When health secretary Andrew Lansley unveiled the public health white paper last November he called for a “paradigm shift” by which professionals would be locally empowered to bring about the improvements that a plethora of central initiatives failed to achieve under New Labour.
Spearheading the revolution in each area were the directors of public health, now working for the local authority rather than the primary care trust. They would “have the resources and the authority to make preventive interventions to improve the health of their communities”.
That was the vision anyway. The Association of Directors of Public Health and the Faculty of Public Health warn that many councils are planning to relegate the director position to the second rung of the local government management ladder.
Rather than reporting directly to council chief executives, many directors are more likely to report to directors of social services. It is feared this status may be insufficient to knock local big beasts’ heads together to invest in projects that can prevent intergenerational poor health and, in turn, alleviate some of the NHS’s long term financial woes.
In response to these concerns Mr Lansley has said it is his “expectation” that directors will report directly to council chief executives.
It is unsurprising that local authorities are reluctant to give directors of public health their seat at the top table. Many have in recent years merged directorates in response to controversy at the perceived number of “council fat cats” and, of course, the need to make huge savings.
Many councils are seeking to combine the roles of director of children’s services and director of adult social services – the top two biggest spending positions – an Association of Directors of Children’s Services survey revealed earlier this year. If these colossal roles are being merged, it is hard to justify public health going it alone.
We have also heard in the past week from the Department of Health that it is “continuing work to establish the future size” of the ringfenced public health budget to be given to local authorities. Ominously for councils, perhaps, the NHS Commissioning Board will have access to the national public health budget to commission “appropriate” programmes.
Shadow budget allocations are due to be given to councils by the end of this year and much work is required to ensure that a mechanism is in place to fairly transfer funds to local government. In our finance column this week, Sally Gainsbury discusses the huge differences in public health spending reported by PCTs. In London there is apparently a 24-fold disparity between the highest and lowest spenders – a figure that leaves as big a question mark over their ability to calculate current expenditure as over what constitutes a fair level. How can you hand the cash over to councils if you do not know how much they need?
Dark clouds are gathering over Mr Lansley’s vision for public health. He is used to dark clouds but on this occasion they are threatening a downpour over a vision with much merit.
Adequately funded directors of public health situated in councils are well placed to work alongside those in housing, social care, children’s services, planning and transport, to encourage cycling, sport and sexual health and tackle smoking, alcohol abuse and the spread of fast food outlets.
However, with councils facing budget cuts of 26 per cent over four years, it is not difficult to see public health directors’ new colleagues looking unfavourably towards joint spending projects, even if they will save the state money in the long term. Without their support the vision will wither and die.
The government must prove the paradigm shift amounts to more than the shifting of an intractable problem from health to local government.