The Socialist Health Association is a membership organisation, established in 1930, which promotes health and well-being and the eradication of inequalities through the application of socialist principles to society and government. We have an extensive and varied membership which provides a wealth of information, knowledge and experience of the care system, both academic and practical.
We defend Nye Bevan’s original concept of the NHS – a set of socially owned and locally socially accountable organisations. Through these society promotes the health of the people by addressing the determinants of health and by providing health care according to need rather than ability to pay. That concept has been eroded in the numerous reorganisations of the NHS so that some believe that it has been reduced to just the last eleven words.
The concept that the NHS addresses the determinants of health was weakened in 1974 when NHS community services separated from local government. Today we find it hard to remember that it was public initiatives that cleared the slums and cleaned the air. Bevan’s comment that the NHS would improve the health of the people is often taken as a naive faith in the power of health care. In fact local authority health departments were part of Bevan’s original vision, including an occupational health service which never came to pass. That still should remain the objective. Although the model of the NHS adopted in 1974 has now existed for longer than the one adopted in 1948 it is still important to realise what the term “NHS” meant to the founders of the organisation and how, despite its failure to achieve everything that was desired it still achieves the ambition which Bevan described as being ‘freedom from fear’.
The concept that the NHS was locally socially accountable underpinned the role of local authorities, and the composition of hospital management committees and executive councils but was eroded by a succession of managerial reforms in the 1980s and early 1990s. This was done to the point that we now speak of the democratic deficit as if it has always been there. Today the concept that socially owned organisations provide health care is under threat. The fear that arises from current proposals is that the NHS may be destined to be no more than a brand name.
Our evidence to this inquiry focuses on re-establishing the idea that the NHS exists to addresses the determinants of health. As a first point we ask the committee not to remove public health from the concept of the NHS but, if it is to transfer to local authorities, to re-establish the 1948-74 status of local authorities as primarily public health bodies, including the concept that they are part of a locally accountable NHS.
THE NATURE AND STATUS OF PUBLIC HEALTH ENGLAND
It is inappropriate for a civil service body to be responsible for the direct provision of important health services. It should be an NHS body with the right to employ medical consultants and with no restraints on the freedom of staff to speak and publish. It must be seen to be independent.
If we want a single public health structure at national level there is no reason why a part of the Department of Health (DH) should not operate as a single functional entity with an NHS body chaired by the Secretary of State. Indeed ideally the structure would also contain an Office of Public Health Responsibility or Public Health Commission accountable directly to Parliament. This trio of organisations could operate as a single entity and there is no reason to duplicate administrative or support services. It is more a question of finding the right constitutional status for each function. An organisation of this kind would be more integrated than the current structure of the DH which separates Public Health England, the Policy section of DH and the office of the Chief Medical Officer.
THE ROLE OF THE SECRETARY OF STATE
The prime role of the Secretary of State for Health should be to promote the health of the people, representing this social objective in all Government decision-making. The present Secretary of State appears to support this idea.
What should the Secretary of State being doing? Britain faces an alcohol epidemic which has already produced a situation which in many parts of the country means that the generations born since 1970 enjoy worse health to date than did those born in the 1940s, 1950s and 1960s. The Secretary of State should be promoting active travel and policies for healthy active ageing – the most effective way to reduce the burden of health and social care costs of a demographically ageing population. He should be concerned with the pricing of energy for heating, ensuring public health concerns are taken into account on planning applications, enabling walkers and cyclists to be a greater priority on the highway and that streets are used for community interaction, as well as ensuring a realistic minimum price for alcohol to stop people getting drunk cheaply at home and to protect the pub as a community resource. These political determinants of health have more influence on health than anything that can be resolved at local level so it is important to get the structures right. A government committed to a Big Society would boost the role of social networks, oppose the cuts in funding for civil society and articulate a vision of community development to address the health care difficulties about which the Secretary of State frequently reminds us. What will not work is appeals to individual responsibility which ignore the context of commercial irresponsibility which explains so much of the culture of health harm.
The promotion of health is linked to improving economic productivity and there is ample evidence to show that healthy working conditions attract new knowledge-based industries, promote economic activity generally and reduce the health damage from economic dislocation. Disparities between indicators of economic progress and indicators of well being were a sign of the emerging speculative bubble (WATKINS, S (2010) “Income and Health – from a Minimum Wage to a Citizen Income?” Int J Management Concepts and Philosophy vol 4 no 2 pp137-144). The work of Martin McKee suggests that a strengthened civil society was the best protector against the alcohol epidemics in Eastern Europe and the work of Wilkinson and Picket suggest that inequality is itself a prominent cause of ill health.
The principle should be articulated that the health of the workforce and the health of householders are paramount. The problem of the current system is bureaucratisation and low morale.
Instead of addressing these issues the current Secretary of Sate spends his energy in reorganising, yet again, the National Health Service – based upon speculative and wishful thinking about the results. He has ignored every single piece of advice, except that offered by organisations and individuals who seek to enhance their self interest.
We welcome the Government’s recognition that social responsibility of business is important to health but responsibility deals are unlikely to work unless they are negotiated against the background of an underlying willingness to regulate. These measures should be independently evaluated and evidence-based. At present they lack both. The risk is that they are simply efforts to divert attention away from the problem; in effect a delaying tactic.
It was a Conservative, Benjamin Disraeli, following Cicero, who said “the health of the people is the first concern of Government”. We approve of this type of Conservative thinking. That is to say conserving health. This is a tradition of obligation found among socially-responsible Conservatives which appears to have been sidelined. What we have instead is economic liberalism whereby human values are reduced to economic valuations alone. The agenda we describe has still not become the main way of thinking about health of any part of the political spectrum.
THE DIRECTOR OF PUBLIC HEALTH AS A HEALTH PROFESSIONAL TREATING A POPULATION
The Bill defines a DPH as a local government officer overseeing the public health functions transferred from PCTs. The DPH should also be a health professional treating a population, a local representative of Public Health England and an independent advocate for health operating across all agencies and also within the business and voluntary sectors. It is important that public health specialists continue to be seen by the public as health professionals offering them honest and trusted advice and that they continue to have a right of challenge on a multi-agency basis. For this reason they have always had guarantees of professional independence – the Medical Officer of Health was protected from dismissal for exercising their professional independence and in the NHS they have worked under the consultant contract in an atmosphere where there are acknowledged traditions balancing managerial authority and professionalism.
Whilst the best local authorities recognise this, there is a danger that if it is left to local discretion public health will be muzzled in the areas where effective public health challenge is most needed. In the nineteenth century many local authorities tried to avoid their responsibilities because they were in thrall to ratepayer interests.
DPHs need to be effectively trained and professionally qualified in order to confront the complex factors which determine health. It is essential DPHs are experienced in the field, drawing upon cross disciplinary and multidisciplinary skills. To that end there needs to be statutory provision on appointments and statutory registration for public health specialists.
HEALTH AND WELL BEING BOARDS
We welcome the Secretary of State’s suggestion that Health and Well Being Boards become the democratic voice in the NHS and regret that he proposes few powers for them and does not envisage transferring to them any part of the NHS managerial resource. They should have powers over providers as well as commissioners.
THE ROLE OF SECOND TIER AUTHORITIES
District councils are close to local communities and have important roles in public health including housing and environmental health. They should not be excluded from the Bill as they currently are.
Public health departments in county councils will need to work with district councils and to do this properly they will need to provide each district council with a named public health lead. This will command more ownership if it is a joint appointment. People will need to go out from the county to districts and local communities anyway. The question is about how the workforce should be organised not how big it should be.
There is a view that the designated specialists to district councils should be called “Director of Public Health” to enhance their standing in the district council, the fact that they serve the population of the district, and to emphasise that in that role they will have direct accountabilities to the district population rather than merely representing the county. On the other hand there are those who think that this would be confusing and would lead to expectations that full scale departments would be established. These questions should be openly addressed.
Whatever the role is called it is likely, in all except the largest districts, to be a part time role. Usually it will be combined with a consultant role at county level and this offers professional development opportunities for those aspiring to a full DPH appointment in future as they experience the functioning of a large department but also experience the development of personal relationships and authority in a small local authority. Other possibilities are to appoint somebody who wants to work part time, or to appoint a dually accredited GP/public health physician to work part time in general practice and part time as a consultant in public health.
HEALTH CARE – PUBLIC HEALTH
The subspecialty of health care public health is concerned with optimising the contribution the health care system makes to the health of the people. It is a vital component of NHS commissioning and has received inadequate attention in this process.
It is important that it should remain integrated with the rest of public health and that it should also be fully integral to commissioning bodies. This is only possible if public health professionals continue to serve populations rather than agencies.
It has a role with providers as well as commissioners.
There are significant workplace development needs in public health, partly arising out of the transition to new employers and partly out of shortages resulting from the lower priority past Governments gave to public health.
There is no suggestion that Public Health England will be well-equipped for workforce development roles and Government has not fully engaged with this problem. It seems to see it as a problem to be solved locally but the shortage of specialists will make that difficult to achieve. The risk is that specialists will work in professional isolation and with variable support.
Even if it were believed that the arms length approach to the development of the system may in principle work well in the longer term it would still have seriously disruptive transitional consequences. These could create an irrecoverable situation. In some areas it may be impossible to recruit the needed specialist skills.
Information analysis is another important area of shortfall and the Government is not taking the steps necessary to preserve the skills in the Public Health Observatories, whose existence is being prolonged only by a short term extension with no clear strategy for the longer term. This is a critical matter. There are questions of independence of viewpoint, academic linkages and mix of skills which need to be considered.
Public Health England should take on a workforce development role. This should include reserve powers to ration scarce resources and to apply training levies.
The medical profession is not the only participant in the public health endeavour. Public health is open to non-medical entrants and we welcome the BMA’s acceptance that these are professional colleagues deserving the same standing as medical consultants. There is however a danger that this will simply move the divide from a medical/non-medical divide to a specialist/non-specialist divide in which important groups of public health professionals will be on the wrong side. What is needed is a more flexible career process but this cannot become so flexible that the significance of a qualified public health specialist is lost.
THE ROLE OF COMMUNITY ORGANISERS IN PUBLIC HEALTH
We support the BMA in calling for community organisers to be employed in the public health field. There needs to be detailed discussion of this proposal and especially of its relationship to local government and to the Localism Bill but detailed questions should be resolved so as to make arrangements for this through general practices, NHS bodies, local authorities, parish councils or voluntary organisations according to local interest and commitment of the various potential sectors..
Funding mechanisms need to be discussed and identified but we are aware of BMA calculations which place it at £150m to £200m less than 0.2% of the NHS budget
It is important that the division of the NHS budget into prevention and treatment occurs but that this
does not institutionalise past underspending on prevention
does not precipitate a process of asset-stripping of PCTs
takes proper account of all NHS contributions to public health and doesn’t leave local authorities open to demands for buildings or IT that were not included in the budget or to pay NHS providers for preventive work that was previously accepted as just good professional practice
accounts for the forthcoming expansion of health visiting and family nurse partnership as a charge on the entire NHS budget rather than being a charge on a static public health budget.
similarly accounts for any developments of new national institutions or improved health protection arrangements instead of top slicing them from local budgets
provides a mechanism for using savings on treatment costs (for alcohol related diseases for example) to fund preventive programmes
recognises that small sums for the NHS as a whole can be huge sums for public health – 1% of the NHS budget is 25% of the public health budget – so minor errors in the division can have major impacts on public health
It is also important to be aware that the NHS contribution is only part of the funding of public health.
Public health in England was once thought to be world-class. That was always an optimistic claim but it remains an important ambition. Public health services locally need to be strengthened but there also needs to be a strong iterative relationship between central government and local government. Furthermore action should be taken across the departments of central government in order to secure public health gain as an overriding aim of economic, transport, social security, farming, and other policies. There is a major opportunity to institute sustainable development through public health in ways which reduce transport emissions, boost physical activity, reduce self-destructive patterns of behaviour, and promote sense of local belonging and trust, upon which a collective vision of a healthy society can be based. Essential parts of this vision were shared by Disraeli and Bevan. It is definitely not shared by those who think only in terms of business opportunities and not collective health goals.