The role of the DPH. ADPH, November Final report from projects funded by Department of Health. Association of Directors of Public Health

Transcription

1 The role of the DPH Final report from projects funded by Department of Health ADPH, November 2010 Association of Directors of Public Health

2 Executive Summary This report details findings from two projects funded by DH and undertaken by ADPH in The final report has been delayed in order to ensure that it is relevant within the context of the current changes to the NHS and PH systems. Views on the DPH role were obtained from 150 current local DsPH (from all UK), Regional DsPH, Local Authority Officers and Members, NHS colleagues and external stakeholders. There was a remarkable degree of accord over the core purpose of a DPH: independent advocate for the health of the population and leadership for its improvement and protection. Despite very different professional strengths, populations and organisational expectations, the basic roles that DsPH undertake are also consistent across the country with differences highlighted in priorities rather than the way that DsPH work. These roles align well with the ones explored in Perspectives on Joint DsPH Appointments ed. David Hunter (Durham University 2008). Also explored are: specific issues around working in LAs; DPH development needs and independence. The following recommendations are offered around the DPH role. The DPH role should be primarily defined in terms of its population rather than the structures in which it sits. The DPH role should only be undertaken by a highly qualified regulated and experienced PH professional working to PH professional standards. The DPH role is across the three domains of public health practice and the ability to have oversight of the whole agenda must be maintained. The DPH works across and between agencies and sectors and the existing close links with NHS and primary care must continue and indeed be strengthened. The ability to influence across the wider determinants of health is vital to make progress on reducing health inequalities and this should be enshrined in the new structures through the level and authority of the DPH within LAs. The DPH must work with a professional team of PH specialists and practitioners and have unproblematic local access to more specialist support from the PH Service. High quality public health information and intelligence must be available locally to DsPH and their teams. The independent view provided by the DPH is highly valued and should not be compromised through their employment within the LA. There are development needs for DsPH which should be addressed with some urgency. There are also development needs for LAs in understanding the public health agenda and DPH role. ADPH

3 Contents Introduction...1 Background...1 Context...1 Methodology...1 Principles...1 Findings...2 Overview...2 Core DPH role...2 Public Health and Local Authority...3 Added value of a DPH...3 Core offer...4 Development needs...4 Independence...4 Recommendations...5 Glossary of terms...5 ADPH

4 Introduction This is the final report detailing findings from two projects (B300 and B326) which were undertaken by ADPH and funded by DH. Two independent reports support this work. One commissioned by IDeA on behalf of ADPH, ADASS and ADCS is available on-line: and the other, commissioned by ADPH from Solutions for Public Health. Background The aim of both projects was to define the role of the Director of Public Health (DPH) through collating views of current DsPH (B300) and stakeholders (B326). This included a literature search looking at the historical context as well as looking forward to the new arrangements proposed by the Coalition Government. DsPH views were collated through a series of regional (English) and national workshops and electronic conversations and surveys, involving 150 DsPH. This included input from Wales, Scotland, Northern Ireland and the UK Islands, and Regional DsPH. Local Authority views including Chief Executives, Elected Members and LA Directors were taken from a survey initiated jointly by IDeA, ADPH, ADASS and ADCS and undertaken by Shared Intelligence. Other stakeholders were interviewed as part of a project sub-contracted to Solutions for Public Health. Context This work was initially conceived early in 2009 when joint DPH appointments were gradually being embedded within NHS and LA structures. The emphasis was to be on the new role across the public sector and how that could work better through the leadership of the DPH. The importance of the work to inform potential changes after the election in May 2010 soon became apparent and throughout the project we aimed to ensure that this work would not be made redundant by new structures. This has meant a delay in bringing out the final report but the findings are now up-to-date and relate to the DPH role as it goes forward through the newly proposed NHS and LA arrangements and Public Health Service. Methodology A Delphi process was used. The project was launched with discussions at our Annual Conference amongst around 50 DsPH. A total of 8 regional workshops were held (Scotland; North East; North West; Yorkshire and Humber; East Midlands; West Midlands and London & South East) between November 2009 and April These workshop discussions included more than 90 local and regional DsPH. Further views were sought from all members through Executive meetings, teleconferences and electronic methods. Principles The definition of the DPH role should be based in a historical context and not in terms of structures (which are likely to change and are in any case different across different parts of the UK) in order to ensure a lasting definition. The definition should allow for local differences of emphasis and priorities particularly given the localism agenda of Local Authorities and differing structures. ADPH Page 1 of 5

5 Findings The following represents the findings from the project. Although some of this is PCT based (such as the Medical Director role) it highlights strengths and lessons that are transferable to the new PH and NHS systems and structures. Overview The DPH role is based on a population of interest rather than a specific geography or structure. The DPH is a highly trained professional accountable to their population for their health improvement and protection and for the reduction of health inequalities. The core purpose of the role is as advocate for the population and leadership for health and wellbeing. Because of this accountability the emphasis has to be on outcomes and not on services or functions which vary depending on assessed need. However, there are services and functions that are core to public health (i.e. essential for all populations) and work on defining these is currently being undertaken collaboratively by ADPH and FPH. This is a wide remit covering the three public health domains of health improvement, health protection and health and care services. The DPH must lead and influence across organisations and sectors working not only with their team but with the professional public health workforce based in other sectors, organisations and directorates. Core DPH role The core purpose of the DPH is as independent advocate for the health of the population and leadership for its improvement and protection. This core role is often supplemented by extra responsibilities (see diagram) which can add value and be synergistic but on occasion may cause problems or conflicts of interest. The core roles a DPH undertakes can be categorised under the following headings. These map well across to the independently researched models of practice as defined by Tony Elson (Durham University; Perspectives on Joint DsPH Appointments ed. David Hunter). Public face media work; independent advocate; advice to the public (community advocate and leader) Partnerships / networking leading health partnerships and facilitating collaboration across organisations (catalyst) Corporate Director top team responsibilities and high-level performance (critical friend and adviser) Delivery management of team(s) & programmes; ensuring Public Health system delivery (provider) Expert a public health professional providing high-level intelligence, information and advice; education, training & development (expert) ADPH Page 2 of 5

6 Public Health and Local Authority Currently there are around 80% DPH joint appointments between LA and NHS in England. These vary in context, content, funding and crucially success. The best (as defined by health and well-being outcomes) are characterised by coterminosity, shared objectives and leadership, strong partnerships and Elected Member support. Professional Public Health practice has a wide span across three domains: Health Improvement; Health Protection and Health and Care services. The public health workforce is similarly widely ranged including those employed in NHS; Local Authority; Primary Care; HPA; social enterprises and more. As well as those directly managed by the DPH, practitioners include health visitors and public health nurses, health protection staff, environmental health. Furthermore to achieve a reduction in health inequalities, influence over the wider determinants is key and other professionals including those in primary care; planning and housing, provider NHS etc are vital. Research into joint appointments has shown that DsPH are valued within LAs for their: independent evidence based advice and population perspective; brokerage and facilitation across organisations; knowledge of population needs; credibility within and knowledge of the NHS; technical expertise. The DPH role as described is one of influence and partnership across sectors and not traditionally one carrying large directly managed budgets or teams (unlike other LA Chief Officer roles). The public health workforce is not directly led by the DPH and the funding to undertake the public health function is spread across many organisations and directorates within them. These differences in role are not well understood in LAs by Officers or Members and this tension needs to be addressed. Although presenting huge opportunities in tackling health improvement and inequalities placing the DPH within an LA base risks losing the close links with the NHS and strong influence that is needed over the NHS public health workforce. Added value of a DPH We also sought to answer how the DPH adds value to the top team. The following areas were highly valued by senior colleagues and partners from outside the NHS. Leadership across the three PH domains pulling the agenda together and maintaining an overview including credible leadership within the NHS Population perspective putting the denominator on the table and ensuring the needs of the population are considered alongside those of individuals Translation and interpretation translating different approaches (from differing cultures and backgrounds) and interpreting views to produce actionable insight a distillation that enables decisions to be taken Real understanding of population advising and taking decisions based on deep knowledge of the local population and their health and well-being needs The expertise provided through the high-level professional education and training in PH competencies including evidence base and needs assessment and the wide-ranging experience gained as Consultant or Specialist in Public Health. ADPH Page 3 of 5

7 Core offer The DPH like other top level appointments brings individual strengths to the top team gathered from their experience and knowledge. However there is a core offer that all DsPH bring which was summarised as follows. Corporate director the ability to act at top team level; develop and promote corporate policy; contribute to whole organisational decisions. Leadership across settings for population health and well-being and health inequalities leading pan-organisational solutions across the 3 PH domains. Independent advocate for health and well-being DsPH are seen as independent brokers and in a facilitation role. Credibility with Members seen as key to making progress on the health agenda. Translation and interpretation ability to bring agencies together through translation of culture and language and brokering solutions. Expert advice PH professional skills such as needs assessment and evidence base and knowledge of population. Credibility within NHS and across sectors. Delivery and management - management of public health teams (Health Protection; Health Improvement; and Health Care Services) ensuring delivery of core PH function and where required DsPH can manage teams to ensure delivery of the wider PH and well-being programmes based in the LA. Development needs Whilst seeking to define the DPH role discussions were also held around what development is needed to maximise the DPH impact particularly within local Authorities. The following areas of development were felt to be the ones specific to DPH requirements over and above more generic Director level leadership skills development. Increasing influencing skills in a political and organisational context. Developing excellence in delivering the DPH public health advocacy role. High level leadership through innovation particularly in a financially challenging environment. In order to fulfil the role immediately and in the future there needs to be both Aspiring DPH programmes and on-going development for current DsPH including peer support. Independence Historically the DPH role is seen as independent and the ability to produce an independent Annual Report is valued as a key advocacy tool. In Scotland this independence is enshrined in DPH contracts. This does not mean that DsPH are not corporately responsible and we know of no specific cases where their corporate role as LA or PCT Executive Board member has been compromised through their independence as defined by, for instance, their ability to act to protect health. This is not unprecedented within LAs; the Solicitor role has a similar independence under the Section 151 legislation. It will be important going forward in the new PH system that this valued objective voice and advocacy on behalf of the population is maintained despite the political context in LAs. If the DPH is perceived to be speaking from a political standpoint this will compromise their credibility. Similarly within the LA the DPH voice will not be seen as objective if viewed as coming directly from DH. Information and evidence based policy and practice will be vital. ADPH Page 4 of 5

8 Recommendations The following recommendations are drawn from the research and made within the context of the current changes in systems. The DPH role should be primarily defined in terms of its population rather than the structures in which it sits. The DPH role should only be undertaken by a highly qualified regulated and experienced PH professional working to PH professional standards. The DPH role is across the three domains of public health practice and the ability to have oversight of the whole agenda must be maintained. The DPH works across and between agencies and sectors and the existing close links with NHS and primary care must continue and indeed be strengthened. The ability to influence across the wider determinants is vital to make progress on reducing health inequalities and this should be enshrined in the new structures through the level and authority of the DPH within LAs. The DPH must work with a professional team of PH specialists and practitioners and have unproblematic local access to more specialist support from the PH Service. High quality public health information and intelligence must be available locally to DsPH and their teams. The independent view provided by the DPH is highly valued and should not be compromised through their employment within the LA. There are development needs for DsPH which should be addressed with some urgency. There are also development needs for LAs in understanding the public health agenda and DPH role. Glossary of terms ADPH ADASS ADCS DH DPH (DsPH) GP HPA IDeA now renamed LGID JSNA LA NHS PCT PH Association of Directors of Public Health Association of Directors of Adult Social Services Association of Directors of Children s Services Department of Health Director(s) of Public Health General Practitioner Health Protection Agency Improvement and Development Agency now Local Government Improvement and Development Joint Strategic Needs Assessment Local Authority National Health Service Primary Care Trust Public Health ADPH Page 5 of 5