Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by the Royal Institute of Public Health and Hygiene and the Society of Public Health (PH 15)


  1.1  The Royal Institute of Public Health and Hygiene and the Society of Public Health is an organisation formed by the merger of two long established voluntary bodies each having an interest in the health of the public. It has its roots in the public health movement of the mid-nineteenth century. It currently works on a broad portfolio of public health issues, particularly food safety and nutrition; occupational health and safety; hygiene in the home and in the skin and hair care occupations. The main activities of the Royal Institute are policy development and education and raising awareness about public health.

  1.2  The Royal Institute is an organisation which promotes inter-agency and multidisciplinary approaches and which gives priority to collaboration with other organisations. It is currently working in partnership with the Faculty of Public Health Medicine and the Multidisciplinary Public Health Forum on a project to develop national standards in specialist public health practice. The project is supported by the NHS Executive and Healthwork UK (from whom progress bulletins can be obtained). The project Advisory Group is chaired by Sir Kenneth Calman and it works in consultation with a broad spectrum of other bodies, including the Royal College of Nursing, the British Medical Association, the Chartered Institute of Environmental Health and the Department of the Environment, Transport and the Regions.

  1.3  The Royal Institute welcomes parliamentary interest in public health and is keen to support the work.


  2.2  In general, co-ordination between health and local authorities has been promoted by the various Action Zone initiatives. Their mutual interest in the public health and their interdependence in its delivery have been reinforced. The Royal Institute would draw the Health Committee's attention to the need for local co-ordination to be mirrored at regional level. At present there is comparatively little evident co-ordination between Regional Development Agencies and the Regional Offices of the NHS Executive, even though it is well recognised that economic development makes a large contribution to public health.

  2.3  However, the Royal Institute wishes to focus on one aspect of co-ordination which has been made more difficult in recent months. This is in the investigation and control of gastrointestinal infections. While the separation of consumer and producer interests, with the creation of the Food Standards Agency (FSA), has been welcomed the responsibility of the Agency for food borne illness represents another fragmentation in central responsibility for human disease. For example, in the event of human E-coli O157 infection having an animal source those responsible for investigation and control have to liaise with MAFF.

  With a water borne source liaison is with the Drinking Water Inspectorate and with a food borne source liaison is with FSA. In a large scale outbreak all three sources are possible simultaneously obliging those responsible locally to liaise with three different central organisations. To the extent that it is human disease that is under consideration the Health Committee might consider this division of responsibilities centrally to cause unnecessary complexity in the handling of acute outbreaks and potential confusion for members of the public. The Royal Institute recommends that the Department of Health be given a co-ordinating responsibility for the investigation and control of all human cases of gastrointestinal infection, no matter what the route of transmission, so that those responsible locally have only one body with which to liaise and so that it is clear to the public which central department holds responsibility.


  3.1  The Royal Institute has welcomed the innovative energy which has underpinned these new approaches and feels that it is right to be dealing with the socio-economic determinants of poor health. It is important for the HAZ and other initiatives to be incorporated into authorities' mainstream work. If they are allowed to remain as "bolt on" extras they will not engage the imagination of all staff and in consequences might fail to be delivered. Therefore HAZ targets need to be included in Health Improvement Programmes so that their performance can be monitored and managed.

  3.2  The Royal Institute has been disappointed to learn that ministers are alleged to be less keen on HAZs because they have not produced immediate improvements in health. We would counsel patience and perseverance. Measurable change in biological parameters takes time and assessment of the benefits derived from HAZs must necessarily be conducted over several years. We are aware of one HAZ where some measurable improvement in population blood pressure has been achieved over two years. For that to produce subsequent improvement in the incidence of and mortality from stroke will take several more years yet. No doubt there are similar examples in other parts of the country.


  4.1  The establishment of a body aimed at developing a sound evidence base for public health is applauded. The Royal Institute hopes that the Agency will work closely with other bodies devoted to relevant science, both at home and overseas. Similarly it will be important for the Agency to work closely with the National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement.


  5.1  Currently, PCGs are committees of health authorities (HAs). As such their public health responsibilities are carried out on behalf of, and with the direct support of the HAs' public health staff. As they become PCTs they will have to discharge a range of public health duties on their own behalf. To help them with this there are suggestions that PCTs (and indeed other NHS Trusts) should include public health expertise at Board level (either executive or non-executive).

  5.2  Unfortunately, it is unlikely that there will be sufficient skilled people to afford such support to all PCTs. Any attempt to place public health expertise in each and every PCT is likely to outstrip the supply of appropriately trained and experienced practitioners and put each practitioner in a position of professional isolation which would militate against good practice. The Royal Institute recommends that public health support to PCTs is drawn from health authorities where sufficient critical mass of public health expertise can be maintained to ensure good practice.

  5.3  The clinical aspects of public health carried out by clinical medical officers will need to be remembered. These are currently usually located with Community Trusts. Some of their responsibilities have been taken over by Consultant Community paediatricians over time but there is still a body of some 2,500 doctors whose skills need to be maintained and replaced through training and education of their successors.


  6.1  In common with many other organisations, the Royal Institute greeted the appointment of a minister with special responsibility for public health warmly. Similarly, the promotion of cross-departmental approaches between Government departments has been welcomed, particularly because a significant proportion of public health matters ie are also the concern of departments beyond the Department of Health (housing, transport, environment and education).

  6.2  The Royal Institute recommends, therefore, that there should be a multidisciplinary, cross-departmental Public Health Advisory Group with a brief to advise ministers and the civil service on the public health promote inter-agency approaches to public health problems and to carry out public health impact assessment of Government policies.


  7.1  This role was propounded in the report, Public Health in England (Cm 289, January 1988). It is set out at paragraph 5.3 et seq. For ease of reference it is paraphrased below:

    —  to provide epidemiological advice on the setting of priorities, planning of services and evaluation of outcomes;

    —  to develop and evaluate policy on prevention health promotion and health education;

    —  to undertake surveillance of non-communicable disease;

    —  to co-ordinate the control of communicable disease;

    —  generally to act as chief medical adviser to the authority;

    —  to prepare an annual report on the health of the population;

    —  to act as spokesperson for the authority on public health matters; and

    —  to provide public health medical advice to local authorities, family practice and other sectors.

  7.2  The Royal Institute believes that this role has stood the test of the last 12 years and is just as appropriate now as it was when first published. We acknowledge, however, that there have been recent changes, heralded in Saving Lives: Our Healthier Nation. This has established that there will be Specialists in Public Health who will not be medically qualified. The fourth, fifth and last bullet points above will need to be reconsidered if and when an authority chooses to appoint a non-medical DPH. The control of communicable disease calls for clinical judgements and some interventions which would be beyond the capacity of a non-medical practitioner. Similarly, the provision of medical advice would exceed the capacity of a non-medical practitioner. No doubt the Health Committee will wish to consider the need for medical advice in support of future DsPH who come from disciplines other than medicine.

  7.3  Some DsPH have experienced some problems. These have stemmed, firstly, from the creation of the NHS internal market with a consequential bias towards purchasing from secondary care services. Although that market has now been abandoned there is a residual bias towards commissioning secondary care services. Given the epidemiological advice of the Director of Public Health (DPH) commissioning can be satisfactorily performed by someone else. Secondly, there has been some deskilling of DsPH in the field of infection control, with the consequence that some of their colleagues (Consultants in Communicable Disease Control) have expressed a wish no longer to be accountable to the DsPH. We believe that this would be a mistake, causing the fragmentation of public health responsibilities within health authorities and, therefore, the Royal Institute recommends that:

    —  consideration is given to the need for medical advice in support of future DsPH who come from disciplines other than medicine; and

    —  medically qualified DsPH be encouraged to revert to the role as set out in 1988.


  8.1  Health authorities (their Boards and staff) are well acquainted with problems of health inequalities and the socio-economic factors which underlie them. Through their HAZ initiatives and Health Improvement Programmes they are working to reduce the inequalities where they can. They are very conscious, however, that most of the factors that influence the inequalities lie outside their direct control. It has been demonstrated vividly, in the past, that the greatest impact comes from employment. The various regeneration programmes are, therefore, very important and give emphasis to the co-ordination at regional and local level referred to above (paragraph 2.2).


  9.1  The Royal Institute has noted the intention of the Health Committee to study alternative models of public health provision. Drawing on the evidence cited by the Committee of Inquiry which produced Public Health in England (cited above, paragraph 7.1) a model which separates the public health function from the rest of the NHS, as existed from 1948 to 1974, is likely to cause confusion and lack of understanding.

  9.2  We are aware that there are proposals for the public health function to be consolidated in a new central body; a Public Health Commission, outwith both the NHS and local authorities. The proponents of this model believe that it will protect public health from the competitive advantage of acute health services when it comes to the apportionment of resources. Those who recall the pre-1974 service do not accept this argument. All public services are always in competition for scarce resources and it would be unnatural for anyone given the responsibility for allocating them to knowingly disadvantage acute services.

  9.3  Another consideration to set alongside any study of alternative provision is the impact of major structural change on public services. Each time such a change takes place there is an outflow of expertise that can be ill afforded. The history of the NHS reorganisations and restructurings since 1974 gives eloquent testimony to this.


  10.1  Communicable disease control was one of the major factors which gave rise to the Committee Inquiry which reported in 1998 (Public Health in England, cited above, paragraph 7.1). Since that time new communicable diseases have emerged (E-coli O157, VCJD/BSE). Diseases that were nascent at the time have become established problems (HIV/AIDS, legionellosis). Several recommendations were made in Public Health in England. Although many have been followed the recommendation to revise the law on communicable disease control is still outstanding. The Department of Health issued a consultation document in 1989. Many people responded but no follow up action has ensued and we still have a situation where both health and local authorities have responsibilities and expectations placed upon them but no-one has a statutory duty to control communicable diseases.

  10.2  We are aware that there is a Communicable Diseases Strategy Group working to the Chief Medical Officer and have some hopes that the situation will be resolved. Nevertheless, it would undoubtedly be helpful if the Health Committee evinced an interest in a topic which is still one of the major concerns at a time when the era of reliance on antibiotics is drawing to a close.

July 2000

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