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.