Responsibility for Public Health provision in England is moving from the NHS to Local Government – “Halleluiah” I hear some say – public health is on its way home – back to where it was located before 1974.
The move is welcomed by many public health professionals. The changes are a move towards greater localism and this will provide an opportunity for public health to work ever closer with colleagues in housing, environment, social services etc. It will also provide an opportunity for some public health programmes to be further tailored to local needs. Yet many of these things are already happening and have been for sometime and are broadly effective. So while the benefits of closer working between traditional local government departments and public health teams are well established what could be the problems created by these organisational changes?
There must be concerns about budget allocations. At a time when all public service budgets are being squeezed it may be convenient for housing departments to reduce funding for elements seen as being ”public health” so placing extra pressure on the core and ring fenced public health budget. The same could be the case with other departments where public health related work is currently undertaken.
But the greatest concern must be the culture change that public health staff will experience once they are fully integrated into their local authority.
One of the keys to successful public health programmes is the professionalism of public health staff. Directors of Public Health and their teams have an array of expert skills that range from epidemiology, environmental assessment and data management to evidence review and health impact assessment. Public health staff are committed to evidence based policy making and a respect for scientific understanding. Together these are skills that enable teams to deliver programmes that are based on the best available evidence.
However, the proposed changes will bring public health under the direct control and influence of local Councillors. This means that, while in other parts of the health service the Secretary of State is attempting to take accountability away from politicians, in public health political accountability is being introduced. In itself this isn’t a bad thing; it is already the case for social care and education and many other vital services. Yet it does expose Public Health to the possibility of emotional and political policy making rather than the more rational approach currently adopted by public health professionals.
When the Director of Public Health presents the Joint Strategic Needs Assessment to the Health & Wellbeing Board with options for action, there will be many opportunities for members of the Board, some of whom will be local Councillors, to block politically unpopular programmes or redirect activity to their own preferred communities. When action to tackle sexually transmitted infection or drug addiction are being considered alongside public health programmes for older people, will there be a moral or political position taken to block schemes and support a vocal and politically significant section of the community instead?
If the status of the Health and Wellbeing Boards is high, then the likelihood of irrational and overly political decisions being made will be reduced. Effective Boards will attract public and media attention and decisions will therefore have to be defended in public. However, if the Boards are seen as uninteresting and ineffectual then they will be poorly attended and ignored by the wider community. Once this happens the voices of minorities rather than the majority could very quickly come to dominate the decision making process.
My hope is that the Health and Wellbeing Boards attract high calibre and motivated members, that they are rational places where expert opinion and evidence are strong influencers. However, local democracy is never that straightforward. There will inevitably be times when the loud voices of a particular community are supported despite evidence to the contrary. That is the case already for many public services and life goes on – let’s hope that the same will be true in the new public health world and that local democracy and accountability will prove to be a force for progressive and effective policy making, rather than narrow minded or reactionary cost cutting.
Dave Roberts is a health specialist and Director and Founder of MorganRoberts, providing strategic advice and practical support to policy makers at all levels.