Douglas Noble on the fragmentation of public health

douglas nobleTalk to almost any public health specialist and they’ll express their biggest concern about the current NHS reforms in England as fragmentation of the public health service. To understand why fragmentation is a bad thing, we first need to know what it is that could be broken up. 

Public health has traditionally consisted of three main domains of practice. 

Healthcare public health is the nitty gritty of making sure high quality and safe medical services are available, based on the health needs of any given population. As demand always outstrips supply, tough decisions have to be made. In an inner city population with an average age of 35, providing a national average level of incontinence services and dementia clinics is unlikely to be an appropriate use of the healthcare budget. Such communities are more likely to need more antenatal services, baby clinics, and school nurses. The detail involves: health needs assessment; assessing cost effectiveness; and monitoring outcomes. In reality commissioning health services don’t just need GP commissioners. They need a team of GPs, secondary care consultants, and public health specialists, a surprisingly little-thought-of triad for success.  Public Health Specialists working in health services are mostly based in PCTs with instant access to all things NHS. 

Health promotion is into the softer sciences of stopping people smoking, promoting green spaces to reduce obesity levels and curbing the alcohol pandemic. Have you seen advertisements on buses urging you not to binge drink yourself senseless? Or to visit your pharmacist for a “healthcheck” and to quit smoking? Behind it all (somewhere) is a group of public health specialists trying to apply evidence about population health promotion to actual interventions. Public health specialists in these areas currently also work in PCTs, and work very closely with local authorities. 

Health protection monitors all biological, chemical, and other hazards in the UK, and takes action when background rates exceed “normal levels.”  This extends from, say, managing the distribution of chemoprophylaxis for meningitis after several cases on a university campus, through to working with the police and fire brigade to determine if a fire of unknown cause presents a toxic threat to local residents (and if so arranging appropriate decontamination and hospital capacity). Public health specialists in health protection work almost entirely within the independent Health Protection Agency (HPA). 

It currently all works, almost. And if “the pause” doesn’t end, food handlers with Shigella will continue to be excluded from work, obese children will be nudged into healthier choices at school, and health services based on evidence of health need will be commissioned. 

So what is being proposed that raises the pulse rate of public health specialists? 

Here’s the worst case scenario from the white paper, health bill, and a bit of reading between the lines on the reasons for “the pause.” 

Firstly, health promotion and healthcare public health specialists are moving wholesale into local authorities. They won’t be NHS employees, they won’t have a seat around the top table, and directors of public health will report into adult and social services. The ring fenced budget for public health will be controlled by council chiefs.  Employees of the council who currently wear a public health badge (perhaps because they work in alcohol licensing for example) will claim public health specialist status without any of the training or accreditation. The director of public health will lose independence, will be constrained by local politicians on his annual report on the state of public health, and will struggle to influence health services at all because they’re not part of the NHS anymore. 

Secondly, health protection public health specialists will be moved into central government to a new body called Public Health England. Politicians will exert influence directly over disease control and reporting of threats to human health.  Funding will dry up as the grants the HPA can obtain are not available to central government bodies. 

All this will result in the undermining of an entire historic and effective speciality and doctors will lose interest in influencing public health. 

So when you hear a public health specialist say they are concerned about fragmentation, it’s not really fragmentation they mean so much as the obliteration of an entire profession. 

Let’s hope “the pause” lasts a long time.

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.