Over the last few weeks I have become increasingly concerned about the potential conflicts of interest inherent in the new arrangements for Public Health for those of us who work in Health Services PH.
As you will all be aware, the majority of PH is being moved to the Local Authority (LA). From the very start of this upheaval it was clear that those who were designing the new system did not understand PH at all. In particular, they had no understanding of the three pillars of PH. I have explained before that these are Health Protection, Health Improvement and Health Services Public Health. I may even have intimated that only Health Services PH would be really disadvantaged, but the more we have learned the clearer it has become that this is not so.
Health Protection is that branch of PH that attempts to protect the public from both communicable and non-communicable health hazards, like the Legionnaire's Disease that we are hearing so much about at the moment. It also encompasses, however, the screening and immunisation programmes. It is clear that the Government equated this with the work that is currently undertaken by the Health Protection Agency (HPA) and it was of the view that it could be picked up and dropped into Public Health England (PHE) with a minimum of fuss and trouble. What the powers that be completely failed to take into account is that much of the day to day activity takes place, not at the HPA, but in the PH departments of PCTs. The result has been a shambolic rush to attempt to find a way to safeguard the screening and immunisation services, to attempt to define lines of accountability that will work in the new system, when half the staff will be in PHE (a branch of the Civil Service) and the others will be in Local Authority. In private, even Department of Health officials will admit that this is a real problem area.
Health Improvement is largely to do with lifestyle choices: smoking, alcohol, obesity. All of this is going to LA, where there will be interesting opportunities for collaboration. There will also, however, be opportunities for reducing budgets. It will, I suspect be very dependant on the strength of the Director of Public Health and local relationships, with the result that it will work very well in some places and very badly in others. I thought we were trying to improve the system, not make it worse.
Health Services PH is that branch of the specialty that deals with commissioning NHS services and dealing directly with requests for individual funding packages. This, we are told, will be provided by PH consultants employed by LAs but 'offered back' to the NHS though the Core Offer. It sounds fine, until you start to think about the detail. One of my responsibilities is Continuing Care: looking after the most vulnerable in our society because they are elderly, or terminally ill, or have a mental health issue, or have a learning disability. The rules are complex, but essentially there are ways of assessing whether an individual is entitled to Continuing Health Care, or whether the package of care needed to look after the individual should be jointly funded by health and social care. If somebody qualifies for Continuing Health Care, then the NHS picks up all the costs, even those that are essentially social care.
Am I alone in seeing the huge potential for conflict of interest here? Already I receive letters from both MPs and Local Councillors about individual constituents asking that we 'reconsider'. As it stands, that is fine; I can assess the case and decide whether there is a problem. But when my salary is being paid by the LA, there will be a far greater pressure to do what LA councillors want. I believe that is unconscionable. I am surprised that our elected representatives are incapable of seeing the problem.
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