Feature

Shifting and unbalanced

Labour’s current NHS reforms are throwing the whole public health infrastructure into the air, says Tony Jewell

This is an unsettling time for many public health practitioners. Since 1997 the overall direction of government policy has been supportive of public health values and objectives – and the current commitment to reduce health inequalities, taking an intersectoral approach, is a good example. But with the latest structural reorganisation of the NHS, there is deep unease among public health practitioners about their future place in the new order, particularly for those of us currently based in health authorities, which are effectively being abolished.

In a pre-election rush of blood to the head Alan Milburn, in a speech launching the Modernisation Agency last April, promised to save £100m in ‘bureaucracy’ by reducing health authorities by two-thirds and reforming Department of Health and NHS regional offices. The Conservative party had a manifesto commitment to abolish health authorities and many believed that Milburn’s was a political pre-election address which could be re-examined later.

But the publication of Shifting the balance of power in July showed there was no turning back. The rhetoric is to ‘shift the balance of power to frontline staff’, but in practice we are faced with a major structural reorganisation of the NHS which is on a par with those of 1974 and 1991. Change at every level of the NHS, plus the creation of 300 primary care trusts (PCTs), is hardly a recipe for securing effective delivery of The NHS Plan. The NHS public health workforce has been based mainly in health authorities and these sweeping changes necessarily mean a substantial change in how public health capacity is distributed.

When Labour came to power in 1997 there was a sense of relief for those of us with a commitment to equity and to the purpose and values of the NHS. The publication of the white paper The New NHS: Modern, Dependable was innovative in its main policy objectives, and further reassured us, but it was the ‘health improvement programmes’ (HImPs) which caught our imaginations. With HImPs came the explicit expectation of a ‘duty of partnership’ between the NHS and local authorities, allowing us to develop a three year plan for a defined population. HImPs could include regeneration and anti-poverty strategies as well as NHS disease-focused programmes, and existing local authority planning processes such as joint investment plans could be incorporated as part of the HimP.

The public health strategy, Saving Lives: our healthier nation, soon followed. It built sensibly on the previous government’s Health of the Nation strategy, providing some continuity but also stressing the primacy of reducing health inequalities. This strategy gave the new minister for public health a clear agenda to drive forward across government and there have been achievements such as agreeing national targets for reducing health inequality.

But the full potential of the public health strategy has not been realised. Many public health practitioners feel that HImPs have never had the profile they deserve. Saving Lives has seemed marginal to ministers’ concerns and key policies on tobacco advertising and fluoridation have faltered. ‘Public Health and Inequalities’ is Chapter 13 of The NHS Plan. The demotion of the public health minister to under-secretary status has underlined this and while the public health minister is on maternity leave, her role is simply being divided between busy ministerial colleagues.

The current structural changes affect public health at four levels. At a national level the Chief Medical Officer relates to other government departments and national public health specialist bodies such as the Health Development Agency and the Public Health Laboratory Service. At the regional level the focus is on the link to regional government and regional strategic planning. The regional director of public health’s attention will be on influencing the decisions that affect population health for the whole region The new ‘strategic health authorities’ will be mainly concerned with clinical networks, such as cancer care networks. These extend beyond individual PCTs and hospitals and involve regional centres. There will be a more clinically-oriented public health focus at this tier led by a director of public health (DPH) for the strategic health authority.

PCTs, together with their relevant local authority, form a ‘local strategic partnership’(LSP). The local government side offers local democratic accountability and a scrutiny role, while the NHS side focuses on users, with their patient fora, and a national accountability to ministers. Each sector also has neighbourhood or primary care teams who can provide more locally sensitive and informal accountability. The House of Commons select committee report on public health published in March was critical of the leadership of some DPHs and questioned whether they should be based either in local government or be joint appointments with the NHS. Ministers are understood to be unimpressed by public health doctors and current policy does not spell out the need for a DPH at PCT level. But a DPH for the LSP would provide a focus, across both statutory authorities, for improving the population’s health at this tier of governance.

The time-honoured recourse of secretaries of state – to try to achieve their objectives by reorganising the NHS – poses a risk to public health capacity, unless great care is taken to avoid fragmentation and a loss of critical mass. At the same time, the proposed new structures do offer opportunities to achieve stronger collaboration with local government through local strategic partnerships. But to realise the public health potential, this time round, will need local public health leaders and an expansion of the public health specialist workforce to support the increased range of partnerships and the widening public health agenda.