Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by East Sussex, Brighton and Hove Health Authority (PH 42)

  1.  This is a submission from East Sussex, Brighton and Hove Health Authority to the Commons Health Select Inquiry into Public Health. We welcome the opportunity to contribute to this inquiry and have structured our comments around the Committee's Terms of Reference.


  This is a complex and evolving area and in some ways it is hard to draw firm conclusions. However, it would be wise to review the effectiveness of these initiatives once they have been evaluated. Not withstanding this observation, it is clear that there is significant commitment from this Government to cross cutting themes and this is welcomed. Such approaches are critical to improving public health and to the delivery of the public health function. They also emphasise the importance of partnerships and collaboration both centrally and locally. However, there is some tension between the Health Improvement Programme and the Community Plan. The Local Government Bill identifies the duties of local authorities to promote the social, economic and environmental well being of their communities—but it is not clear whether the HIMP or the Community Plan is the over-arching plan for any local area. Conflict over this would not be helpful. It would be useful to develop explicit guidance about the relationship between the two plans. Options include a specific section of the Community Plan on health improvement—or to have health improvement as a cross cutting theme within the community plan.


  We welcome and support the Health Development Agency. The development of a clear evidence base for community based public health interventions should lead to both improved public health practice—and as importantly, greater credibility for public health interventions within both the NHS and local government sector. However, there are areas of overlap between the HDA and organisations responsible for standards in public health practice; and these will need to be addressed.


  PCGs and PCTs have clear responsibilities to improve public health—but to do this they will need greater capacity and capability. As a generalisation, they are often committed to public health—but it is not clear whether their understanding of the complexity of the public health function and of public health issues is as developed as it needs to be. At the moment, there is some inevitability to this because of the focus of the NHS on health care. However, it is clear that the PCTs will not be effective public health organisations unless they actively develop their public health capabilities.

  In doing this, the trick is to ensure that all organisations (including PCTs) have effective public health leadership, and that the appropriate level of responsibility goes to each organisation.


  There is no doubt that the status of the Minister for Public Health has decreased over the course of this Government. This is widely seen as a significant problem and echoes the difficulties created because of the absence of national inequalities targets. The development of such targets (which could be created—but which have been avoided to date) and accountability for delivering them linked to the Minister for Public Health would undoubtedly increase both Government and local organisations' attention to major public health issues.


  The role of the DPH is complex in relation to its span, range of skills and the consequences of having a degree of "independence". There is no doubt that the best Directors of Public Health pull this off effectively and exert wide influence in the interests of public health.

  In general, it is helpful to have a clear focus for the public health function and for health improvement—but there is a debate about where this is best placed. The Acheson Report (1988) reached conclusions about creating decent sized public health departments, stopping single handed practice, strengthening communicable disease control teams . . . The principles around these issues remain. Fragmentation would be a problem.

  On the other hand, there is no doubt that there are some advantages in placing the public health function and the Director of Public Health within local authorities. There would be closer organisational links to other key professional groups, and the possibility of a greater impact on local authority policy and actions. Whether the DPH would be more or less effective in an organisation whose policies are determined more by local democratic methods is debatable. Arguments can be constructed either way.

  However, there are distinct disadvantages in moving the function and the DPH to local authorities. These include:

    —  the risk of splitting the current public health function and all the disadvantages that flow from that;

    —  the real difficulty of delivering the public health roles which are intimately related to the NHS. This would be particularly true for work with NHS Trusts. The agenda around effectiveness, efficiency, appropriateness and equity is central to the NHS and requires public health skills; and

    —  the risk of more single handed/isolated practice.

  Perhaps most critically, in a world of partnerships, there is no benefit in going for a structural change because influence and impact can be achieved in other ways. One particular way of achieving this would be to make the DPH a joint appointment between health authorities and local authorities. Doing this would emphasise the links—but it may well be that many current and future DsPH would need a modified sort of training and development from what they currently have. It would also be helpful to think about and develop local public health networks which cut across organisational boundaries to deliver their function.

  It is essential to emphasise the important contribution that the DPH (and the current public health function) makes to the NHS. There is some evidence that it is Directors of Public Health who have kept inequalities on the NHS agenda and have constantly been proponents of the "evidence based medicine" movement. There is no doubt that some of the skills and tasks of Directors of Public Health overlap with those of Medical Directors in NHS Trusts and clinical leaders within PCGs/PCTs, but they inevitably bring a focus on population health and the population impact of health care interventions because of their background. It is hard to see how local NHS policies and services can be developed appropriately without a significant public health input.

  One further important role that DsPH play is that of being the "top doctor" in the local Health Economy. They facilitate change, help deal with difficult issues and broker deals, particularly ones which relate to senior medical staff in NHS Trusts. This is not a strict public health role, but is an important one within the NHS.


  It seems likely that this Government focus on reducing child poverty, the New Deal and strategies on neighbourhood renewal will have an impact on health inequalities. However, it is very hard to know if this is the case because there are no national targets for health inequalities and no national monitoring of them.

  8.  Finally, as with many parts of the public sector, this is a very uncertain time for public health. The arrival of the Health Development Agency, the imminent report from the Chief Medical Officer on the public health function, the development of regional public health development plans and the Department of Health commissioned work on standards for the public health function are all shaping the future, but at this moment, creating uncertainty. It would be helpful to bring these all to a resolution as soon as possible so as to deliver an over-arching framework for public health to allow public health capacity and capability to develop. This would set standards for public health practice and develop appropriate accreditation mechanisms including ones that are relevant to sub specialist areas. It would also create greater clarity for the basis of professional public health practice and for the roles that individual practitioners play.

5 July 2000

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