Douglas Noble on the public health white paper

douglas nobleLast week the British Medical Association hosted a listening event for over 200 public health professionals, including representatives from various public health bodies (Faculty of Public Health, Royal Society for Public Health, UK Public Health Association, Chartered Institute for Environmental Health, Association of Directors of Public Health and Royal College of Nursing).  

The impetus for the conference was the release of the recent public health white paper which, while only a consultation document, is likely to result in a major restructuring of the public health service.  

Parliamentary under secretary of state for public health, Anne Milton, opened the conference with a rousing speech in which she said:  “cuts to public health (jobs) should not be happening.”   This was music to the ears of most, if not somewhat hard to believe given the on-going controversy about redundancy of public health specialists in primary care trusts. 

The political rhetoric was impressive, calling for power to be put back to local communities, for decisions for health to be based on intention not instruction, and a determined stance that public health was everyone’s business and everyone’s responsibility.  All seemed well until it was pointed out by one of the delegates that if public health is everyone’s business, then how do we stop everyone getting their hands on the ring-fenced public health budget.  This question encapsulates the fears of the public health profession. 

Laudably, the government appears to be giving a clear, central mandate for public health specialists – independence, ring-fenced budgets and support for a highly skilled professional workforce.  However, in the same breath it is very clear they won’t interfere with the means by which this happens locally – an ideological certainty of the coalition government.  And this is where the journey into tiger country begins. 

On the one hand you could say that public health specialists are being thrown the opportunity of a generation to lead councils, GPs, the NHS and allied sectors in the ways of population health, evidence-based policy and healthcare public health commissioning.  But, is this realistic given that most public health specialists face being transplanted from primary care trusts to local authorities?  An environment where non-public health specialists working on public health agendas already exist?

To complicate matters further, the public health specialist workforce is not tightly defined.  It’s fairly clear who’s an ophthalmic surgeon and who’s not, and there are few employers who would commission the gouging out of cataracts to displaced health service managers, local government hacks, or untested private providers – even if they’re salaries were allegedly lower.  Yet in public health the boundaries are distinctly blurred and legitimate fears exist about how the new GP commissioners will regard (and recognise) the true public health specialist. 

No doubt public health specialists have their work cut out for them to justify their existence and capitalise on the clear support central government has for them.  How they fare amongst the tigers is yet to be seen.

Douglas Noble has worked in surgery, emergency medicine, public health and for WHO. From 2006 to 2008 he was clinical adviser to the chief medical officer for England.