The recently published Design of the NHS Commissioning Board (CB)  “presents recommendations for the organisational design of the NHS CB”. This was followed by the Commissioning Intelligence Report, which contained the Commissioning Intelligence Model. The juxtaposition of these two documents highlights the lack of joined up thinking about NHS commissioning and, the involvement of Public Health (PH) in commissioning NHS services.

The Design paper lays out the constituent functions of the NHS CB. It explains that there will be corporate teams and that the approximately 3,500 strong workforce will be committed to matrix working. What it most spectacularly does not talk about is public health involvement. There are medical, nursing and operations directorates but none have identified PH posts within them.

The Commissioning Intelligence Model has been written largely to inform the intelligence needs of CCGs for commissioning. This report makes many valuable points about the need for timely, accurate data to enhance patient care and commissioning. When I got to the Commissioning Intelligence Model, the full impact of what I was reading struck home.  It could be a diagrammatic representation of the Health Services Public Health parts of the FPH curriculum. This is what every PH consultant is trained to do, and what health services PH specialists have spent years perfecting, studying and improving.  The Commissioning Intelligence Report says that discussions with PH in LA will be necessary. This totally misses the point.

There are two fatal flaws in the reasoning behind these documents.

1.    CCGs will need this commissioning intelligence, but it is a fundamental part of the commissioning process, not a bolt-on extra.. This has to be embedded in the commissioning process, so that the conversion of data into useable information for clinicians and others involved in commissioning is seamless. This will not happen if it is seen as something separate from the main commissioning focus. Health services PH professionals need to be embedded with CCGs, not sitting in LAs offering ‘advice’.
2.    If this is necessary for CCG commissioning, then surely it must also be necessary for the NHS CB. Yet nothing in that document mentions it. Why this resistance to PH at the level of the NHS CB? How will the NHS CB ensure it has commissioning intelligence if it has not got the expertise within it? To say that Public Health England will offer such advice as is necessary is, again, to miss the point of the reality of every day working, taking hearts and minds with you in managing difficult decisions.

Commissioning intelligence is going to be vital if the challenges facing the NHS are to be met. Commissioners have to be properly trained in all aspects of population health. The NHS already has a fully trained cadre of professionals ready to undertake the work. Some of us have been doing it for years. Importantly, we are the only group who can guarantee that we have maintained our skills and who can bring together all the skills demonstrated in the model.
If the jobs are not guaranteed by Faculty standards, where are the safeguards for the future when the current crop of PH professionals retires?

Since before Christmas, women have been concerned by the revelations about faulty implants used in breast surgery. There has been much debate about whether or not these should be removed and, if so, who should foot the bill. The expert committee convened under Sir Bruce Keogh, Medical Director of the NHS, reported Friday 6th January. However, many Faculty members fear the issue is just one small example of what might happen on a larger scale if the changes to the health service now  going through Parliament proceed without proper risk assessment/ challenge.

The revelations of multiple failures, of manufacture, regulation, and responsibility, should make Peers consider the facts very carefully. The government proposes a vast increase in private provision of health care just as we are told that existing private providers are unable to supply adequate records of what they have been doing and are charging women for information on what happened to them.

There is complete confusion about who is responsible for putting things right, except that we know it is not the manufacturer, which has ceased trading. Private companies are citing ‘commercial confidentiality’ as a reason for not producing data. Yet, Peers are now being asked to endorse a Bill that may increase the risk of such events occurring without being able to see the government’s risk register.

The Bill will lead to further fragmentation of data collection, as the Faculty has said, and contains no clear failure regime for private providers. This will be even worse than the failed data collection which meant that the Independent Sector Treatment Centres established by the last government were unable to provide data to assess whether they were providing value for money, or even complying with the terms of their contracts.

This has just been one example of the failure of private provision with a  requirement for the NHS to pick up the pieces, as local authority care has had to step in with the Southern Cross disaster. Such examples show how services  provided by the taxpayer are then required to divert their resources from other pressing needs. And there is little come back for the private citizen, the patient, caught in the middle of this failure.

There is also an additional cause for concern. The Secretary of State for Health was interviewed about the breast implant issue on Radio 4’s Today programme Wednesday 4th January.  Under current legislation and under a clause that has stood since the beginning of the health service, the Secretary of State has a duty to secure, and to provide comprehensive health care for all.

In the new Bill, this Duty to Provide will be removed. The Secretary of State will be able to disclaim responsibility and say that it is the responsibility of each Clinical Commissioning Group that authorized their use. The Secretary of State has been  reduced to exhorting  private providers to fulfill their moral duties but has no  authority to  make them.  If the Health Bill becomes law, who will then be interviewed on the Today programme, stand up and be counted and admit, ‘the buck stops here?’

By Sir Richard Thompson, President of the Royal College of Physicians

Prevention is better than cure. It is a cliché, but it is true. There are opportunities within public health policy to address the rising demand on the NHS and other public services. It is obvious to me that the future viability of the NHS depends on a coordinated approach to public health, nationally and locally.

Secondary care specialists and public health doctors are crucial, providing specialist knowledge and expertise on clinical issues and the health of the population.

Giving local authorities greater public health responsibility does give us an opportunity to tackle the broader social determinants of health, such as housing and air quality. However, there is a risk that there will be a dislocation of ‘medical’ and ‘public’ health.

To avoid this, we need to take an integrated approach. I believe public health specialists should also sit on the board of all Clinical Commissioning Groups (CCGs) and the NHS Commissioning Board. Reciprocally, hospital doctors should be represented on Health and Wellbeing Boards, which will be based in local authorities. This will help to develop and strengthen their links with the NHS.

I have been calling for the statutory registration of public health professionals. This will help to ensure that directors of public health, and public health staff that support them, have the skills and experience needed for this expert and specialised job. I would encourage the government to give the Health Professions Council the role of regulating public health professionals.

I am extremely sceptical about the Responsibility Deal’s ability to resolve major public health issues, such as obesity and alcohol. The RCP, along with five other health organisations, declined an invitation to sign up to the alcohol responsibility deal because of serious reservations about the proposed alcohol pledges.

There is an inherent conflict of interest when industry drives public health policy, and in particular the alcohol deal only set out a number of aspirational, unenforceable and weak pledges. The ‘carrot’ approach of voluntary agreements with industry is unfortunately not enough to prompt healthy behaviours; it needs to be complemented by the ‘stick’ approach of legislative solutions where necessary.

Recently, the Health Select Committee voiced concerns about the independence of Public Health England (PHE) and I must say that I echo its unease. PHE must be authoritative, independent and able to hold the government to account. To do this, PHE must be visibly and operationally independent of Ministers. Locally, directors of public health must have sufficient influence, and therefore should be appointed to chief officer level within local authorities. They should have the authority to determine the best way of distributing the local authority public health budget.

There are opportunities within public health policy to address the rising demand on the NHS and other public services; they must not be missed. The government must use all available levers to improve and protect the health of the population, otherwise the NHS will be swamped.

Download the RCP’s public health submission to the NHS Future Forum.

At this moment in time thousands of public health nurses are left in limbo, seeing changes on the ground but with no real news or updates from the people making them. The RCN is concerned that significant changes are being made to public health staff, in the absence of the guidance promised by the Government.

In the Update and Way Forward policy statement in the middle of July, the Department of Health committed to producing updates on the five key areas of reform during the autumn. Just to be clear, this set of work is an overhaul to the way we tackle public health issues, it isn’t a list of mere tweaks and small changes.  In case you aren’t aware, the five areas are:

• Public health outcomes framework
• Public Health England operating model
• Public health in local government and the director of public health
• Public health funding including shadow local authority allocations for 2012-13
• Public health workforce strategy consultation

Here at the RCN, we understand that the shadow budget allocations and consultation on the workforce strategy may not be released until 2012. What’s more, there is no sign of updates on the remaining three areas as 2011 draws to a close; meanwhile, RCN members are being affected right now.

Back in early November, the RCN welcomed the Health Select Committee’s report on Public Health; it recommended that uncertainty around the future structure and focus of public health in England must be resolved as quickly as possible. You can understand why we’re now concerned.

At the time, the RCN Chief Executive & General Secretary, Dr Peter Carter, commented that “Many public health nurses are currently in a state of limbo as they wait to see how proposed transfers to local authorities will affect their jobs and the services they offer to the public.”

While we understand that the issues requiring consideration are significant, nursing staff need clarity and deserve answers. On behalf of public health staff everywhere, I very much hope that 2012 provides us with more information, not only for the benefit of staff, but the patients who are so dependent on the care that they provide.

The Health and Social Care Bill 2011 represents the biggest threat to public health for 60 years and it is time for the public health community to stand up and say so.

Deliberately conceived as an ‘Abdication and Abolition Bill’, the proposed legislation would sever the duty of the Secretary of State to secure and provide comprehensive healthcare throughout England.

Entitlements to health care are to be abandoned in order that a consumer market can be substituted for a needs-based system and, in David Cameron’s words, the NHS turned into a “fantastic business for Britain”.

As these briefings to the House of Lords show, the Bill will destroy the public health foundations of comprehensive healthcare and the ability to gather information and monitor inequalities.

Geographic administrative units – the hallmarks of the NHS – are to be abolished. Whilst commissioner populations will be made up from GP registrations, GP boundaries are being dissolved.  Patient enrolment and disenrollment will lead to unstable denominators and render fair service allocation and planning impossible.

No-one will have ultimate responsibility for ensuring everybody in a geographic area gets access to a GP. Above all, the ability to monitor equity of access within a comprehensive system will be undermined by lack of data and local variations in entitlement.

Public health will be shunted out to local authorities but the resources, functions and services that will go with it are not defined.  It is even impossible to tell the populations for which it will be responsible.

Local authorities and clinical commissioning groups will have enormous freedom to decide what they will and won’t provide and the boundaries between chargeable and non-chargeable services will be blurred and subject to local eligibility criteria.

In place of equity will be service and patient selection by commissioners and service providers intent on managing the financial risks of the marketplace.  Commissioners will be allowed to outsource their functions to healthcare companies that specialize in these techniques.

The marketisation of healthcare will lead to the denial of care on a scale not seen in England since pre-war days.

At a minimum the Bill must be amended so as to restore all the Secretary of State’s duties and functions and the structures of a national public health service.

The results of our latest member survey show despair, uncertainty and distress about the NHS reforms. We share members’ anger and frustration, reflected in feedback from local boards and committees. The results articulate the possibility of a wholesale departure from the specialty and major risks to the protection and improvement of the public’s health and the services they receive.

Credit: Andrew Hood, using wordle.net

Wordcloud: Adjusted responses (phrases/themed/categorised), from the first 200 responses in the survey (maximum 50 phrases)

As peers continue to debate the reforms, attitudes of public health professionals, and FPH’s leadership, are hardening. Faced with a government which does not seem to value professionalism or standards, it is essential that we continue to fight for the standards, accreditation and regulation of public health. No-one else will – and our partners in the public health national lobby agree with our stance.

Members have broadly supported this direction of travel – until now.  The ignorance and disregard in high places of what public health is and has done over 40 years in the NHS is alarming. FPH continues to hold a strong expectation for:
•    An independent and robust Public Health England;
•    A coherent career and training structure for public health professionals;
•    Protection of terms and conditions of staff;
•    Directors of public health reporting to chief executives of councils,
•    Clarity in the size and applications of the ring fenced budget and
•    Professional regulation for all public health specialists.

These issues were met with welcome support in the House of Lords committee stage.  However, a substantial cadre of our members believe that the public health community must campaign more explicitly against the likely negative health impacts if the reforms go through unchecked.

The Secretary of State has had a duty to ‘provide and secure’ the NHS since it began.   NHS planning has historically relied on regulations and guidance, not legislation.  This enables the NHS to move forward if the Secretary of State is in charge. If not, every line of the Health Bill becomes crucial.

Hard-pressed local authorities will only do what they must by law CCGs also will only do what they are required to do in law. The health system becomes a giant free-for-all; everyone doing the least possible, or the most lucrative and pocketing taxpayers’ cash. Some services may be deemed ‘bad business decisions’ and not be provided.

Where will these be without the Secretary of State’s duty to secure? This is a health insurance versus public health model. It calls into question the ideal of public service with which most of our members entered the NHS. Everyone in public health and health service users should be concerned about that.

As part of this debate, we have invited a range of organisations to contribute to this blog.  It remains open for members’ comments and more formal critiques. We look forward to your contributions here and through your local board members and FLACS.

As the Health and Social Care Bill makes its journey through the Committee Stage at the House of Lords, FPH continues to actively engage with members, key stakeholders, parliamentarians, as well as through its representation on strategic working groups and supported by its wider media work.

Committed to ensuring the Bill will provide the structures and safeguards necessary to protect and improve the health and wellbeing of the people of England, FPH is working hard to ensure a strong and viable public health workforce is maintained and strengthened for the future; and a rigorous framework for the statutory registration and regulation of all public health specialists to protect the public is established. 

As we continue to press hard for amendments to the Bill, at the forefront of our minds the risks to the public posed by the Bill – E.Coli, SARS, pandemic flu, Buncefield, heatwaves, flooding, immunisation and screening – loom large. To meet this challenge, with Lord Patel taking a lead on FPH’s amendments, we maintain a focus on statutory regulation; the role, qualifications and accountability of directors of public health; the organisation independent of Public Health England; public health expertise in the new NHS Commissioning Board; employment conditions for public health professionals at parity with the NHS.

Over the past few months, FPH has developed and implemented a firm lobbying strategy. We have written to all MPs and peers taking part in the Health Bill readings in both the House of Commons and Lords, setting out a clear case for our amendments to the Bill. We have the support of a broad range of peers from across all political parties – and have regular meetings with peers to discuss the possible impacts of the Bill in the context of public health.

We are also working with other health and public health organisations through our chairing of the PHMCC task group, and actively engaging with local government colleagues – including producing a joint statement with the Local Government Group. We also have representatives on key strategic groups, including the Public Health England Group (feeding into the development of the PHE Outcomes Framework) and the Workforce Advisory Group and have taken an active involvement in the NHS Future Forum Process with a submission recently sent in for the Second stage. FPH also maintains close working relationships with other faculties, Royal Colleges and stakeholders to share information and horizon-scan.

Informing our position, three member surveys have been conducted to ensure that we are engaging our members in a full and meaningful dialogue. At present we are in the process of analysing the results of our latest survey of members’ views of the Health Bill, with a full analysis to follow shortly. In addition, FPH works closely with its Local Board Members to encourage their active engagement with local MPs and relevant stakeholders.

Our lobbying work around the Bill has been supported by our wider media work, delivering news articles including a recent response to the Health Select Committee 12^th Report on Public Health appearing in the Guardian (a copy at this link); and letter to the Times outlining our key concerns with the Bill. In turn our monthly bulletin continues to keep all of our 3,500 members abreast of the latest developments.

For all the latest news on our work on the reforms visit www.fph.org.uk

For the past eight years, I have had the sometimes-dubious pleasure of living in London’s King’s Cross neighbourhood.  Being so close to the centre of the city, I do my best to cycle as often as I can around town. However, my repertoire of safe cycle routes is rather limited, and I dread straying too far away from my familiar routes and ending up somewhere where I have to battle my way home through the frenzied London traffic. The result is that I cycle less often, and less far than I would like to.

To be fair, these days there is a wealth of websites and apps that could help me navigate safely around London by bike.  The trouble, though, is that the safe bike routes themselves are just too complicated.

Take an example. Let’s say I wanted to cycle from my home in King’s Cross to St. Thomas’s hospital near Waterloo.  Although I know the walking route I would take to get there, I have no idea how reach the hospital safely by bike.  Go to the Transport for London  (TfL) website and it suggests a route that involves no fewer than 57 stages—as compared with two stages for the same journey by tube (Piccadilly line to Leicester Square, then the Northern line to Waterloo).

Indeed, London’s cycle network is so complicated that TfL appears incapable of displaying it as a complete map on its website.  Instead cyclists must order 14 paper maps to cover the whole city, plus a separate PDF for each of the new cycle superhighways that are currently being built.  Even where individuals have gallantly tried to produce simplified bike maps of London, the end result still bears too much resemblance to a plate of spaghetti.

Other cities have had a go at creating much simpler cycle maps aimed at encouraging more people to cycle. In Edinburgh, for example, Mark Sydenham and Martin Baillie have developed a tube map for bikes.  But the reality is that Londoners, like the citizens of many large cities, actually use the public transport network as their “mental map” for getting around their city.

The idea that Tim Miller and I suggested is that planners should build a bike network that recreates this mental map we are all so familiar with.  London’s bike network would directly resemble the tube map; Newcastle’s would follow the metro map, and so on.  In the jargon, what we are calling for are cycle networks that are “homeomorphic” or “topologically equivalent” to their public transport network. So in London, the cycle network we would like to see built would join up every tube station using analogous bike lanes to the tube lines – sharing the same names, colour codes and destinations as the tube lines.

So in this new world, my journey from King’s Cross to St. Thomas’s would simply involve taking the “Piccadilly bike lane” to Leicester Square, and turning left to go down the “Northern bike lane” to Waterloo.

What would be the costs and benefits of this proposal? Clearly, to build a network of safe cycle routes would take a large, sustained investment.  It would require building tens of kilometres of off-road bike lanes and closing off a considerable number of streets to through vehicular traffic.

However, the London tube map is a fixed asset that will be with us for generations to come, so this expenditure should be viewed as a very long-term investment. Just as with the tube network’s 150 year history, we would need to start small and build up the cycle network slowly, bike lane by bike lane and tube stop by tube stop.

From a public health perspective, I suspect the benefits of this proposed scheme would be at least fivefold.  First, it would encourage more people, including visitors to the city, to make longer journeys across town because they would now have more confidence that they could get to where they were going and be able to find their way back in one piece.  Second, it could reduce fatalities if more cyclists used off-road cycle lanes and quiet roads that had been closed to through vehicular traffic.

Third, it would reduce the city’s carbon footprint. Fourth, it would encourage cross-modal journeys because the cycle network and the rail network would now be inextricably linked. But finally, and rather sneakily, we might be able to increase journey distances from point A to point B by designing cycle routes between tube stations that were slightly more circuitous than were strictly necessary.

Move along there: Gelada baboons

By Dr Jackie Spiby

We are still here in Addis Ababa. We have survived the rainy season and the sky is blue again.

Many of you will have seen the news about the famine in the south east of Ethiopia where it borders Sudan and Kenya. Sitting in Addis, it is as difficult to understand the whole story here as it is at home. We pick up the news and some of the debate from the BBC when the internet is working. When we travelled to the south recently, everywhere looked really fertile and verdant as it was just after the rains. But at work I do hear about problems with food-aid delivery and families that can’t feed their children.

As recipients of Global Fund money, my organisation has to have pristine financial arrangements. The management audit letter we received recently could have been one found in any PCT. By the way do PCTs still exist? The only difference was that they were querying why a goat had been bought. I recently found myself on an appointments committee for an internal auditor – something I have managed to avoid in the UK. Amazingly my interviewing instincts rose to the fore. I was delighted that my first choice was the same as the finance director’s. It did help that the interviews were in English. So, another country another culture but actually much is the same.

We took a few days off to travel north to trek in the Simien mountains. Ethiopia lies in the East African Rift Valley so much of the north and central areas are hilly in stark contrast to the desert areas bordering Sudan and Somalia. We were walking at three to four thousand metres and were surprised that it was still scattered with villages, and, wherever we went, small children were keeping an eye on the cattle and sheep. They said they went to school but I wasn’t really convinced.

Walking into a BBC crew filming the gelada baboons was quite surreal. We had just stopped to put on our macks as it was raining when we heard a very posh voice asking if we could move please as they were trying to film the baboons running down that particular hill. If you ever see a documentary on these baboons in the Simiens we were there, and we saw the locals on the other side of the hill ‘encouraging’ the baboons to move.

One of my areas of work is developing a volunteers’ strategy. Not international volunteers but local volunteers. PLHIV associations are similar to charitable organisations in the UK so their boards are all volunteers and most of the programmes workers are also volunteers. However they do get expenses. The latter get 206 birr a month for travel. That is £7.60. In the focus groups they tell me they do it for humanitarian reasons. However when I asked if they also had paid work, they said it was hard to get work as they were HIV+. So what is a volunteer? I really enjoy the focus groups: however formal I try to make them, we have to have a coffee ceremony, and they usually end with music and dancing. The highlight last week was meeting a 22-year-old woman who finished school at grade 6 but was carrying a beautiful, chubby smiling baby who everyone proudly told me was HIV negative.

Am I making any difference? Not an unusual question for anyone in public health. I’ve been asking it my entire career. I’d better get back to work and make sure that I am.

So now we know the shape of things to come. Barring a major upset with the Health & Social Care Bill, we now have a pretty firm idea of what the new public health system in England will look like. The command paper, Healthy Lives, Healthy People: update and way forward, deals with many of the concerns raised by last autumn’s white paper.

But how well will it all fit together? Will its wheels fall off at the first major outbreak?

In theory, Public Health England (PHE) as an ‘executive agency’ of the Department of Health, with the Secretary of State having ‘a clear line of sight to the front line,’ should make for a stronger, tighter command and control mechanism in times of crisis. But there are downsides.

One is that public health professionals within PHE will find it harder to challenge ministerial diktat than from their current positions in the quasi-independent HPA or public health observatories.

Another is the lack of absolute clarity about who will be responsible for health protection decisions at local level. The DPH will have to ensure plans are in place and will have (so far unspecified) health protection delivery functions, but the lead in most circumstances will be coming from PHE. Quite what circumstances and how this will work in practice (the ‘operating model’) are still being thought through by the PHE transition team. The risk is that something important might fall between the stalls. Or that DPHs could find themselves at loggerheads with their PHE colleagues.

The PH system has to be robust and reliable, functional and effective, flexible and responsive. Standards have to be exemplary. Senior public health specialists make life-and-death decisions affecting thousands. Their competence and leadership skills must be assured. Ultimately, public safety is at stake.

And yet there’s still no decision about the statutory regulation of all public health specialists regardless of professional background. The white paper consultation found massive support for it and the Future Forum recommended it. But Public Health Minister Anne Milton is still not convinced of the need. Risks? she asks. What risks?

Well, let’s start counting shall we – very slowly so the words sink in. E.coli, SARS, pandemic flu, Buncefield, heatwaves, flooding, immunisation, screening – need we go on?

You can bet your boots that without proper safeguards and a solidly regulated public health system, the compensation lawyers, the media and Her Majesty’s Opposition will all have an absolute field day.

OK Minister?