The evolution of the public health function in England (2): 1997–2009
The evolution of the public health function in England (2): 1997–2009
Abstract and Keywords
This chapter reviews the policy and organisational changes that have occurred since 1997 following a change of government. New Labour sought to accord a high priority to the health of the public and was strongly committed to putting both health improvement and health inequalities back on the policy agenda. An important symbol of this new policy emphasis was the appointment of the UK's first ever Minister for Public Health. The chapter presents and assesses the various policy developments from 1997 to the present day, including the two public health White Papers of 1999 and 2004 respectively. It also examines other developments affecting public health within this period, including changes in the structure of the NHS, the relaunching of commissioning under the heading ‘world class commissioning’, and the policy shifts towards markets and choice in the provision of health and health care.
The election of the New Labour government in 1997 represented an important shift for public health, or so it seemed, as the party had made bold and ambitious commitments to tackling health inequalities and addressing the wider determinants of health in its election manifesto. A series of documents and debates stressing the need to give higher priority to the health of the public, to end the fragmentation of the public health function and to start seriously developing and strengthening its multidisciplinary nature subsequently emerged (Department of Health, 1998a 1998b; Secretary of State for Health, 1999). The decade or so since 1997 has been a particularly active and fertile period for public health, although many of the issues at stake are familiar and have their antecedents in the period reviewed in Chapter Three. It has also been a somewhat chaotic and turbulent period, marked by numerous policy initiatives and structural changes, many of which appear to lack coherence. A number of these changes were not directed primarily at the public health function but their impacts have nevertheless been profound and are still being worked through. Some public health functions were relocated to arm's length bodies, a network of stand-alone organisations that include the National Institute for Health and Clinical Excellence (NICE) and the Health Protection Agency (HPA). Box 4.1 charts the changing organisational context for health protection. (p.64) (p.65)
(p.66) In what follows, we provide a brief overview in chronological order of the major policy and organisational changes that have occurred since 1997, which gives an indication of the changing topography of the policy and organisational landscape. We then describe their implications for the public health workforce and the objective of strengthening its multidisciplinary nature. As we concluded in Chapter Three, little progress had been achieved on this front prior to 1997. Since then, however, there have been a number of important developments, although how far these will truly succeed in gaining recognition for, and acceptance of, a multidisciplinary public health workforce remains to be seen. There has been greater emphasis on these issues over the past decade or so in response to perceived weaknesses in the evidence concerning particular interventions and in their effective implementation. A final section brings together some concluding observations from both this and the last chapter. It sets the scene for a discussion of the key issues that have come to the fore in recent debates about public health policy and practice, which forms the subject of Chapter Five.
The changing policy and organisational landscape in England
The period since 1997 has witnessed many important policy developments and changes in the management of public services, including an emphasis on joined-up working (that is, partnerships), which have contributed to local government being seen to have an increasingly significant public health role. There have also been developments around the organisation and delivery of health protection, a growing emphasis on the importance of the evidence (p.67) base underpinning health interventions and increasingly extensive commitments to the use of targets in the performance management of policies and services. The period is also notable for a series of other major policy developments, including the impact of political devolution in the UK, with all that this implies for increasing divergence in health policies and structures (Greer and Rowland (eds), 2007; Greer, 2008). At the same time, and contributing to the growing policy divergence evident across the UK, within England there has been a strong push towards developing a market-style ethos in the NHS, with a focus on competition and choice. This has been accompanied by a renewed emphasis on commissioning for health and an expressed desire for more active public involvement. While these developments are not all aimed principally at public health, they have important implications for the function.
Major initiatives following the arrival of the New Labour government in May 1997 included the appointment of the first ever Minister for Public Health in 1997, the production of a new health strategy to replace The Health of the Nation, an independent assessment of the impact of The Health of the Nation (Department of Health, 1998a) and the establishment of an ‘independent’ inquiry into inequalities in health (chaired by Donald Acheson, a former Chief Medical Officer (CMO) for England) who had led the inquiry into the public health function in 1988. The Acheson Report (Acheson, 1998) made 39 recommendations for tackling health inequalities, the vast majority of which stretched far beyond the remit of the NHS. In the same year, an interim report of the Chief Medical Officer's Project to Strengthen the Public Health Function, mentioned in previous chapters, expressed a commitment to multidisciplinary working (Department of Health, 1998b).
In 1999, a new health strategy to replace The Health of the Nation was published, Saving Lives: Our Healthier Nation (Secretary of State for Health, 1999). It had been preceded a year earlier by a consultative document, which many working in public health considered to be a better document from a broader public health perspective (for example, Fulop and Hunter, 1999). In particular, the insertion of the first two words, ‘saving lives’, into the title seemed to signal that the strategy would remain firmly located within a health care model, with less emphasis on supporting communities to remain healthy and more on keeping individuals alive (Fulop and Hunter, 1999). Moreover, the strategy focused mainly on disease-based themes, despite criticisms that this represented an overly narrow, reductionist view of public health. As we outlined in Chapter One, this approach was predicated on a deficit model of health rather than an assets-oriented one, despite the (p.68) fact that two independent assessments of the impact o£The Health of the Nation, combined in a single published report, had demonstrated that the strategy's domination “by a disease-based approach” that was ‘heavily ‘medically led’…was a cause for concern among those local authorities which believed that they contributed more to a health agenda in its broadest sense than health authorities” (Department of Health, 1998a: 14). It was suggested that, in the case of the new health strategy, a sound and logical argument could be made for local government rather than the NHS taking the lead role in local implementation. Indeed, such a view was advanced in the Local Government Association (LGA) and UK Public Health Association's (UKPHA's) joint response to Saving Lives: Our Healthier Nation (LGA and UKPHA, 2000). These organisations concluded that the government's actual strategy amounted to little more than “the traditional concerns of public health medicine” and gave too little attention to the need to integrate local planning mechanisms in order to achieve truly joint strategies for health improvement. Indeed, very little progress was made on this front until the Tackling health inequalities: A programme for action initiative in 2003 (Department of Health, 2003a) (see later in this chapter).
In many respects, the more radical aspects of the government's early strategic thinking around public health, which gave it a significant leadership role, were subsequently overshadowed by the NHS Plan, published in 2000 (Department of Health, 2000). By this point, the NHS had risen back up the policy agenda and concern over waiting lists and times, the quality of care and a perception that NHS management was weak began to dominate the discussions about health policy, both inside government and in the media. The laudable intention to put health before health care began to fade and traditional health care delivery issues came to dominate ministerial attention once again. Indeed, the NHS Plan proved to be the first of an outpouring of policy redirection, advice and guidance, which appears to have continued, largely unabated, ever since.
The NHS Plan's aim was to modernise the NHS and it outlined an ambitious ten-year strategy for doing so. With its principal focus on health care, public health did not figure prominently. Indeed, the issue was confined to a slim chapter, buried deep inside the Plan. There was, however, an emphasis on improved partnership working and cross-government action, and new local strategic partnerships were announced. The other important development was the announcement of national targets for reducing health inequalities in 2001, which were subsequently revised into a single target on health inequalities in 2002, namely, by 2010 to reduce inequalities in health outcomes (p.69) by 10% as measured by infant mortality and life expectancy at birth (HM Treasury, 2002). Previously, the government had resisted setting such targets, leaving the matter to local discretion. The NHS Plan also announced the introduction of new single, integrated public health groups across NHS regional offices and government offices of the regions. These forums were intended to encourage an approach to neighbourhood renewal and regeneration that combined social and economic development with health concerns.
The NHS Plan was regarded as the apotheosis of a command and control style of policy making and, as such, was heavily criticised. The government was accused of ‘control freakery’ and of adopting a highly centralised style of management, which was deemed wholly inappropriate. In response, the government did an unexpected volte-face, announcing a major shift in the balance of power from centre to periphery in 2001 (Department of Health, 2001d). These changes plunged the NHS into yet another extensive upheaval and ushered in a period of instability and uncertainty, which ended only with the next major restructuring commencing in 2005. The Shifting the Balance of Power (STBOP) (Department of Health, 2001d) changes served to distract attention from implementing the NHS Plan as employees worried about their future jobs. The centrepiece of the STBOP changes introduced in 2003 was the primary care trusts (PCTs), which were to assume control over 75% of the NHS budget as well as responsibility for commissioning care for their local populations. Each PCT board had to appoint a director of public health. The location of directorates of public health in PCTs and the formation of public health networks to cross organisational boundaries could be seen as encouraging the long-standing division between primary health care and public health that is described in Chapter Three.
The other key development as far as public health was concerned was its strengthening at regional level. This entailed replacing the existing eight NHS regional offices with four new health and social care regions. In fact the four regions were soon disbanded and their functions absorbed by the strategic health authorities (SHAs), but the regional directors of public health (RDsPH) largely remained located within the regional government offices (although at least one BTJPH has relocated himself to the SHA). Although the move of regional public health into the government offices was widely welcomed on the basis that it was hoped a strong health component could be built into regional programmes in areas such as transport, environment and urban regeneration, there remained doubts over whether the public health function, as currently configured, would be able to meet the challenge. (p.70) Moreover, there was no option but to fill RDPH posts with medically qualified personnel, since the role combined local government office duties with those of medical director.
Reflecting a more widespread concern that public health was failing to receive the attention it both deserved and had been promised by the incoming Labour government, the House of Commons Health Committee launched an inquiry into public health in 2000. Its terms of reference were “to examine the co-ordination between central government, local government, health authorities and PCGs [primary care groups]/PCTs in promoting and delivering public health” (House of Commons Health Committee, 2001a: xii). In the course of its inquiry, the Committee examined a number of initiatives, including health action zones (for a discussion of these see Box 4.2), healthy living centres and health improvement programmes, the role and status of the Minister of Public Health (which was allegedly downgraded following the departure of the first post-holder) and the role of the Director of Public Health (DPH). With such wide-ranging terms of reference and only limited time (under a year) to produce its report, the Committee could not do justice to the full complexities of the subject but nevertheless made a brave attempt. In addition to the main report, the inquiry resulted in a considerable amount of evidence, which was published in a second, accompanying, volume to the main report (House of Commons Health Committee, 2001b). The Health Committee was critical of government health policy and its focus on health care, concluding that policy approaches were out of kilter with much expert opinion and with the government's own early commitment to shifting the policy agenda from a preoccupation with health care to one more committed to health improvement and wellbeing. In its view, ‘fix and mend’ medical services continued to receive the major share of attention and resources, and there remained profound systemic and structural problems with joined-up working, which went beyond the mere absence of incentives to collaborate. The Committee also expressed concern that the NHS Plan represented a lost opportunity to give a real boost to public health and that the health strategy, Saving Lives, had been somewhat marginalised by it. (p.71)
(p.72) The Committee's report probably had little impact other than to keep the issue of public health and its importance alive within policy and media debates. It did, however, lead to one small tangible outcome, which was the publication of the final report of the CMO's Project to Strengthen the Public Health Function (Department of Health, 2001c). Despite being completed months earlier, it had not been published for reasons that had remained unclear. In the end, the report was published on the same day as the Health Committee's report in March 2001 (this review has already been commented on and is revisited in the sub-section below on workforce issues since 1997).
The next major policy development with implications for public health came when former banker, Derek Wanless, was commissioned by the then Chancellor of the Exchequer to examine future health trends and the resources required over a 20-year period (2002–22) to improve performance and deliver the NHS Plan. Unexpectedly, Wanless's report provided much-needed and welcome ammunition to those who had become concerned at the government's apparently weakening commitment to public health (Wanless, 2002). Wanless gave considerable prominence to public health and saw better measures in this area as essential to significantly reducing the growing demands for expensive health care interventions. He was critical of the current balance of care (and policy), which he argued focused too greatly on the acute hospital setting and mpatient beds. Improving the health of the public was portrayed as a means of ‘investing in health’, thereby lowering projected resource requirements for health care. Wanless did not say anything that those engaged with the public health function did not already know or had not sought to express on numerous occasions. Indeed, in its World Health Report 2002, the WHO reiterated its view that much scientific effort and most health resources were unwisely directed towards treating disease rather than preventing it (WHO, 2002). It called on governments to redress this imbalance, maintaining that it was a lack of political will that hindered progress. Nevertheless, the fact that Wanless was an outsider to these debates about public health and his background was rooted firmly in economics and the worlds of business and finance meant that his review marked an important development in post-1997 policy approaches to public health, paving the way for renewed interest in preventive approaches.
Underlying the Wanless review was a conviction that good health is good economics and that, far from being a cost, investment in health benefits the whole of society. What Wanless referred to as “the fully engaged scenario” (the other scenarios being “solid progress” and “low (p.73) uptake”- see Box 4.3) involved a major shift in emphasis towards public health. The scenario assumed health would improve:
dramatically with a sharp decline in key risk factors such as smoking and obesity, as people actively take ownership of their own health…People have better diets and exercise much more…These reductions in risk factors are assumed to be largest where they are currently highest, among people in the most deprived areas. This contributes to further reductions in socio-economic inequalities in health. (Wanless, 2002: 39)
In terms of addressing the issue of joined-up working across the NHS and local government in tackling health inequalities, Wanless argued that future health expenditure could only be reasonably contained by engaging the public in its health and reducing risky lifestyle behaviours (Wanless, 2002).
The government immediately signed up to the ‘fully engaged scenario’ and some short time later, in 2003, invited Wanless back to undertake a review of progress in meeting it. Although Wanless felt (p.74) insufficient time had elapsed to say whether or not the government was on course to fulfil the scenario's requirements, he agreed to assess the direction of travel. However, this time he insisted his report should be addressed to the government and not merely to the Chancellor of the Exchequer. Consequently, he was able to ensure the Prime Minister and the Health Secretary (a post that had just been handed over from Alan Milburn to John Reid) both signed up to this second review and its terms of reference. Wanless's second report focused on the public health system as a whole and he produced a powerful critique of the public health function, which he argued lacked managerial grip, focus and capacity (Wanless, 2004). Perhaps not surprisingly, he found little had been achieved and recommended a range of changes, including an attempt to refocus the NHS from being an illness service to a health service. He was especially critical of PCTs, arguing that their small size made them ineffective in public health terms, and he considered the evidence base concerning why interventions succeeded or failed and how, if successful, they could be replicated more widely, was weak. However, he reserved his severest criticism for the failure of central government policy, noting that:
The government might have felt that such criticism was unfair or misplaced, as it had been engaged in a major initiative to strengthen partnerships in tackling health inequalities. Moreover, in 2003, the Department of Health had published Tackling health inequalities: A programme for action, which outlined how the findings of both the Treasury-led Cross-cutting Review of Tackling Health Inequalities (HM Treasury, 2002) and the Acheson Inquiry could be implemented. While the importance of mainstreamed and targeted activity was highlighted, this report made it clear that tackling health inequalities involved coordinating activity across traditional boundaries at governmental, regional and local levels, and working in partnership with “front-line staff, voluntary, community and business sectors as well as service users” (Department of Health, 2003a: 3). However, in his 2004 report, Wanless pointed out that the ‘programme for action’ gave no (p.75) indication of costs or of how much various aspects of the strategy would contribute towards meeting the health inequalities targets, concluding that it would consequently be difficult to prioritise across the many possible interventions at a local level (Wanless, 2004: p 90, para 4.46).
Numerous policy statements and initiatives in the field of public health have not resulted in a rebalancing of policy away from health care (‘a national sickness service’) to health (‘a national health service’). This will not happen until there is a realignment of incentives in the system to focus on reducing the burden of disease and tackling the key lifestyle and environmental risks. (Wanless, 2004: 23)
The problem with policy approaches of the type favoured in the Department of Health's ‘programme for action’, which depend on partnership working, is that for the most part they are not being evaluated, so it is impossible to say how effective they are in influencing outcomes. Moreover, as we have seen, the structures themselves are subject to constant change and tinkering and therefore become insufficiently stable to allow partnerships to develop, mature and become sustainable (Perkins et al, 2010; Smith et al, 2009).
The government chose not to respond directly to Wanless's second report, preferring instead to focus on the production of a new health strategy to replace Saving Lives, published just five years earlier (Secretary of State for Health, 1999). Although the existing strategy still had to complete its course in terms of implementation, the government believed that there was now a need for a new and updated one, which would endeavour to do for public health what other strategies had done for the NHS in terms of modernisation. What this meant was a strategy replete with the vocabulary of health care reform that was by now familiar; there was a great deal of emphasis on personal choice and on providing information to people to enable them to make more informed decisions about their lifestyles. It was no longer considered acceptable, if it ever had been, for government to tell people how to lead their lives and risk being accused of acting as a ‘nanny state’. As if to make this point as boldly as possible, the new strategy itself was informed by a major public consultation exercise in the lead-up to the final document and was given a title that overtly emphasised personal choice. Choosing Health: Making Healthy Choices Easier (Secretary of State for Health, 2004) marked a significant departure in terms of how the government saw its role in health improvement and tackling health inequalities. Whereas earlier statements had stressed the dual approach between government and individuals in promoting health, the new strategy shifted the focus far more firmly and explicitly towards the individual. The language around choice and individual responsibility in leading healthier lives was new, at least in a public health context, and the role of government was recast as an enabling, facilitating one designed to provide information and support to individuals who could use it to make healthier choices.
Similar language and objectives informed the health strategy published in 2006, Our Health, Our Care, Our Say (Secretary of State for Health, 2006). This White Paper came on the back of another (p.76) round of major structural change in the NHS, which included halving the number of PCTs and modifying the roles of SHAs. An effort was also made to strengthen partnership working locally through the introduction of local area agreements from 2004/05. The strategy reiterated the government's commitment to health improvement and to better health outcomes. However, its influence was overshadowed by the organisational changes and financial problems sweeping across the NHS over this period. With fewer NHS organisations, job losses were inevitable and it took nearly two years to get the new structures in place and appoint senior managers to key posts. As with past NHS reorganisations, public health was not immune from such developments.
It was hardly surprising, therefore, that when Wanless came to undertake a more searching assessment of the government's attempts to implement his proposals for a ‘fully engaged scenario’, at the invitation of The King's Fund, he blamed the lack of progress on the constant reorganisation of the NHS and frequent policy initiatives, which had contributed little to the much needed improvements in health and instead served to divert management attention (Wanless et al, 2007). In particular, Wanless and his co-authors concluded that too little progress was being made with attempts to tackle complex public health challenges such as obesity and that, unless there was a major shift in direction, the fully engaged scenario to which the government had committed itself was unlikely to be realised. Indeed, as things stood, Wanless and colleagues argued that the government might not even achieve ‘solid progress’ and was instead somewhere between this and ‘slow uptake’ (see Box 4.3).
Two further, and final, policy milestones with implications for public health merit a mention. First is the NHS Next Stage Review, led by a surgeon turned junior health minister, Lord Darzi, which was undertaken in 2007 at the request of the incoming Prime Minister, Gordon Brown, with the aim of reconnecting clinicians with the reform agenda, placing them at the centre of future change. Darzi's final report was published in the summer of 2008 (Department of Health, 2008a). Although it mentions the importance of public health and the need for the NHS to work with local government, its focus is heavily on clinical care. Indeed, Darzi's review is a reassertion of the importance of quality of care and clinical governance — issues that New Labour had promoted during its initial years in office (Department of Health, 1998c). Moreover, much of the policy direction remains the same as that set out in the 2006 White Paper, Our Health, Our Care, Our Say (Secretary of State for Health, 2006). This direction was reinforced in Prime Minister Brown's first major speech on the NHS, delivered (p.77) in January 2008, which placed a great deal of emphasis on secondary prevention and disease management (Brown, 2008). While there is obviously a public health dimension to these concerns and priorities, they form only part of the picture. As 2009 drew to a close, the public health system remained largely fragmented and appeared to have slipped down the government's policy agenda once again, although there were some countervailing pressures, notably the world class commissioning initiative (see later in this chapter) and related activities such as the joint strategic needs assessment (JSNA), and joint directors of public health appointments. It is too early to pass judgement on such developments, but in respect of JSNA a review of progress so far, which has been conducted by the Improvement and Development Agency (IDeA), concludes that “the signs are good” and that “the JSNA story so far is looking positive” (Hughes, 2009: 21). Nevertheless, the challenge remains one of how positive processes in respect of establishing joint priorities and effective partnerships can be translated into actions that have real impact on outcomes for people. Much the same applies to joint DsPH posts, which have been the subject of another IDeA review (Hunter (ed), 2008). The principle of joint posts has been widely welcomed, but much unfinished business remains to ensure that they are both viable and effective when it comes to meeting public health objectives. So far, such posts have lacked independent and systematic study. In his critical appraisal of them, Elson (2008) emphasises the need for more transparency about how the post is to be used and argues that remits ought to be matched to the needs of the local context.
All may not be lost on the wider policy front either. A reminder of the importance of the wider public health system came in August 2008 in the form of the report of the WHO Commission on Social Determinants of Health (WHO, 2008a). Adopting a social justice perspective, the authors concluded that: “action on the social determinants of health must involve the whole of government, civil society and local communities, business, global fora, and international agencies. Policies and programmes must embrace all the key sectors of society not just the health sector” (WHO, 2008a: 1). Health ministries were called on to “champion a social determinants of health approach” and “support other ministries in creating policies that promote health equity”. Responsibility for the health gap was attributed to a “toxic combination of bad policies, economics, and politics” (WHO, 2008a: 26) and the following three principles of action were advocated:
• improve the conditions of daily life — the circumstances in which people are born, grow, live, work and age;
• measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health and raise public awareness about the social determinants of health.
A principal concern of the review was to examine the levers and incentives to ensure effective implementation of policy and bring about change, including interagency working, (economic and other) incentives, the role of targets and indicators, and workforce implications.
In its final report, the review concluded that national policies would fail to reduce inequalities if local delivery systems were unable to deliver them (Marmot Review, 2010). It accepted the evidence received from local practitioners that they wanted freedom to develop locally appropriate plans to reduce health inequalities within nationally agreed principles. The review proposed that strategic policy should be underpinned by a limited number of aspirational targets that supported the intended strategic direction to impove and reduce disparities in (p.79) life and health expectancy and monitor child development and social inclusion across the social gradient. The role of local government was seen to be pivotal both to improve health and to reduce health inequalities. Although the need for strong partnerships between local authorities and NHS PCTs was stressed, it was acknowledged that the current partnership framework needed considerable development and enhancement with less focus on targets, which often reinforced silo-working, and more attention to a whole systems perspective. Appropriate leadership skills were also needed and should be invested in to ensure that partnerships were effective.
Setting targets and performance managing
Another important departure in the post-1997 Labour government's approach to health has been a focus on targets and performance assessment. This focus has been extended to health improvement and health inequalities, for which targets have also been set, although arguably without the same degree of commitment or consistency as applied to others, particularly access targets (Hunter and Marks, 2005; Marks and Hunter, 2005). For example, the 1999 health strategy Saving Lives: Our Healthier Nation set out various health improvement targets in particular ‘health problem areas’, such as coronary heart disease and cancer. Since then, a series of changes and additions to targets of relevance to public health have been made, including the introduction of health inequalities targets focusing on life expectancy and infant mortality (Department of Health, 2001a) as well as targets focusing on changing lifestyle behaviours, such as smoking. Public health was one of the seven domains for which core and developmental standards were monitored by the Healthcare Commission as part of its Annual Health Check (Healthcare Commission, 2004). The Healthcare Commission was replaced by the Care Quality Commission in April 2009. At the time of writing, its approach to monitoring and inspection is undergoing changes to publish more timely data, although it is likely to retain much of its predecessor's approach and method. This includes assessments of conformity with public health guidance from NICE and developmental standards that emphasise the importance of a whole systems approach. In addition to the notion that targets should act as drivers for action, some of the broader public service agreement targets were used to promote collaboration between local government and the NHS through shared responsibility for outcomes and have since been absorbed into local area agreements (LAAs), agreed across central government and a local area, and across the partnerships (p.80) within local areas. From April 2009, LAAs were assessed through a comprehensive area assessment (CAA) led by the Audit Commission (Audit Commission et al, 2009). The CAA replaced the comprehensive performance assessment of local government and makes all partners within a local authority area, including PCTs, accountable for shared outcomes.
Developments in the workforce: making a reality of multidisciplinary public health
Perhaps as a consequence of the lack of a clear conception of its purpose and raison d'être, the public health function has been subjected to a considerable degree of change and uncertainty. As was asserted in a recent House of Lords debate: “Nowhere, perhaps, has reorganisation been more disruptive than in public health” (House of Lords, 2006). For ease of reference, and to avoid cluttering the main text with the numerous structural changes that have occurred with increasing rapidity since 1974, the various changes are described in the Appendix. As noted earlier, these changes have invariably not been directed primarily at the public health community but have nevertheless had a major impact on policy and practice at all levels of the system. This is particularly true of those sections of the workforce employed by, or working for, the NHS. All these developments have resulted in a public health community that is increasingly insecure and unsure of its purpose or fitness for whatever that purpose proves to be. This was borne out by the comments made by many of our interviewees, some of whom testified to the resulting poor morale within the public health community:
Despite the constant policy and organisational churn in evidence from 1997 to the present, there were also some encouraging developments for the public health workforce, particularly with respect to strengthening (p.81) its multidisciplinary base. Soon after the government had entered office, there followed a detailed commitment to developing multidisciplinary public health, including a specific pledge to creating a new, non-medical role of specialist in public health in the White Paper, Saving Lives: Our Healthier Nation (Secretary of State for Health, 1999). This announced a number of initiatives intended to help develop a genuinely multidisciplinary public health function. These included the production of a National Public Health Workforce Development Plan (which, although virtually completed, was never published), the completion of a Public Health Skills Audit, the creation of a Public Health Development Fund and the establishment of the post of specialist in public health, which, it claimed, would “be of equivalent status in independent practice to medically qualified consultants in public health medicine and allow [non-clinical public health specialists] to become directors of public health” (Secretary of State for Health, 1999: 136). The same White Paper also announced the establishment of the Health Development Agency (replacing the Health Education Authority), which was charged with a mandate to build and disseminate the evidence base for public health and to facilitate the sharing of knowledge and good practice.
PCT: I've seen lots of colleagues who have just said this is enough, and honestly I'm feeling I couldn't cope with…getting my head around yet another reorganisation…So I think it's really tough keeping morale up now.
NGO: None of the money that's promised for public health has seen itself through…I mean it's an absolute scandal. Yes, people are leaving the profession, the cuts are big…have been throughout the system. Morale is very, very low indeed. And also they're worn out with organisational change.
The following year Alan Milburn, then Secretary of State for Health, gave the London School of Economics and Political Science annual health lecture, in which he called on those involved in public health to end “lazy thinking and occupational protectionism” and “take public health out of the ghetto” (Milburn, 2000):
In 2000, the year after the first consultant-level specialist public health posts to be open to candidates from disciplines other than medicine were advertised by some health authorities, the Faculty of Public Health Medicine agreed that membership of the Faculty should be opened to candidates from disciplines other than medicine and dropped ‘Medicine’ (p.82) from its title, becoming the Faculty of Public Health. Also in 2001, as mentioned in earlier chapters, the final Report of the Chief Medical Officer's Project to Strengthen the Public Health Function was published (Department of Health, 2001c), providing further support for the earlier policy statements’ calls for a multidisciplinary approach to public health. This report identified three broad categories of people comprising the public health workforce:
[T]he time has come to take public health out of the ghetto. For too long the overarching label ‘public health’ has served to bundle together functions and occupations in a way that actually marginalizes them. So by a series of definitional sleights of hand the argument runs that the health of the population should be mainly improved by population-level health promotion and prevention, which in turn is best delivered — or at least overseen and managed — by medical consultants in public health. The time has come to abandon this lazy thinking and occupational protectionism.
• Specialists: consultants in public health medicine and specialists in public health who work at a strategic or senior management level or at a senior level of scientific expertise to influence the health of the population or of a selected community.
• Public health practitioners: those who spend a major part, or all, of their time in public health practice — for example, health visitors and school nurses.
• Wider public health: most people, including managers, who have a role in health improvement and reducing health inequalities although they may not recognise this, including teachers, social workers, local business leaders, transport engineers, town planners, housing officers, regeneration managers and so on.
This categorisation, which does not suggest medical training is essential for individuals working in any of the three categories, remains central to Department of Health policy. The CMO's report also highlighted problems of undercapacity in the public health workforce and recommended significant government action to address the deficit:
We need to make sure that the public health workforce across all sectors is skilled, staffed, and resourced to deal with the major task of delivering the Government's health strategy. An increase in capacity and capabilities must be achieved. (Department of Health, 2001c: 24)
Importantly, the report suggests that a renewed drive to increase public health workforce capacity should be accompanied by moves to ensure the workforce becomes more multidisciplinary in nature. However, identifying exactly who or what comprises the public health workforce has created problems. Crowley and Hunter (2005: 265), for instance, argue that:
A number of studies have assessed the impact of the 2002 NHS reorganisation on public health. For example, one study found that medically qualified specialists were less skilled in community development, leadership and management (Barts and City University London, 2003). Gaps in information analysis skills were common. Another study of the capacity and capabilities of the public health workforce found there was:
…greater clarity and focus is required if public health is to deliver…especially in respect of health improvement that (p.83) demands skills from a range of agencies outside the NHS and located within communities.
• a lack of clarity surrounding the term ‘specialist in public health’ and confusion regarding both the role of a specialist and the general public health function;
• fragmentation of the workforce;
• a loss of critical mass and the potential for professional isolation; key skills gaps including health protection, partnership working and leadership (Chapman, Shaw et al, 2005).
Between 2001 and 2002, the Faculty of Public Health gradually opened up its public health examinations to non-medical candidates. Within the new PCTs, of which there were over 300 arising from Shifting the Balance of Power (Department of Health, 2001d), the first directors of public health from backgrounds other than medicine were appointed, and the Minister for Public Health at the time officially welcomed the fact that “this generation of DsPH come from a variety of backgrounds — both medical and non-medical” (Blears, 2002). She also welcomed the new DsPH who were jointly appointed by both the NHS and local government, suggesting that such developments provided cause for optimism “that multidisciplinary public health will become a reality” (Blears, 2002). However, to allay any fears about substitution or marginalisation, she also stressed that doctors “remain a crucial part of this new world” (Blears, 2002). Also at this time, and in keeping with the renewed emphasis on strengthening the wider public health workforce, the UK Voluntary Register for Public Health Specialists was established in 2003 to help quality assure this new breed of non-clinical specialists; the first trainee from a background other than medicine successfully completed their training through the Faculty of Public Health route in 2005, by which time one third of the Faculty's 3, 000+ members were from backgrounds other than medicine (Evans and Knight, 2006).
(p.84) Many of those involved in public health have welcomed the expansion of public health responsibilities to include a wider range of players (for example, Wright, 2007). However, the shift away from a requirement for public health specialists to have medical training towards a more inclusive approach has not been without opposition, as a series of debates in the British Medical Journal in 2000/01 illustrates (for example, McPherson, 2000; McPherson et al, 2001). Wright (2007: 219) claims that medical resistance focused on concerns about whether the route to such specialist posts open to non-medical specialists (achieved via a portfolio approach) constituted real equivalence to the route taken by medically qualified personnel, suggesting it was perhaps “an easy alternative to higher specialist training”.
There were also concerns that public health might lose its critical mass, with Jessop (2002:1) warning: “NHS public health workers will be dispersed to the loneliness of 300 primary care trusts…they will face professional isolation, with hence an inevitable struggle to retain competence and sanity”. To counter the fragmentation of the public health workforce, the government announced the establishment of public health networks (Department of Health, 2001d) — see Box 4.5. (p.85)
(p.86) There are also concerns about the extent to which the moves towards a multidisciplinary workforce have actually succeeded. As Wright (2007: 219) points out, the new route for non-medical specialists was, in reality, open to relatively few senior professionals, “leaving a disaffected and unsupported majority of the workforce in need of further training” to reach the levels of competence required. In 2001, the House of Commons Health Committee (2001) claimed that the government had failed to redress the balance between health care and health. A year later, Evans and Dowling (2002) reported that significant barriers to multidisciplinary public health persist, including a continuing lack of clarity about policy aims combined with a belief that training, registration and career pathways remain unclear for individuals who do not have medical qualifications. In 2003, Evans wrote:
Closely related to the tensions between medical expertise and the drive for a multidisciplinary workforce, long-standing debates about the best location for the public health function have remained alive (Hunter, 2003). The retention of the major public health function within the NHS is linked to the survival of the speciality of public health medicine and yet, as Hunter (2003: 111) claims: ”All available evidence suggests that the NHS, essentially a ‘sickness’ service, will never take the wider public health seriously”. The belief that it is irrational to maintain the location of the majority of public health specialists within the NHS when most of the major levers for achieving public health's aims lie beyond the NHS is supported by the evidence that the first joint Director of Public Health to be appointed in England, Dr Andrew Richards, presented to the House (p.87) of Commons Health Committee's inquiry into public health in 2001 in a memorandum (House of Commons Health Committee, 2001b: 442). He argued that “the location of DsPH at the heart of the NHS has inevitably pulled them away from, rather than towards, those parts of the wider system that most powerfully influence health”. In support of joint DsPH appointments, he considered it to be “irrational that most of the interest, skills and resources to improve public health are outside the NHS while the DPH is locked into it”. Therefore, “there are strong arguments that DsPH have to be eased out of the NHS box”.
Despite the rhetoric of inclusion and equivalence, in practice there is continuing demarcation between medical and non-medical public health jobs. Regional director of public health posts and consultants in communicable disease control remain restricted to medical candidates. Non-medical directors of public health in PCTs earn between £15–20, 000 less than medical colleagues apparently doing the same jobs. Although the FPHM [Faculty of Public Health Medicine] has opened its examinations and membership to non-medical candidates on an equivalent basis, there are many structures that remain essentially uni-disciplinary (Evans, 2003: 965)
The Labour government's second White Paper on public health, Choosing Health: Making Healthier Choices Easier (Secretary of State for Health, 2004), demonstrates how important it is for those working in public health to look beyond the NHS. It highlights six key themes for public health, all of which require engagement by partners beyond the NHS — notably, local government but also other agencies — sexual health, mental health, tackling obesity, smoking reduction, reduction in alcohol intake and reduction generally in health inequalities. The crucial role of the public health workforce is emphasised with regards to achieving the desired behavioural changes in all of these areas. Annex B of Choosing Health considers the importance of ensuring public health practitioners have the correct skills for their work in improving health, including a strong leadership capacity, and makes commitments to addressing critical shortfalls in specific staff groups.
Given Wanless's criticisms about the weak implementation of public health policy, the issue of delivery was a key one for the architects of the public health White Paper. An accompanying document, which was published some months later, Delivering Choosing Health (Department of Health, 2005a), outlines the government's commitment to developing the public health workforce as a key means of improving health and tackling health inequalities. In the Supporting Strategy B of this document (pp 42–3), it is suggested that new contractual arrangements within the NHS ought to be used to engage primary care staff in improving health through everyday practice. This section also outlines the development of some new roles within the field of public health, including health trainers, which were proposed in the Choosing Health White Paper. Health trainers were to be recruited from local communities and were funded to offer tailored information, motivation and practical support to individuals and groups who were interested in adopting healthier lifestyles, helping them to set personal goals in areas such as stopping smoking, doing more exercise, eating healthy foods, practising safe sex, dealing with stress and tackling social (p.88) isolation. They were also intended to identify barriers to healthier choices and signpost people to relevant local services. The initiative has been described as “taking the NHS to people” (Secretary of State for Health, 2004).
As well as encouraging local delivery and strategic plans to help identify gaps in the workforce, the delivery plan suggests a national workforce strategy and competency framework is required “to underpin the development of education, skills and work across the health and social care community, local government, business communities and the voluntary sector” (Department of Health, 2005a: 42). A single public health skills and career framework was subsequently produced, having been developed in response to an expressed need for a mechanism that “facilitates collaboration and coherence across this diverse workforce” (Public Health Resource Unit and Skills for Health, 2008: 4). The framework is designed to help “ensure rigour and consistency in skills, competence and knowledge at all levels, regardless of professional background, and by enabling flexible public health career progression” (Public Health Resource Unit and Skills for Health, 2008: 4). For the first time, it brings together into one development framework the various standards, competencies and training routes pursued separately by each professional group.
Another important development has been a desire to achieve some degree of role and pay parity between public health practitioners with clinical and non-clinical backgrounds. A government initiative entitled Agenda for Change (Department of Health, 2004) aimed to bring the whole of the NHS workforce (with the exception of doctors and dentists) into a single pay framework. Although this policy was not specifically intended to unify the public health workforce, Wright (2007) argues that the changes it has brought about are leading to a coherent approach to job definitions and pay scales in public health for the first time. The absence of alignment has been a major stumbling block in terms of encouraging non-clinicians to enter the public health workforce.
A subsequent White Paper, Our Health, Our Care, Our Say (Secretary of State for Health, 2006), placed further emphasis on the need to develop the capacity of, and skills within, the health workforce. It pointed out that, currently, very little of the money the NHS and social care sectors spend on training goes on training people in support roles and argues that “it is not acceptable that some of the most dependent people in our communities are cared for by the least well trained” (Secretary of State for Health, 2006: 188). The document goes on to make commitments to spending more money on training and support (p.89) for the wider health and care workforce, and to developing joint service and workforce planning between the NHS and local authorities. It is not yet clear what progress, if any, has been made in achieving these aims. Alongside these developments, important changes among the various NGOs and professional groups involved in public health have occurred over the last decade (see Box 4.6).
(p.90) In addition, attempts have been made to encourage primary care professionals to focus more explicitly on preventative health measures. For example, the new GP contract, implemented in 2004, allows for payment to be tailored to specific services and was partially intended to develop further the health promotion aspects of this key primary care function. However, as Peckham and Exworthy (2003) note, primary care in the UK has been primarily focused on general practice working within a medical model of health. The social model on which public health draws has generally been the exception in primary care. In her evidence to the Health Committee's inquiry into public health, Professor Jennie Popay referred to the “awesome” (p.91) expectations laid on primary care to deliver the public health agenda, noting the absence of evidence to suggest that GPs either “have the capacity or the inclination” to move upstream (House of Commons Health Committee, 2001b: 91).
How far have things changed?
Despite the promising policy rhetoric around public health, the structural reorganisation of the public health function, and commitment to developing public health practitioners and the specialist workforce, the recent literature on the public health workforce makes for disappointing reading and does not suggest that the problems outlined by Brackenridge (1981) and others over 20 years ago have yet been fully dealt with. Time after time, more recent research on a range of different sectors and aspects of the public health workforce has cited problems of undercapacity and a lack of clarity around training, career progression and interdisciplinary working. For example, Brown's (2002) scoping study of the public health workforce in the North East, Yorkshire and Humber found a great deal of consensus among members that it was under capacity, under resourced, had skill gaps and that there were significant organisational difficulties in promoting collaborative and integrated working. The findings from this study (which are discussed further in Brown and Learmonth, 2005) also indicate that problems around professional barriers and ‘turf wars’ were impeding partnership working, and that there had been little practical progress in terms of building capacity across the three levels of the workforce identified by the CMO (Department of Health, 2001c; see also above) because of a lack of resources.
Studies on the role of public health nurses have found problems in training and associated gaps in skills, a lack of clarity of individuals’ roles and experiences of marginalisation from other members of the public health and healthcare workforces (Burke et al, 2001; Latter et al, 2003). Research on the role of public health specialists (for example, Chapman, Abbott et al, 2005; Chapman, Shaw et al, 2005; Gray et al, 2005) identifies key skills gaps, a lack of clarity over the role of the specialist and the public health function, fragmentation and attrition of the workforce, and inadequacies in training and continuing professional development.
Around the same time as these various critical accounts emerged, a report commissioned jointly by the Department of Health and the Welsh Assembly Government (2004), which aimed to tackle some of these issues, was published. Acknowledging many of the problems (p.92) outlined above, the report sought to help define the roles, functions and development needs of the specialist public health workforce. In the context of the White Paper Choosing Health (Secretary of State for Health, 2004), this report focuses particularly on the health promotion aspect of public health specialists’ roles. It recommends long-term sustainable staffing structures (and associated funding), a clear and recognised career pathway allowing free movement between the NHS and local government, and supporting education and training.
The prospects for better public health education and training may be constrained, however, as evidence suggests that the academic side of public health is also struggling with a range of difficulties. An investigation into academic public health raised serious concerns about capacity and identified significant problems with the funding of academic posts (Public Health Sciences Working Group, 2004):
Consecutive surveys of the specialist public health workforce, undertaken by the Faculty of Public Health in 2003 and 2005, also highlight issues of undercapacity in the specialist section of the public health workforce (Gray et al, 2005; Gray and Sandberg, 2006). These surveys indicate that there was a fall in numbers of consultants/specialists in public health of 17% (224 individuals) in the UK between 2003 and 2005, reducing the overall level of total specialist public health capacity in the UK from 22.2 per million in 2003 to 18.5 per million in 2005 (Gray and Sandberg, 2006). The report's authors claim that this fall appears to have related particularly to public health specialists working in the NHS in England and in universities. In addition, the surveys found evidence of significant regional variation in the distribution of public health specialists, widespread dissatisfaction with public health team capacity and a significant proportion of specialists (17.6%) who were considering leaving the speciality within the next five years.
The report highlights the extraordinary disparity between, on the one hand, the overriding importance of the public health sciences for public protection, service provision and health improvement and, on the other, the limited strategic interest that is taken in their infrastructure and conduct. Impressive achievements in the biomedical sciences and medical care can obscure the fact that the circumstances in which people live, whether these circumstances are under their personal control or not, are still the major determinants of health. (Public Health Sciences Working Group, 2004: 2)
(p.93) Problems with undercapacity in the public health workforce are noted by the CMO in his 2005 annual report (Department of Health, 2006), which highlights a deficit in public health capacity affecting the 48% of England's population living in the Midlands and the North. The report also suggests public health funds are being “raided” to support clinical activities in some areas. In light of this, the CMO suggests that the lack of progress “is more compatible with the Wanless ‘slow uptake’ scenario than with the ‘fully engaged’ scenario” to which the government is ostensibly committed (Department of Health, 2006: 39). In conclusion, the CMO suggests consideration should be given to “establishing a comprehensive review (the first in almost 20 years) into arrangements to improve and safeguard the health of the public” (Department of Health, 2006: 45).
While such a review seems unlikely, other developments have occurred. For example, following the recommendation of Delivering Choosing Health (Department of Health, 2005a) that a national workforce and competency framework was required, plans to develop a coherent public health career framework for use across the UK have been implemented. As mentioned earlier, this work, which was undertaken by Skills for Health and the Public Health Resource Unit (on behalf of the Department of Health), has sought to create a simple and easy-to-use tool to facilitate collaboration and coherence across the diverse public health workforce.
The framework, which is aimed at the development not only of the professional public health workforce but also the wider workforce, is based on a modified version of the generic NHS Career Framework. It consists of nine levels, from initial entry to the public health system to the most senior positions in relevant organisations. Each level contains descriptions of the main competencies and knowledge required to work at that level. Public health work is based on various competencies, in a combination of core areas, which everyone in the field is expected to have, and non-core areas, which apply to more specific domains of public health. These competencies relate closely to the ten areas of public health practice that underpin the UK Voluntary Register for Public Health Specialists. The revised competencies already form the basis for the job description of directors of public health (Faculty of Public Health, 2006).
The core areas are:
• surveillance and assessment of the population's health and wellbeing;
• assessing the evidence of effectiveness of interventions, programmes and services to improve population health and wellbeing;
• leadership and collaborative working for population health and wellbeing.
• health improvement;
• health protection;
• public health intelligence;
• academic public health;
• health and social care quality
Following testing of the framework, necessary changes have been made to ensure that it is fit for purpose, although it will continue to evolve as the workforce and the focus of public health policy change. This will be especially important in the context of recent changes in public services, notably the NHS and local government. These include a greater emphasis on commissioning and on making a clear distinction between this and the provision of services, better partnership working, and more diversity of service providers with a bigger role envisaged for new third sector social enterprises. In addition, further work is required in respect of public health leadership development, including reaching an agreement as to what further work might be undertaken in this area to provide appropriate leadership programmes for director-level staff. Some progress has been made in this area with the Improvement Foundation working with Durham University and the local government IDeA to offer a new national Leading Improvement for Health and Well-being Programme (Hannaway et al, 2007). In addition, the NHS North West has also launched an Aspiring Directors of Public Health Leadership Programme being run by the consultancy group Salomon's.
How is progress viewed on the ground?
Our interviewees were asked whether they considered the public health workforce to be multidisciplinary and to discuss which skills they felt were required by this workforce. Opinions about the extent to which the current public health workforce (at the time of the interviews) was multidisciplinary depended on the way in which they defined ‘multidisciplinary’. Those who suggested a multidisciplinary workforce already existed either felt that not everyone who contributed to it (p.95) necessarily saw public health as part of their role (and that this was relatively unimportant), or had a rather narrow view of what constituted a multidisciplinary workforce. For example, the following interviewee fell into the former category:
DH: I often have to pinch myself before I get into a debate about the public health workforce because I don't actually think of this group of people with sort of public health workforce labels and t-shirts on as they go round. I think of people across the whole of the public sector who have some aspects of public health work within their role and remit and who make a contribution. And therefore I don't actually necessarily usually distinguish between a group of full-time public health professionals and the broader public health or health improvement role of people who work in Housing or Education or in Benefits Services or in the NHS, in fact. So I always struggle when we get into this debate and I think that sometimes we almost create a bit of a paper tiger.
In contrast, the following interviewee presented a rather narrower view of ‘multidisciplinary’, defining it merely in terms of the mix of medical and non-medical specialists:
PCT: [A multidisciplinary workforce] is very much a reality, certainly here…I'm intending that, when my consultant posts are all filled, they should be a mix of medical and non-medical posts. In pure numbers’ terms, the majority of people who work in the public health directorate are non-medical.
Indeed, the divide between interviewees who focused on a medical model of health and those who focused on wider social and economic determinants was quite stark in several aspects of the data but particularly in relation to discussions about the workforce. For example, the following two interviewees were both keen to emphasise that they felt medical expertise was essential to achieving public health objectives, or at least to undertaking certain aspects of the work that are currently expected of DsPH. In this regard, it is important to distinguish between belief in a medical model of health on the one hand and recognition of the tasks that fall to DsPH in PCTs on the other (one of which is control of health care associated infections):
PCT [different interviewee from above]: I'm conscious of what I do, in my day-to-day job, a huge amount of it is not technically public health. I'm a Medical Director but also I cover a huge number of other things because I have a clinical background and because I'm jolly experienced at this, that and the other.
However, many other interviewees, especially those based in local and central government and in NGOs, felt that the dominance of a model of public health in which medical professionals were accorded higher status than non-medical professionals was a major cause of many of the problems dogging the current public health system. In fact, an interviewee based at the Department of Health (DH) expressed frustration that some public health specialists working within central government did not take his/her views seriously because s/he did not have medical training:
While, on the whole, those subscribing to a narrow definition of the public health workforce tended to be public health specialists who had undertaken medical training and those who emphasised the importance of a model of public health that focused on wider determinants of health tended to have non-medical backgrounds, this was not consistently the case. It is important to emphasise that many public health specialists (DsPH and RDsPH) were extremely supportive of the need to include a broad and diverse mix of skills in the public health workforce and were generally encouraging about the potential for people from outside the traditional public health community to move into public health specialist posts. Furthermore, the majority of (p.97) interviewees felt that progress had been made over the last five years, despite professional resistance from some ‘old-fashioned public health leaders’, and this was perceived to be embodied in the increasing number of joint appointments and teams straddling the NHS and local authorities. Nevertheless, with the exception of the few interviewees who felt that a multidisciplinary workforce already existed, most of the interviewees suggested this was an area that still required a great deal of further development.
DH: I'm reflecting some of my own frustrations around trying to get my colleagues in public health to take anything that I do in this area seriously because I'm not a doctor. I've found it very easy to get a lot of other people to change but I've found it enormously difficult…It's funny, isn't it? You know, here I am [in the Department of Health in a public health role] and the people I've had most difficulty getting any engagement with in national policy are the people running public health.
This suggests that efforts over recent years to encourage the specialist public health workforce to broaden its constituency, and to link more closely with actors and sectors beyond the specialist workforce, are having an impact, although it is hard to judge precisely what this might be in the absence of systematic evidence. While it is true that mechanisms such as local strategic partnerships and local area agreements have been widely welcomed, the evidence concerning their impact on outcomes is hard to come by (Perkins et al, 2010). Bearing in mind that the shift in outlook on the part of public health specialists requires cultural as well as policy change and that it is dependent on a range of factors, including changes in training programmes, it is unsurprising that this shift has not occurred quickly.
A significant number of interviewees reported that recruitment to public health specialist posts remained problematic and expressed a range of concerns, including the limited resources available to public health and the difficulties caused by the raft of recent reforms (both issues have already been touched on and are discussed further in Chapter Five). As a consequence, several of the interviewees felt that there was a worrying dissonance between the skills required by new specialist public health posts and those that were being promoted through the various career routes to these posts. For example:
The skills that were mentioned most often as those that public health training courses failed to address but that candidates for specialist posts were expected to possess related to: commissioning, collaborative working, leadership and financial management (key (p.98) themes that are all discussed further in Chapter Five). Unfortunately, while most interviewees felt this was an area that ought to be addressed, few of the interviewees working within the specialism believed current arrangements were adequately dealing with these problems. Furthermore, several interviewees suggested that the gaps in training programmes were being exacerbated by a lack of clear career development paths for those entering the specialist workforce.
SHA: We've got this problem that the new public health directors require a new set of skills, and I don't think that public health was really prepared for that, and I think over the last five years we've failed to tram people with the right skills to deliver on the new agenda. And it's been really hard to recruit high quality directors of public health — we just can't find them.
In the light of the above comments, it was unsurprising that many interviewees also expressed a desire for changes relating to the training of the public health workforce.
Overall, although now more multidisciplinary in nature, the public health community is also more fractured and disunited and faces a persistent lack of clarity about workforce roles. All this supports Hunter and Sengupta's (2004: 4) claim that: “There remain serious concerns over the purpose of public health, and over the capacity of the workforce and its capability to deliver what is required”. As Beaglehole and colleagues suggest, and returning to a central theme of the last section, the problems facing the development of an effective, multidisciplinary public health workforce are closely tied to the question of what public health is: “If public health practitioners are to address national and global health challenges effectively…a clear vision of what public health is, and what it can offer, is required” (Beaglehole et al, 2004: 2084). A failure to achieve this sense of unity will result, Wills and Woodhead (2004) claim, in public health continuing to be marginalised and failing to form the central concern of any of the various professions deemed part of public health.
These issues are by no means unique to this period in time within England (Beaglehole et al, 2004; Scally and Womack 2004; Tilson and Gebbie, 2004). For example, former WHO Director General, Lee Jong-wook, raised similar concerns in the international context:
Similarly, in a recent review of the public health enterprise in the US, Tilson and Berkowitz (2006) cite a range of challenges to public health that overlaps with many of the issues that have been highlighted in England, including a lack of clarity about the public health function (p.99) and lines of accountability, gaps in competencies, skills and training, and a paucity of good research.
…progress will at best falter if the capacity issues in public health continue to be ignored or downplayed, if the medical dominance of the speciality reasserts itself, or if the absence of a shared set of values hampers an integrated approach across disciplines and agencies. (Jong-wook, 2003)
It might be that adopting the concept of a public health system could offer a way of tackling some of these tensions and deficits. It is certainly the case that some kind of new approach is required, since simply revisiting the issues over time and coming up with the same analyses and prescriptions has not yet resulted in significant progress in improving the public's health, despite the mounting challenges facing it. Chapter Two elaborated on what is meant by such a system and outlined how it might be applied, taking advantage of the diverse sectors and range of expertise that are not axiomatically regarded (or that do not regard themselves) as making a major contribution to improving the public's health. Perhaps trying to get agreement on a definition of public health and discussing the public health workforce as if it comprised only those with public health in their job title should give way to a focus on a complex public health system with multiple facets and resources, and to accessing its relevant components according to the particular public health task requiring attention. Indeed, given the difficulties of defining the public health workforce and determining who should be doing what, we should perhaps focus instead on clarifying the nature of the public health system.
Some final reflections on the evolution of the public health function
Looking back on the history of public health covered so far, it is clear that it has been marked by lack of clarity over purpose, location and the composition of the workforce. Adherence to the three domains of public health developed by the Faculty has tended to reinforce and compound these tensions by simply bundling all of them into the remit and job description of various public health practitioners.
Currently, a lack of clarity over the public health function persists with, for example, Crowley and Hunter (2005:265) claiming that public health is “being interpreted through the narrow prism of ill health and disease”. Elsewhere, Hunter (2003: 101) argues that the term ‘public health’ is itself a handicap, “since it is not recognised outside the NHS and is imbued with medical overtones”.
On a practical level, Holland and Stewart (1998) outline three potential options for the location and organisation of the public health function:2004: 200). Recent changes mean arrangements in Wales are now similar to the former New Zealand public health commission model, but these changes have not yet been in place long enough usefully to evaluate or reflect on them. Moreover, following a review of the public health system in Wales, it is likely that there will be changes in these arrangements with a termination of the national agency approach to organising the public health function and a strengthening of the function at local level.
Reflecting on this chapter alongside the previous one, our review suggests that a number of persistent and recurring concerns about the public health function and the associated workforce have been evident (p.101) throughout the period from 1974 to the present day. The following five merit particular attention:
• Lack of agreement over what the public health function comprises involves persistent tensions between its technical-managerial role and its activist role.
• There is no agreed or shared philosophy governing public health activities, with the result that different models of public health compete with each other, resurfacing over time and jostling with each other for positional supremacy, rather than coexisting in a balanced approach.
• A never-ending succession of organisational reforms (especially affecting the NHS) has presented difficulties for staff trying to settle into posts or build supportive relationships. This has posed a particular barrier for the development of cross-agency partnerships.
• There has been an ongoing debate about how the public health workforce is defined and where it should be located. However, there does now appear to be a consensus that shifting the lead for public health from the NHS back to local government would not in itself resolve the complexities that are intrinsic to the public health function, for it is increasingly recognised that the issues facing public health are not resolvable via structural solutions alone, having more to do with disciplinary and political cultures and associated perceptions of responsibility.
• Despite a recent and welcome shift towards a multidisciplinary workforce, the government's efforts to achieve this through altering training programmes have left a gap in terms of agreeing a set of values to unite the public health movement. (p.102)