Both public health as a concept and the public health profession as an identity have long been in a state of flux; constantly being formed and reformed. While the role has always been loosely defined in terms of ‘prevention’, both the inputs and the measurement of health and economic outputs have been varied, have changed dramatically over time, and have often spanned organisational and jurisdictional boundaries. A management accountant’s nightmare. So how are such activities controlled? How are interventions strategized? And how can we establish value for money?
These are questions commonly asked in public sector accounting and policy research. What makes public health especially interesting, both in terms of accountability and professional identity, are the changes coming from the 2012 Health and Social Care Act that bring public health back into local government after 40 years in the NHS. The entire organisational environments of public health professionals were abolished, and teams ‘dragged and dropped’ into an entirely new (and entirely alien) landscape; that of the local authority.
My doctoral research at the University of Birmingham is looking to give a more public voice to the professionals experiencing this change, together with the range of actors within and around the ‘community of practice’ of public health. Indeed, the Department of Health and Local Government Association claim explicitly that this must not be a ‘drag and drop’ exercise; that local authorities will be able to ‘embed health and Wellbeing into everything they do’, that synergies will be created and that public health will be brought back under democratic accountability. But what is the lived experience?
Following my initial pilot interviews it seems that new social links are being forged, and that both public health teams and their clinical commissioning groups have very much had to find their feet, start again, and build anew. Within councils public health activities are indeed rolling out more broadly than ever, which partly indicates a kind of ‘scope creep’; with councils being able to make savings by dropping other teams with minimal budgets into ‘public health’ to benefit from the protected ring fenced grant monies, but this is also indicative of a new opportunity to engage with a much wider set of actors with real links to local communities and to refocus a wider range of activities on a public health agenda.
Additionally, the removal of public health from the NHS seems to be presenting teams with real data challenges as they no longer have access to the ward by ward figures generated from patient level databases. And as public health activities enter their new environment they can no longer assume legitimacy in what they do, with challenges coming from other directorates and budget holders suffering cuts to extremely sensitive areas such as specialist disability and mental health services, care services for the elderly, and services for young children and families to name but a few. Indeed, the opportunity to bring in some additional funds to councils is welcomed given the funding pressures elsewhere, but the implementation of these funds is certainly being carefully watched.
The battle for legitimacy and to embed public health activities is likely to be significant in the coming years, and one tool used in this regard is often the public health annual report document. But legitimacy, identity, and issues around coherence (especially of evaluations) within the community of practice also play out on a daily basis, and it is here that the identity of the public health profession is seeking to prove its value.
Complicating the challenges to identity, as I put it, are a range of potentially conflicting accountabilities; with the Directors of Public Health having a statutory responsibility to Public Health England, a budgetary responsibility to the director of finance, and political accountabilities to council members. All the while, the teams of public health professionals are trying to implement their own unique expertise; attempting to establish a discourse of prevention, of spend to save, and a more universal focus on quality of life.
Such is the current dynamic situation, but this change is not always seen as having an end in sight. Some participants and sources already anticipate further changes following another general election, and, under current legislation, the efforts to embed public health will be put to the test when the protection afforded them through the ring fencing of their grant is removed in April 2016. It will be at this point that legitimacy and conflicting accountabilities will be put to the hard test of financial realities. But as participants have already pointed out to me, public health has always had to fight its corner. Challenge and scrutiny may be no bad thing, and once in a local authority environment public health has no right to sit naturally above any other council activities.
My interviews are ongoing, and focus on public health teams, elected members, directorate leaders and budget holders from across my case study authorities, as well as key actors from clinical commissioning groups, central government and other private sector advisory firms and not for profit agencies. Together with follow up interviews over the next few years I hope to shed light on how budgetary pressures and accountabilities affect, emancipate, or enthral professional practice, and tell the story of public health in local government.
James Brackley is a lecturer in Accounting at the University of Birmingham Business School teaching audit, financial accounting, and public sector accounting courses. He is also working on a PhD project at the University of Birmingham on Public Health activities in local authorities, with a particular focus on accountability and professional identity.