No time for nostalgia in public health
28 January 2013
Duncan Selbie looks to the future in his role as chief executive of Public Health England
‘When the public health profession say they are very anxious about their future, I think they should have been very anxious about their past,’ says Duncan Selbie, the recently appointed chief executive of PHE (Public Health England).
‘What was it about the past that was so great?’
It is a brave statement from someone who has become a key player in the much maligned reorganisation of public health under the government’s reforms.
Public health doctors have battled continuing uncertainty as councils have become skittish over staffing for their new health-improvement responsibilities, following months of delays in revealing funding allocations.
The problems have been compounded by the late announcement of arrangements for immunisation and screening, terms and conditions for staff moving to PHE, pensions rights and the PHE code of conduct, and lingering questions over whether there would be enough of the right kinds of jobs.
Mr Selbie acknowledges that this has been a difficult period, and hopes staff now have the confidence that their terms and conditions will not be at risk when they move into PHE or local government.
‘It’s easier for me to say, of course, that it is better to get it right than to get it all settled early,’ he acknowledges. ‘I would have wished to have done both, and I recognise folk have lived with that uncertainty, but I am hopeful now that folk can see that we have got to a good place.’
The former chief executive of Brighton and Sussex University Hospitals NHS Trust has great hopes for PHE, which will be taking on responsibilities around health protection, immunisation and screening and some new objectives that are part of the health outcomes framework.
‘For the first time there is a voice for the public health system in a single place,’ he maintains. ‘Observatories, people that have been working in health services public health advising the NHS on priorities, working on improvement or working in protection are coming into a single organisation.’
He defends PHE’s position as an executive agency of the Department of Health against BMA calls for its independence as an NHS special health authority.
‘We have the operational freedom to lead the public health system,’ Mr Selbie insists, adding that PHE will have a relationship with local government and the necessary freedoms of speech and publishing.
It will be led by public health professionals, he stresses, and the focus will be on the pursuit and spread of knowledge and drawing attention to available evidence.
‘I think it’s about making it accessible in every part of the country, whatever the question that a local authority or a clinical commissioning group might be facing,’ he explains. ‘It could be a health service thing like lung cancers, or it could be about paediatric mortality or it could be “should we be doing something about speed restrictions or accidents at work?”’
'Lift and shift' jobs move
Most of the 5,000 people coming into PHE will be moved under a ‘lift and shift’ arrangement from their current arrangements, and Mr Selbie insists that the numbers affected by competitive job matching are in the tens rather than hundreds.
‘Now for those 50 to 60 people, that uncertainty is real. I would feel it if I were in their position. That will settle again this month and again the following month, so by the end of March at the very latest everybody will know what they’re going to be doing,’ he says.
‘The bit that I don’t so easily recognise is that folk are being asked to do jobs they didn’t, because almost 95 per cent — maybe 97 per cent — of people are moving exactly as they are into the new system.’
He insists there is the potential for ‘a golden age’ in public health. He says: ‘Local government has always cared about health and [its] determinants … and this is a moment to recognise that and to re-energise the public health system around more than the treatment of illness, the diagnosis of ill health, and get into prevention and early intervention.’
‘Best chance ever’
While recognising that local government cannot do this on its own any more than the NHS was able to, he believes that having a focus on the public health system separate but alongside the NHS ‘gives us our best chance ever’.
Although the new public health funding allocation to local authorities is ringfenced, there will be flexibility over how it can be spent.
‘I have a generous view about what contributes to public health,’ reveals Mr Selbie. ‘We know [having] a job is the single most important contribution to how people can live well and in a healthy way. If you are isolated and live on your own, that’s a killer; that’s a desperate position.
‘So where local authorities are able to help people get decent housing, where there’s not a fear of crime, where they can get work, inward investment, job creation — these are all public health measures.’
Yet he insists councils will have to show how money has led to an improvement through the health outcomes framework. ‘They are not free to spend it on just closing a deficit, but they are free to work out how they want to spend it,’ he says.
Council directors of public health will have direct access to the chief executive as chief officers, although there is freedom over how this is organised.
‘My concern is that the director of public health has a voice about the entire spend of a council and not just that bit to do with the historical public health piece,’ says Mr Selbie.
The BMA has been particularly concerned over how frontline local work will continue through the transition, and hopes councils will continue to see locally relevant health protection functions as a priority.
Mr Selbie says local government has a legal obligation under the Health and Social Care Act to protect the health of the public.
He emphasises that PHE is a category one responder. He says: ‘In the event of difficulties PHE discharges the secretary of state’s responsibilities for health protection across the nation.
'We have the absolute power to intervene whenever we need to about health protection.’
However, he adds: ‘Ninety per cent of health-protection incidents are handled locally and will continue to be so. The school that has an outbreak, the nursing home that has an outbreak, the restaurant that poisons local people will be handled at a local level by the Health Protection Agency, now part of PHE, and the local director of public health.
‘And then anything in the 10 per cent beyond those that you thought were going to be handled locally but surprisingly became a much bigger issue, or what was obviously a huge issue like a flood, would be handled principally by PHE but with the director of public health.’
PHE will also be embedding public health expertise within the NHS Commissioning Board and working with it on services such as immunisation and screening.
Mr Selbie says: ‘We have this wonderful immunisation and screening system that is fêted around the world. It is sort of a miracle really that it works, because it’s been a very fragmented arrangement around the nation. Although it’s been very painful for the last year or so, what we will have for screening and immunisation for the first time ever is a budget and a workforce that we can work with and invest in over the next number of years.
‘So PHE’s contribution will be the setting, maintenance and assurance of standards, making sure that we are investing in education and training and further development, and ensuring that we continue to keep at the cutting edge. There’s new screening possibilities coming along all of the time, and we need to be ready for that.’
Public Health England chief executive Duncan Selbie on why the specialty has a place outside the NHS
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