Select Committee on Health Appendices to the Minutes of Evidence


Further supplementary memorandum by the United Kingdom Public Health Association (PH 23B)


  The UKPHA, as a multidisciplinary, cross-organisational non-governmental association, has members in all four nations of the UK and is involved in the development of policy and the new public health initiatives. We therefore think that much can be gained from a UK-wide perspective.

  To the meaning of "function" we interpret this to mean public health interventions and professional involvements in the fullest sense. These range from the specialist professions, encompassing the work of Directors of Public Health and Health Promotion Departments in health authorities to Directorates of Environmental Health (the names of environmental health departments, and their management arrangements, vary) within local authorities to partnership arrangements, for example involving Health For All, Health Action Zones, and more recently HIMPs. Casting the new wider public health "functions" are also undertaken by numerous professions, groups and organisations, ranging from, to take the example of drugs, alcohol and tobacco, from members of Drug Action Teams to Customs and Excise staff.

  At present there are reviews being undertaken, such as that by Healthworks, in order to develop a fuller picture of roles and functions in public health. Additionally, many of our member organisations have themselves been reviewing their own role and that of their members. These include, for example, the Royal College of Nursing, the Community Practitioners and Health Visitors Association and the Faculty of Public Health Medicine. This is a development area, therefore, and it may require some period of stability before comments can be realistically made on how these changes are impacting in practice. Nevertheless, it can be said that in part change is occurring because there is dissatisfaction with the fragmentation of role and function and lack of clarity about objectives. What is clear is that public health is not one profession but many, and it embraces a multiplicity of skills and knowledge bases.

  Turning to the UK side of this question, there are differences in law and custom and practice throughout the UK, and, as a consequence of devolution, different national public health strategies, variations in emerging institutional form, and differences in professional emphasis and/or strategies for involving communities.

  This situation is historic and reflects the contours of national difference within overall UK structures (eg, the first public health legislation in Scotland fell under the Police Act and in England and Wales is primarily associated with the first Public Health Act (1848). Recent devolution has brought other changes, including four separate public health strategies (with the NI strategy one of first off but last to be completed). On the other hand developments in the UK are also influenced by a mix of international trends and recent, and potentially unifying, national concerns. For example, the formation of the Food Standards Agency, which is mirrored in eight other countries of the EU and by the formation of a Europe-wide body.

  One of the recently observed differences between England and Scotland and Wales is that England has established the Health Development Agency and national observatories. There is no observatory in Scotland and this function is likely to be assumed by the new Public Health Institute. In Wales a new initiative is also being formed and there Local Health Groups have been formed with coterminous health and local authorities, a situation which is not only lacking in England but is manifoldly confused and confusing. There are outstanding questions over which organisations in Wales and Scotland (and NI) would assume the new functions being undertaken by the English Health Development Agency. In Northern Ireland there are cross-border links being established through the Public Health Institute, based in Dublin, part of the Royal College of Physicians. There are regular meetings between UK health ministers and between civil servants in each of the departments of health.

  These comments only scratch the surface and the full picture is complex and shifting; moreover, it is likely to continue along this path in the immediate future. We think that there is value in mapping these developments and reporting upon them. This requires a concentrated period of research which is beyond the time scale of this response which potentially engages a large number of institutions and organisations. This may be a matter on which the House of Commons Health Select Committee might like to formulate recommendations and certainly this is a task towards which the UKPHA is well-placed to be involved.

  The UKPHA believes that the following factors might be addressed by such a review.

Unifying or common themes, institutions and practices

  These might include, for example:

    —  similarities between national public health strategies (objectives, goals, targets, practices) and by implication where they diverge; and

    —  UK-wide professional structures.

Dissimilarities in themes, institutions and practices

    —  variance by governmental structure (the Committee is already examining the combined health and social services structures of NI);

    —  variance by institutional purpose (eg the formation of HDA in England versus the continuance of, for example, the Northern Ireland Health Promotion or the Health Education Board for Scotland;

    —  variations in law, governance, geographic boundaries and responsibilities; and

    —  variations in developing professional practice (eg resulting from tradition and culture or more recent changes, such as recommendations on specialist professional practice).

Evidence on effectiveness

    —  some of the organisations, institutions and practices are very new, however, many are not and organisational reviews may be available; and

    —  the development of the new role assumed by the HDA or other organisations defined on a UK-wide basis.

Opportunities for collaboration, cross-fertilisation and information sharing

    —  there is an opportunity to document exemplary practice from variations across the UK, mindful of differences in traditional and culture which may limit such transfers;

    —  information sharing across "borders" and from central to local, is made much easier by new technologies, as some already by health and public health websites, NHSOnline, Electronic Library for Health, etc. The UK as a whole may benefit from a unifying internet "health portal"—as proposed by the UKPHA.

Subnational differences

    —  England contains 83 per cent of the UK population and it would not be surprising if regional variations were not considerable. There is already the emergence of new more regionally-identified public health arrangements and networks (in particular in London).


1.   Would a split between the public health medicine function and the broader public health function make public health more manageable?

  We acknowledge that there are different views on how to establish better integration and resolve issues of scope. In one sense there already is a split, in that public health medicine is a highly distinct island in the ocean of multidisciplinary/multi-agency public health. There is, however, a need for greater clarity in the light of the fact that PHM is a professional discipline, a branch of medicine, and a function, or more correctly part of a function, since, in the broader perspective this is carried out also outside the NHS, for example through environmental health departments.

  We support the development of better integration on a multi-disciplinary, and cross-organisational model. This would have implications for the "location" of the public health function within Health Authorities/Boards, the links between non-medical specialisms and agencies, and general leadership, support for, the broader public health agenda. On the matter of public health medicine, a key consideration here is the changes in the size and role of Health Authorities. Only a decade ago many of these served populations of as little as 100,000. Now many serve over 500,000. This means that DPHs can have far larger teams of experts immediately to hand, in addition to resources such as the internet.

  To summarise, we think that there should be an exploration of different models of management and location, clarification of the scope of the public health function—into perhaps its medical and non-medical elements, and clarification of the role of public health medicine as one part of the full picture of the public health function. Clarification, we hope, will lead to better integration and more effective joint working, and not further fragmentation.

2.   In your opinion, does the Director of Public Health have to be medically qualified or is it sufficient for medical expertise to be available to put it colloquially, do doctors have to be "on top" or "on tap"?

  There is no need for the Director of Public Health to be medically qualified, any more than would be the case for a Director of Social Services to have a social work qualification. It is essential that the Director of Public Health has sufficient skills and experience to meet the demands of the task and that a range of skills are available, including medical expertise, social science, statistics, etc.

3.   What skills does a modern Director of Public Health need? Are these different from their predecessors in the past? If so in what ways?

  The most effective DPHs in the past were those who had offered foresight, judgement, the ability to work with politicians, the skills to bring to bear on deep-seated problems, etc; hence there is little reason for the desirable range of skills to be any different. We also have to acknowledge that we are living now in a post-deferential society with more emphasis on communication and participation. In addition to technical skills, therefore are political, presentation and communication skills and a work environment that requires a strong inclination towards multi-disciplinary and cross-organisational working. Therefore, there is a need for DPHs' skills to change in order to take all these factors into account. Additionally, there are other issues of scale and scope:

    —  the enlarged populations they serve;

    —  the far fuller multi-agency public health agenda they, and their HAs, are encouraged or required to participate in (HIMPs, HAZs, etc);

    —  the far closer integration of public health and other policy domains; and

    —  "joined up thinking" (in relation to poverty, pollution, lifestyle choices).

4.   Does the Association consider there to be a tension between the core business of public health much of the management workload of DPHs? Is there a risk of the urgent always driving out the important?

  We are not sure if this question is intended for the UKPHA.

5.   Are Directors of Public Health appropriately trained for their job? Are there any skills deficits? If so how might these be filled?

  Unless a full research programme is carried out the answer to this question would be anecdotal. The answer is probably for some, but the real question is the level of support for multidisciplinary working.

6.   Is there a general skills deficit in public health, and if so who, apart from health professionals, if so how should we be training?

  Yes, in individuals but no, not if the multidisciplinary team is the model. The arrangements should cover training for everyone but health professions but should be training all the obvious skills—along with input from social scientists, geographers, epidemiologists, environmental scientists, community development workers, transport strategists, etc, etc.

  There is a need for a range of levels of training, whose requirements in terms of students' prior education, work experience and role, and the course's study time, and tuition fees, are tailored to identified audiences in all sectors. Qualifications such as MPHs must be just part of this.

December 2000

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