KEY POINTS FOR DECISION MAKERS
The Public Health Crisis
Britain faces a public health crisis. Life expectancy is in decline. The NHS is buckling under the weight of preventable illnesses. The welfare system is struggling to cope with high levels of unfitness to work, including amongst young people. Poor health damages the economy.
In these circumstances it might be thought that a Labour government would prioritise public health. Instead spending on public health is falling in real terms, services for physical activity are being abandoned, there are wide disparities in the availability of services like smoking cessation services and health visiting. Proven beneficial measures like community development are brushed aside because they do not fit models of individualised care.
The public health specialist service (a medical specialty which also has a non-medical route of entry) is unable to address this problem because the breadth of its authority has been restricted and its establishment is often sacrificed to maintain spending on services. The reorganisation of public health national organisations is actually making health protection specialists redundant. The reorganisation of NHS England threatens to dismantle healthcare public health. Local authorities in England rarely feel able to fund an adequate public health specialist service and the freedom of public health specialists to offer advice across the whole range of the public services is often constrained by the belief that their responsibilities are limited to corporate responsibilities in their own authority.
Parity of Esteem
At a number of levels this reflects lack of parity of esteem. We are particularly concerned by
- Lack of parity of esteem between preventive and treatment services
- Lack of parity of esteem between preventive services and prevention by means of social policy
- Lack of parity of esteem between that part of the statutory comprehensive service which is defined as part of “the NHS” and those to which that nomenclature is denied
- Lack of parity of esteem between the specialty of public health and other medical specialties
- Lack of parity of esteem between health professionals employed in local government and health professionals employed in the NHS
- Lack of parity of esteem between public health specialists from the medical and non-medical routes of entry to the specialty.
Action Requested
To address these issues, we request:
- Funding of the public health system must be viewed as being as high a priority as funding of front line NHS services
- Health in all policies must be institutionalised at national level in the machinery of government, with a commitment to a just transition for workers and communities affected by addressing commercial determinants of health) whilst at local level legislation should protect the broad multiagency role of Directors of Public Health. We can provide a draft for that legislation which could be a single clause added to the health service legislation proposed in this session of Parliament.
- The term “the NHS” should in future be used to refer to the whole of the statutory comprehensive health service (as it was from 1948-74) with the term “NHS Healthcare” being used for those services defined as “the NHS” by s66(4) of the Health & Social Care Act and the term “NHS Public Health” being used for the services provided for the health service by local government and the Secretary of State (we can provide a draft of the necessary legislation, which could be a single clause in the coming piece of health service legislation)
- Discrepancies of earnings and status between consultants in public health and other medical consultants should be addressed.
- A directive should be issued that all health professionals employed by local government or the civil service in the provision of the statutory comprehensive health service should be employed on NHS terms and conditions
- Public health specialists from the non-medical route of entry should be paid on medical and dental terms and conditions of service like their medical colleagues doing the same job.
FURTHER DETAILS
Parity Between Preventive and Treatment Services
Spending on the public health services transferred from the NHS to local government substantially increased in 2013 and notched up slightly more in 2014. But this was only a small part of total public health spending. With “public health” removed to local government the NHS faced even less pressure to prioritise prevention whilst, outside the ring fenced field of “public health”, local authorities were subject to severe spending cuts which were eroding environmental health services, youth services, community development and other services central to a public health strategy.
A significant part of the new money committed to public health services was used to ease the consequences of those wider local authority cuts.
The division introduced in 2013 between “the NHS” and the “statutory comprehensive health service” allowed the 2015 Cameron Government to cut funds for public health in England saying health visiting, school nursing, drug and alcohol services and NHS health checks were no longer part of the NHS! Andrew Lansley’s aim in introducing the division might have been to give public health a higher priority but it actually was used in the exact reverse way. The argument was that because “the NHS” had to have protected funding it was important that other areas of DH funding should be squeezed to help find that money. The 2013 and 2014 growth money were taken away and the cuts in public health spending then went further, biting even into the inadequate levels that Lansley had set out to improve.
Although this erosion has been partially halted by this Government, it has not been reversed. Indeed when spending on the national public health bodies is added in, spending on public health continues to decline in real terms.
Parity Between Preventive Services and Prevention by Means of Social Policy
Although the Government has developed some health strategies which go beyond mere provision of preventive services, especially in relation to tobacco and obesity, these still focus on modifying individual behaviour and, insofar as they seek to influence commercial determinants at all, they do so without addressing the issue of just transition for the workers and communities affected. At the start of the Government there were commitments to Health Missions in a number of departments of government, but most of these have withered away and the staff have been reallocated. There has been no equivalent to the Welsh legislation on well-being of future generations, and the Minister for Public Health in England focuses on preventive services not on cross-departmental coordination.
At local level public health specialists report that they are not free to comment on the health implications of broader measures, either within their authority or in outside agencies. They are perceived as speaking for their employer and attempting to doi their job of advising the population on health issues is perceived as corporate disloyalty. With most public health specialists at local level being subject to such restrictions and most public health specialists in national organisations operating under civil service restrictions, journalists tell us that they cannot rely on the professional integrity of any public health opinions. From 1875 to 2013 the people always had access to the professional opinions and advice of doctors whose job was to analyse, comment on, advocate for, and work to improve the health of the people. They have this access no longer.
Parity Between the NHS and the Rest of the Statutory Comprehensive Health Service
The NHS is not just a way of paying for health care. It is also a mechanism whereby the health of the people is pursued as a social goal,
Nye Bevan’s NHS had three wings – family health services (general practice. pharmacy, dentistry and opticians), the hospitals and the Health Depts of local authorities. Since a sharp bureaucratic divide now separates the NHS and local government we often forget that part of Bevan’s NHS was run by local authorities and focused on prevention. In its first quarter of a century the NHS cleared the slums, cleaned the air, eradicated polio and diphtheria, and dramatically reduced the incidence of TB, enabling TB hospitals and TB wards to be closed or reused.
These achievements of the early NHS show that the NHS did once emphasise prevention. But since reorganisation in 1974 it has lacked the means to do so. Important elements of public health, such as environmental health, remained with local government but were no longer seen as part of the NHS, so that addressing the social and environmental determinants of health was no longer within the remit or the capacity of the NHS and no longer under the direction of public health specialists committed to analysing and improving the health of the people. Those specialists were now in the health authorities and were generally redirected away from addressing the determinants of health and towards health service planning. They were separated from public health nursing which moved to the new health districts and came to be seen merely as specialist community nurses.
From 1974 to 1997 spending on public health by the NHS and by local government depended entirely on the local priority given to it. Many environmental health departments were run down by their local authority and integrated into a regulatory function in which public health was only one element. Many NHS bodies did not perceive the importance of prevention and saw health visiting, school nursing and community clinics as sources for savings to fund their priorities in the hospital service. On the other hand, many local authorities and NHS bodies did see the importance of public health and where such prioritisation existed on both sides of the NHS/ local government divide vibrant public health programmes could be developed.
There was a brief period under the leadership of Barbara Castle that public health had a national priority but she thought it too late to reverse the 1974 changes, perhaps not fully realising their baleful effect, and she survived only through the Wilson Government. There was no significant prioritisation of public health under the Callaghan Government, and the Thatcher Government had an ideological antipathy to public health.
The Major Government had a stance of regretting the decline of public health and expressing support for local initiatives but doing nothing to generalise them. Even this limited support changed in 1997. The Health Dept in the Major Government had not prioritised public health but it had permitted it to be prioritised locally. From 1997-2010 prioritisation was centralised and it became more difficult for localities to pursue different priorities. Public health was not a priority of the Blair Government.
This changed briefly for the better in 2010. Andrew Lansley is not a hero of ours – he did much to damage the NHS by his unnecessary reorganisation, by his misplaced belief in commercial solutions and by his fundamentally damaging procurement laws. However, in one respect he is to be praised. He stands alongside Barbara Castle as one of only two Health Secretaries to have genuinely prioritised public health.
The adverse effects of 1974 could therefore have been reversed in England when public health returned to local government in 2013 but instead the coalition with the Liberal Democrats decided to introduce a distinction between “the statutory comprehensive health service” and the “NHS”, with the latter being only a part of the former. Andrew Lansley’s vision was that “the NHS” had become too firmly identified with health care and a new public health system needed to be built alongside it and to become the dominant element of the Dept of Health. However, like Barbara Castle, Andrew Lansley was quickly replaced by successors who did not share this vision.
Indeed, as we pointed out in our paper “Orwell and Environmental Health” in 2012 one consequence of redefining the NHS so as to consist only of healthcare is that it begins genuinely difficult to conceptualise an NHS which is the mechanism by which society pursues health as a social goal and genuinely difficult to understand its history and the debates that surrounded it in its first quarter century. Take away the word for something and you make it harder to imagine it.
Parity Between Public Health and Other Medical Specialities
There have been a number of issues, not only in relation to pay but also in relation to workforce planning where public health has been treated differently from other specialities.
In England the fact that public health doctors have a higher proportion of employment in local government, the civil service and the Universities than do other specialities has made this worse as those groups have been treated disadvantageously.
We deal with local government in the next paragraph, but the civil service is also problematical because of the failure to perceive public health (even health protection) as a service rather than as a managerial role, and because of the pressures that have been brought to abandon the clinical ring fence.
Parity Between Health Professionals in Local Government and in the NHS
There is a substantial pay differential in England between consultants employed in local government and those employed in the NHS. Although it was agreed in 2012 that local authorities needed to have the power to employ health professionals on NHS terms and conditions, only a minority did so and most of those have now stopped. In some cases, this has been because of fears that separate TCS would open the risk of equal pay claims – a fear that could best be allayed if, as in with the teachers’ scheme, it was made compulsory.
The problem was aggravated by the refusal of LGE to recommend the Faculty guidance on job descriptions and job evaluations. Initially, where that guidance (which emphasised the cross-agency and public-facing role of consultants) was followed, job evaluation usually produced a grading within the range of NHS consultants salaries. However, many local authorities evaluated jobs without regard to that guidance and with inadequately expressed job roles.
As time has passed and NHS salaries have moved ahead of local government salaries this problem has deepened and some salaries which were initially acceptable have now slipped behind.
Similar problems have arisen for some other groups of health professionals when local authorities have taken services in house.
We ask for a directive to be issued that NHS TCS should be used for health professionals employed in local government public health. There is a power to do so in the 2012 Act.
Parity Between Routes of Entry to the Speciality of Public Health
The training that public health specialists undergo is the same whether they enter through the medical or non-medical route and their job descriptions are identical, yet a significant gap has emerged as medical and dental pay has moved ahead of AfC pay. The simplest way to ensure comparability would be to extend the medical and dental TCS to include public health specialists as they are members of a medical specialty who have undergone training approved by a medical Royal College.
This is not only UNITE policy but also BMA policy.
Doctors in Unite 