Health and Social Care Bill

Debate between Lord Rea and Baroness Cumberlege

Wednesday 29th February 2012 Lords Chamber

[Baroness Cumberlege]

My Lords, I have added my name to Amendments 121 to 125, 128 and 152. Noble Lords will be grateful to learn that I am only going to speak to two of those amendments. I want to reinforce the views that are being expressed, and I too pay tribute to the noble Lord, Lord Patel, on the way he has introduced all these amendments in such a comprehensive fashion—but not the government amendments, of course—and other noble Lords who have spoken. I am interested in the situation of the status and accountability of directors of public health. They are going to be very important people. They have access to elected members and senior officers in a new way in terms of recent history. I shall go into that history a little later in my remarks.

Their responsibility is to consult and advise the members and senior officers directly on a range of issues from emergency preparedness to concerns around access to local health services and many other activities, some of which have been mentioned. Acting as the lead officer for health in a local authority and being the champion of health across the whole of an authority’s business is very responsible work, along with the day-to-day management of the ring-fenced public health budget, which is going to be delegated to them by the chief executive. They are also statutory members of the health and well-being boards. It is their direct accountability to the chief executive of the local authority and head of the paid Civil Service that I am concerned about.

This is a good measure to be putting forward. I have read the new Public Health England’s Operating Model published by the Department of Health, particularly the fact-sheet covering the role of the director of public health. It states that,

“we would expect there to be direct accountability between the Director of Public Health and the local authority Chief Executive for the exercise of the local authority’s public health responsibilities and that they will have direct access to elected members”.

So far, so good, but I am not sure that that is actually happening. On this occasion I should like to declare an interest, as I often do, as the executive director of Cumberlege Connections, which is a training organisation. Recently we have been working in an area with a shadow CCG. I had a lot of correspondence after the workshop we ran, particularly from the director of public health. He said:

“It is apparent to me that, especially with organisational development plans in … Council, as in other councils, it is intended to reduce the number of ‘senior’ directors at the top table … in many such instances the director of public health will not be a member of the most senior management team nor report to the chief executive, but report to another director. This is not necessarily the likely model everywhere”.

Here he mentions another authority, and says that,

“the City Council chief executive is currently proposing that the DPH report directly to him and should be part of the most senior management team. It thus seems likely that there will be different models in different local authorities”.

We of course accept that in terms of localism, but there should be some basic principles that all local authorities adhere to, which I believe is the Government’s intention. He goes on to say:

“It is also apparent that a number of medically qualified consultants and directors of public health consider that the likely change of status in becoming a local government officer and being made to leave the NHS … is not what they want”.

I can think of at least three directors of public health who have already quit their jobs to return to general practice, to take up a medical director post in the PCT cluster—that seems to be a rather short-term career move, but there we go—or to take very early retirement. The Government need to put out some very strong messages about this and we need a monitoring system to ensure that their intentions are being carried out.

A point has been made about the termination of employment of directors of public health. In Committee, we discussed quite fully the position that used to be the medical officer of health—it certainly existed in my council when I was a local councillor. They would be a person of huge character and have great clout within the council and the whole geographical area. One of the reasons for their being able to be so robust and to say how they really saw the health situation within a geographical area was that the only person who could terminate their employment was the Secretary of State for Health—in those days, he was called the Minister for Health. That was a very good safeguard. I know that the Government are keen to involve the Secretary of State, but I would like to know to what degree, and that it is not just consultation via e-mail or a piece of paper but something that is real and is going to make a difference.

Let us suppose that in an area where childhood obesity is presenting a real problem a fast-food company wants to build a restaurant in close proximity to a school. That could clearly conflict with the director of public health’s work to reduce childhood obesity. Local authorities, which will have some strong local interests, will be tempted to influence, with local councillors, situations that may go against the professional view of the director of public health. I hope that my noble friend Lady Northover will be able to give me some comfort on these issues.

[Lord Rea]

My Lords, I apologise to the noble Lord, Lord Patel, for not being here when he spoke to his amendment and for wanting to ask the Minister a question that may already have been covered in the debate. It is on the relationship of directors of public health, who are going to be situated in local authorities, with the clinical commissioning groups, which are going to cover very much the same area—although we still do not know exactly what it is going to be. At the moment, directors of public health work closely with primary care trusts. I imagine they will be largely the same people who move to local authorities.

However, many of the activities of PCTs concern directors of public health. I am not sure that we have yet agreed on whether the local authority director of public health will have a seat on the board of the clinical commissioning groups in the same area. We still do not know whether they are going to be precisely contiguous and/or whether there will be several CCGs in one authority boundary. I would be grateful if the Minister could clarify the relationship between local authority directors of public health and the local CCGs.

Health and Social Care Bill

Debate between Lord Rea and Baroness Cumberlege

Wednesday 2nd November 2011 Lords Chamber

[Baroness Cumberlege]

My Lords, I should like to ask a few questions about Amendment 10A. I thank the noble Baroness, Lady Finlay, for her introduction, but we do not yet have a precise definition of what she means by area-based populations. All sorts of different services have different catchment areas. At the beginning, the noble Baroness cited family planning services. She said that she felt that perhaps it was a bad example, and I think it probably is because there are so many different services that require different boundaries. I am for coterminosity as far as we can get it, because when I was a regional chairman, I saw that where you had coterminosity between the health service and local government, you could achieve a great deal. That worked well, but when one examined it carefully, it was not so much about the boundaries; it was about the relationships built between different people. That was what made the services work extremely well.

With regard to GP practices, GPs usually want people within their area, especially if they will have to do home visits. I have been in the situation—I am sure that many noble Lords have—where I had an emergency in London but my GP is 52 miles away. That can be coped with; you can still manage that, although it is quite awkward in some respects. My anxiety about allocating patients to different GPs—being neat and tidy and trying to get all the boundaries sorted—is that I do not know what it does for choice. Perhaps the noble Baroness will say something about that. What happens when people want to choose a different GP who is out of their area, which is what we want to do locally but are unable to because the boundaries have been so clearly fixed, I have to say, by the GPs themselves?

[Lord Rea]

My Lords, the noble Baroness, Lady Finlay, has somewhat stolen my thunder because I had meant to say almost exactly what she said, but I was going to mention it when we got to the part of the Bill describing the clinical commissioning groups. Schedule 2, which relates to clinical commissioning groups, states:

“A clinical commissioning group must have a constitution … The constitution must specify”,

the name, the members and the area of the group. That is there. I would like the noble Earl to describe how that area is to be measured and whether it is to be coterminous with existing boundaries, particularly local authority boundaries, for the very reason given by the noble Baroness, Lady Finlay.