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.

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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 . )