The fact that Andrew Lansley and the Coalition Health team are putting so much importance on Public Health is to be welcomed. The Public Health White Paper has recently been issued and is currently being consulted upon. However, so far the emphasis of the consultation and the public debate has been about a future role for local authorities in public health, and not about the NHS role or the need of the NHS for public health skills. The current proposals suggest that all public health doctors will be moved into local authorities, which could leave a significant gap in NHS commissioning expertise.
Public Health is defined as “The science and art of preventing disease, prolonging life and promoting health through the organised efforts and informed choices of society”. But what do public health practitioners (who are usually doctors) actually do? Their work is divided into three domains (and they usually sub-specialise):
- Health protection – The public will know this as managing outbreaks of disease and pandemics, immunisation programmes, and the management of incidents such as bio-terrorism and chemical incidents that may affect human health.
- Health improvement – The public will know this as the promotion of health and wellbeing and the prevention of disease – particularly by focussing on investigating and reducing risk factors such as obesity and teenage pregnancy rates.
- Health care public health – The public will understand this as the optimisation of health service provision to ensure the best clinical outcomes possible within the resources allocated by government. This involves the assessment of health care needs and the clinical effectiveness of different interventions, the development of evidence-based “pathways of care”, prioritisation of resources to focus on the most effective and value for money (cost-effective care) and evaluation of health services and new health technologies. They use medical knowledge (most fully trained public health practitioners are doctors), health economics and statistical analyses, evaluation skills and critical review of the medical literature (this requires five years of additional training on top of normal medical training). [Screening sits somewhere between the second and third domain, and the National Screening Committee and local implementation of screening programmes are public health led].
Many health care specialised public health consultants are employed in the Department of Health (usually but not always the Chief Medical Officer is a public health doctor), Cancer Registries, Clinical Networks, the National Screening Committee, NICE, Medical Schools and Research Departments (as all doctors need a basic competency in public health skills), but most are employed in PCTs.
Although there are very few of these sub-specialised doctors around, most national and local work developing pathways of care involve public health input and leadership – working with doctors and other health care professionals in general practice, the community and hospitals. Most national and local work on improving outcomes in cancer, heart disease, diabetes and stroke (the major causes of death and disability), as well as countless other work streams on outcomes also have public health input or leadership.
The current proposals do not make it clear that the value for money, evaluative and evidence-based skills that the health care public health doctors have will remain in the NHS. GPs and commissioners are concerned about the implications for the new GP consortia if this resource is not available. The BMA GP’s committee leader stated: “We felt that the role of public health doctors was woefully absent in the various government white paper documents and we felt this was an omission as we consider public health doctors as having a vital role in supporting GP commissioning consortia”.
Public health doctors would bring crucial advice and support in making the best use of finite resources based on population needs, said Dr Nagpaul. He predicted “GP consortia will be faced with some very tough prioritising decisions in making use of limited budgets”, and recommended that all consortia should have some dedicated public health doctor time – but acknowledged they were in short supply.
The first two domains of public health (addressing health protection and health improvement) would sit happily within local authority leadership. Now is not, however, the time for the NHS to lose the skills, expertise and experience of the small number of doctors who have particular expertise in value for money and evidenced based health care commissioning. As the BMA GP committee says, each consortium needs some dedicated public health doctor time, and the Department of Health needs to ensure that this resource is not permanently lost to the NHS in the re-organisation.