Joint directors of public health will be weak in the job
02 May 2013
Giving responsibility for public health to local authorities, together with a ring-fenced budget to manage it, is obviously the right thing to do. Councils used to have a role in health back in the 1970s; like many issues in public policy, the more things change the more they remain the same. Local authorities are well placed to manage public health because they can tailor strategies to local needs. Now Michael Marmot's work on the social determinants of health is so widely accepted, local authorities could bring education, housing and other services together to tackle all the issues that affect the health of the public.
But there are real challenges: local authorities are granted the job of public health and the new money at a time of unprecedented financial pressure. The government has mandated only a few specifics and, for the rest, local authorities can spend the money as they see fit. So the danger is that public health money will be raided for areas such as social care at the expense of core public health concerns – mental health and sexual health.
In these circumstances, local leadership will be very important. Yet some local authorities are attempting to save money by appointing directors of public health shared with other boroughs, choosing people with no public health qualifications at all or candidates who may be too junior. A weak director of public health (for instance, someone trying to cover the challenges posed by two inner London boroughs) will not be well placed either to implement innovative strategies or withstand attempted raids on their budget.
There are particular problems in London where "open access" services such as sexual health are threatened by the apparent absence of agreed funding and charging arrangements between boroughs. This could threaten excellent facilities such as the Dean Street sexual health clinic, which provides an invaluable service (including HIV testing) for gay men who visit Soho from all over London. Already there has been a hastily organised re-commissioning of London's HIV services, which has managed to cut out every single cross-capital service targeting the African community.
In principle, I support the handover of public health to local authorities. But, in practice, because the government has become so preoccupied with reform of the NHS, this handover spells real danger.
The challenges for healthcare professionals will include:
• The danger of fragmentation under the new system.
• The fact that not all local authorities will necessarily have the expertise to commission public health services.
• The "ring-fenced" public health budget could be raided for other essential services such as social care.
The government only announced the public health financial allocations just before the transition of responsibility to local authorities. This was far too late and has made it impossible for councils to plan properly. More importantly, that distribution has been blatantly unfair.
The amounts per head of population will vary wildly, from £22 a head in Windsor and Maidenhead to £132 in Westminster. There is also no weighting towards the public health needs of children and young people, whose frontline services are already being cut in some areas.
Despite all the promises, some of England's healthiest and wealthiest areas are lavished with the biggest pots of money. Given that poverty causes so much ill health, it's common sense for more deprived areas to get extra support for their public health services.
With local authorities in the driving seat, different choices over public health priorities will be made. If these are well informed and evidenced decisions, this may actually mean less variation in overall health outcomes between areas as services will adapt to local needs. But there is a clear risk that outcomes could vary; certainly there will be cases where in one area a service is funded, and in another it is not.
It is for this reason that I will shortly be launching a toolkit for local authorities, highlighting best practice from around the country.
Localism has great potential, and the public health structure designed by government can work – but only if the right care and attention is paid to the process.
We're facing a number of huge public health challenges that must be met with great ambition. I want our public health workforce to know that Labour shares their ambition, and that we understand the scale of the challenges ahead.
This article was first published here: http://www.guardian.co.uk/local-government-network/2013/may/02/diane-abbott-public-health-weak-councils
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