Political restriction: DsPH welcome but want some support

We’ve seen a fair amount of debate over the past eighteen months about political restriction of Directors of Public Health and senior teams.  There was a twitter conversation on this between a number of Directors of Public Health in the last fortnight.

I’ve kept a reasonably close eye on this, and as someone who has been employed by Local Government in politically restricted posts for more than six years, I’ve often been asked to speak about what it means, what it does and the implications of it for you as a person.

My view, for what it’s worth, is that political restriction is a really important and very welcome tool, because it helps you maintain the impartiality you need to retain the confidence of elected members and also not be seen to be pushing any party political agenda.  But I was helped in my first politically restricted post by having senior officers who helped me understand this as part and parcel of the culture of working in local government. But so much for my views. I’ve also been helped in my last and current role by having wise and supportive officer and member colleagues.  

But what do others think, and what strategies have DsPH developed to help them?

Perceptions in the public health world two years to eighteen months ago

What I am about to say can hardly be regarded as a systematic sample – it’s more a convenience sample of views I have had from correspondents and people at events. Between 2010 and 2011 I did a lot of speaking, workshops and discussions on what it means being a DPH employed by a local authority. People I spoke to, or who spoke to me (and I include in this over 100 registrars, trainees, consultants and DsPH) were understandably very mixed in their views. Some were fearful of what this provision which exists in local government but not the NHS meant for them. Others felt this was a deprivation of their ability to speak out and be an independent voice for public health. Some were working out what the boundaries were and wondering who would help them. So the profession in some ways was getting its head round part of what it means to be in the new home called Local Government.

What do DsPH think in 2013?

In the last week or so I rang round or emailed ten DsPH, which I know is hardly more than anecdotal , choosing some new to local government and a few who’d been joint appointments for some time. I asked them for their take. It seems to me from discussions and debate that perceptions in the public health world are changing fairly rapidly; at least the ones I spoke to.  Most DsPH saw benefits in political restriction. A couple were slightly wary.  There are several people in the public health world who have chosen not to join local government or PHE because of political restriction and the fact they are all politically active. This has been a wrench for them, and we have to remember the advent of this was not of their making. So this process has not been without pain for some colleagues.

But while there are still some who have undountedly counted this as a factor in staying within the NHS or moving into posts other than PHE/LAs,  the majority of people I have been in contact with now suggest that political restriction has a range of benefits.

The benefits are articulated as:

• Helps you remain impartial and give impartial advice
• Understanding this gives you a key to understanding thewhole architecture of officer-member culture in local government
• Makes you available to all members though obviously you have to served the elected portfolio holder well and professionally
• Affords you protection when some members may wish you to set aside impartiality
• Protects the confidence of members and the public that your advice and decisions are based on best available evidence, and you can bolster this by relying explicitly on evidence when you speak
• Keeps the distinction between officer and member
• Gives you air cover when things get party political

There are others too, doutbless, but these are the benefits which have been most often articulated to me. A key point articulated by a few is that, if you really like local government, you’ll be fine. Personally, I find this heartening.

Preparation for the role and culture : some challenges and some tips for development

The one thing everyone agreed on was that until you’ve worked in local government, you can’t fully appreciate the culture and ways of working, including on issues like this; and however good some of the preparation for transition was, most felt the preparation for this aspect could have been better.

Many DsPH are finding that not just they but their deputies, consultants in public health in some cases and others are considered to be politically restricted. Equally they have found their authorities largely very supportive in helping them

The most obvious challenge is that the guidance is not the most stunning read you’ll ever come across, but mostly that this whole area sits in the “soft” skills and competencies which, however good the NHS was, are very different from local government.  Having a good mentor, building good relationships with your authority’s lawyers and learning from your Chief Executive were felt to be key strategies here.

Another issue is when a particular party asks you to address their party group. The culture around this varies by local authority – some forbid it, others encourage it, others are fine provided all parties get the same treatment. One or two DsPH found that even neighbouring authorities did things differently. The best advice here was to take advice from your CEO. If in doubt, ask.

But the biggest challenge is speaking publicly with confidence and voice,and what you can and can’t say. Eventually, you get a feel for this, but several DsPH in the early days were clearing lines of what to say on an issue like fluoridation or sexual health through Portfolio holders and through chief execs.

A few common strategies DsPH seem to be using:

These are a number of strategies DsPH are using:

• Start from the ethos of public service: the public expect me to be impartial, serve the people they elected and do a good job. Political restriction helps, seen in this light because you are an officer, not an elected politician
• Learn from the Chief Executive about reading the style and the signs of your local authority
• Member induction training and seminars on public health challenges are important and valuable to officers (direction from members) and members (understanding what issues they need to factor into their decision making)
• Find a good local government mentor who is/has been a Chief Exec or Chief Officer in an authority with a similar style to yours
• Build good relationships with portfolio holders and negotiate the boundaries they expect
• Observe other chief officers and their relationships and styles, and learn
• Know your evidence, know your field, and speak from that in giving your best advice.
• Reading and checking out the LGA and LGiU  (if your authority is a member) and NLGN websites and publications
• Organise a learning set on local authority culture within the senior public health team and invite the CEO and other key officers along
• One or two have thought about or joined SOLACE, which as a Chief Officer a DPH is eligible to join (as are their direct reports) or even ALACE, a specifically local government senior officers’ trade union, while others are not sure what the benefits of these organisations are. And to clarify, you can belong legally to more than one trade union, so you could have Managers in Partnership (MiP) or BMA  or RCN etc membership alongside ALACE or others.  For more information try here.

Although they have stopped writing it, and I really wouldn’t rely on their advice or views about political restriction, the We Love Local Government blog has been helpful to some.

There is no hard and fast set of rules about making political restriction work for you other than the law on political restriction. But there are those clear tips and tools above.

Some learning needs still to meet?

It’s easy to get focused on how we make the Health and Wellbeing Boards work, but we need to remember that many of us as DsPH don’t have the experience of working within the local government context that Directors of Adult Social Services or Directors of Childrens’ Services do. That’s no criticism. But it does mean that we may have some development need arising from this, especially when the ADPH view of an issue may diverge from what ADASS or ADCS perceive to be the issues.

There is also a feeling that the BMA and Managers in Partnership, the two bigger trade unions for DsPH, have perhaps been less visible in support of DsPH on some of these issues than they could have been

While many of us are busy getting our heads round Schemes of delegations, our place in the Council’s constitution and a whole range of other issues, some learning needs emerge which have not yet been met for many DsPH focus around the soft and cultural/situational skills needed. Perhaps ADPH, LGA or other bodies could help us work on these:

1. The cultural and soft competencies of being a local authority Chief Officer
2. Like learning a language, we need to understand the idioms of how local government works
3. Building strong relationships with elected members

From the transactional to the transformational?

While many of us are trying to negotiate contracts and commission, and get people settled in to delivering, understanding political restriction and impartiality is a first step in helping us move from the transactional to the transformational agenda for local government public health.  The steps (easier said than done but we have to do them) seem to me from speaking to DsPH, CEOs and other Chief Officers to be:

• Understand the constitution and scheme of delegations and delegated authority
• Understand the council’s approach to transformation and the local government financial agenda
• Understand how this translates to your commissioning responsibilities as a DPH
• Understand what public health skills can contribute to the transformation agenda (evidence, effectiveness, investment etc)
• Develop an agenda to get the public team through this cycle

Two articulated desires for learning

There is a fair amount of interest among DsPH I have been in contact with on a learning set on the soft and cultural competencies.  Moreover, the need for development or a learning set on moving from the transactional to the transformational has also been expressed. A mix of organisational development, local government nouse and public health expertise represented in the members and the facilitators of such a learning set could take us a long way. Anyone up for it?

Postcript: How did political restriction come about and what does it mean?

A. Political Restriction in Local Government

The Local Government and Housing Act 1989 introduced the concept of “politically restricted posts” in Local Government.” These reforms were made in response to the Widdecombe report which had identified issues of concern involving local authority officers and the apparent lack of political impartiality, which lead to separate loyalties and prejudicial service[1].”  Essentially, the law regulates some political activities of local authority employees. This includes restrictions on becoming an elected councillor[2]. Directors of Public Health as statutory chief officers are included in such provisions[3]. Those reporting directly to them and those who have posts dealing closely and frequently with elected members will almost certainly be included.

 The definition turns on either the seniority or nature of the post. It used to turn upon salary scale partly but this has changed[4]. These posts are a mixture between what they are (senior position within the authority) and what they do (advising members/speaking with the media). The definition of such a post includes: 

1. Head of Paid Service, Chief Officers and Monitoring Officer
2.  Deputy Chief Officers (reporting as respects all or most duties directly to a Chief Officer but excluding secretarial or clerical posts)
3. Political assistants
4. giving advice on a regular basis to the authority, its committees, jointcommittees or Cabinet members or
5. speaking on behalf of the authority on a regular basis to journalists and broadcasters. The standards committee of the employing authority can consider applications for exemption from political restriction for the posts in these circumstances.

 Politically restricted postholders may not stand as a candidate for the House of Commons, the European Parliament, the Scottish Parliament, the National Assembly for Wales or a local authority, or act as an agent or sub-agent for a candidate for any of those bodies. They may not canvass on behalf of a political party or a candidate for election to any of those bodies. They may not be an officer of a political party or any branch of it (or a member of any committee or sub-committee of such) if their duties would be likely to require participation in the general management of the party/branch or to act on its behalf in dealings with persons other than members of the party.

 Politically restricted postholders may not (except where this is necessary as part of their official duties):

1. speak publicly with the apparent intention of affecting public support for a political party; or
2. publish any written or artistic work which appears to be intended to affect public support for a political party (or cause anyone else to do so). (Assistants to political groups have slightly different restrictions)

The salient point here is to ensure that one sees these rules as preserving the independence of the Officer role, rather than an imposition on one’s own right to speak. In practice the restrictions are minimal, and the rules can actively protect officers who might otherwise feel pressured in some circumstances into overtly political behaviour. The key issue here, as with pre-election restrictions, is to understand and work effectively within the culture and legislation.

B. Political Impartiality and Public Health England

Added to this was the announcement in several pieces of developing public health policy that staff in Public Health England would be required, in line with the Civil Service Code , to be politically impartial.  You can read an interesting and helpful take on this here. http://www.civilservant.org.uk/c21.pdf 

But civil service impartiality, at the end of the day, and political restrictions in local government, are not the same. There are nuanced differences and in many senses Chief Officers in local government have much wider discretion to shape and inform policy as officers and working with members, and make commissioning decisions on that policy, than most civil servants other than the very senior ones do.

With that goes greater responsibiity on us as officers to serve our members well. And different local authorities have different styles of working which doesn’t work in the same sense as the civil service-ministerial relationship. For some local authorities the subtle, softer side of members needing to have confidence in your impartiality will be the most important.  And each local authority varies in how, when and where members and officers are engaged in the policy process. These style issues are important. Public Health England and DsPH will need to understand that the reality of being a DPH varies sometimes dramatically in cultural and style terms from one local authority to another.

References

[1] Local Government Employers (2012) Political restrictions on local government employees. http://www.lge.gov.uk/lge/core/page.do?pageId=119739 .

[2] You cannot be elected to a council you are employed by. The law disqualifies anyone holding any paid employment with the Council itself from becoming or remaining an elected member of it. These direct links with a person’s own authority create an automatic disqualification whatever the level or nature of the post held. (Employment appointments by a joint committee involving the Council can also be caught – seek advice). Teachers at all schools maintained by the Council are treated as employees of the Council for purposes of this disqualification, even if they are not strictly employed by the Council.

[3] The author holds a politically restricted post. The challenge is to a) see these as liberating and work within the rules. It does not prevent him from writing or publishing or speaking, and there are rules and frameworks within which to operate.A user-friendly guide to the provisions can be found here http://www.parliament.uk/briefingpapers/commons/lib/research/briefings/snpc-03883.pdf

[4] The Local Democracy, Economic Development and Construction Act 2009 S.30 amended the Local Government and Housing Act 1989. It removed the duty to maintain a list of posts earning above the previously determined salary to become politically restricted. Local Authorities need to consider whether those posts previously politically restricted because of salary or grade should be genuinely restricted. Some authorities may continue this but others will consider the nature of the role employees actually perform.In any case DsPH are likely to be caught by the regulations.

Psychology, public health and the enduring vitality of a discipline

Someone once said that history repeats itself; it has to because nobody listens the first three times around. The relationship between some of the social sciences and public health practice sometimes feels a bit like that to me.

Psychology as a part of public health practice is something which still elicits a range of opinions. There are those who feel it is an essential tool for any behavioural programmes, and the (relatively) recent field of Health Psychology is an example of what psychology can bring as an ally to public health practice. Others feel that psychology has a limited contribution to the science of public health because public health as a medical science has different epistemological foundations and approaches to those of psychology. (To be fair, even psychologists differ on whether psychology is art, science, social science or hybrid. But I’m not going to get into the philosophy of psychology here, much as I know that would thrill you.)

The nature of public health as a discipline and insights from others

This, though, raises the question once again of whether public health is art or science or both. There are those who strongly defend the scientific basis of public health, and that’s a good thing. Others highlight the political and tactical nature of public health when engaged in policymaking.  But my own view is that public health is more of a technology – a means of organising, integrating and using a range of different tools, methods, sciences and techniques to achieve outcomes.  Biology, environmental science, epidemiology, mathematical statistics, probability, organisational behaviour, law and political economy all have a role to play. And yes, social sciences besides political economy have a role too.  

In early Summer2013  the British Academy will launch a report on the contribution of social sciences to public health with a foreword by Michael Marmot, whose idea the report was. As one of the Editorial Group and co-author of the introduction my hope is this forthcoming publication will help public health and policymaker colleagues identify and make more use of the social sciences in the daily work of delivering public health.

This ability of public health to absorb insights, methods and techniques from different tools and perspectives is something we should see as a sign of strength and vitality: public health is in rude health, in some senses. 

This vitality applies whether it’s the stricter academic science of public health using and testing methodological innovations as we saw in the public health science conference in November 2012 (and coming again on 29 November 2013), or the recognition that public health leadership needs a range of insights and tools to enable leaders to do their jobs well.  It’s a sign of such rude health in our discipline that as a discipline we have people from a range of philosophical backgrounds, methodological persuasions and professions from communications to environmental health and so on. What we perhaps need to spend some more time doing is revisiting the philosophical and value core of who and what we are as people in the public health field(s). I suspect if we do we will reinforce what the history of public health tells us, it has always been a “both and”  field taking insights and tools from where it needed, and building on the core discipline of the actor. It has never really been an “either or” field – science or politics.

And this is perhaps the greatest lesson we can learn from history – both the history of ideas and the history of cultures : the most successful and enduring movements, states and ideas have taken insights from other cultures they encountered. Christianity absorbed hellenistic philosophy in the first five centuries as a dialogue partner to help it explain itself. Aristotle was introduced via Arab culture in the middle ages to mediaeval philosophy and theology. The Romans absorbed anything they thought would add to their vitality. So public health shouldn’t be worried – taking a lesson from history, public health is doing precisely what successful movements have done for centuries. 

This doesn’t mean everything for public health is rosy,  but it does mean that as a discipline faced with a new world and new home we have the intellectual horsepower to recognise we need new and different tools and we also have the heritage of doing that more or less successfully; which should stand us in good stead. That is a strong ground for hope for the future of public health, even if some of the organisations and bodies in public health have over the last two years seemed much less agile than we needed them to be.

Disposition counts

The key issue of our success will be whether we adopt a hermeneutic of suspicion (a perspective that nothing good comes from other disciplines; I exaggerate) or a hermeneutic of generosity ( we ask what is there in other disciplines which might help me, without losing my own best traditions and insights from my public health training.) I’d rather, personally, be generous than suspicious. And one of the things I know is that building public health requires building alliances. For me, working with business, social entrepreneurs, third sector and others to bring a range of insights to challenges has been essential to achieving the outcomes I need. That lesson was reinforced most recently when in Hertfordshire we participated in a succesful  trial of promoting routine physical activity in the workplace, via StepJockey. 

Revisiting the contribution of psychology: health psychology as an example

And this brings me to my first point about psychology – the nature of the public health challenges facing us is so heavily linked with behaviour, lifestyle and lifecourse accumulation of risk and morbidity that we need psychology as a set of tools to help us face what many regard as the major epidemiological challenge of the twenty first century. The psychology content of the public health training curriculum is no longer fit for purpose. We need to bring to public health practitioners and teams across the country the best of what psychology can offer. It’s being done elsewhere: psychology for nurses, psychology for ministers of religion, psychology for business leaders. If  they can do it, we in public health can.

Taking health psychology, the putative “public health psychology” movement has generated quite a literature, and below is just a very select sample which predates “nudge”. (And no, I’m not a fan of nudge. If you want to know why, read Martin Delaney’s blog here.) These examples alone create a significant agenda for us to work on.

1. http://www.nsph.gr/Files/FileManager/Psihologia_ygeias/Notes/1h_imera/Editorial5-12.pdf
2. http://www.thepsychologist.org.uk/archive/archive_home.cfm?volumeID=18&editionID=129&ArticleID=947
3. http://www.ncbi.nlm.nih.gov/pubmed/14683568
4. http://www.emeraldinsight.com/journals.htm?articleid=17053907
5. http://onlinelibrary.wiley.com/doi/10.1348/135910700168955/abstract
6. http://www.ncbi.nlm.nih.gov/pubmed/14683577
7. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1382037/
8. http://www.apa.org/pubs/books/431644A.aspx
9. http://courses.washington.edu/phequity/Glass%20and%20McAtee.pdf
10. http://www.sagepub.com/upm-data/26636_Chapter1.pdf
11. http://www.med.mcgill.ca/epidemiology/courses/655/chapter1.pdf

Health Psychology since its emergence some 50 or so years ago has pretty much become its own discipline. It needs to be a stronger part of the public health training curriculum, and needs to have a stronger showing in how public health organisations tackle the growing burden of issues like vulnerable older people, non-communicable disease and young people developing avoidable psychological and physical morbidity. That is an agenda in itself for public health. But we could do worse than dialogue much more closely with health psychologists and develop tools and insights.

To take but one example, intervention mapping has become a powerful tool to help keep behavioural intervention programmes consistent with the evidence and theory, so they are well implemented. I know from my own experience how useful the insights of intervention mapping can be, especially in large scale behaviour change programmes.

More than just good friends: an agenda for psychology and public health

But there is a much wider set of issues on which psychology can help public health professionals, and this brings me back to what I mentioned above as our ability in public health to absorb and adapt insights. Looking across public health, there are a range of fieldsor sub-disciplines. Commissioning public health, for example, or environmental health as well as health protection and health improvement. Psychology too has a a range of sub-disciplines, and has a regular habit of throwing up new sub-disciplines whenever a body of scientific knowledge emerges to support them.  This is exciting but can be confusing for non-psychologists. But it shows that psychology and public health are both adaptive and thriving.

Rather than go through every single sub-discipline in psychology, I am going to selectively choose just a few to illustrate some benefits of using psychological insights.  Yes, this list is biased, but we have to start somewhere. In any case, benefits from clinical psychology, neuropsychology and so on should not be that unclear to many of us.

1. Health Psychology – the benefits of this field for prevention and management of non-communicable disease, achieving and sustaining behaviour change, making every contact count in a meaningful way, and the thorny issue of good self-management in secondary prevention are salient and need to be explored further.
2. Occupational Psychology -this could inform recruitment, selection, training and job design for the public health workforce. Designing jobs with the competencies people need for local government and community interfaces, and then designing the training for those roles.
3. Organisational Psychology – can help us in understanding organisations and how to influence them. Recent work on strategic leadership in business could be applied to strategic leadership in the public sector to help us embed public health across local government functions especially.
4. Developmental Psychology – the growth of lifecourse methods and aproaches in epidemiology and public health is significant.  Lifecourse approaches to chronic diseases theoretically and evidentially show promise. The use of lifecourse approaches for maternal and child health, and in children with complex disabilities, are two areas of particular challenge.  Combining these insights with approaches from developmental psychology such as behavioural development, cognitive development, socialisation, the influence of peers and others on behaviour and factors likely to mitigate for healthier lifestyle or good emotional resilience could have applications ranging from child obesity to child mental health and resilience, as well as inform issues like risk-taking and bullying.
5. Positive Psychology -  Some folk would call this an application of psychology or a perspective rather than a sub-discipline but positive psychology is a fast growing perspective and is the study and promotion of optimum human functioning and happiness. This very new sub-discipline can make significant contributions to public mental health and resilience, design and planning of the public realm for better human functioning and even design of emotional resilience programmes for schools. There are even applications across workforce design such as strengths psychology.
6. Community Psychology – another relative newcomer where there is a debate about whether it’s a mindset or a sub-discipline. Community psychology focuses on communities as the unit of intervention with the aim of reducing inequalities and improving well-being. There could be a lot of benefit here in some joint consideration of community interventions and technologies for two fields (public health and psychology) which have often wanted to intervene with communities but whose methodological and evidential comfort zone is too often the individual as intervention focus.

Ok, this is ambitious, and some of you undoubtedly think I am flying a kite. But we have to start somewhere, and speaking from my own experience I have found the various sub-disciplines of psychology a rich source of insight for public health practice. If we at least map out where there are links, we can identify some priorities to take forward.

What’s not going in the British Academy report: an opportunity

What isn’t going to be in the forthcoming British Academy report is an enormous amount of psychology, partly because the report is trying to take an overview of where social sciences can help (and showcase some of the less obvious), and partly because psychology could take up the whole report. But equally - as I hope I have shown – the report doesn’t need to. There is more than enough out there already for us to build on. We have the opportunity to have conversations and develop some tools and joint areas for work between psychologists and public health. We should just get on and do it.

Next steps in the conversation

It would be great to see a series of masterclasses organised around areas of psychology and public health interface.  Perhaps some brief guides on applications of psychology to public health practice could follow. We have in the UK some of the leading academics and practitioners who can do this.

What would also be useful would be for us to have an eirenic discussion within public health and with dialogue partners about the epistemological and hermeneutic issues the challenges to public health practice bring about, and to look at what this means for us and how we bring in social scientific and psychological insights to help us with those challenges. The two public health science conferences are an attempt to show and disseminate the strength and innovation in research and science.  Perhaps we need something similar on social science and public health interfaces.  One way as suggested above is to have some psychology and public health masterclasses for public health professionals.

While we’re at it we could look once again at how we train our workforce for the challenges they will face. As we await the much vaunted launch of the workforce strategy, holding its principles and insights up to the mirror of occupational psychology could help us develop a public health workforce which is resilient, adaptable, able to integrate insights to deliver change and can renew itself: a bit like the intellectual corpus of public health itself.  That can only be a good thing, surely.

Jim McManus is a Chartered Psychologist, Chartered Scientist and Associate Fellow of the British Psychological Society.

Terms, Conditions and Value: Consultants in Public Health and Local Government

I have heard a lot in the past few months about the debate around terms and conditions of Consultants in Public Health who may transfer over to Local Government. (This debate has been quite heated despite the fact that no HR guidance has been forthcoming either from DH or Local Government Employers yet, and won’t be for a little while. ) People are understandably anxious.  I would be anxious if I’d been in one organisation for 20 years and were suddenly being transferred. And the change from NHS to Local Government does feel like the leap of faith till you realise hundreds of people each year go between the organisations and back again.  I work with people who have had eight different nhs employers in ten years, and one local authority employer for five or more years.  There is cause for optimism while we await the frameworks. And there is much we can do to foster the desire and skill for our best talent to flourish in local government. (More on that next blog.)

But the discourse I have so often been on the receiving end usually goes “you’re in local government, aren’t you?” followed rapidly by “Well Local Government doesn’t want to pay Consultants in Public Health the salaries they’re on and I think everyone should be employed by Public Health England.”

 The debate seems still to be heated, and when I sit down with people, what usually gets agreed between us is a) there is still some anxiety about local government, public health england is perceived by some – not all – to be safer  [for more or less good or bad reasons] c) the delay in getting HR issues resolved is unsettling a lot of folks and d) some of the folks on both sides of the organisational divide have made remarks which make it feel like people coming from the NHS will have to do the equivalent of asking Charon to ferry them across the Styx to Hades, or pass through Dante’s gates into hell, leaving behind all hope as they do; driven by the ”necessity, not pleasure” which brings them there (Canto XII of the Inferno.)

This less than charitable or helpful debate is despite the fact that many local authorities are publicly saying  they want to welcome public health staff as a valued source of talent and strength to the local authorities existing strengths, and get the best from all.

People are not, and should not expect to feel, as if they are crossing the Styx or entering the Seventh – or any other – cirle, leaving behind their terms and conditions and any idea of career advancement and satisfaction behing them. And in our heart of hearts we must surely know that we need less foretelling of woe and a wee bit more honest engagement in this debate. The sequence of recent letters and commentaries in the medical press has certainly sometimes shed more heat than light.

We all know a few folks in local government – NOT ALL – have made some statements as rash and unfriendly as those coming from a few folks – NOT ALL – in the NHS and other agencies.  (I am not throwing mud here, I am saying there must be a better way.) We  and I may even have contributed to this, however unwittingly or unintentionally, ourselves.  

Trying to find a more eirenic approach which is based on mutual appreciation of strengths is building steam across the Country. I think this will bode well for recognising the tremendous asset public health consultants could be to local government.

I have written elsewhere, and am about to produce more, on how we can bring local goverment and NHS into a constructive agreement. But meantime, here are thoughts on the thorny problem of considering why consultants in public health should be valued. First we need to look at what’s not working in the debate currently.

So, what are the arguments unlikely to work?

None of what I am about to say in any way diminishes how important I feel public health is, or how much of a unique contribution we can make. But our issue is in how we present this and make a credible case for it.

Claims that public health consultants are somehow so different ( by virtue of regulation or accountability or the fact they are public health) to the other professions local government employs,  that they are unique, seem to fail very quickly.

From an HR or finance perspective in local government, or any large set of systems, this argument is not really very strong. In common with consultants in public health, the following professions (just a sample) employed by local government are all i) regulated statutorily or otherwise, ii) have specific qualifying routes and iii) have accountability to professional bodies:

• Veterinarians (statutorily regulated)
• Nurses (statutorily regulated)
• Psychologists (statutorily regulated)
• Architects
• Solicitors (statutorily regulated)
• Barristers (statutorily regulated)
• Chemists (Royal Society of Chemistry regulated)
• Paralegals
• Engineers (craft workers)
• Electricians (craft workers)
• Architects
• Trading standards officers with police and criminal evidence act powers
• Social workers (statutorily regulated)
• Teachers (statutorily regulated)

All of these professions have salary grades and terms and conditions recognised in one or more of the local government frameworks. Most local authorities are moving to single or grouped categories of salaries contracts for all of them (except craft workers) because it provides ease of management and has financial benefits to the organisation. All of these professions have some “special” or “different” or “unique” role. From a local government point of view, the uniqueness of the public health role is actually nothing new. Far from being a point of anxiety, we should treat this as a point of encouragement in negotiations.

Typically also salary grades in local government are made up a) of seniority reflected by budget and staff/service management responsibilities and b) technical or other expertise which is admittedly somewhat  secondary, but not always. So arguments about uniqueness are not likely to succeed, especially when they have not succeeded with any of the above professions.

When seen from an HR profession, this is just one more profession local government absorbs into a range of specialist professions making up the workforce to do what the Local Authority needs to do.  Public health is not “unique” in HR terms when you are managing so many “unique” professions .            

Yet as Directors of Public Health we will depend very much on the talent of good consultats in public health (and public health medicine), and hope to make them our successors. So we need to make a sound and credible case for why local government needs them, and why we should value them at the extent we do.

 So what might work?

This will need some careful advice and input from HR, but here is the combined set of arguments I think from discussions with colleagues in and outside local government, which is likely to preserve most of the terms and conditions and value of the Consultant cadre.

1. Safety and effectiveness of the service: A public health service, especially given the highly technical nature of it, will not be safe without consultants. Their range and span of responsibility is significantly beyond that of comparable deputy/assistant directors because of the technical and other responsibilities.  Because of this they need to be at the peak of the profession scientifically.  The post of consultant in the NHS has historically been given to someone who has reached the practice peak of their profession, and their training and expertise reflects this. In order to be safe in the discharge of public health functions, the local authority needs consultants because they have the requisite training and expertise.
2. In particular, Government has now stated that the statutory functions of advising NHS commissioning will come with the Director of Public Health, along with statutory health protection functions. Because of the highly specialised nature of these, these positions need consultants a) to be able to practice safely and effectively [and not end up with clinical commissioners suing the Council for duff advice] and b) to be able to influence other clinicians who will expect people of an appropriate status of expertise and professionalism from public health to be making decisions.
3. Recognition of Specialism. Local Government frameworks do recognise specialisms to an extent. The specialism of public health consultants is very high, on a par with consultant clinicians. They bear significant weight of responsibility for the advice they give and the expertise they have, and their accountability. It is this which is reflected in their training, salary and conditions; and their registration to protect the public. This needs to be recognised by local government.
4. Investment to save. Consultant posts should be seen as an investment to save, they have some key skills which could be applied across the council’s whole portfolio, not just for health improvement but to help the council meet its entire goal set. The skills are: a) Assessing and finding evidence of effectiveness, b) Identifying effective interventions, c) Identifying value for money, d) Service redesign, e) Monitoring and evaluating impact and f) Priority setting
5. Corporate impact. Consultants can make the following impact corporately across the local authority as well as i)  Understanding the key drivers of health and wellbeing, and the interventions to improve population health, ii)  Understanding the principles of how to target programmes, interventions and policies ,    iii)  Understanding and managing the conflicts between population and individual concerns (equity), iv) Finding, assessing and applying equity, v)  Understanding and applying structured ways of doing needs analysis, vi) Applying decision analysis and helping with decision and economic analyses of policy, vii) Supporting effective commissioning using i) – vii) above, viii)  Identifying likely prospective policy impact when the evidence is silent, ix) Understanding research and evaluation and applying this to council business, x)   Supporting the evaluation of commissioning and xi)  Supporting the understanding of complex variables (e.g. different influences on childhood mental ill health) and their interaction in policy and decision making.

These sets of competencies could have a wide and strong application across local government. Applying these skills to youth crime, gangs, looked after children, housing problems and so on – not just core public health – could help develop in local government the evidence and other skills it wants. The impact of public health consultants could be enormous, seen in this light. But first they need to be made to feel welcome, as well as realise that some things will change, hopefully for the better.

I talk and blog often about the “deficit” approach to skills – and how unhelpful it is. Coming into an agency assuming you have all the skills is rarely a successful strategy. Good organisational bringing together sees and values honestly the assets of each stakeholder. I hope, with colleagues, I have found one way of doing it which we’re working on currently.

Those authorities who are having this discussion – and there are some –  seem to be developing an ever stronger desire to incorporate public health and include the consultants’ terms and conditions favourably.

It does mean that we as DsPH have some work to do, some of which is about transferring skills. More on that in my next post.

The Holiday reading list: or who are we kidding?

The ritual of choosing (and deluding myself about) holiday reading is one of the great joys of going on holiday. it is second only to the sheer fun of choosing a pile of reading and music for the Christmas season.

I don’t do sprawling beside the pool holidays by choice and I don’t do beach holidays (I am usually afraid, even having lost a pile of weight, that some short-sighted trawler will mistake me for an edible whale and then harpoon me.)  So my quantum of reading time is necessarily circumscribed by the fact my inner five year old is being let loose on another collection of medieval cities, frescoes, byzantine era mosaics and general gorgeousness, and the momentary savour of the reading will wait for a few hours.

My favourite holidays are cycling round bits of Italy  or Spain that I haven’t been to. (I wrote off a bicylce cycling round Monte Subasio to Assisi when the brakes failed. Either Saint Francis was looking after me or the Almighty was hoping for a bit more peace and quiet before I came round disturbing things.)

I love discovering Italian and Spanish cities – especially the medieval bits.  This is – like every year –  a “walk till I drop” holiday, of long days enjoying the city and leisurely evenings spent being thankful.  I am already anticipating the sixth century Ivory throne in the museum at Ravenna, and the mosaics in the basilicas so green, purple and white that they could have been laid yesterday.  This year Bologna (the City in whose railway station an insalata is not a salad but a cheese and ham croissant) Ravenna, Modena and Ferrara beckon. 

And all good holidays need some good reading, or so someone who should have known better once decided.

So, it’s that time of year when I look at the five foot and growing pile of unread books in the study and think – “which of you lot do I take with me in order to kid myself I am going to read any of you?”  I give up and put the kettle on instead. Fortified by procrastination and two cups of tea [one lapsang souchong, the other apple and cinammon] I clean the floors, scrub the bathrooms, dust the entire flat, offset the carbon I will use up in flying then go for a walk and then finally return to the pile resolved to sort this thing.

I savour the possibilities of which twenty items I will take. Then I ask who I am trying to kid…me, the airline or my rucksack?  So I think through:

• The book to read while on the plane. (Honestly? One cup of tea and a plough through every journal article I can lay my hands on later will be followed by fallng asleep for about half the flight, before spending the descent reading the in-flight magazine ( in both languages  depending on the airline) as a vocabulary building exercise;  topped off by making a really bad decision to find and then fiddle with my Ipod - sorry iPod -  for the remaining two minutes before we are told we are about to land.
• The theological or historical tome to read while sitting on trains rushing ( or pootling ) through the Italian countryside to that day’s destination. (Continuing the vein of honesty I will do my usual of raiding the newstand and bookshop near the station and buying newspapers, the Italian edition of Scientific American [Le Scienze], The Jesuit Bi-Monthly La Civilta Cattolica and devour these on the train instead.
• The leisurely evening read. (Then I remember they have bookshops in Italy which are still like bookshops were here when I was an undergraduate.  And I always end up buying stuff while there.  Some schlock horror Italian giallo crime novel will be chosen, or another volume in the series of modern theologians I love reading.)

So, as usual, into my patient and long-suffering rucksack goes a selection of more or less randomly chosen items:

• The collection of medical and scientific articles which I will plough through over breakfast and on the plane. This year I’ve taken a collection of papers on health inequalities and policy change culled from The Lancet, Journal of Epidemiology and Community Health and a host of others. A collection of 27 papers I will read and reflect on with relish. Including the special issues of JECH I picked up at the World Congress of Epidemiology earlier this year.
• Volume 2 of the works of Teresa of Avila – our Carmelite group is continuing the study of this amazing woman in preparation for the fifth centenary of her birth.   I also slip Rowan Williams’ amazing study of her in. I would finish this but for the fact I re-read every chapter several times.
• Nancy Krieger’s Epidemiology and the People’s Health – this should be on every trainee’s reading list
• A slim volume on evidence synthesis which I will get through in one train journey
• The New Testament
• If I have been there before, my little black city book – favourite cafes, galleries, museums, haunts, bus routes, restaurants and so on to my last place of holiday.

 The Journey Back also brings the pleasures of reading, but that’s another story.

If you have had your time of renewal and refreshment, I hope you enjoyed it. I intend to thoroughly enjoy mine.

After the disturbances: does public health have a role?

This post also forms the Editorial for Birmingham’s Health Matters, Issue 7, 2011. August/September

As you have all heard over and over again, I love Birmingham. It’s an amazing city of wonderful people, and arguably the most diverse place I have every lived or work, even more so than East London. But we have many challenges, from the ongoing challenge of reducing inequalities in disability, ill-health and death to the more multifacted – the short and long term measures we need to take after the disturbances in our Cities.

I think public health has a role to play in helping our City meet its ongoing ambitions. Lots of people I come across do.

Against this background, work is currently nearing completion to produce a new revised health profile for every electoral ward and every constituency in Birmingham. We will be able to identify a snapshot of the health of our population, across the Lifespan, at electoral levels. These are part of the work of creating the new style JSNA, so that you can look at the City or any part of it and understand the health and social care challenges at a glance.

 Birmingham now has a library of needs assessments (deep dives into health and social care issues) covering 36 different topics. This has been a huge task, but the next task is to bring these together into one summary. That will be done by Christmas.

So why are we renewing the ward and constituency profiles at this point?  Is this not an odd thing to do? Why should this be important when we are in the middle of massive change in health and social care configuration, Dilnot has reported on social care funding, and many are still reeling from the shocking experience of civil disturbance?

I believe the answer to renewing information profiles is that it takes us to the heart of one aspect of what we want Public Health in Birmingham to do. Providing easily accessible, high quality information on the health of our local area is one part of the public health cycle. It enables us to identify what we need to address. In other words it gives us very clearly an overview of what’s not right, or if you want the jargon, areas of inequity and inequality.

The next steps of this cycle are about identifying evidence of what can be effective in addressing inequity and inequality and working with commissioners to implement and deliver this. Public health “science” means we need to know what the problem is and what can be done about it. Public health “art” is about getting it done. In that sense, our elected members and NHS non execs are among our greatest “public health artists”. The “scientists” should support the “artists” in achieving change.

This public health cycle (or one form of it at any rate ) is actually conceptually simple:

1.  identify need, 
2.  identify greatest inequality, 
3.  identify effective interventions, 
4. agree priorities, 
5. support commissioning of them and
6. evaluate what difference it made.

This is what the heart of public health should be about. The specialist training of public health consultants is intended specifically to help us do this. It’s a corny joke, but when we don’t use the public health cycle properly, it’s no surprise that sometimes the wheels come off what we do.

Let’s take an example – stroke. Stroke causes avoidable disability which limits the quality of life of people with stroke and takes a great deal of effort to recover from, and is a substantial avoidable cost on the public purse. We need to adopt a whole system approach. Clinicians and the Cardiac and Stroke Network have done an amazing job of identifying interventions at ambulance, entry to hospital and first 72 hours. What we need to do now is sort out the other ends of the system – stopping people getting strokes in the first place (we know the evidence – addressing Atrial fibrillation, diet, exercise, smoking) and rehabilitation for independence afterwards (social care, recovering activities of daily life.) Unless we know populations at highest risk for stroke, we can’t intervene. These profiles will help us.

But it’s a partnership, and public health works best in this cycle when it knows its role, supports the commissioners in their role, and supports elected members and decision makers in their “art” of public health.

So does public health and its cycle have anything to say about civil disturbance? 

Certainly the City’s formal and informal leaders (from the loving Father preaching peace through searing loss, to the sikhs and muslims who guarded each others places of worship, to those of us who simply took brush and shovel to help with the clean up) have been clear they expect us all to play our part, and follow their lead.

Laying flowers on Dudley Road in memory of Haroon Jahan, Shazad Ali and Abdul Musavir made me wonder what my contribution as a public health specialist might be, in addition to being a (relatively recent) citizen of this city is , both professionally and personally. I believe public health does have a contribution, and it seems to me that this contribution lies across four sets of issues. So here is a starter for ten. Do feel free to disagree with me, and correct me where I am wrong:

1. Victims of disturbance – the long term effects of being a victim of disturbance in riots is reasonably  well documented. Post traumatic stress (whether short  or long term) is important to look out for, along with  other health effects (stress leading to psychological  or physical health issues like anxiety or heart disease, for example). We need to monitor peoples health and  intervene early.

2. Communities – identifying how the disturbances  have affected our communities health, confidence and resilience (socially and economically) and then helping identify what can be done, and how to target resources for recovery. Identifying what builds health and social resilience, confidence, and cohesion in our communities can help our colleagues working there. This is in addition to building the healthiest communities we can, and prioritising our communities with the worst burden of ill-health. Health is not “the” answer, but it is a part of it.

3. Offenders – working to identify effective interventions which rehabilitate and prevent re-offending could be a contribution here alongside criminology.

4. Root Causes – the method of identifying evidence and analysing root causes is something public health could bring to the table, along with the other disciplines, when we sit down and reflect why this happened.

Ok, so information isn’t everything. But if we believe public health has a role, surely the public health cycle is something we bring to the table, and knowing the situation we face is a part of that.

Ten years ago I worked for a national crime reduction charity applying public health science to crime reduction and community safety.  I still remember the eleven year old boy in a particularly challenging area of South London, who was one of our peer researchers on a research project run by and for young people, to identify their experience of crime and disorder.  He used to go out every night when his dad came home in the taxi with that day’s takings.  He, armed with german shepherd dog and baseball bat, escorted his dad up to the family flat.

That experience – and many others – has stayed with me, not least because he and his mates (the youngest was 9) asked me one night what it was I felt my skills did. He was my first, and most searching “what use are you?” review.

The “big tent” discussion of different disciplines which went on while I worked in that role,  in places as various as the Criminology Journals, the streets and the then Home Secretary’s table helped, I believe, address some issues on drug related crime and on violence against women, and sexual violence. We can and must bring our best expertise from all our disciplines to this challenge. That’s what our citizens – rightfully – expect from us.

So, perhaps we can make a contributon to the recovery from the disturbances, as part of what we can do? My thoughts above are what the discipline of public health can bring.  It is a truism that many social problems have no simple easy solution. Nancy Krieger’s new book Epidemiology and the People’s  Health (Oxford:2011) should tell us that.  But it is equally true that we have to and can start somewhere. The debate about the nature of psychology (is it science, social science, moral science or all three) rages. In public health at least we recognise our work is blend of art and science.

So, can public health find the “start somewhere” evidence and point for the victims, communities, offenders and root causes?  Our predecessors would have sought to do so.  Birmingham will be hosting (as cheaply as possible in these straightened times) a series  debates later this year about what goes into our health and wellbeing strategy. I invite you to come along, take part, or even just email me your views. Jim.McManus @ birmingham.gov.uk  (sorry the email link isn’t fully done. It’s to prevent spam . )

 

 

 

 

 

Bringing Value..what public health specialists bring to local government, and what’s already there

A few weeks ago I started some work with local government and NHS colleagues on the different models which people operate around public health, and what each different field has to offer, and bring to the table. As part of some research, I have been run a few joint NHS-Local Government focus groups on this issue.

This is building on the “find strengths not deficits” approach I have blogged about earlier.

I’m working this up for publication, but here are the immediate things which have come out of it, in the form of some simple propositions:

Public health in local government is alive and well in different forms than in the NHS. It takes a variety of forms from very recognisable (environmental health roles) to the less recognisable (seasonal deaths work) but can always be fitted into the “three domains of public health” model

• Health Improvement – examples - healthy schools, planning strategies,
• Health Protection – examples - food hygiene, public protection, trading standards,
• Service Quality – examples – integrated care pathways in social care, models of service quality, reviewing services against evidence

The opportunity for us is about taking NHS public health strengths to these local government strengths, adding those NHS strengths to what is there already, and from this to create a model of public health which works in local government.  That means we need to recognise both the local government public health family and the NHS public health family have things to bring to the table, and things they need.  I’m not going to talk about the things they need for now, that can be done later. I am going to focus  on what we can both bring to the table.

NHS trained public health specialists do have a formidable range of skills. That’s no insult or poor reflection on local government, it’s just recognising that these folks have a range of domains of competence they can bring to the table. And they can be applied outside public health across the whole authority. I have deliberately not put these solely in the realms of public health (e.g. immunisation uptake or other functions which might transfer) I have tried to put them in the sense of how they can impact positively on the business of the whole council. So what are the skill domains? Well, they are the following:

1. Understanding the key drivers of health and wellbeing, and the interventions to improve population health
2. Understanding the principles of how to target programmes, interventions and policies
3. Understanding and managing the conflicts between population and individual concerns (equity)
4. Finding, assessing and applying evidence
5. Understanding and applying structured ways of doing needs analysis
6. Applying decision analysis and helping with decision and economic analyses of policy
7. Supporting effective commissioning using 1 – 6 above
8. Identifying likely prospective policy impact when the evidence is silent
9. Understanding research and evaluation and applying this to council business
10. Supporting the evaluation of commissioning
11. Supporting the understanding of complex variables (e.g. different influences on childhood mental ill health) and their interaction in policy and decision making

These sets of competencies could have a wide and strong application across the NHS and also across local government. Leaving aside the debates about salaries, terms and conditions and risk, those authorities who are having this discussion seem to be developing an ever stronger desire to incorporate public health.

And here is an acid test of them: Take one of your council’s thorniest issues and work out what the public health competencies above could add to help.  Then tell me public health consultants do not have riches to bring to local government.

People already in local government have a range of domains of competence they can bring to the table, and public health specialists who learn these skills to add their portfolio, or combine their skill sets with these, could be really powerfully placed to have a major impact in local government:

1. Working in political systems
2. Understanding the complex stakeholders engaged in the policy process
3. Multiple stakeholder relationship building (good for working with GPs)
4. Working with multiple policy frameworks from different government and other influencers and stakeholders who feed into local government (much more than the NHS often does)
5. Policy skills (there is usually a policy unit in local authorities)
6. Pragmatic research skills (there is usually a research team)
7. Programme management
8. Large scale service and intervention delivery
9. A strong sense of place and its impact on interventions

Interestingly, much of the work on Intervention Mapping as a set of techniques in delivering public health programmes (see Bartholomew et al, Kok et al) and an increasing amount of the research points to the salience of these local government skills in determining whether public health programmes are as effective as they could be.

In social care, for example, there is a significant range of opportunity to benefit from the kind of approach public health has taken with NHS commissioning, using the domains of skills above.

While both of these lists are shorthand,you can see that there are significant opportunities for skills to be used across systems and we should avoid a situation where we might be minimising the skills of someone without close enough consideration of what they can bring to the table.

I’ll share more of this work as I write it up.

What public health can bring to local government…getting acquainted

Getting to know each other

A few weeks ago I started some work with local government and NHS colleagues on the different models which people operate around public health, and what each different field has to offer, and bring to the table. As part of some research, I have been run a few joint NHS-Local Government focus groups on this issue.

I firmly believe that the opportunities for public health specialists in local government are significant, exciting and worthwhile.  While some folk might be apprehensive (and fair enough, if you’ve been in the NHS for 5, 10 or 15 years, suddenly to be told you’re moving can be quite daunting), I think there are some real opportunities here. As someone who made the jump into local government, it’s a fantastic place to do public health.

Government’s recognition of the need to continue public health input to NHS commissioning in its response to the Futures Forum actually improves the opportunities within public health to focus not just on the important aspects of ensuring NHS commissioning is supported effectively by public health, but gives us tremendous opportunities to work on integrating health and local government services.

So, what have I heard?

1. It’s about mutual skills, not defecits

This is building on the “find strengths not defecits” approach I have blogged about earlier. The idea is that each side has a range of strengths they bring to the table, and a focus which looks to them initially will get further than one which assumes one side has all the strengths, whereas the other has the defecits in skills/knowledge or expertise.

I’m working this up for publication, but there are some immediate things which have come out of this work, and I’d like to share this in the form of some simple propositions:

2. Pubic Health takes a diversity of forms in the NHS, Local Government and elsewhere

We’re used to this concept when we look at community advocacy for health, so it really shouldn’t be difficult for us to accept that public health in local government is alive and well, albeit in some very different forms than in the NHS. Within local government it takes a variety of forms from very recognisable, regulated and accredited (e.g. chartered and legal regulated environmental health roles) to the less formally regulated but still important (seasonal deaths work, seasonal flu vaccine uptake in social care.)

In 1974 the public health family went in a variety of directions,some of it went into the NHS, but not just into the NHS. It’s almost like a series of branches evolved within the NHS and outwith the NHS, with different concerns and issues. And if we can join up the best of each, we could have a fantastic approach to public health.

3. Recognising different branches of public health focus as they evolved after 1974

You can either say that the public health world actually shows distributed leadership (I believe Paul Corrigan hypothesises most on this in his health policy blog) across systems – NHS public health has led on a number of areas with bits of local government focused public health leading on others. If we take a taxonomy approach, we can and should always be able to fit public health work in local government (and in the NHS)  into the “three domains of public health” model we are very used to within the NHS.

Health Improvement.  The key features here are that the work is seeking to improve health of a specific population which experiences worse health outcomes or worse inequalities than the general population. There may also be some general population work (e.g. school meals must meet Government standards) because of the legislative and policy context of local government. We need to understand that universal services in local government can and need to be done in a health improving way, just as we would understand that this is the case in the NHS

Health Protection. The key features here are a regulatory or statutory or policy approach to minimising threats to the health of the population. Food hygiene inspections, trading standards work, animal health are all examples of this in local government. (And let’s not forget that Consultants in Communicable Disease Control derive their legal powers as Proper Officers of the Local Authority.)

Service Quality. Key features here are an attempt to use evidence and tools such as decision analysis and prioritisation to improve services and the outcomes of services. So integrated care pathways are an example of this.

Ok, local government could be a bit more rigorous about using this approach, but if we try this taxonomy out, we might find surprising synergies between and across organisational and cultural boundaries.

4. What each brings to the table
The opportunity for us is about taking NHS public health strengths to local government, add these to what is already there, and create a model of public health which works in local government. It’s not that dissimilar to bringing public health into working more closely with GP Consortia. Those of us who worked with Practice Based Commissioning groups will remember the learning process we all went through then.

So, we need to recognise both the local government public health family and the NHS public health family have things to bring to the table, and things they need. I’m not going to talk about the things they need for now, that can be done later. I am going to focus on what we can both bring to the table.

NHS trained public health specialists have a range of domains of competence they can bring to the table. I have deliberately not put these solely in the realms of public health (e.g. immunisation uptake or other functions which might transfer.) I have tried to put them in the sense of how they can impact positively on the business of the whole council, because I think public health skills could impact on the whole work of the local authority. Indeed, the assumption of the Marmot Review (www.marmotreiew.org)  is that they need to impact on the totality of local government and public sector to achieve the outcomes Marmot set.

So here is an early take on what public health specialists have to offer local government:

• Understanding key drivers of health and wellbeing, and interventions to improve population health
• Structured ways of doing needs analysis
• Decision analysis and helping with economic analyses of policy to help setting outcomes
• Supporting the understanding of complex variables and their interaction in policy and decision making
• Resource allocation for policy and interventions
• Understanding targeting action and interventions to bring most benefit
• Understanding and manage the conflicts between population and individual concerns (equity)
• Finding, assessing and applying evidence
• Supporting effective commissioning using 1,2 and 3 above
• Evaluation of commissioning against desired outcomes

Public health specialists, especially those who are registered, should recognise this skill set.  These sets of competencies have a wide and strong application across the NHS and they equally can have a wide and strong impact across local government.

Leaving aside the debates about salaries, terms and conditions and risk, those authorities who are having this discussion seem to be developing an ever stronger desire to incorporate public health.

Now , to turn to what local government brings to the table, people already in local government have a range of domains of competence they can bring to the table:

• Working in political systems
• Multiple stakeholder relationship building (good for working with GPs)
• Working with multiple policy frameworks from different government and other influencers and stakeholders who feed into local government (much more than the NHS often does)
• Policy skills (there is usually a policy unit)
• Pragmatic research skills (there is usually a research team)
• Programme management
• Large scale service and intervention delivery
• A strong sense of place and its impact on interventions

5. Look for mutual benefit from each side to the other

Interestingly, much of the work on Intervention Mapping as a set of techniques in delivering public health programmes (see Bartholomew et al, Kok et al) and an increasing amount of the research points to the salience of these local government skills in whether public health programmes are as effective as they could be. So public health could benefit strongly from some of these skills and competencies.

While this list is shorthand,you can see that there are significant opportunities for skills to be used across systems.

In social care, for example, there is a significant range of opportunity to benefit from the kind of approach public health has taken with NHS commissioning, using the domains of skills above.

So, to those of my public health colleagues who might be feeling a little concerned about what skills they bring, and what exists, my message is simply take heart. Up and down the country there are processes of learning going on.  Local government doesn’t just want you, it needs you. And that is a potentially very good place to be, without minimising in any way the good of what being in the NHS has brought.

I’ll share more of this work as I write it up.

After the listening exercise…the opportunity

As I get ready to speak to a Local Government Association Session on Public Health at their upcoming conference, I find myself trying to distill my thoughts, and looking back on what I learned from the last session I gave at a conference.

I got asked recently by some Public health colleagues and NHS Non Executive Directors (NEDs), somewhere in England, at a conference session I had been asked to lead whether Public Health was safe in Local Government. “How safe do you feel it has been in the NHS?” I asked. Nods.  This wasn’t a hostile exchange, nor an implication that public health is unsafe in the NHS, nor that it will be less safe in local government or public health England. It was trying to identify what our tasks for public health are now. There was some concern among the NEDs partly because they were very committed to public health, and partly because they were wondering what their leadership role was now.  A conversation ensued over coffee among a small group of us. We missed the next session but over the course of the next hour or so we mapped out together some issues, with a small mix of us, NEDs, PCT staff, a journalist, a civil servant or two and a couple of local authority people all sitting round in a group.

The detail of what happens where and with what resources will be worked out in due course (and we should seek to support and influence that so that forms and structures deliver what will benefit our citizens best)  and discussions will be had, but there is a leadership task - I prefer to call it a leadership opportunity -  for all of us who want public health to be core to our future, and deliver its best.

You may think on reading what I am about to say that I am foolishly optimistic, or too hopeful, or haven’t seen the enormous challenges we have to achieve what Government has set out. Fine. I disagree.  Why? Because it is possible to lead public health into a future where the best of what has been and is NHS public health  thrives along with the best of what it has been, is and can be in local government. And no, I’m not going to share what organisational forms I think that could take. Well, not in this bit anyway. I want to talk about our Leadership Opportunity first.

The leadership opportunity

If you take leadership at its very simplest, it is a set of influencing tools and processes, used by people in a position to use them, to get to a desired state. Public Policy increasingly tells us that such a desired state should be shaped by a range of stakeholders: Commissioners, Clinicians, Elected Members, Non-Execs, Citizens (including those who use what we produce),  other agencies such as community groups, think tanks, research experts and so on. One of the things about Public Health is that at its best we have been good at managing and building such relationships and that skill and tool should serve us well now.

But there are three key things we need to do in working our what our respective leadership opportunities are; i) to work out who we need to influence,  ii) what sets of tools and processes to use, and iii) what our desired state is.  And my own listening and learning tells me that these three things need to be different when we look at short, medium and desired future terms.

I know some public health colleagues tell me I am far more optimistic (I prefer to call it hopeful) about the future than they feel. But it seems to me we have a hugely important set of tasks to achieve, and looking around the public sector, private sector and third sector there are a lot of resources we can use to get there. 

 Trying to lead in situations like this is about making sense of the environment,a process of  trying to identify how best to respond to that environment, and from that to decide ideally what environment we need and how to create it for the future.   Yes, it’s much easier said that done. And yes, I am probably sounding  like one of those inferior “how I led Shmoogley Bumpkins Co from one cheese scone bakery in one city to three”  books you find in airport bookshops. (Don’t tell me you haven’t looked!)  But I really believe this.  And when we examine the value base we share in public health (we do, don’t we?) isn’t that what we get out of bed for in the morning? 

Three leadership oportunities for public health then, and I believe there are quite a lot of people who will appreciate us doing it, from Commissioning colleagues to GPs through to those who will be our next generation of public health specialists.  I can name at least fifteen people who inspired me to come into public health even though it was going through massive change. Who will say that of you or me in the future? That’s really up to us.

Yes, it’s a big job, but if you look at the changes wrought to a number of areas of public service and private enterprise over the last ten years, two points emerge. Firstly, this is a massive opportunity for public health. Secondly, other have done things similar and greater, and have gotten there or are well along the road.  It’s no different for us.  It could be a test of our mettle.

Conceptualising and operationalising the leadership opportunity

I once led a workshop on that title to a bunch of leaders in religious organisations who were trying to come to terms with the cultural challenge of responding to child abuse in their midst. Looking back some years later, those participants I’m still in touch with felt this focus was right. I think personally that I can learn from that experience in the situation I am in now. So, here goes:

The  task, I think, breaks down differently for NEDs, elected members and for us in the core of  public health.

Tasks for Core Public Health – cultural agility and customer focus

• Short term -  ensuring that we understand what we can offer now and for the short term to a range of stakeholders, and that we do this clearly and that we are seen to add value. Who are our top customers, for what, what products are we offering, with what outcomes? Who owns it, and how can we own the short term tasks together?
• Medium term -  Keeping an eye on the day job and delivering that while building the future, preparing people for it and working through this complexity.
• Longer term – Engaging stakeholders in building a vision of what public health could be. How do we work with environmental health? How do we work with GPs?  Culture and relationships will be crucial here

Tasks for Elected Members and Local Government Officers

• Respect the Cluster and its priorities. Respect consortia and their priorities. And dialogue with them
• Work with your counterpart NEDs to create and lead some cultural agility from the top – try to interpret the ways of local government to the NHS, and vice versa. Local government is complex, and seems very different indeed from the NHS, to many (not all.)
• Champion the importance of public health in creating a healthier county, city, borough. See the opportunity and work with NHS and local government colleagues to start on it.
• Be honest that is is not a matter of public health “leaving” the NHS and “coming back” to local government. Public health is a series of systems, or at the very least a complex web of responsibilities. Some bit of public health have never left local government. Some bits of public health (the GP role in health improvement) will never leave the NHS.  That’s fine. The important thing is how we build the coherent systems in a way that they work together.

Tasks for Non Executive Directors

• Understand, and promote within your agencies understanding of, the complex cultural and priority issues facing local authorities.
• Work with your counterpart elected members to ensure together you create an understanding of the challenges the public health family in your area (NHS public health, environmental health, regulatory services, health protection agency and so on) have been facing and the opportunities they have
• Champion the enduring NHS need for public health contributions to health improvement, service commissioning and quality and health protection
• Interpret and champion to NHS colleagues the important local government contribution
• Help public health colleagues build the cultural agility needed for the world of local government

Cultural agility

I’m not in any way denying there is a huge amount of transactional stuff in all this – HR structures, pay scales,asset tracking, and all that important stuff. But if we focus too much on this, and don’t turn the leadership opportunity into concrete things to achieve, we might just find we miss that opportunity.

And I think in trying to turn that leadership opportunity into concrete things, there is something we have left out. That’s what I call cultural agility (I’ll track down the source of that term if you want me to.) What do I mean? Well simply this, the ability to work across different cultures, to understand common aims and ends among them, to understand differences and what they mean, to find and respect in those cultures assets for us to work with, and then to work with them to create something. When you look across an average public health function you see people doing this all the time. Working with communities, applying their diversity skills. The reorganisations proposed, on one level, pose the same challenge of us; and ask us to use the same tool chest.

Making cultural agility live is the same task when we come to Local Government, GP Consortia, Clinicians of myriad hue and Citizens, isn’t it? We need to overcome our fears of the “other” (and let’s be honest, there’s a lot of talking about Local Government as the “other” among some public health colleagues currently whish is unhelpful. Yes, there has also been some unhelpful stuff from some local government people but folks, we really need to change the debate.)

When you look at public health, it becomes very clear that it is a series of systems and functions spread out over a range of institutional hosts. Health Protection Agency, NHS, Local Government, and so on. What makes them work is not beautiful system design, it’s cultural agility and goodwill.

We need to think how we build cultural agility together, across the various bits of the system. Public Health should be good at doing this. I’ll write about cultural agility next time, including some tips on acquiring it, from someone who is by no means an expert.

Meantime, some practical tips on cultural agility:

1. Do some shared problem solving around a public health issue like Obesity and model solutions now, in 18 months time and in 3 years time
2. Engage in some function design - take the lead in proposing workable solutions which engage everyone following on from the problem solving,

The role of NEDs and Elected Members, and Cluster Directors and Local Authority Directors could coalesce easily around shared problem solving.

 A Guide to Local Government

As an aid to the issue of cultural agility, I have finished the drafting of  an e-book and a learning presentation on understanding and working with local government with some colleagues. We are currently testing this. We hope to post it online shortly.

Public Health in two-tier local government areas: some tips from experience

One of the issues causing concern among Directors of Public Health in England is how, when and if Public Health transfers to Local Government, you configure public health to work in two-tier areas. By that I mean areas where you have both County Councils and District Councils. (All major Councils in Wales and Scotland are unitary, though both Wales and Scotland have a layer of Community Councils underneath the major Councils. So what I say here applies only to England -including Cornwall  and the Isles of Scilly.)

The model of Public Health in Local Government has been written for unitary or all-purpose authorites, and there have been a number of constitutional fudges over the last ten years or so which have put “top-tier” authorities (unitaries or Counties) in charge of some things. The phrase “top-tier” can sometimes feel patronising to District Authorities. But there are ways of making Public Health in two-tier Local Government areas work.

This blog is written from the perspective of someone who has worked in Public Health in the NHS, and has had a range of public health and Public Health roles in and around Local Government. I love Local Government and am passionate about its role, history, potential and significance.

I have worked in a number of two-tier areas, either as an employee or a Consultant, and the key is to understand the respective powers, duties, issues and concerns of each Council, the politics between them and how you can play them in to achieve your objectives. Ok, much more simple than it is, but in eleven years working across multi-tier areas in one capacity or another it has never failed me.

So, here are the things which have worked for me:

Firstly, understand that Local Authorities essentially fall into three Categories 

•  Principal Councils are those which undertake major functions like Housing or Social Care. In London and many places these are all-purpose unitary councils. But England has a long tradition of two-tier local govermThese are Counties and Districts in County areas. The phrase “two-tier” essentially means you have two types of Authority. Counties cover a whole County such as Warwickshire or Dorset. Districts or Boroughs within the County cover a part of the County, such as Dorchester.
• Local councils are parish or town councils which are very local. More about these later. In some ways calling an area two-tier is a misnomer when there are Parish councils around. Parish Councils can be significant for public health.
• Specific purpose authorities are those like the North York Moors National Park Authority, and in some places specific Joint Fire Authorities, which usually exist in places where the Fire Service covers a number of local authorities, such as Tyne and Wear.

Secondly, understand what powers you might want to work with. Principal Authorities in two-tier areas have the following division of functions:

County Councils

• Social Care for Adults
• Childrens Care
• Schools
• Adult and Child Safeguarding
• Health and Wellbeing Partnerships (proposed)
• Category 1 Responder for Civil Contingencies Act
• Waste disposal
• Crime and Disorder Reduction Partnerships
• Consumer Protection and Trading Standards
• Strategic Planning
• Libraries
• Transport
• Animal Licensing

District Councils (may also be called Borough Councils) 

• Planning Control and local planning
• Housing
• Environmental Health
• Waste collection
• Building Regulation
• Appointment of Proper Officers for Public Health Act purposes
• Appointment of Proper Officers for Section 47 National Assistance Act
• Disease Notification
• Category 1 Responder for Civil Contingencies Act

All councils have different powers on similar issues

• Leisure services and Culture have duties and powers across Districts, Counties and even Parishes
• Roads and highways (Counties, Districts and Parishes all have different functions)

Parish Councils (sometimes called Town Councils)

Parish Councils vary enormously in size and functions. We might be tempted to think of the Vicar of Dibley when we look at Parish Councils but some of these very local bodies do struggle while others have functions and budgets not far off several million, often undertaking functions on behalf of their District and County sisters. You can find a really useful guide to the surprising powers of Parish Councils here http://www.townforum.org.uk/servicesstructure/parishcouncilguide2007.pdf. You can also find two very useful quick reads, The Role of Parish Councils http://www.camlink.org.uk/wiki/The_role_of_the_Parish_Council and the National Association of Local Councils, which is the Parish and Town Council answer to the Local Government Association http://www.nalc.gov.uk/Default.aspx

There are a whole host of things which Parish Councils can do you might not know about:

• The provision of community facilities ranging from allotments to bars, laundrettes and even mortuaries, cycle parks, swimming pools and green spaces.
• Undertaking functions on behalf of other councils
• The right to raise a local precept for their parish through council tax collection

But equally importantly, they can help you engage local communities with policy changes, the Joint Strategic Needs Assessment, etc.

What’s in a name?

You  will find some councils in Counties may be called Districts or Boroughs. There is little difference, really just ceremonial and historical. Boroughs are districts which have been granted the title of Borough and can have a Mayor. Technically their councillors can be addressed as Burgesses not Councillors. Districts have a Chairman, not a Mayor.

Parish Councils and Town Councils essentially have the same functions they just exist in a rural or less rural area, or around a market town or historic town respectively.

Some Top Tips for Public Health to Understand

Thirdly, think through these top tips to develop a strategy for influencing and working across:

1. Bear with me here, I’m going to give you the essence of what Psychology has to say on expert-novice differences and tell you why it’s important to you. The key difference between an expert and a novice in a field, according to psychological research, is that experts not only know the subject (i.e. have domain-specific knowledge of issues like environmental health and housing) but they can relate that knowledge to other areas of knowledge (i.e. how housing and social care interact) and can create mental maps and landscapes of how to work within and across those. What that means for you is get to know the Councils, understand how you can knit things together to create an integrated approach to public health, and understand who can help you.  A friendly local government lawyer is usually a help; while having both a County and a District member as a mentor can help too, especially if the two get on well and will agree to mentor you in joint sessions.
2. The Elected Member theme here is crucial.  County Members and District Members have both different portfolios (housing, social care) and common concerns (their local area and electorate.) Personally I think elected members are crucial to making public health work and building an effective relationship with them is key. They have a difficult, not very well remunerated and often thankless task which they have to fight to be able to discharge. But they are a rich resource of learning and collaboration. The top tips are to remember – they are elected, you are not; you need to understand with both Chief Officers and Members when to relate to whom; treating them with respect and keeping some clear boundaries between their role and yours and finally staying politically impartial are all important. This comes with practice, hence finding a mentor.
3. Remember always that Local Government in England has been around for centuries, so historical anomalies are important and you should accept these. The fact that the Common Council of the City of London and the Common Council of the Isles of Scilly have some unique functions is just one of these anomalies, and the fact that the Common Sergeant of the Inner Temple is actually a Local Authority (is He the only Local Authority who goes to bed at night?) is another.  Localism has been around for centuries, and the quirks and quaintnesses of local authorities up and down the land is just one manifestation of this rich heritage.
4. Even if the public health transition intended in the White Paper is ultimately significantly downplayed or changed, Local Government remains crucial to the achievement of better health for our population. Counties and Districts, and Parish Councils can all have roles and they all have powers and duties you will probably want to tap into.
5. While you will want to work in a two-tier area with both Districts and Counties (e.g. work with environmental health on food hygiene and education on school health) you need to understand that minimising the role of Parishes could be counter-productive. Make sure you think about Parishes, they can often be very helpful.
6. Think about options for working together before or even without whatever comes out of the NHS listening exercise. Understand that there are models around for collaboration in two-tier areas already. Despite the political differences and challenges, Councils in two-tier areas often have a history of working together. They may have joint boards constituted between them (e.g. Joint Drainage Boards) which can give you governance models. There is probably a countywide Community Safety Network whose models you can learn from.
7. Professional bodies often work well across counties. Trading Standards (County) and Environmental Health (District) often come together in networks for regulatory affairs. How can you use these to help? Similarly the lawyers might meet. The Chief Execs almost certainly do and there may be a members’ liaison forum.
8. Professional groups are important sources of good practice in Local Government. Think about this. Can you work with the local Chartered Institute of Housing branch to help include housing people? Equally, the Chartered Institute of Environmental Health is a crucial body. It has now opened its doors to people from all public health backgrounds, and a good vote of confidence if you really want to be embedded in local government might be to join, and gain value and possibly some respect from your local government peers. I have decided to do this and am putting together my application and portfolio. Let’s hope I make the grade!
9. Understand that local government thinks it never lost some aspects of public health. The Local Better Regulation Board with the Chartered Institute of Public Health and the LACoRs [Local Authority Co-ordinators of Regulatory Services] put together an excellent paper on the contribution by these bodies to public health. Get and read a copy! http://www.lbro.org.uk/
10.  Think about whether, in the transition, you might want to set up a Joint Public Health Board, through agreement between the Authorities. Members and Officers can be given appropriate delegated powers within schemes of delegation.  The Council’s Lawyers (sometimes in Counties called The County Secretary) should be someone you want to speak to.  You might even want to consider the use of Agency Powers under the Local Government Act 1972, where one Council can arrange for another to carry out some of its functions as an “agent” on the commissioning Council’s behalf.
11. Most Counties have shared County Level strategies and will have learning from this experience you can tap into.
12. Counties and Districts have their own networks within the Local Government Association. These can be rich sources of learning. There is a County or District somewhere that has grappled with the constitutional, administrative or configuration challenge you are facing, so network!
13. Make sure you are a regular visitor to the Local Government Association Website www.lga.gov.uk and if your Council is a member of the Local Government Information Unit , a Local Government Think Tank, you could benefit from making sure you see their publications. www.lgiu.org.uk

I hope this helps. Working in single tier areas brings is own challenges, but working effectively in two-tier areas can really bring its own rewards.

Further Reading

You can get some basic readings on two-tier local government here

http://www.idea.gov.uk/idk/core/page.do?pageId=1121355

http://www.direct.gov.uk/en/Governmentcitizensandrights/UKgovernment/Localgovernment/DG_073310

Jim McManus (2011) Understanding Local Government – a guide for public health professionals. E Book. Forthcoming

Sir Alfred Hill, Birmingham’s Public Health Pioneer

Sir Alfred Hill

Birmingham’s first Medical Officer of Health 1866-1903

You can read about other Medical Officers of Health here

http://en.wikipedia.org/wiki/Medical_Officer_for_Health#cite_note-hardy03-1

Until he retired in 1903,he threw his energies into improving the health of the City. By dint of will and effort,working with Chamberlain and as President of the Society of Public Analysts he wrought changes to sanitation,housing,food purity and living conditions which we still enjoy the legacy of today. He was obsessed with improving housing, food quality, sewage and the quality of health and life of the poorest in Biringham. He became President of the Society of Public Analysts and Society of Medical Officers of Health. He was a major pioneer in the destruction of tens of thousands of slum dwellings in Birmingham and their rebuilding. An unsung figure without whose work and dedication Birmingham would not be Birmingham.

 Hill surveyed the health of the City every year,and set about addressing what he saw as key problems. If he returned today,I think there are a number of things he would want to tell us. Several of them might well begin with “why on earth did you…?” But he would give us insights that would be important to the health of our City. Hill knew that living conditions were key to health,and in his own language expressed that being able to have good quality of life,education,housing and purpose were all important to good health. His arguments about public parks and housing are still revelant today.

2011 is the 14th anniversary of his appointment.  We intend to hold some events to help us look at priorities. 2016 is his 150th anniversary. We hope we can celebrate it with you.