Why independence for directors of public health is so important

The public were shocked at the conclusions of the Francis inquiry into the management failures at Mid Staffordshire Foundation Trust. A core problem was that some professional staff did not speak out about the risks to patients arising from the poor policy and practices they observed within the hospital − sometimes seeing this duty as secondary to protecting the reputation of the corporate institution that employed them.

‘It may be elected members and not hospital management whose policy decisions come under critical public scrutiny’

One consequence is that now many health professionals may have a “duty of candour” − a responsibility to place the known risks to patients (and the public) in the public domain.

If directors of public health are to do their job properly, the public will expect them to do the same, but it may be elected members and not hospital management whose policy decisions come under critical public scrutiny. This is new territory for all concerned, and it brings the issue of directors’ independence into sharp focus.

Their independence is complex and may be viewed with some ambivalence by local authorities that have a much stronger “locally corporate culture” than the nationally accountable primary care trusts that were the previous employers of directors of public health.

The roles is different from other chief officers in a number of ways. Directors of public health commission only about half the public health services for which they are accountable. The other half of public health services provided to their local residents are commissioned by Public Health England, clinical commissioning groups and NHS England.

So, while they are employed as statutory officers of the local authority, they are jointly appointed between the local authority and PHE. They vote alongside elected members on the statutory health and wellbeing boards and they have to be accredited members of the Faculty of Public Health to even be eligible for the role.

Statutory responsibilities

Many directors are also members of their local clinical commissioning group boards − a role that carries additional statutory responsibilities. Directors’ job descriptions require them to “produce an independent annual report on the health of the population”. Section 73A(1) of the NHS Act 2006, inserted by section 30 of the Health and Social Care Act 2012, gives the director of public health responsibility for “all of their local authority’s duties to take steps to improve public health”.

‘Effective elected members will certainly not cede any of their democratic policymaking prerogative to directors of public health’

This responsibility stretches the new role out beyond a simple management responsibility for “health directed” public health grant expenditure and into leadership of all “health relevant” resource allocation and decision making of the council.

Public health is “the science and art of preventing disease, prolonging life and promoting health through the organised efforts and informed choices of society”, according to the Wanless report. Most things that improve or harm the public’s health don’t come with a “public health” label. Good population health is often the outcome of multiple public policy decisions taken for non-health reasons.

In 2010, the National Audit Office reported that only 15-20 per cent of variations in mortality that exist can be directly influenced by “health interventions” such as specific health services or disease prevention programmes. The remaining 80 per cent of mortality differences arise from social, economic or environmental conditions in areas like housing, employment, education and transport.

Policy interventions

Directors of public health must aim to improve these “conditions“, which means they have to intervene directly in local public policy, where in local government it is the elected members who have the democratic mandate to lead. Effective elected members will certainly not cede any of their democratic policymaking prerogative to directors of public health, but effective directors will not censor, equivocate, amend or keep silent about the health risks affecting their local community − even when such risks arise from policy decisions made by their employers.

To be effective at improving public health, both councillors and directors have to respect each other’s independence and they will have to manage this paradox carefully.

This may in the end be about style and culture. Directors of public health have generally spent the past 25 years honing the declaratory arts of policy influence and “advice giving” in a professionally dominated national service with a vertical (non-democratic) accountability structure. Most senior council officers have spent their 25 year careers developing a wide range of subtly different influencing arts.

‘Both councillors and directors have to respect each other’s independence and they will have to manage this paradox carefully’

These skills enable them to work with a diverse range of locally elected members, navigating a shared space on a journey to their jointly preferred policy destination − through negotiation and persuasion. Some directors of public health have quickly, and sometimes painfully, learned that they may not yet have the skills to do this well. The “independent style” that (sometimes) worked for them in the NHS can cause abreactions on a scale ranging from mild irritation, through fits of intense aggravation, to life threatening apoplexy among many local government and elected member colleagues.

Directors need to seek a collaborative independence with council colleagues and elected members. If local independent political leadership and independent public health advice work together, they could change the world.

At the moment that is exactly what’s needed to create equal life chances for many of our most vulnerable citizens.

Dominic Harrison is director of public health for Blackburn with Darwen Borough Council, follow him on Twitter at @BWDDPH