Whatever happened to child public health?
Written by Julie Mytton
It is over two years now since the Health and Social Care Act 2012 came into force on 1st April 2013 leading to the NHS reforms in England that included the closure of Primary Care Trusts and the creation of Clinical Commissioning Groups. A large proportion of the English Public Health workforce were employed by Primary Care Trusts prior to these reforms, and needed to find new employers. What became of all those child public health colleagues that you used to know? What are they all doing now?
The NHS reforms led to a complex creation of multiple new organisations. If you want a little refresher of how these organisations all relate to one another, take five minutes to watch the ‘alternative guide to the NHS’ video created by the Kings Fund (http://www.kingsfund.org.uk/projects/nhs-65/alternative-guide-new-nhs-england). This simple and engaging video helps to explain relationships between the component organisations and helps reassure you that there is a very good reason why you think the new structure is confusing – that’s because it is confusing.
Most of the staff from public health teams in the Primary Care Trusts ended up in one of two places; Local Authorities and Public Health England (an executive agency of the Department of Health). Spreading a small professional group across two different organisations was always going to generate difficulties, not least in maintaining professional networks and visibility to healthcare colleagues, such as those in Community Child Health. With the transfer of Public Health into local government, upper tier and unitary Local Authorities have become responsible for a number of mandatory Public Health functions.
Local Authorities’ public health responsibilities include:
- Commissioning sexual health services
- Commissioning drug and alcohol services
- Ensuring delivery of the National Childhood Measurement programme
- Ensuring delivery of the NHS Health Checks programme
- Improving the health of the local population, e.g. through Stop Smoking Services, Healthy weight promotion activities, and specifically to reduce inequalities in health
- Ensuring robust local arrangements are in place for the protection of the health of the population from infectious diseases and hazards, and emergency planning
From April 2013 Local Authorities have been responsible for the commissioning of, and ensuring delivery of, health services for children and young people aged 5-19 years and the Healthy Child Programme for this age group. This has included School Nursing Services. From October 2015 the commissioning of services for the 0-5s will also transfer to Local Authorities, including Health Visiting Services and the Family Nurse Partnership.
Each Local Authority Public Health team is led by a Director of Public Health. Public Health teams link back into the NHS through two routes; the Health and Wellbeing Board and the ‘Core offer’. The Health and Wellbeing Board is hosted in the Local Authority but has membership from both the Local Authority and local Clinical Commissioning Groups. The Board provides a forum where joint ownership of decisions that have a consequence for the health and wellbeing of the local population can be debated and agreed. Usually the Director of Public Health sits on the Health and Wellbeing Board. The second way the public health team links to the NHS is that Consultants in Public Health have a mandatory function to provide a ‘core offer’ to their local Clinical Commissioning Group. This is in fact a requirement that 40% of their work is directly with colleagues in the CCG on the development and commissioning of health care services. Frequently this is in the provision of advice regarding the health needs of the local population, the evidence of effectiveness of treatments and services, and the development of the CCGs health care strategies and policy.
The Director of Public Health remains responsible for the production of an annual report on the health of the local population, and to the publication of a Joint Strategic Needs Assessment or JSNA. Production of the JSNA has led to some interesting challenges, not least the fact that much of the data on the health of the population is held by health services and that local authorities, sitting outside the NHS, are not able to routinely access NHS data. This means that new data sharing agreements have had to be established to enable access to data that was once readily available. The JSNA should inform the development of the Joint Health and Wellbeing Strategy, the overarching health plan for the local community. With responsibility for commissioning (and sometimes providing or hosting) clinical services, such as sexual health or drug and alcohol services, another new challenge has emerged. Local Authorities have had to establish processes to ensure clinical governance of advice given to members of the public.
Public Health England was organised into 15 PHE Centres (‘Local teams’) spread across 3 regions of England, bringing together a range of public bodies. Immunisation programmes and national screening programmes are now commissioned by NHS England, and the quality assurance of these programmes became the responsibility of public health staff employed by Public Health England. Public Health England also became home to Health Protection teams (to advise on communicable disease and environmental hazards) and the former Public Health Observatories (now known as Knowledge and Intelligence Teams or KITs). One of the groups that seem to have coped well with these changes has been the former Child and Maternal Health Observatory (ChiMat) now known as the National Child and Maternal Health Intelligence Network. This group collate and interpret routinely collected health data on children, young people and maternity services and present it in easily digestible formats and as tools to enable understanding of local health needs, and to support the commissioning and development of local health services and maternity services. If you haven’t seen this website before, do take a look at the child health profiles for your area and see how you compare to the rest of your region and England as a whole (www.chimat.org.uk).
NHS England has been responsible for the commissioning of the childhood immunisation programme and child and maternal national screening programmes. It is also responsible for commissioning national specialist health services for England. Despite only being created in April 2013, in 2014 NHS England and Public Health England were both required to make substantial reductions in their budgets by 2015/16, leading to the new organisations having to restructure within two years of their creation. There is inevitably an opportunity cost of having to restructure twice in such a short period of time.
A recent unexpected challenge has been the announcement in June 2015 of £200 million cuts to ‘non-NHS services’, which quickly emerged to mean a cut to the Public Health budget in Local Authorities. In reality this is likely to translate into a budget cut of about 6-7% in this year and in future. The exact details of the cuts for individual Local Authorities are expected to be announced shortly, but for those Local Authority Public Health teams where budgets have already been committed for 2015/16, the expected shortfall in funding will pose a significant challenge.
So in answer to the question, “What became of all those child public health colleagues that you used to know?” many are still working to improve the health of local populations of children and young people, but in different organisations and in challenging financial circumstances, though some have left the profession through retirement, redundancy or due to change-fatigue. If you have lost touch with your old allies in child public health I’d encourage you to seek them out again. More likely than not you’ll be able to find out where they are by contacting your Local Authority Public Health team or the Local Area team of Public Health England. There is still work to do to improve the health of the local child population, whatever organisation we happen to be working in at the moment.
Dr Julie Mytton
Associate Professor in Child Health, University of the West of England, Bristol, and Consultant in Child Public Health, Bristol City Council
BACAPH Executive Committee member