Public Health in Local Authorities: One year on (Alan Page 14.04.14)

April 1st saw the first anniversary of the reintegration of public health back into local authorities. There was concern expressed prior to the move from sections of the media (Hetherington 2012) and inevitable concerns from those within the Public Health units of the NHS about the future.

So where are we 12 months on?  Well the answer is mixed. There is concern expressed in a report by the Royal Society of Public Health (2014) that over half (52% of Directors of Public Health, public health consultants/specialists and health improvement practitioners) are unconvinced that the move to local authorities will aid in public health in the short term, whilst 75% were hopeful that the historic skills of LAs to engage with the residents will aid in future improved delivery. What I found the most revealing through was that 59% of respondents felt that health decisions were being based on a political basis rather than on evidence. Welcome to the swamping world of local authority decision making. Their response is that 80% feel they need better influencing skills, something we as EHPs might learn from.  At a time of decreasing budgets the politics of competing budgets are only likely to increase.   On the other side of this debate is John Middleton the outgoing DPH for Sandwell who suggests the move back to LAs returns public health to where is belongs with LAs able to “weave public health into local government tapestry” (Bindle 2014) with investments in leisure, social housing, market gardens as clear public health functions.  Of course my favourite part of his piece is that he states “public health money ….. could justifiably be diverted into food safety inspection if those inspections also looked at salt or trans fats content”, something already picked up by a number of councils.

The RSPH respondents did though make an interesting point about the type of evidence that is available highlighting that much of the existing data around public health related to savings to the NHS and not savings to LAs. Of course this is interesting to EHRnet which is trying to foster research within the profession and this latter point should of course be built into our future research and I would suggest will be easier than showing direct savings to the NHS budget.

Of equal import is the concern raised by Iacobucci (2014) in which he points to the fact that the ring fenced public health budget is being used to prop up other services; that staffing in some regions were being reduced; and that the public health workforce is spread too thinly. I take issue with some of these comments since many roles within local authorities have their basis in public health and welfare promotion.  It can be argued that the resources for public health have grown with the move to LAs and that a new vision of the public health workforce needs to be developed.  The report points to money being deployed to domestic abuse services, leisure services and housing all of which have a clear public health dimension.  Indeed PHE has defended the use of monies used in this way (ibid).  I do understand the concerns over monies being removed from substance misuse, sexual health, smoking cessation, and obesity interventions, but in light of local priorities can it be shown that these are the key priorities for the area?   I attended a county PH development meeting last year and I am honest in saying I was surprised that the DPH was suggesting a status quo plan for spending money on priorities brought from the NHS with no thought of wider public health interventions.

One the other side of the developing turf war is the LGA who has questioned the whole idea of a ring fenced budget (Dunton 2010).  More worrying is the view of Jongsma (2014) who points to a recruitment crisis in public health medicine with only 12% of those surveyed (n=590) thinking there will be enough PH consultant posts to serve the population in 10 years time, only 36% thinking their role was understood; and that medical professional are less willing to work for LAs in light of LAs not valuing their skill set and potentially employing non medical professional due budgetary restrictions.  However the figures are called into question by Gamsu 2014 who provides a very useful critique of the debate and use of numbers to support one side of the turf war.

As we enter the second year of the new public health era, EHPs MUST start to collate the vast amount health data held by LAs both at a local and regional level, without this evidence our voice will be lost. We must also look to our current functions to see where it fits to the local public health priorities and John Middleton offers a useful example which could be shaped in other services.  If there is one thing to learn from the above it is that the future remains uncertain but public health will continue to be a key function of the future LA and EHPs must learn to be part of this agenda and must learn to evidence the effectiveness of their interventions.

Brindle, D., (2014). John Middleton: ‘Public health is about making ordinary lives richer’  The Guardian, Wednesday 26 March 2014

Dunton J., (2010) Councils say “no” to public health ring-fence. Local Government Chronicle 5 Oct 2010.     www.lgcplus.com/briefings/joint-working/health/councils-say-no-to-public-health-ring-fence/5020148.article

Gamsu, M., (2014). BMA survey of public health workforce – transition and division? Local democracy and health available at http://localdemocracyandhealth.com/2014/03/31/bma-survey-of-public-health-workforce-transition-and-division/   dated 31.04.14.

Hetherington, P., (2012). Public Health will cost local government money. The guardian 26.06.2012

Iacobucci, G., (2014). Raiding the public health budget. BMJ Vol 348:g2274 pp 1-4

Jongsma, H., (2014) Findings from the public health survey. London, BMA Health Policy and Economic Research Unit

Royal Society of Public Health (2014). The views of public health teams working in local authorities year 1. London, RSPH

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