Written evidence from UK Faculty of Public Health (PHE0020)

 

About the UK Faculty of Public Health

 

The Faculty of Public Health (FPH) is the standard setting body for specialists in public health in the UK. FPH is the professional home for more than 3,300 professionals working in public health. Our members come from a range of professional backgrounds (including clinical, academic and policy) and are employed in a variety of settings, usually working at a strategic or specialist level.

 

FPH is a joint faculty of the three Royal Colleges of Public Health Physicians of the United Kingdom (London, Edinburgh and Glasgow).  In addition, FPH advocates on key public health issues and provides practical information and guidance for public health professionals, aiming to advance the health of the population through three key areas of work: health promotion, health protection and healthcare improvement.

 

Introduction

 

  1. FPH welcomes this opportunity to comment on the Health Committee’s inquiry into Public Health England. FPH looks forward to its ongoing and constructive engagement with Public Health England to help it to realise its mission to protect and improve the nation’s health and reduce health inequalities.

 

  1. FPH sees immense potential for this body, which is dedicated to the public’s health and is enthused by the many opportunities to do things differently and make connections with other parts of the system. In presenting this evidence, FPH seek only to highlight those areas where clarification is needed.

 

Public Health England as Special Health Authority

 

  1. Making Public Health England (PHE) an Executive Agency of the Department of Health (DH) has afforded it some independence. However, FPH remains of the view that the preferable option would have been to have PHE as a NHS organisation with responsibility for all three domains of public health practice, rather than as a civil service body. This would protect the independence of the organisation and maintain the credibility of public health advice.

 

  1. FPH welcomes the decision of PHE to employ public health consultants on NHS Terms and Conditions of Service (Ts&Cs), but is aware of anecdotal evidence from members employed by PHE that adherence to civil service rules and regulations is having an impact on their ability to do their work. Particular concerns have been raised about bureaucracy and the ability to discuss or criticise public health policies in public.

 

  1. FPH is concerned that working for a civil service may impact on the ability of public health consultants to do their work. The imposition of civil service bureaucracy onto previously workable NHS systems is a specific concern.

 

  1. FPH notes that having PHE employ public health consultants on NHS Equivalent Terms and Conditions (Ts&Cs) was vital for the survival of public health medicine. While we acknowledge the efforts that have been made in establishing the PHE Code of Conduct to address outstanding issues between the Civil Service Code and the NHS Medical/Dental Consultant Contract, tensions remain over a doctor’s right to discuss PHE policy in a public forum in their own name.

 

Health Protection

 

  1. While recognising that statutory regulations give Directors of Public Health in the local authority responsibility for provision of information and advice, they have no direct role in response to emergencies, while the specific health protection roles and responsibilities of PHE and the local authority Director of Public Health (DPH) remain unclear. This is clearly unsatisfactory, particularly in relation to incidents and outbreaks – and unsafe.

 

  1. In practice Directors of Public Health find themselves in the frontline of many infection control and chemical incidents. They also commission major services which are likely to be called upon. It is necessary to further clarify who will do what in response to situations and exactly what the Secretary of State’s powers to direct local authorities and Public Health England are in practice.

 

  1. PHE has also decided to change the leadership of the HPU. Currently, each HPU has a Unit Director. Due to the disparity in geographical and population size between PHE’s regional Centres, the number of HPUs in each Centre ranges from one to four. PHE is currently consulting on changes which would mean that there would only be one Unit Director per Centre, whose job title would change to Deputy Director of Health Protection.

 

  1. FPH is concerned that this reform misunderstands the role of the Unit Director, which is the effective running of a world class, but locally rooted, health protection team. As such, this places limitations of scale on the size of the team. It is hard to provide effective professional leadership of the type currently provided by the Unit Directors to a large and geographically diverse team.

 

  1. It also has implications for the size of the area covered, since much of the current role is based on the Unit Directors’ relationships with those external to PHE, especially Directors of Public Health (DsPH) and the NHS. Any amalgamation of Unit Directors into a smaller group with responsibility for a larger area would create a vacuum of both team leadership and local engagement. The consultation makes no reference to how this vacuum could be filled.

 

  1. FPH is concerned that Public Health England emergency responses escalate to other PHE centres and nationally but there is no connection with local authority public health which is particularly important for incident management in emergency situations, (e.g. Buncefield and bird flu) where 24/7 response within the planning group (Local Resilience Forum level) is expected.

 

  1. FPH is concerned by the standard for Public Health England attendance at Strategic Coordinating Groups for emergency situations as within 4 hours – which it views as inadequate.  An opportunity for a joined up response from the local authority and PHE public health specialists at Local Resilience Forum or centre level has been lost. 

 

Public health workforce development

 

  1. In order to fulfil their responsibilities, public health professionals complete a five-year training programme to a high level of competence, giving them the skills to assess local health needs and assets, to undertake epidemiological, statistical and policy analysis and to deliver and evaluate evidence based interventions for health and wellbeing.  These skills are central to the local authority duty to protect and improve the health of local populations.

 

  1. There is therefore a need to maintain equity of esteem between local authorities and PHE NHS posts, and to ensure free movement between organisations. However, while the size of the public health ring-fenced budget was large enough to have allowed all substantive staff to have been transferred to the local authority, this has sometimes not occurred; while there have also been reductions in the terms and conditions of public health staff.

 

  1. Some local authorities have failed to recognise continuity of service, with non-medics not being offered the NHS consultant contract (in contrast to medics) despite previous service within the NHS. This may deter more senior medical consultants from applying from positions since not only would they not have NHS terms and conditions (which they would in PHE), but their salary would be capped significantly below possible PHE/NHS earnings.

 

  1. Data, though incomplete, around applications for posts has begun to show a clear trend towards greater numbers of non-medically qualified specialists applying for LA posts, and greater numbers of medically qualified applying for posts in PHE. Indeed, some LA posts receive no applications from medically qualified specialists at all.

 

  1. If a council advertises and appoints a role at lower than the market rate it potentially undermines the development of a strong specialist workforce within Local Authorities. It is important that the quality of public health advice in local authorities is assured and is at parity with PHE or the NHS, and that this can be assured and public health consultant and DPH posts within the local authority remain an attractive career option.

 

  1. It is therefore essential that comparable terms and conditions are available across the public health system, including (but not exclusively) Public Health England, local authorities and academia if public health is to remain an attractive career option and a two tier public health system is to be avoided.

 

 

Public Health role in clinical commissioning

 

  1. Directors of Public Health and local authority based public health consultants must be allowed to sit on Clinical Commissioning Groups. The anomaly within the National Health Service (Clinical Commissioning Groups) Regulations that stops this ought to be addressed immediately.

 

  1. Within the key priorities for PHE in its first year there is no mention or particular link to health services.  The NHS spends £110 billion on healthcare services, of which much will be a major contribution to health improvement across the population who are ill although this is not at the traditional upstream end. 

 

  1. There is potential for greater improvement if NHS commissioning improves its quality of commissioning but the other key point is that if the NHS doesn't get to grips with priority setting then the ongoing pressure to fund new technologies will not allow the right proportion of investment in upstream health improvement / disease prevention.

 

  1. FPH is concerned that Schedule 5, of the National Health Service (Clinical Commissioning Groups) Regulations 2012 excludes Directors of Public Health and public health consultants within local authorities from sitting on the Board of their local CCG.

 

  1. FPH is concerned about measures which disqualify individuals who have both the public health expertise and local knowledge to make a vital contribution. This needs to be urgently addressed.

 

Data Governance

 

  1. Difficulties caused by the uncertainty over data governance across health system boundaries needs to be addressed as soon as possible. Currently, there are problems over the ownership of data that arises from the NHS but needs to be analysed within PHE.

 

  1. There are also problems around data sharing for commissioning itself.  NHS England has a big gap in getting any patient activity data (for specialised services, which has almost £12 billion worth of funding) that could be used for better long term commissioning strategies or for managing short term risks including financial risks. 

 

  1. The number of information people is very small. Commissioning Support Units are meant to provide information but are remote and not well connected with the day-to-day work. PHE recognises that its Knowledge and Information Teams (KITs) are important but these originate in places like public health observatories and are not used to managing and analysing routine NHS data. 

 

  1. PHE need to take on board that the KITs need to have a wide remit from health services commissioning to health improvement.

 

  1. FPH has concerns about the disruption of data flows across the health service, caused by the removal of public health expertise out of the NHS, and about whether the Health and Social Care Information Centre (HSCIC) has adequately addressed this issue. FPH would like reassurance that public health professionals, including public health academics, Directors of Public Health, and public health commissioning within CCGs, will continue to have access to data that is essential for their function, within a new PHE information governance (IG) framework. 

 

 

A written agreement or memorandum of Understanding with NHS England on Healthcare Public health

 

  1. NHS England is the largest public health budget holder, and has a strong focus on primary care, commissioning and health inequalities. NHS England does not appear to employ any public health consultants within the organisation so it is harder for it to access public health advice easily or to understand what PH is about.  It is of deep and continuing concern that their sole public health input is through seconded staff – this is an inadequate situation.

 

  1. Expert public health input must be embedded in the fabric of NHS England commissioning – including on the Board of the NHS England, and not seen as an optional extra which can “influence‟ on request. Public health skills must be engaged in the entire commissioning process.
  2. In addition, PHE needs a written agreement or memorandum of understanding with NHS England about what it expects to deliver in terms of healthcare public health, which could be both specialised services and something wider, but also needs NHS England to involve PHE in issues that may have a wider impact, such as pathway issues that cross from NHS England into CCGs and local authorities.

 

  1. There is no detailed agreement (at least for healthcare public health, perhaps more for health protection) that clarifies what PHE employees should provide for NHS England.  NHS England appears to not know when to ask for advice or when to include someone with public health expertise to possibly give it a more rounded picture on dealing with some of its issues. 

 

  1. Without a directly employed public health consultant it is difficult to tell NHS England about what they don't know and when to involve public health consultants either for advice or perhaps even more operational support with some of the complex issues.  It is unclear whether the upper levels of PHE entirely understand what healthcare public health is about or why it has its place and is important. 

 

November 2013