Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by Dr Andrew Richards

  I understand that the Health Committee is making an enquiry into public health and its organisational arrangements. This letter is to ensure that the Committee is aware that in a number of places some practical action has been taken to move public health closer to local government, with the creation of joint Director of Public Health posts. The first of these was in Solihull, and from 1 January 1999 to 14 March 2000, I held this post. Funding was shared jointly by the Health Authority and by the Solihull Metropolitan Borough Council, which also provided council office accommodation and Chief Officer status to the postholder. A similar post now exists in Wolverhampton, and there is a joint Health Authority/Social Services Director of Public Health in Somerset. These arrangements draw on the practical experience and example of districts like Stockport and Sandwell, where close working has been evolving over a number of years.

  These arrangements recognise the interest that local government has in health improvement and the long history of local government's responsibilities to protect the public health. They follow a trail of logic from public health's historical roots through to "Our Healthier Nation" and the current focus on partnership. These joint appointments are consistent with a wider movement towards greater integration.

  The duty of local government to improve the social, economic and environmental well being of their communities dovetails sweetly with health authorities' responsibility to improve health and reduce health inequalities. It is only an accident of organisational history that these related goals are vested in separate places. Joint DsPH can act as a bridge between the NHS and local government as they begin to pull together to improve the quality of life in their locality.

  Over the last quarter century there has been an emphasis on public health professionals working within the NHS. It is no sin to apply one's skills and knowledge primarily to the needs of one's employer; however, an inevitable but unfortunate consequence has been an attrition of the application of public health in fields beyond the NHS. Paradoxically the major threats to the health of the population are not related to the provision of health services, but to poverty, unemployment, and an unhealthy lifestyle and environment. The location of Directors of Public Health at the heart of the NHS has inevitably pulled them away from, rather than towards, those parts of the wider system that most powerfully influence health. Posts that are not wholly accountable through the NHS might counteract this gradient.

  The experience of such posts is limited both in time and number. These may be the first public health doctors to work directly for local authorities for a quarter of a century and a lot has to be relearned. I believe that while working across local government as well as the NHS adds to a set of responsibilities that is already heroic, it is the right thing to be doing. The Director of Public Health is being pulled in many directions but I believe that the primary duty is to provide leadership across a community for those who seek to improve health and well being. It is irrational that most of the interest, skills and resources to improve public health are outside the NHS while the Director of Public Health is locked into it. Within health authorities some Directors of Public Health have made a substantial contribution towards improving the quality, clinical effectiveness and efficiency of health services. This remains important and no doubt they can do the same for PCTs in the future. But this is simply to use public health skills and knowledge where they are usefully applied rather than where they are best applied.

  The evidence that the current organisational structures for public health are successful in addressing the main public health concerns of today is limited. An ideal solution may not exist but there are strong arguments that Directors of Public Health have to be eased out of the NHS box. Joint posts might help to place the Director of Public Health closer to the centre of the web of responsibilities, budgets, skills, interest and power than can impact on health in their locality. This should help them to provide the necessary leadership for public health at a local level, which governments and health authorities have found difficult to make a priority. I hope that in its deliberations the Committee will wish to consider the place of joint Director of Public Health posts.

5 July 2000

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