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. CO -ORDINATION
IN DELIVERING PUBLIC
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. ACTION ZONES/HEALTH
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. THE HEALTH
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. PCGS AND
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. ROLE AND
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. ROLE OF
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
to provide epidemiological advice
on the setting of priorities, planning of services and evaluation
to develop and evaluate policy on
prevention health promotion and health education;
to undertake surveillance of non-communicable
to co-ordinate the control of communicable
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. REDUCING HEALTH
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