EVIDENCE FROM THE BRITISH MEDICAL ASSOCIATION TO THE HEALTH SELECT COMMITTEE INQUIRY ON PUBLIC HEALTH ENGLAND About the BMA The BMA is an independent trade union and voluntary professional association which represents doctors and medical students from all branches of medicine across the UK. With a membership of over 152,000 worldwide, we promote the medical and allied sciences, seek to maintain the honour and interests of the medical profession and promote the achievement of high quality healthcare. Executive summary We believe that public health consultants, whether working for Public Health England (PHE) or Local Government, have a vital role both in protecting and improving the health of the population and in helping the NHS to deliver on its outcomes. Making PHE an Executive Agency of the Department of Health (DH) has afforded it a degree of independence from overt Governmental interference. However, if PHE was an NHS, rather than a civil service, body it would be more independent and better able to carry out its duties to the NHS. While we welcome the decision of PHE to employ public health consultants on NHS Terms and Conditions of Service (Ts&Cs), BMA members who are employed by PHE report that the requirement to adhere to civil service rules and regulations is having an impact on their ability to do their work. Particular concerns have been raised about bureaucracy; the ability to publicly discuss or criticise public health policies, and relations with the academic sector. Seven months on from the creation of PHE and the transfer of public health responsibilities to local authorities, the specific roles and responsibilities of PHE and the local authority Director of Public Health (DPH) remain unclear about health protection issues. This is unsatisfactory, particularly in relation to incidents and outbreaks. We also have a number of concerns about PHE s recent consultation to change the leadership of Health Protection Units. PHE s decision to offer NHS Equivalent Ts&Cs is vital for the future of public health medicine and it is important that this commitment is honoured in every new consultant appointment. We are deeply concerned by reports that some local authorities are advertising public health consultant posts with Ts&Cs which are significantly lower than equivalent posts in the NHS. Comparable salaries must be offered across the entire health service (including local authorities and higher education) if public health medicine is to remain an attractive career option and a two-tier public health system is to be avoided. DPHs and local authority based public health consultants must be allowed to sit on Clinical Commissioning Groups. The anomaly within the National Health Service (Clinical Commissioning Groups) Regulations 2012 which prevents this must be urgently addressed. The difficulties caused by the uncertainty over data governance across health system boundaries needs to be addressed as soon as possible. Currently, there are problems over the ownership of data that arises from the NHS but needs to be analysed within PHE.
Introduction 1. The BMA welcomes the opportunity to submit written evidence to the Health Select Committee s inquiry on Public Health England (PHE). We have a number of ongoing concerns regarding the implementation of public health reforms, including PHE s status as a civil service organisation, the transfer of public health professionals into the civil service, the impact this has had on this specialist workforce and public health involvement in commissioning. PHE as a civil service body 2. Our evidence to the Health Select Committee s 2011 inquiry on public health reform argued that PHE should not be placed within the Department of Health (DH), since it would undermine the independence and thus the credibility of public health advice. 1 The BMA recognises that making PHE an Executive Agency of the DH has afforded it a degree of independence. We also note that the senior management team within PHE has consistently stressed the need for PHE to be independent and that the PHE Code of Conduct states that it will have operational autonomy. It will be free to publish information and advice it obtains from any source and provide it to whomever it wants. 2 However, we continue to have concerns about PHE s status as a civil service body. The BMA would have preferred that PHE was a NHS organisation with responsibility for all three domains of public health practice - health protection, health improvement and health services public health. This would protect the independence of the organisation and maintain the credibility of public health advice. Public health doctors employed as civil servants 3. BMA members who work for PHE have expressed concerns that working for a civil service body has had a significant impact on their ability to do their work: specific issues have been raised about the imposition of civil service bureaucracy onto previously workable NHS systems 3. 4. While we acknowledge the efforts that have been made in establishing the PHE Code of Conduct to address outstanding issues between the Civil Service Code and the NHS Medical/Dental Consultant Contract, there is continued disagreement about a doctor s right to discuss PHE policy in a public forum under their own name. This is despite the fact that the NHS Consultant Contract says: A consultant shall be free, without prior consent of the employing organisation, to publish books articles, etc and to deliver any lecture or speak, whether on matters arising out of his or her NHS service or not. 4 5. This was particularly evident following PHE s announcement that they would be running the health check programme 5. The health check programme is a deeply contentious issue among public health professionals. Many are of the opinion that the programme lacks a robust evidence base and will divert money from proven schemes and may even be harmful; other public health professionals have expressed the opinion that despite the lack of conclusive evidence in support, health checks are a worthwhile experiment, the results of which will need to be carefully evaluated. A number of our members have reported that they were actively discouraged from expressing their professional opinions publicly. PHE and health protection 6. PHE inherited a health protection system from the Health Protection Agency (HPA) in which local Health Protection Units (HPUs) provided support and advice to Primary Care Trust (PCT) based health protection staff. Seven months on from the creation of PHE and the transfer of public health responsibilities to local authorities, the specific roles and responsibilities of PHE
and the local authority DPH remain unclear in regard to health protection issues. This is clearly unsatisfactory and unsafe. 7. PHE has also decided to change the leadership of the HPUs 6. These changes fundamentally misunderstand the role of the Unit Director, which is the effective running of a world class, but locally rooted, health protection team. This places limitations of scale on the size of the team, since it is hard to provide effective professional leadership of the type currently provided by the Unit Directors to a large and geographically diverse team. It also has implications for the size of the area covered, since much of the current role is based on the Unit Directors relationships with those external to PHE, especially DPHs and the NHS. Despite this, PHE is consulting on changes which would mean that there would effectively only be one Unit Director per PHE Regional Centre, whose job title would change to Deputy Director of Health Protection. Currently, due to the disparity in geographical and population size between PHE s regional Centres, the number of HPUs in each Centre ranges from one to four. Any amalgamation of Unit Directors into a smaller group with responsibility for a larger area would create a vacuum of both team leadership and local engagement. The PHE consultation makes no reference to how this vacuum could be filled. PHE and developing the specialist workforce 8. We believe that the multidisciplinary nature of specialist public health is one of the strengths of public health in England. Having medical and non-medical consultants working together provides opportunities for public health teams to bring a variety of backgrounds and perspectives to bear on intransigent public health problems. As such, it is vital for population health that public health doctors work in all parts of the public health system. 9. PHE s decision to offer NHS Equivalent Ts&Cs is vital for the future of public health medicine. For public health to remain an attractive career option for the best medical students, it is essential to ensure pay parity with the rest of the profession. Reaching agreement with PHE on an honorary contract for university-employed public health academics was also vital in ensuring that their pay parity with NHS and PHE colleagues and access to the clinical excellence awards scheme was retained. 10. We are also concerned about the relationship between PHE and the university employers of public health academics and the commitment to the principle in the Follett Review Report 7 of joint management of such doctors. In particular, PHE seems to be proposing an unnecessarily complex appraisal process which does not appear to us to meet the requirements of the Follett Report and the subsequent Memorandum of Understanding between the NHS and university employers. 11. We have significant reservations over the Ts&Cs being offered by some local authorities. A number have recently advertised for public health consultants offering salaries below the entry point of the NHS Medical/Dental consultant salary, which stands at 75,249. If such salaries become commonplace, this would have a significant impact on the number of medics who would be willing to practice public health and would lead to a two tier system where medically qualified public health doctors work for PHE and non medically trained public health consultants work for the local authority. 12. The salaries offered by local authorities are often seen as a reflection of the importance that they place on public health. Where a local authority offers a salary below the NHS consultant scale, there is a perception that the local authority does not value the expertise, experience and abilities that public health training engenders. In particular, the problem seems to arise within those local authorities that use the National Joint Council (NJC) job evaluation scheme. This scheme fails to give value to the strategic influence that public health consultants should have on local authority decision making. Those authorities which
use the Hay system are producing evaluations closer to, and sometimes above, NHS expectations. 13. Conversations with DPHs from across the country reveal that a significant minority of them are expected to report to another local authority Director. This is likely to have a negative impact on future public health professional recruitment. 14. A split is beginning to emerge between medical and non-medical public health consultants, with those from a medical background particularly keen to seek careers within PHE. This may be for a variety of reasons, including the salary and the type of work particularly in health protection and health services public health being done by PHE. The BMA believes that it is vital that those with responsibility for the future of public health have a good understanding of the views of the profession on these issues. Currently, we feel that no organisation has a clear understanding of the profession s views. It is for this reason that we will be conducting a wide ranging survey of the consultant workforce (including nonmedical consultants) 8 including their intentions and expectations regarding their future careers. 15. At present, there is no data about how many public health consultants are employed in local authorities, or the proportion of medics to non-medics or their terms and conditions of employment. We therefore made a Freedom of Information (FOI) request to gather this information 9. Unfortunately, the request will not be able to ascertain how many public health consultants have left the English health system during the reforms either by seeking employment abroad (including in the devolved nations); taking early retirement; or being made redundant. 16. We believe that whilst it is not PHE s role to dictate to local authorities the terms and conditions that they should offer public health consultants, PHE should be gathering intelligence on the number of consultants that local authorities are employing and the terms and conditions they are offering. PHE should also seek to ensure that it is aware of the number of clinical academics engaged in research and teaching in public health, whether they have an honorary contract with PHE or with the NHS. This is particularly important given that PHE intends to provide the responsible officer who will make recommendations to the GMC regarding public health doctors continuing licence to practise. 17. This issue of salaries is likely to become more pertinent as the cuts to local authority budgets continue. For this reason, PHE should be able to say whether, as we believe, offering public health consultants NHS equivalent terms and conditions and giving them the freedom and influence to act on public health issues from across the entire spectrum of local health from housing to leisure is the most effective way for local authorities to tackle their public health responsibilities. 18. In the longer term we would welcome greater clarity on PHE s relationship with Health Education England on the development of the public health workforce and with the National Institute for Health Research and the new Health Research Authority on the nurturing and development of clinical academics in public health.
Public health involvement in commissioning 19. A key theme in our 2011 evidence to the Committee was the lack of attention paid to health services public health during the formation of the structures of Clinical Commissioning Groups (CCGs), NHS England and PHE. This concern was echoed by almost every public health organisation. 20. In response to these arguments, the Health Select Committee said in its report that: It has now been clarified that DPHs and their teams will provide public health expertise, advice and analysis to CCGs, HWBs and the NHS Commissioning Board; and this will be one of the mandated public health services that local authorities must commission or provide. However, this is not enough. The local DPH should be a member of the Board of each CCG. There should be a qualified public health professional on the NHS Commissioning Board; and the Board should routinely take advice from qualified public health professionals when commissioning decisions are being taken. 10 21. It is particularly unfortunate therefore that Schedule 5, of the National Health Service (Clinical Commissioning Groups) Regulations 2012, states 11 : SCHEDULE 5 Individuals disqualified from membership of CCG governing bodies 1. A Member of Parliament, Member of the European Parliament or member of the London Assembly. 2. A member of a local authority in England and Wales or of an equivalent body in Scotland or Northern Ireland. 3. (1) An individual who, by arrangement with the CCG, provides it with any service or facility in order to support the CCG in discharging its commissioning functions, or an employee or member (including shareholder) of, or a partner in, a body which does so. (2) The services and facilities mentioned in sub-paragraph (1) do not include services commissioned by the CCG in the exercise of its commissioning functions. (3) In this paragraph, the commissioning functions of a CCG are the functions of the group in arranging for the provision of services as part of the health service. 22. NHS England has stated that they believe that DPHs and local authority based public health consultants are disqualified from sitting on CCGs under both paragraph 2 and 3 12. We have serious concerns about any measures which disqualify individuals who have both the public health expertise and local knowledge to make a vital contribution to commissioning. We have asked the DH to urgently address this and for the position of public health academics to be clarified. Information Governance 23. The disruption of data flows across the health service, caused by the removal of public health expertise out of the NHS, remains an issue. We have ongoing concerns about whether the Health and Social Care Information Centre (HSCIC) has adequately addressed this issue. We would like reassurance that public health professionals, including public health academics, DPHs, and public health commissioners within CCGs, will continue to have access to data that is essential for their function, within a new PHE information governance (IG) framework. Policy development 24. The relationship between the Chief Knowledge Officer s (CKO) Directorate, the National Institute for Health and Care Excellence (NICE) and public health academics remains unclear.
We believe that this lack of clarity of around responsibility is having an ongoing impact on policy development. 25. On its website, PHE states that it intends to be the centre for researching, collecting and analysing data to improve our understanding of health and come up with answers to public health problems. 13 To do so, PHE needs to have the freedom and independence to carry out research into Government policies that impact upon the population s health. It is not clear that this would be permitted within a civil service organisation which exists to carry out government policy. The health checks programme is an example of a government initiative lacking evidence that PHE, being an executive agency of the DH, is required to implement. 26. A further concern is whether public health academics, who have their honorary contracts with PHE, will be able to research government policies free from both overt or implied pressure especially if they if they produce evidence of lack of benefit or value for money. Recent research by the London School of Economics has reported that academics working on government commissioned projects feel pressurised into making their findings chime with Whitehall s political objectives. 14 If this is so of academics who only receive funding from Government, it is likely to even more true of those who have a contract of employment with Government. November 2013 Notes 1 BMA s written evidence to the Health Select Committee, October 2011 http://www.publications.parliament.uk/pa/cm201012/cmselect/cmhealth/1048/1048we16.htm 2 Code of Conduct: Public Health England - https://www.gov.uk/government/publications/code-of-conduct-public-health-england 3 BMA members who work for PHE have expressed their concern that working for a civil service body has a significant impact on their ability to do their work. One doctor said that the regulations imposed by the civil service will slowly strangle PHE to death. The doctor gave as an example the way in which cancer screening reports that are normally sent out after a quality assurance visit are regulated by having all of the commentary removed. The reports are then placed on the civil service publications list (the Gateway) which can cause significant delays and extra work. The doctor felt that this process could result in these reports becoming simply a box-ticking exercise. 4 The 2003 Medical Dental Consultant Contract, 2003, p25 - http://www.nhsemployers.org/sitecollectiondocuments/consultant_contract_v9_revised_terms_and_conditions_300813_bt.pdf 5 NHS Health Check implementation review and action plan, July 2013 - https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224805/nhs_health_check_implementation_review _and_action_plan.pdf 6 PHE Consultation Paper: Leading Local Health Protection Teams 7 http://bma.org.uk/practical-support-at-work/contracts/academics-contracts/follett-review-principles 8 This will be sent out to all UK based public health consultants (both medics and non-medics) in November 2013 9 The BMA submitted its Freedom of Information request in October 2013 and are currently analysing the results of the responses that were received. We will be comparing these figures to the number of public health consultants employed by PCTs before the public health reforms were implemented. 10 The Summary of the Health Select Committee s Twelfth Report - http://www.publications.parliament.uk/pa/cm201012/cmselect/cmhealth/1048/104803.htm 11 The National Health Service (Clinical Commissioning Groups) Regulations 2012 - http://www.legislation.gov.uk/uksi/2012/1631/contents/made 12 ibid 13 Public Health England, What we do - https://www.gov.uk/government/organisations/public-health-england/about 14 Government-commissioned researchers 'leaned on' Times Higher Education 31 October 2013 http://www.timeshighereducation.co.uk/news/government-commissioned-researchers-leaned-on/2008567.article