Despite the scale of the reforms 10 years ago, former Wigan Director of Public Health Professor Kate Ardern believes there are still changes that need to be made to complete the journey of public health back into local government.
Professor Kate Ardern believes public health had “lost its way” during its time in the NHS. “During the 1970s and 1980s it had become very narrowly focused on the bio-medical elements – it was all about epidemiology, data and statistics and lost its historic connection to health determinants like housing.
“I think the emergence of HIV as a global health protection threat changed things. The CMO at the time Donald Acheson started reshaping the way we thought about public health and its interplay with wider societal factors.”
She said by the time the 2013 reforms were introduced public health was already beginning to see joint appointments between primary care trusts and councils as public health reached out across NHS boundaries.
She was, in fact, one of them after being jointly appointed by the NHS and council to the role of director of public health in Wigan in 2008.
Whole council became a ‘public health organisation’
Professor Ardern, who was one of the longest-serving directors of public health when she stepped down last year, said: “Once the reforms came in it accelerated what we had seen so far. Directors of public health were working alongside colleagues in education, housing, planning, trading standards and environmental health.
What was great was that the whole organisation became involved in improving and protection the public’s health rather just the preserve of a small specialist team. The influence we have been able to have has been significant.
“I remember sharing a platform with Andrew Lansley and telling him it was the part of his reforms that was absolutely spot on. You have to remember public health was always historically in local government from the mid 19th century until 1974 where its greatest achievements in terms of advancing rapid increases in life expectancy and significantly reducing the risks of dying prematurely from preventable infectious diseases– the time in the NHS was an aberration by international comparators too
“The national government cuts to both the public health grant and to council generally have been and continue to be a significant challenge, but it’s very clear if we had stayed in the NHS the budget would still have been cut. It always had been low priority because of the NHS focus on hospital service.”
Professor Ardern said what has become apparent over the past decade is the importance of influencing skills and handling the political elements of the job. “In the NHS it is all about your experience and qualifications. That is what gives you authority. In local government you have to wear your experience and qualifications lightly. It is about influencing people and that’s required public health professionals to have to be willing to adapt and learn new skills.
“You need good communication and political skills and relationship management – and that means not being party political. Being a DPH is a politically-restricted post, but also being a statutory chief officer role means you actually have more freedom to speak to truth to power.”
What needs to change
But despite the benefits of the reforms, Professor Ardern believes the job is not yet complete. She wants to see more changes made to further embed public health in local government.
“I would like to see the public health grant responsibility moved out of the Department of Health and Social Care. It has left us susceptible to money being taken from public health to fund the NHS. Instead, it should be an integral part of the main financial settlement Treasury gives to local authorities and announced at the same time.
“It would then be truly seen as part of local government finance – maybe within that there would need to be some ring-fencing for health protection preparedness and other specific national outcome priorities.
“But I think given how far we have come and the understanding councils have about public health it would work well with oversight and public accountability provided by the health and wellbeing boards and health overview and scrutiny committees. With local devolution in Greater Manchester, that is effectively what we had in Wigan.”
She also believes there needs to be a further transfer of services. “Screening is in the right place in the NHS because it links in with cancer pathways – perhaps DPHs could have more oversight and assurance. But I think for immunisations and prison health services there is definitely a case for more devolution of responsibilities to local government with local democratic oversight on outcomes and scrutiny reviews on quality and performance.
“The pandemic showed what can be done with immunisation in particular. Councils got involved and were very effective at reaching out to their communities. And with prison health services there is so much overlap with core council services - welfare, housing, employment, education and social services – that I think it would help create more integrated support on community rehabilitation and prevention of reoffending.”
‘It’s time to fight for public health’
But Professor Ardern is concerned about some of the more recent changes that have been made to the public health system. “I’m not sure disbanding Public Health England in the middle of the pandemic was the right thing to do.
“There were problems with PHE – it had a tendency to be too top-down culture with a one-size fits all in its approach and the quality and effectiveness of its partnership working was inconsistent to say the least. It needed significant reform rather than abolition.
“I remain to be convinced that UKHSA’s approach has really learnt the lessons and risks going down the same route and I question what influence the Office for Health Improvement and Disparities is having on wider government policy and approach to investment in prevention – you only have to look at what is happening with the approach to obesity, the Khan review on smoking and tobacco control and the scraping of the health disparities white paper to see it is not winning the battles over public health.
“It may be left to local public health to try to influence policy, but we have to be realistic. You cannot influence people who are ideologically driven so we will be better off working with our elected members, including metro mayors and combined authorities, progressive local NHS leaders, business, VCSE and academic sectors and, most of all, engaging the power and support of the citizens we serve as this will need to be a grassroots movement for radical change.”