Shifting the Balance of Power – securing delivery
Comments from the PHMEG
The Public Health Medicine Environmental Group (PHMEG) welcomes the opportunity to comment on the recent guidance document Shifting the Balance of Power – securing delivery. The PHMEG is a national organisation which aims to promote and develop the practice of health protection and to represent the views of consultants in communicable disease control (CsCDC) and others working in the field of health protection (see annex 1 for further details). 1 Current arrangements for Health protectionHealth protection is an important element of the public health function. It has been defined as the application of a set of multidisciplinary public health knowledge and skills that aims to protect the public’s health from biological, chemical and physical hazards in the environment. This encompasses the control of communicable disease and the health consequences arising from exposure to non-communicable environmental hazards as well as the health emergency planning response. Many non-health agencies, such as Local Authorities, contribute to health protection and currently within the health service there are responsibilities at three levels; national, regional and local.
The Department of Health leads on national policy and international links with some responsibilities discharged through bodies such as PHLS-CDSC, JCVI and the National Focus.
At regional level the residual RHA functions for communicable disease control are discharged through the national contract for the Regional Epidemiology Service. In addition there are regional arrangements for access to specialist units for expert advice in relational to chemical hazards. These units generally have only a limited public health response capability.
Responsibility for the local health protection function lies principally with district health authorities in close collaboration with local authorities. Health authorities have corporate responsibility for ensuring that arrangements are in place and the professional responsibility for discharging the function is normally within the remit of the public health department. The function is led by a medically qualified consultant, the Consultant in Communicable Disease Control (CCDC), who is professionally responsible for a defined population. The CCDC is usually the appointed "proper officer" of the coterminous local authority or authorities to discharge duties and exercise powers under the Public Health (Control of Diseases) Act 1984 and the Public Health (Infectious Diseases) Regulations 1988. The CCDC role was created in 1988 following the recommendation from the Stanley Royd Inquiry of the need to ensure accountability for the control of communicable disease for a defined population. This remains a fundamental principle of communicable disease control.
The PHMEG welcomes the recognition given to health protection as a key element of the broad public health function. We consider that having the RDPH in the Regional Government Office ultimately accountable for the function will both raise its profile and help improve intersectoral collaboration. We would however also wish to see clear local accountability to a defined population, particularly for communicable disease control, and for the elements of the health protection function which are dependent on collaboration with local authorities.
Given the very short timescales for implementing the organisational changes there is an urgent need to define the scope of the function and to ensure that the current DHA responsibilities are assigned to the new NHS organisations. Then the public health resources needed to deliver the function can be identified and the necessary teams and networks established, taking into account local circumstances.
As the professional organisation bringing together most of the public health doctors working in the health protection field PHMEG has begun to consider what resources and competencies are needed and how governance of health protection might be assured. We look forward to contributing to the development of the detailed local, regional and national arrangements for this function.
We would like to comment on how some of the generic NHS changes will impact on the delivery of the health protection function.
The organisational changes proposed in "Securing Delivery" are designed to support a bigger and longer term change in culture and ways of working within the NHS and we believe that the changes could provide an opportunity to strengthen the health service contribution to the health protection function. Although many agencies participate in health protection, the NHS has a major role. Most communicable disease control programmes from surveillance to treatment are delivered through the NHS, for example the very successful Meningitis C immunisation campaign.
We therefore welcome the general thrust of the proposals designed to bring about a change in culture within the NHS and improve service to patients. These include moves to :-
Build an NHS that encourages bottom-up innovation within a national framework
Devolve power to frontline staff and patients
Align responsibility and capacity at the most local levels
Devolve resources along with responsibilities
We would like to explore how these principles could be applied to communicable diseases control (CDC) programmes, once the Chief Medical Officer’s strategy for CDC is published.
We welcome the recognition of the need to move "towards a model of partnership whereby citizens have a greater connection with their local services and have a say in how they are designed, developed and delivered". Recent events have shown how the successful delivery of CDC programmes such as universal MMR immunisation or TB prevention and control in disadvantaged communities can only be achieved in partnership with target communities.
We welcome the recognition that goals in improving health and reducing inequalities can only be achieved by multi-sector, multi-agency working at local, regional and national level. This is particularly true for health protection goals, as local authorities play a key role in communicable disease control and as management of environmental risks to the public’s health is not a health service responsibility.
2.3 Roles and responsibilities 2.3.1 PCTsWe welcome the acknowledgement that PCTs will need a strengthened public health function to enable them to discharge their responsibilities for improving the health of the community and the recognition that PCTs will need to co-operate through public health networks to pool resources and talent for some functions. Health protection is clearly one area where collaboration between PCTs will be important, as generic public health specialists will continue to provide a necessary contribution to the health protection function. It is essential that local health protection teams are not divorced from the populations or organisations which they serve. Most PCTs will not be big enough to support a health protection team and some metropolitan districts are for example proposing a shared health protection team to serve the constituent PCTs, NHS Trusts and local authority/ies which make up the Local Strategic Partnership (LSP).
We welcome the recognition that PCTs will need to co-operate at SHA level to secure the full range of services for their local community. Some elements of the health protection function will need to be co-ordinated at this level, for example specialist support on chemical incidents and possibly county-wide interagency emergency planning.
Many CsCDC are concerned at the implication of the statement that "aspects of public health such as epidemiology and advice on communicable diseases should rest at a Government Office level". Day to day advice to PCTs on local communicable disease control matters would need to be provided at a much more local level, and epidemiology is an integral part of every public health programme. This statement also contrasts with the stated objective of devolving responsibility and resources to the local level.
2.2.2 Strategic Health AuthoritiesWe welcome the recognition of the importance of public health at this level. The delivery of public health programmes by NHS organisations will need to be included in the annual agreements and performance managed at this level. Along with other public health networks there will be a need for a managed health protection network at this population level, to develop health protection within the strategic health district and to prevent professional isolation of individual CsCDC. A lead CCDC could function as clinical director of the managed network, with accountability to the RDPH. In some parts of the country, a regional-level managed network with a clinical director may be more appropriate to local circumstances.
2.2.3 Regional Directors of Public HealthWe welcome the lead role the RsDPH within RGOs will have in health protection. This clearly presents an opportunity to improve the co-ordination at regional level of the multi-sectoral response to threats to the public health. We believe that it will also provide a mechanism to ensure that local NHS bodies are clear about their health protection responsibilities and ensure that local teams are adequately resourced. The current changes present an opportunity to review the role of PHLS/CDSC’s Regional Epidemiology Service and we believe that this is an opportunity to broaden the remit to include surveillance of diseases resulting from non-communicable environmental hazards.
3 ConclusionIn conclusion we welcome the new guidance and the opportunities it presents to strengthen the health protection function. We look forward to the CMO’s strategy on communicable disease control which is expected shortly. This should set the national framework for this important element of health protection. Shifting the Balance promises that responsibility and resources will be devolved to local level with organisational changes to ensure that local services deliver national programmes to meet local health needs. At the local level, the health protection team’s role would be to lead the local development and implementation of programmes to deliver the CDC strategy, working with PCTs and NHS Trusts and local authorities within a defined patch. The CCDC should be based within a local organisational setting which safeguards their capability to act intra vires as appointed "proper officers" of a local authority with regard to the relevant public health legislation.
Similarly, we would welcome a national framework for managing the health aspects of non-communicable environmental hazards, which clarifies NHS roles and responsibilities at national, regional and local level.
We hope these comments are useful and we would welcome the opportunity of working with the Department of Health to develop the new arrangements for delivering the health protection function.