Public health faces an uncertain future

Public health has been thrown into uproar, as plans for the biggest upheaval for some 35 years brings staff cuts, reorganisation and reform.

As the health secretary, Andrew Lansley, publishes the government's health bill , leaders of England's public health programmes tackling levels of diabetes, cancer and obesity are worried about a brain drain of a generation of expertise.

At present, large sections of public health work falls under the aegis of primary care trusts (PCTs) and strategic health authorities. But following the decision to axe both, most responsibility for public health will be shared between local councils; Public Health England (PHE), a new quango; and GP commissioning services. PHE will take over the work of the Health Protection Agency and the National Treatment Agency for Substance Abuse, which are closing.

The new public health service is planned to be in place by 2013 but is expected to take a couple of years to bed down. Funding for public health will then have a specific ringfenced budget.

Directors of public health – who can manage up to 100 staff and programmes tackling problems such as smoking and health inequalities as well as being on call for emergencies – will shift to work for councils in 2013. They will also report to the chief medical officer.

A Department of Health spokesman says: "We want local government to lead public health programmes that work in their local area so we see a real improvement in the public's health."

But the move comes at a time when councils are in a state of upheaval over the scale of austerity cuts in their budgets and directors of public health are worried that town halls are not in a position to give public health the priority it deserves.

John Middleton, director of public health in Sandwell in the West Midlands and vice-president of the Faculty of Public Health, says: "This is a climate when councils are being pared back to the bone; it is very difficult for local authorities and very difficult for us. The sheer depressed state of local government matters."

Some directors of public health have already been told to plan for staff redundancies this year as part of budget cuts at soon-to-be-abolished PCTs. Others face having to reapply for their own jobs, amid the expectation in some parts of the country that up to four jobs could be merged.

Some are already voting with their feet. Richard Jarvis, co-chair of the British Medical Association's public health medicine committee, says it takes about 15 years to train as a public health specialist and he is concerned that those with the most expertise will go. "If we lose people, we aren't going to be able to do anything about it for a decade and a half," he says. He cites cases in the last six months of public health specialists retraining as GPs because of the uncertainty, while others may decide not to stay within the health service.

Many believe the sheer weight of the transition, the cost-cutting, and the closure of PCTs is eating into the time they have to spend on the job. "We are using time that could be spent saving lives," says Middleton.

Although some directors of public health already work partly for a council as well as a primary care trust, Martin McKee, professor of European Public Health at London School of Hygiene and Tropical Medicine, suggests that public health is going to be "paralysed" while the massive root-and-branch transformation of the way public health operates takes place. Moreover, he adds, there is no evidence to show this is the right move to make.

Alan Maryon-Davis, professor of public health at King's College London, says: "The reorganisation will be a major distraction from ongoing business. I think we are in danger of failing and we could end up widening inequalities."

Many are also worried about being pushed by the political affiliation of a council towards specific measures. Those who remember the way public health was organised in 1970s and earlier don't necessarily recommend it. "I am very concerned at the lack of independence for public health under the proposed new structure," says Walter Holland, a former president of the Faculty of Public Health, who began working in public health in 1956. "The standards of public health in local government between 1948 and 1974 were extremely variable, largely because of the political interference of councils."

The biggest concern is that public health projects could become an easy target for cuts. Andrew Cozens, strategic head for health and wellbeing at the Local Government Association, which represents local councils, says: "We worry about asset stripping going on in public health and being left with a rump service. It is not clear yet what level of resources are going to be transferred."

It is a view shared by some public health directors. "Before we get into local authorities we will see quite severe cuts," says Middleton. But if programmes on physical activity or obesity, for instance, are put on hold, changes in public attitudes could swing back and public health deteriorate.

Paul Edmondson-Jones, director of public health and primary care for NHS Portsmouth and Portsmouth city council, points out that better public health saves money and that not improving it is extremely costly: "Because of the financial pressures, the NHS may disinvest [from some public health work] in preventive services to make short-term gains," he says. "Smoking, obesity and alcohol place a massive burden on the NHS. Each of those can take 10 years off your life expectancy."

In the end, it is the dramatic scale of change and funding cuts in the NHS and local government that could undermine the government's reforms. "It's being set up to fail," says Middleton.