What is Public Health?
And what are Public Health directorates in local authorities for?
These are questions that have been behind a few posts on
this blog (here’s one,
two,
three,
for example).
These questions occurred to me again today by the coincidence of a discussion
at work and seeing a
post on the Dick Puddlecote blog (via a Chris Snowdon
tweet). Both were prompted (in part)
by this
week’s Health Select Committee report on Public Health England (PHE), which
I acknowledged in my previous post I should probably be writing about.*
A key point in the Select Committee report is that PHE
should “campaign on behalf of those public health objectives and policies which
it believes can improve the nation’s health”.
This is a point Dick Puddlecote puts in bold as something shocking.
The odd bit is how what is effectively part of government
could be a campaigning organisation.
Dick Puddlecote sees this as particularly frustrating
because PHE is at odds with public opinion on issues like standardised
packaging.
These are two separate issues, really: (i) whether the fact
that government (or in fact, just one government department) is at odds with
public opinion is an issue, and (ii) whether the idea of a ‘campaigning’
department makes any sense.
On the first point, without wanting to sound too much like
Robespierre, representative democracy doesn’t imply that issues should be
determined by the popular will. The
reason I couldn’t do what Owen Jones does,
for example, is that I have no idea about the details of many policy issues. I find it hard enough coming to a view on
substance use policy – something I know a bit about – let alone something like
social security, which I should be well-informed about, but don’t have any
expertise in. There’s also a neat point
that (academic) policy
commentators expect more coherence from politicians than they manage themselves. Quite possibly true of me – it’s much easier
to criticise than offer definite solutions.
(Look how I wimp out in the conclusion of this
article.)
I’m also painfully aware that policy decisions should combine
considerations of effectiveness and ideology (as well as politics). But as I’ve said
before, effectiveness can only be measured if we have an aim. And no policy issue has just one aim. So policy debates are about priorities as
much as evidence. And we know that in
reality policy-making
is a messy business, with horse-trading
and competing agendas.
This highlights the importance of the second issue: should
PHE be a lobbying organisation within government?
This isn’t exactly a new development. PHE isn’t so much a new organisation as a
rather odd agglomeration of preceding organisations that made sense, such as
the Health Protection Agency (HPA) and the National [substance misuse]
Treatment Agency (NTA) – and for the period from 2010 to when PHE was
established, the NTA was clearly making the case within Whitehall for substance
misuse.
But this isn’t a new or unusual development. The NTA was a part of the Department of
Health that had responsibility. You don’t
have to subscribe to some Weberian theory of bureaucratization** to see that
this might be an everyday part of government.
Government is not a single impartial observer or
decision-maker, sitting above the fray; it is a complex organisation, with
various interests and ideologies operating within it. (And here I don’t mean government as in the
cabinet, so much as the machinery of government, of which PHE and local
Public Health teams are a part.)
Thinking back to another policy issue I have had some
knowledge and experience of, the same pattern can be seen in Higher
Education. When it came to budget time, the
Department for Business, Innovation and Skills (BIS) and the HE sector had
very similar hopes: for the science budget to be protected, and so forth, to
help the HE sector. Of course, the
Treasury had different priorities – hence the bizarre student loans arrangement
that really is just an
accounting trick.
This doesn’t make BIS a quango or Trojan Horse (or sock
puppet as Chris Snowdon would put it).
PHE might be finding its way, and honing what it can do best
as a national organisation when much of its remit has been taken on by local
authorities – but it certainly does have a remit, and if public health is a
government funding stream (which it is), then there’s a need for some kind of
body to represent that area of activity within central government – even if final
responsibility is mostly devolved to local government.
It might be that some liberals think the
new public health shouldn’t be a part of government, but that’s not the
same thing as thinking that government shouldn’t be comprised of bodies
representing different perspectives. It’s
quite right that the Health Committee should recommend PHE ‘campaign’ for a
policy if it can be demonstrated to be beneficial to public health. You might find that the Treasury, or BIS, or
the Department for Culture, Media and Sport might disagree, but that’s how the
decision has to be made: by all the potential interests putting their points of
view across.
That’s how
I see local public health teams making the most worthwhile contribution: by
being a voice round the table as much as a direct commissioning or spending
department, and informing planning, highways and transport and education, for
example, to make them more conducive to healthy living. Of course every time a decision is made in
any of these areas it will be a compromise, and other interests might win, but
that’s what a healthy debate is, if you’ll excuse the pun.
*I was going to write about older people and alcohol again, in
light of the DrugScope report, but there’s not any real discussion points in
that – apart from their suggestion that services for older people with
substance misuse issues are at threat, which in my experience couldn’t be
further from the truth. I see that as
the future of substance misuse services in Dorset, for better or worse. At least it might be evidence-based, as we’ve
just commissioned Alcohol Concern to conduct a project for us on that very
topic.
**Dan
Malleck has written brilliantly about bureaucratization within the field of alcohol policy.
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