Question 1: Within the structure outlined, how can we best safeguard the independence of scientific advice to Government?
The “strengthened role” for the CMO is essential to safeguard the independence of scientific advice to government and to ensuring the effectiveness of the public health system across government and at national, regional and local level. The policy paper envisages a direct oversight role for the CMO which we strongly support.
There should be a clear understanding between scientists, advisers and policy makers on what advice is being sought, by whom and for what purpose.
When asking experts to identify or comment on policy options prepared by others, those involved should respect the line between the responsibility of experts to provide advice, and the responsibility of departments for any subsequent policy decisions based on that advice. ‘The Principles of Scientific Advice to Government’ are a useful tool for ensuring the respective roles are clear.
Gathering evidence from a range of experts (particularly those with frontline local government public health expertise) or from an expert committee ensures a more independent cross-sectional view.
We agree with the principle, stated in the Principles of Scientific Advice, that ministers should explain publicly their reasons for policy decisions, particularly when a decision is not consistent with scientific advice and, in doing so, should accurately represent the evidence.
Like the Chief Medical Officer, at a local level, Directors of Public Health will be an independent advocate for the health of the population and provide leadership for its improvement and protection.
The Director of Public Health will be the person who elected members and senior officers look to for expertise and advice on a range of public health issues, from outbreaks of disease and emergency preparedness through to improving local people’s health and access to health services. The principles of scientific advice will be just as relevant at a local level as they are at the national.
Expert independent standing committees (eg the National Screening Committee and Joint Committee on Vaccination and Immunisation) are crucial to ensuring the independence of expert advice. Opportunities to set up new scientific advisory groups should also be explored (ie on health inequalities, non-communicable disease prevention).
Question 2: Where and how do you think system-wide workforce development can be best delivered?
Public health services require all those involved in the transformational aspects (planning and design within a complex system), as well as commissioning and delivery, to be well informed, use the evidence base and be fit to practice. It is delivered through a series of interlocking functions requiring a multi-agency approach led by groups of professionals with complementary skills.
We are calling for the proposed new public health workforce strategy building on Fit for the Future to embrace the concept of public health careers that involve experience throughout the new system. Health protection capacity at local level has increased over the pandemic and must be sustainable. Proper integrated workforce planning requires improved data on the public health workforce.
We support plans to see a significant increase in Public Health Consultant numbers and a recognition that Directors of Public Health (DPH), as local leaders for public health, need to have strong links with public health colleagues employed locally and regionally by the NHS and as part of the DPH team. Some development and training opportunities for specialists require national coordination and investment but this must be done with local employers.
Mobility around the system is crucial – both across and up/down - and this requires a solution to the long-standing problems about portability of terms and conditions. We see there is great potential for secondments from local into national to provide expertise and develop understanding.
There is an urgent need to develop a viable national dataset on the public health workforce to enable proper workforce planning; DHSC should work with partner organisations on this. Without the ability to do decent workforce planning, stability of the public health workforce in the post-covid environment cannot be guaranteed.
A single organisation needs to have a coordinating role because there is a such a diverse and growing group of employers with a need to ensure a pipeline of specialists in the future and encourage shared career development opportunities and portfolio careers. There is also a suggestion that the standing group should form the basis of an advisory group to help ensure employer, professional and other interests are central to workforce development.
DHSC should take this coordinating role as many of the existing functions are being absorbed into the department. It is likely that Health Education England (HEE) will need a role on coordinating training courses and placements etc. but it must have a better remit to look at current workforce development needs if it is to be involved as opposed to focusing largely on future pipeline of specialists. The Faculty of Public Health will need to take account of the changing system and public health needs post-covid in curriculum development and work closely with the accountable organisation and there are some opportunities for development specialist registration further through UKPHR.
The LGA, ADPH, FPH and PHE produced The Standards for employers of public health teams in England. These Standards help ensure that the workforce is fit to practice and are relevant to employers and workers with a role in the commissioning or delivery of public health functions.
Question 3: How can we best strengthen joined-up working across government on the wider determinants of health?
Local government’s public health sector is a pragmatic one which has a long history of working effectively with national government and other national partners to improve services for the people we all serve. In this way, councils carry out their functions within numerous national parameters. The best of these are genuinely coproduced with councils as an equal partner, not an afterthought in an engagement process. It is essential that Government approaches the new Public Health reforms in line with this tradition, acknowledging – and making ample space for – the unique contribution that only local councils can make across the wider determinants of health.
We strongly welcome the commitment to joined-up working across government in the policy paper, and the acknowledgement that health is driven by wider determinants, which are within the remit of other departments.
Processes need to be put in place to ensure that the new ministerial board on prevention is able “to drive and co-ordinate cross-government action on prevention and improve accountability on the wider determinants of health.” The lessons of the past are that deliverables based on outcomes are essential to drive true accountability.
The Prime Minister should chair the new ministerial Board to ensure authority to act.
The Board working through the Number 10 Delivery Unit, should ensure that Government departments are held accountable for progress in their respective areas of responsibility and that they engage effectively with key stakeholders such as DsPH to ensure their roles and expertise are valued and resourced.
To further enable local government to meet their public health duty a full review of public health law including ongoing powers for DsPH is needed to ensure councils have the right powers to exercise.
In Wales, the importance of improving social determinants in order to ensure future wellbeing has been recognised nationally through the Well-being of Future Generations (Wales) Act 2015. The Act requires public bodies in Wales to think about the long-term impact of their decisions, to work better with people, communities and each other, and to prevent persistent problems such as poverty, health inequalities and climate change.
The forthcoming National Health Index developed by ONS to sit alongside GDP as a measure of national success is a welcome step forward. The function could provide regular reports on trends in healthy life expectancy and health inequalities and could be further developed to assess options for action to improve health in view of these long-term trends. It is crucial that expert health economic advice to Government is independent and made widely available.
Tackling the social determinants of health is closely bound up with reducing health inequalities, since the factors that influence overall health are the same as those that result in differences, inequalities and inequity in health. Also, more equitable communities tend to be more healthy communities.
Many councils have adopted a Health in All Policies approach. Health in All Policies (HiAP) is a method that systematically and explicitly considers the health implications of the decisions we make. It targets the key social determinants of health, looks for synergies between health and other core objectives and the work we do with partners. There is a lot that national government can learn from HiAP approaches in local government and around the world.
A stakeholder advisory group should be established, bringing together key stakeholders including public health bodies and charities to advise on policy and implementation.
There should be greater flexibility and mobility of public health expertise across Government (ie through secondments and fellowship schemes). A Health Inequalities Strategy should be developed with shared accountabilities across Government departments. This should build on the Prevention Green Paper and include binding national targets to reduce child poverty.
Question 4: How can we design or implement these reforms in a way that best ensures prevention continues to be prioritised over time?
Insufficient public health funding remains a key challenge. The Singapore Health Promotion Board has been cited by Government as an example of success for the OHP to model itself on, but the per head investment is more than double that currently in place in England.
In addition to increased investment in public health, there also needs to be better alignment of the existing money within the system. The Secretary of State must deliver on his commitment to “put the power of the NHS budget behind the prevention agenda”, by empowering the ICS locally to support the integration of NHS and LA responsibilities to promote good health and give them the powers to work together as equal partners to deliver on that promise.
Local authorities must be an equal partner in all ICSs and the DPH role in ICSs must be influential across whole agenda and not side-lined to one work stream. Similarly, ICSs should be actively engaged in Health and Wellbeing Boards.