My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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The proposed new architecture for the NHS – Public Health

Filed Under (Health Policy, Public Health, Reform of the NHS) by Paul on 29-06-2010

The first thing to say is that wherever the organisational line is drawn for public health it is wrong. I think – as does most of public health – that if it is separated from the main commissioning and delivery mechanisms of the NHS then it misses out on one of the major methods of health improvement. But equally if it is separated at all from the other organisations of Government then it misses out on the a close relationship with the social and economic policies that impact upon what public health sees as the social determinants of health.

But this problem with line drawing means one of two things. Either public health is part of a major set of institutions just called “government” or “the state” and everything is lumped in together OR it must work through partnerships all the time. If this is the crucial way of working for public health, then wherever the organisational and structural lines are drawn they are fine.

One of the consistent messages from the Conservatives in opposition was that they saw public health as marginalised by the NHS concerns of the health service. This certainly chimes with the experience of public health. However many times a Secretary of State for Health or a Prime Minister might say that the NHS should be a health service and not a sickness service; or an ounce of prevention is worth a pound of treatment etc etc public health knows that access to NHS services and the delivery of health care has a powerful resonance with the public and therefore politicians. So they feel marginalised.

That is why in opposition, the Conservatives talked of ring-fenced budgets for public health, and even to change the name of the Department of Health to that of The Department for Public Health. The name change was seen as a new recognition of its importance.

Given that within the new architecture one part of the DH – the part that is at the moment the HQ of the NHS – will leave and become the separate NHS Management Board and a second part will leave and join the economic regulator – setting prices and the rules of the system – what will be left will be a focus upon the health of the nation and not its health services.

The new Secretary of State made it clear before the election that he saw the SoS for Health leading all other departments across Whitehall in taking on a pan-Governmental approach to health improvement. It will be interesting to see if this approach will be a part of the job description for Sir Liam Donaldson’s replacement as Chief Medical Officer. How all this will work in Whitehall will have to be worked through and tested, but a Department for Public Health, just concentrating on that issue will have a lot of weight.

The local infrastructure is less clear. The coalition document had the Liberal Democrat policy for a directly elected membership of PCTs as an important element. Given the importance of GP led commissioning of NHS health care, any residual PCT will not be engaged in commissioning. But the local delivery of public health could be a major component of the new style PCTs.

But this is one of those parts of the architecture where I think Parliament will intervene as any Bill goes through the House. Setting up another set of local elections on the same boundaries as local authorities (who the new PCTs would have to work with all the time) looks to me like one new elected body too many. Local Government is powerful in Parliament. It seems likely that either in the Commons or the Lords, Parliament would add the local delivery of public health to elected local government and not create a new body.

Older readers of this blog will not be surprised to see the re-creation of the office of Medical Officer of Health within each major local authority. Public health staff could transfer from the PCT to this new Department. At the moment nearly all major authorities have an elected Cabinet member who is called The Cabinet member for Health and Social Services – or for some Health and Well Being. The public health department will fit snugly into this organisation.
The DPH would contract public health interventions from local government and would hold local government to account for that money. At the local level public health would be securely tied in to the main organisation that commissioned inputs into the social determinants of health.

But as I said at the beginning they would then be separated from the NHS commissioning line and have to ensure that they partnered strongly with GP commissioning.

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