissions for myocardial infarction;13 the successful introduction of new immunisation programmes, such as meningococcal serogroup C conjugate vaccine;14 the successful management of complex public health emergencies;15 and improvements in children’s diets through the reintroduction of nutritional standards in schools.16
Principles for moving forward We suggest an alternative that addresses many of the problems with the current proposals. First, however, we enunciate the principles that any solution should include (panel), drawing on lessons from the system in place in the UK before 1974—when public health doctors were based in local government—and the experience of other countries.
Practical proposals We propose a model that would minimise the extent of disruption to the public health function and would result in much less fragmentation and professional isolation of the workforce. In this proposal, the existing NHS-based public health workforce would be identified and transferred to a new body, which could still be called Public Health England. This body would ideally be within the NHS (as a special health authority) or else be an arm’s-length body sponsored by—but not part of—the Department of Health. This positioning would give Public Health England independence that it would lack within the Department of Health. We compare the White Paper’s proposals with our alternative in the table. Individual staff of Public Health England would also (in addition to the organisation as a whole) retain considerable independence, as is currently the case with NHS staff. This independence is crucial to enable open, evidence-based challenge to public bodies2 or other powerful interests—such as multinational corporations— whose actions pose risks to public health. Staff there would be ultimately accountable to the board of Public Health England, via Regional Representatives of the Board, in the same way that staff involved in commissioning would be accountable to the National Commissioning Board. These arrangements would provide comparability of conditions for medical staff and avoid the deleterious consequences of the two-tier career pathway that existed before 1974, and facilitate joint appointments with universities and social enterprises which could be difficult if employees are civil servants. Existing links www.thelancet.com Vol 378 August 6, 2011
Panel: Principles that should underpin a new public health service • Public health advice should be trusted and independent • Public health policies, including those affecting organisational structures, should be based on the best available research and historical evidence • Public health organisations should have access to timely and detailed intelligence about the health of geographically defined populations • Public health organisations should be able, and encouraged, to work across the many sectors (eg, NHS, housing, education, transport) that contribute to the health of the public • Public health policies, and funding for them, should be driven by need to reduce the social gradient in health • Public health’s contribution to all relevant components of the organisation and delivery of health care (eg, needs assessment, service evaluation, advice to commissioners, etc) should be strengthened by ensuring that public health professionals work within the NHS, in commissioning and provider organisations • Public health policies should be embedded in a responsibility–monitoring– accountability framework • The public health system should be sufficiently attractive to recruit and retain high-quality staff • Public health organisations should be large enough to achieve critical mass • Public health organisations should be flexible and able to respond to crises wherever they arise • The process of moving to any new structure should minimise disruption at a time of widespread societal change and economic challenge • Public health practice should be equitable, empowering, fair, and inclusive NHS=National Health Service.
between the NHS, the Health Protection Agency, universities, and local government work well, and will be essential for the functioning of the proposed national School of Public Health.3 Furthermore, these arrangements would overcome some of the problems that can arise when Directors of Public Health are jointly accountable to local and central governments of different parties. As with the White Paper, our proposal envisages that Public Health England would be organised at national, subnational, and local levels, but be built on existing structures and with clearer lines of accountability than in the current proposals. The national level would have close links to the UK’s National Institute of Health and Clinical Excellence, in view of that institute’s role in producing evidence-based public health guidance (which should be strengthened, not halted17). The national component would include the Health Protection Agency, and recognise that health protection underwent a major review less than a decade ago.18 These arrangements would enable the Health Protection Agency to continue its trading activities. The national component would work closely with the Department of Health, supporting cross-governmental activity to narrow health inequalities—with use of the full range of activities proposed in the Marmot report19 and not just the narrow individualised focus on “nudge” now envisaged.20 537
Viewpoint
White Paper model
Alternative model
Independence of public health workforce to act as advocates of the health of the population
Compromised in the national Public Health Service as part of the Department of Health; at risk in local authorities
Workforce in an independent Public Health England remains free from day-to-day party political influence, retaining and enhancing public trust in its role as an unbiased advocate for the population’s health
Unity of the public health workforce
Threatened by a fragmented structure: sections of the workforce moving to the Public Health Service, others to local authorities; currently unclear where health-care planning would sit
Maintained through a single comprehensive organisation, integrating most public health specialist areas—a “unified, effective and efficient public health service”;8 this model offers clearer opportunities for reducing duplication and increased cost-effectiveness
Ring-fenced budget
Most of the health improvement element held in local authorities, all now subject to substantial financial constraint; risk of other local authority activity being re-designated as public health; if the ring-fence is removed, public health budgets might be decimated
Budget will be truly ring-fenced, held centrally by Public Health England with resource deployed to Directors of Public Health as local leaders for health improvement; maintains scope to pool budgets and to weight allocations by need
Location of staff
Staff distributed between Department of Health Public Health Service, local authorities, and NHS commissioners; loss of critical mass, cross-fertilisation, and efficiencies of scale
Staff working at national and subnational level; staff would be seconded to local authorities to work in arrangements defined in the draft legislation, with local communities and new local structures, including Health and Well-Being Boards and Commissioning Consortia; this sub-national oversight of local designation would have inbuilt flexibility to allow responsive allocation of staff “as needs arise and change”8
Specialist recruitment and training
Currently unclear how proposed changes to medical training will be implemented for public health specialist training
As for White Paper’s proposals but a unified Public Health system would ensure coordinated, varied, and flexible training pathways
Terms and conditions of service for staff
Staff in Public Health England would be civil servants; Directors of Public Health and their teams would be local government employees; specialists employed by commissioners would retain NHS terms and conditions; risk of wide-ranging inequities in Public Health workforce
All public health staff maintained under NHS terms and conditions, so minimising disruption and sustaining equity for medical staff
NHS=National Health Service.
Table: Comparison between White Paper and alternative model
The subnational tier would draw on existing structures of the Health Protection Agency and Public Health Observatories, which it would incorporate. Teams employed at this level would be seconded to the third tier, comprising local authorities, Health and Wellbeing Boards (which each upper-tier local authority must establish to provide oversight of health services), and Commissioning Consortia. Strong links between public health and local government are important, with the relations between the Director of Public Health and the local authority being long term, but with the capacity to deploy staff in a flexible and responsive manner. The Director would present an annual public health report to the local authority and would support the existing Joint Strategic Needs Assessments and Joint Health and Well-being Strategies, which the government now envisages becoming the responsibility of the new Health and Wellbeing Boards. Public health teams from this tier would be seconded to Commissioning Consortia to ensure that the health-care quality domain of public health practice supports commissioning. This three-tier structure within one organisation would simplify the current proposals in which flexibility to deploy resources is confined largely to health-protection emergencies. The structure would be able to respond appropriately to problems across the entire range of public health. Those teams seconded to local authorities would provide strategic leadership for public health (consistent with the government’s commitment to localism), but keeping budgets held by Public Health England would secure ring-fencing and thus avoid the risk of asset 538
stripping. Of course, local authorities already provide a range of public health functions, for which they could provide additional funding when the economic climate improves. By retaining control of core public health staff at a subnational level, individuals could be rotated to overcome existing recruitment and retention difficulties. Specifically, this structure would address the problem of sustaining a critical mass of public health expertise in small local authorities. By contrast, the White Paper’s proposals are likely to exacerbate this problem. We recognise that our proposals might reduce the sense of ownership of public health by some local authorities, although such arrangements already work well in many parts of the country. Finally, consistent with the draft legislation, all work led by Public Health England would be bound by an explicit monitoring framework, with clear lines of accountability. This approach will counter any tendency to marginalisation or downgrading of public health priorities, and directly addresses the findings of the Public Accounts Committee about the failure of the Department of Health to meet its healthinequalities target.12
Conclusion The unexpected decision to propose a complete reorganisation of the NHS has already led to disruption to the function of public health in some places, such as in NHS North West London.21 The current proposals will create further disruption that, we believe, can be mitigated—and thus avoid destabilisation at a time of historic change within the NHS. www.thelancet.com Vol 378 August 6, 2011
Viewpoint
The government calls for a public health system that can deliver world-class outcomes. We believe our model is more likely to achieve this goal than the government’s proposal. Importantly, our model is consistent with the core aspects of the government’s draft legislation and its stated principles of enabling public health to fully engage with the work of local authorities and Commissioning Consortia. Our model can secure a strong public health workforce that can attract and retain high-quality graduates, working effectively within the localism agenda, while safeguarding against the threats posed by the government’s proposals to existing and future capacity. Members of the Commons Health Committee, from all main parties, have already expressed concern about the proposed legislation, promising “significant parliamentary scrutiny”.22 We hope that our alternative proposals will assist this process.
7
Contributors MM, LH, and RA drafted the paper, which was revised by all authors.
14
Conflicts of interest MM has advised the Department of Health on aspects of the NHS performance framework. LH was on a placement at the Department of Health from April until October, 2010, and worked with the Public Health Development Unit who are setting up the Public Health Service RR is in part funded by the NIHR UCLH/UCL Comprehensive Biomedical Research Centre. IW is the wife of The Lancet’s Editor, who took no part in the peer review or decision making process for this Viewpoint.
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References 1 The Lancet. The end of our NHS. Lancet 2011; 377: 353. 2 Department of Health. Equity and excellence: liberating the NHS. London: Department of Health, July 20, 2010. http:// www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_117353 (accessed Feb 21, 2011). 3 Department of Health. Healthy lives, health people: our strategy for public health in England. London: Department of Health, Nov 30, 2010. http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_121941 (accessed Feb 21, 2011). 4 UK Parliament. Health and Social Care Bill. London: UK Parliament, Jan 19, 2011. http://www.publications.parliament.uk/ pa/cm201011/cmbills/132/11132.i-v.html (accessed Feb 21, 2011). 5 McKee M, Lang T. Secret government: the Scott report. Links with industry cast doubt on the government’s role in public health. BMJ 1996; 312: 455–56. 6 Casiday R, Cresswell T, Wilson D, Panter-Brick C. A survey of UK parental attitudes to the MMR vaccine and trust in medical authority. Vaccine 2006; 24: 177–84.
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Local Government Group. The health of the public: Local Government Group discussion paper. 2010: http://www.idea.gov.uk/ idk/aio/24240675 (accessed Feb 21, 2011). Department of Health. Health and Social Care Bill 2011: combined impact assessments. Jan 19, 2011. http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsLegislation/ DH_123583 (accessed Feb 21, 2011). Fulop N, Protopsaltis G, King A, Allen P, Hutchings A, Normand C. Changing organisations: a study of the context and processes of mergers of health care providers in England. Soc Sci Med 2005; 60: 119–30. Stuckler D, Basu S, McKee M. Budget crises, health, and social welfare programmes. BMJ 2010; 341: 77–79. Appleby J. Does poor health justify NHS reform? BMJ 2011; 342: 310–11. House of Commons Committee of Public Accounts. Tackling inequalities in life expectancy in areas with the worst health and deprivation. July 2, 2010. http://www.nao.org.uk/publications/1011/ health_inequalities.aspx (accessed Feb 21, 2011). Sims M, Maxwell R, Bauld L, Gilmore A. Short term impact of smoke-free legislation in England: retrospective analysis of hospital admissions in myocardial infarction. BMJ 2010; 340: c2161. Campbell H, Borrow R, Salisbury D, Miller E. Meningococcal C conjugate vaccine: the experience in England and Wales. Vaccine 2009; 27 (suppl 2): B20–29. Maguire H, Fraser G, Croft J, et al. Assessing public health risk in the London polonium-210 incident, 2006. Public Health 2010; 124: 313–18. Haroun D, Harper C, Wood L, Nelson M. The impact of the food-based and nutrient-based standards on lunchtime food and drink provision and consumption in primary schools in England. Public Health Nutr 2010: 14: 209–18. Kmietowicz Z. NICE is told to halt work on 19 public health topics. BMJ 2010; 341: c7306. Department of Health. Getting ahead of the curve: a strategy for combating infectious diseases (including other aspects of health protection). Jan 10, 2002. http://www.dh.gov.uk/en/Publicationsand statistics/Publications/PublicationsPolicyAndGuidance/DH_4007697 (accessed Feb 21, 2011). Marmot M. Strategic review of health inequalities in England post 2010. Fair society, healthy lives—the Marmot review. Feb 11, 2010. http://www.marmotreview.org/AssetLibrary/pdfs/Reports/ FairSocietyHealthyLives.pdf (accessed Feb 21, 2011). Bonell C, McKee M, Fletcher A, Haines A, Wilkinson P. Nudge smudge: UK Government misrepresents “nudge”. Lancet 2011; published online Jan 16. DOI:10.1016/S0140-6736(11)60063-9. Wikinson A. Alarm at ‘back door’ public health cuts. BMA News Jan 5, 2011. http://web.bma.org.uk/nrezine.nsf/wd/ BSKN-8CTFPX?OpenDocument&C=8+January+2011 (accessed Feb 21, 2011). Wintour P. NHS cuts: scale of shakeup took No 10 by surprise. http://www.guardian.co.uk/society/2011/jan/19/nhs-cuts-scaleshakeup-surprise (accessed Jan 20, 2011).
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Public health in England: an option for the way forward? Martin McKee, Louise Hurst, Robert W Aldridge, Rosalind Raine, Jennifer S Mindell, Ingrid Wolfe, Walter W Holland Lancet 2011; 378: 536–39 Published Online February 28, 2011 DOI:10.1016/S01406736(11)60241-9 See Comment page 468 European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London, UK (Prof M McKee DSc, I Wolfe MSc); Department of Epidemiology & Public Health, University College London, London, UK (L Hurst MSc, R W Aldridge MSc, Prof R Raine PhD, J S Mindell PhD); and LSE Health, London School of Economics and Political Science, London, UK (Prof W W Holland MD) Correspondence to: Prof Martin McKee, European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London WC1H 9SH, UK [email protected]
Introduction It was clear as soon as it was announced that UK Health Secretary Andrew Lansley’s unexpected decision to subject the National Health Service (NHS) in England to revolutionary change1 would have profound consequences for public health.2 The White Paper, Healthy lives, healthy people,3 proposes that the public health function currently based in Primary Care Trusts be fragmented (figure). Some elements will move to the Department of Health, to a division called Public Health England, while others will move into local government. Health-care planning elements might move to proposed Commissioning Consortia and the NHS Commissioning Board, although this is not explicit.4
The problems with the current proposals First, placing Public Health England within the Department of Health sits uneasily with the claim to be “liberating the NHS...from political control”,2 and will strip those transferred of their independent voice as advocates for the health of the population. Independent public health advice is crucial to build public trust. It has taken many years for public health professionals to regain that trust after the bovine spongiform encephalopathy affair,5 and as illustrated by the government’s difficulty in convincing many parents of the safety of the measles–mumps–rubella vaccine.6 Second, the decision to divide the public health function between the Department of Health and local government will fragment the workforce rather than create a “uniting
Department of Health
Public health budget
Public Health England (within Department of Health)
Public health grant
NHS budget
Funds to commission specific public health services
NHS commissioning architecture (Commissioning Board and Consortia)
GPs Providers
Local Authorities
force”.2 It also clouds accountability because the Secretary of State retains wide-ranging powers to “require a local authority to exercise any of the public health functions of the Secretary of State (relating to the protection of the public in the authority’s area) by taking such steps as may be prescribed”.3 Third, although public health budgets transferred to local government are ring-fenced, it is already clear that cash-strapped local authorities might redesignate many of their existing activities as public health, citing the slogan “public health is everyone’s business” in a way that was never contemplated. The Local Government Group recently published a briefing paper arguing against ring-fencing and forced transfer of staff from Primary Care Trusts.7 While the Secretary of State retains powers to address this point, the resources required to maintain scrutiny are lacking. Moving local public health functions outside the NHS risks them being overlooked to a much greater extent than when they were within the NHS,8 and—crucially— local government is not gaining any of the additional regulatory powers it would need to address the determinants of population health. Fourth, even if Directors of Public Health have sufficient status and political support locally, those employed by small local authorities, as in London, will have inadequate technical support to function effectively. Suggestions that senior staff be pooled among neighbouring authorities might work where authorities have the same political complexion, but this situation will be rare and vulnerable to changes in political control. It also adds to the blurring of accountability. Fifth, the proposals include absorption of the Health Protection Agency, currently an arms-length body, into the Department of Health. As well as loss of independence, this move creates practical difficulties such as those that arise from the substantial trading activities of the Health Protection Agency (eg, microbiological testing under contract that sustains highly specialist capacity). The suggestion has been made that these difficulties could be overcome by hiving off these activities,8 but any arrangements that would be compatible with European Union competition law could result in loss of crucial expertise within the Health Protection Agency. Finally, the scale of disruption risks loss of substantial expertise.9 Minimising such disruption is essential to maximise performance in this time of austerity, when a strong public health function is needed more than ever.10
Health and Wellbeing Boards
Building on achievement Figure: Government proposals for the public health function in England Blue arrows=funding flows; red arrows=cross-membership of boards. NHS=National Health Service. GPs=general practitioners. 3
536
It is essential not to lose sight of the enormous achievements of public health in England in the past decade. The government justifies its reforms by citing www.thelancet.com Vol 378 August 6, 2011
Viewpoint
what it sees as past failures. Its criticisms levelled at the NHS have been discredited,11 while those of public health for failing to narrow health inequalities are better laid at the door of the Treasury and the Department of Health, as noted by the Public Accounts Committee.12 Coalition ministers have said less about: the implementation of smoke-free legislation, initially opposed by ministers in the previous government, which is already associated with fewer hospital admissions for myocardial infarction;13 the successful introduction of new immunisation programmes, such as meningococcal serogroup C conjugate vaccine;14 the successful management of complex public health emergencies;15 and improvements in children’s diets through the reintroduction of nutritional standards in schools.16
Principles for moving forward We suggest an alternative that addresses many of the problems with the current proposals. First, however, we enunciate the principles that any solution should include (panel), drawing on lessons from the system in place in the UK before 1974—when public health doctors were based in local government—and the experience of other countries.
Practical proposals We propose a model that would minimise the extent of disruption to the public health function and would result in much less fragmentation and professional isolation of the workforce. In this proposal, the existing NHS-based public health workforce would be identified and transferred to a new body, which could still be called Public Health England. This body would ideally be within the NHS (as a special health authority) or else be an arm’s-length body sponsored by—but not part of—the Department of Health. This positioning would give Public Health England independence that it would lack within the Department of Health. We compare the White Paper’s proposals with our alternative in the table. Individual staff of Public Health England would also (in addition to the organisation as a whole) retain considerable independence, as is currently the case with NHS staff. This independence is crucial to enable open, evidence-based challenge to public bodies2 or other powerful interests—such as multinational corporations— whose actions pose risks to public health. Staff there would be ultimately accountable to the board of Public Health England, via Regional Representatives of the Board, in the same way that staff involved in commissioning would be accountable to the National Commissioning Board. These arrangements would provide comparability of conditions for medical staff and avoid the deleterious consequences of the two-tier career pathway that existed before 1974, and facilitate joint appointments with universities and social enterprises which could be difficult if employees are civil servants. Existing links www.thelancet.com Vol 378 August 6, 2011
Panel: Principles that should underpin a new public health service • Public health advice should be trusted and independent • Public health policies, including those affecting organisational structures, should be based on the best available research and historical evidence • Public health organisations should have access to timely and detailed intelligence about the health of geographically defined populations • Public health organisations should be able, and encouraged, to work across the many sectors (eg, NHS, housing, education, transport) that contribute to the health of the public • Public health policies, and funding for them, should be driven by need to reduce the social gradient in health • Public health’s contribution to all relevant components of the organisation and delivery of health care (eg, needs assessment, service evaluation, advice to commissioners, etc) should be strengthened by ensuring that public health professionals work within the NHS, in commissioning and provider organisations • Public health policies should be embedded in a responsibility–monitoring– accountability framework • The public health system should be sufficiently attractive to recruit and retain high-quality staff • Public health organisations should be large enough to achieve critical mass • Public health organisations should be flexible and able to respond to crises wherever they arise • The process of moving to any new structure should minimise disruption at a time of widespread societal change and economic challenge • Public health practice should be equitable, empowering, fair, and inclusive NHS=National Health Service.
between the NHS, the Health Protection Agency, universities, and local government work well, and will be essential for the functioning of the proposed national School of Public Health.3 Furthermore, these arrangements would overcome some of the problems that can arise when Directors of Public Health are jointly accountable to local and central governments of different parties. As with the White Paper, our proposal envisages that Public Health England would be organised at national, subnational, and local levels, but be built on existing structures and with clearer lines of accountability than in the current proposals. The national level would have close links to the UK’s National Institute of Health and Clinical Excellence, in view of that institute’s role in producing evidence-based public health guidance (which should be strengthened, not halted17). The national component would include the Health Protection Agency, and recognise that health protection underwent a major review less than a decade ago.18 These arrangements would enable the Health Protection Agency to continue its trading activities. The national component would work closely with the Department of Health, supporting cross-governmental activity to narrow health inequalities—with use of the full range of activities proposed in the Marmot report19 and not just the narrow individualised focus on “nudge” now envisaged.20 537
Viewpoint
White Paper model
Alternative model
Independence of public health workforce to act as advocates of the health of the population
Compromised in the national Public Health Service as part of the Department of Health; at risk in local authorities
Workforce in an independent Public Health England remains free from day-to-day party political influence, retaining and enhancing public trust in its role as an unbiased advocate for the population’s health
Unity of the public health workforce
Threatened by a fragmented structure: sections of the workforce moving to the Public Health Service, others to local authorities; currently unclear where health-care planning would sit
Maintained through a single comprehensive organisation, integrating most public health specialist areas—a “unified, effective and efficient public health service”;8 this model offers clearer opportunities for reducing duplication and increased cost-effectiveness
Ring-fenced budget
Most of the health improvement element held in local authorities, all now subject to substantial financial constraint; risk of other local authority activity being re-designated as public health; if the ring-fence is removed, public health budgets might be decimated
Budget will be truly ring-fenced, held centrally by Public Health England with resource deployed to Directors of Public Health as local leaders for health improvement; maintains scope to pool budgets and to weight allocations by need
Location of staff
Staff distributed between Department of Health Public Health Service, local authorities, and NHS commissioners; loss of critical mass, cross-fertilisation, and efficiencies of scale
Staff working at national and subnational level; staff would be seconded to local authorities to work in arrangements defined in the draft legislation, with local communities and new local structures, including Health and Well-Being Boards and Commissioning Consortia; this sub-national oversight of local designation would have inbuilt flexibility to allow responsive allocation of staff “as needs arise and change”8
Specialist recruitment and training
Currently unclear how proposed changes to medical training will be implemented for public health specialist training
As for White Paper’s proposals but a unified Public Health system would ensure coordinated, varied, and flexible training pathways
Terms and conditions of service for staff
Staff in Public Health England would be civil servants; Directors of Public Health and their teams would be local government employees; specialists employed by commissioners would retain NHS terms and conditions; risk of wide-ranging inequities in Public Health workforce
All public health staff maintained under NHS terms and conditions, so minimising disruption and sustaining equity for medical staff
NHS=National Health Service.
Table: Comparison between White Paper and alternative model
The subnational tier would draw on existing structures of the Health Protection Agency and Public Health Observatories, which it would incorporate. Teams employed at this level would be seconded to the third tier, comprising local authorities, Health and Wellbeing Boards (which each upper-tier local authority must establish to provide oversight of health services), and Commissioning Consortia. Strong links between public health and local government are important, with the relations between the Director of Public Health and the local authority being long term, but with the capacity to deploy staff in a flexible and responsive manner. The Director would present an annual public health report to the local authority and would support the existing Joint Strategic Needs Assessments and Joint Health and Well-being Strategies, which the government now envisages becoming the responsibility of the new Health and Wellbeing Boards. Public health teams from this tier would be seconded to Commissioning Consortia to ensure that the health-care quality domain of public health practice supports commissioning. This three-tier structure within one organisation would simplify the current proposals in which flexibility to deploy resources is confined largely to health-protection emergencies. The structure would be able to respond appropriately to problems across the entire range of public health. Those teams seconded to local authorities would provide strategic leadership for public health (consistent with the government’s commitment to localism), but keeping budgets held by Public Health England would secure ring-fencing and thus avoid the risk of asset 538
stripping. Of course, local authorities already provide a range of public health functions, for which they could provide additional funding when the economic climate improves. By retaining control of core public health staff at a subnational level, individuals could be rotated to overcome existing recruitment and retention difficulties. Specifically, this structure would address the problem of sustaining a critical mass of public health expertise in small local authorities. By contrast, the White Paper’s proposals are likely to exacerbate this problem. We recognise that our proposals might reduce the sense of ownership of public health by some local authorities, although such arrangements already work well in many parts of the country. Finally, consistent with the draft legislation, all work led by Public Health England would be bound by an explicit monitoring framework, with clear lines of accountability. This approach will counter any tendency to marginalisation or downgrading of public health priorities, and directly addresses the findings of the Public Accounts Committee about the failure of the Department of Health to meet its healthinequalities target.12
Conclusion The unexpected decision to propose a complete reorganisation of the NHS has already led to disruption to the function of public health in some places, such as in NHS North West London.21 The current proposals will create further disruption that, we believe, can be mitigated—and thus avoid destabilisation at a time of historic change within the NHS. www.thelancet.com Vol 378 August 6, 2011
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The government calls for a public health system that can deliver world-class outcomes. We believe our model is more likely to achieve this goal than the government’s proposal. Importantly, our model is consistent with the core aspects of the government’s draft legislation and its stated principles of enabling public health to fully engage with the work of local authorities and Commissioning Consortia. Our model can secure a strong public health workforce that can attract and retain high-quality graduates, working effectively within the localism agenda, while safeguarding against the threats posed by the government’s proposals to existing and future capacity. Members of the Commons Health Committee, from all main parties, have already expressed concern about the proposed legislation, promising “significant parliamentary scrutiny”.22 We hope that our alternative proposals will assist this process.
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Contributors MM, LH, and RA drafted the paper, which was revised by all authors.
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Conflicts of interest MM has advised the Department of Health on aspects of the NHS performance framework. LH was on a placement at the Department of Health from April until October, 2010, and worked with the Public Health Development Unit who are setting up the Public Health Service RR is in part funded by the NIHR UCLH/UCL Comprehensive Biomedical Research Centre. IW is the wife of The Lancet’s Editor, who took no part in the peer review or decision making process for this Viewpoint.
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