'If the reforms go wrong, the potential risk to public health huge'

The government’s command paper, Healthy Lives, Healthy People: update and way forward, was quietly slipped out in July. Has it mollified the malcontents? How well will all the bits fit together? And crucially, will it be good enough to cope with something on the scale of Germany’s E coli outbreak?

Let’s start with the backbone: Public Health England, a motley conglomerate of the Health Protection Agency, the National Treatment Agency for Substance Misuse, regional public health teams, public health observatories, cancer registries and other leftovers.

These will be aggregated into a national, “sub-national” and local service intended to strengthen emergency preparedness and resilience, gather health intelligence, build the evidence base, support local public health teams and provide leadership and a powerful voice.

But its first challenge will be to maintain its current functionality, particularly with regard to health protection, and forge itself into more than the sum of its parts without losing its best talent and experience.

The health secretary originally wanted Public Health England to be an integral part of the Department of Health so that he could have “a clear line of sight” to the public health front line. Others argued for either a special health authority or a fully arm’s length body to provide a degree of independence. Making Public Health England an executive agency of the DH is a compromise that gives the minister considerable command and control while providing a get-out if things go pear shaped. No such lucky escape for those experts swept into the new body. As civil servants it won’t be so easy for them to challenge the political line – risking a less evidence-based approach in times of crisis. Their main champion, the chief medical officer, can look forward to interesting battles ahead.

Unclear status

If Public Health England is the backbone of the new public health system in England, then its limbs are the local authority directors of public health. They will be responsible for leading on health improvement and ensuring health protection plans are in place, developed jointly with the national body, and that these plans are robust, well honed and hardwired to local services including environmental health, primary care and hospitals, social care and emergency services.

To do this effectively public health directors must have real clout, on a par with directors of children’s services or adult social services. Unfortunately, in deference to localism, the government says it merely “expects” the director to have chief officer status reporting directly to the chief executive. This seems to me to be far too chancy. I would like to see regulations firmly spelling out the directors’ status through the secretary of state’s mandate.

Nor is it yet clear who is responsible for what in an emergency, such as an E coli outbreak. No doubt the local resilience forums will be reconfigured to reflect the new arrangements – but there has to be absolute clarity about roles and responsibilities. I know this is one of the main issues still being worked through by the national transition team.

The effectiveness and reliability of the new system will require the highest standards of professional public health expertise and leadership. Public health is a multidisciplinary specialty benefiting greatly from its diversity. But at present only the public health medics and dentists are subject to statutory regulation. The current voluntary register for non-medical/dental public health specialists is doing a fine regulatory job, but has its limitations, not least the lack of the full force of law (and adequate government funding).

With the public health workforce becoming increasingly non-medical/dental, and with a multiplicity of employers there’s a clear need for consistency to assure quality and protect public safety.

The potential risks if things go wrong are huge. A massive E coli outbreak is just one example of where public health decision making is literally a matter of life and death for large numbers. Another is pandemic flu. Or the next Buncefield. Or an overwhelming heatwave or flooding. Not to mention serious incidents in such public health programmes as cervical screening and immunisation.

And it is not just lives at risk – in an increasingly litigious society we’re bound to see ever more sizeable claims for compensation. Statutory regulation for all public health specialists regardless of professional background and clear rules about senior appointments would go a long way in providing comfort to the public, employers, policy makers and public specialists.

Andrew Lansley’s vision will be the biggest shake-up in public health in England for more than 35 years. Now is the time to ensure that the composite creature he is creating – backbone, limbs and all – is as robust and reliable as it will surely need to be.