Councils have always been concerned with health improvement. Many have adopted Cicero’s dictum “Salus populi suprema lex esto” – “The wellbeing of the people is the greatest law”.
The importance of wellbeing to local authorities was increased in 2013 by legislation giving a duty to improve health, and by the creation of health and wellbeing boards.
Many directors of public health could be described as local system leaders. Is this a natural role, or the result of enthusiasm for system leadership in the English public sector coinciding with the arrival of directors of public health in councils?
The role of a DPH is flexible and can adapt to the differing requirements of different organisations. So the transition to local government in England could just have meant a move from one set of responsibilities to an overlapping set, but there was also the possibility of transforming the role.
DPHs are well placed to lead the improvement of health, but the leadership role is not theirs alone. Decision making within local government, unlike within the local NHS, lies with democratically accountable elected members. The employed role of the DPH is principally as an adviser, and the budget and number of staff directly accountable to a DPH will be relatively small.
In addition, the move from NHS to local government has tended to weaken the links between DPHs and the health service. Public health is on the agenda for sustainability and transformation partnerships and integrated care systems, but it is not at the top of the agenda, and DPHs may find it hard to be heard.
Directors of public health do, though, have some unique skills and attributes that can be used in system leadership. These include a knowledge of, and evidence-based focus, on the wellbeing of local populations. They also have an understanding, often derived from extensive experience, of working in the contrasting cultures and environments of local government and the NHS.
While DPHs do not have a direct democratic mandate, there is a strong professional duty to improve the health of the local population, especially where health is the poorest. That professional obligation overriding institutional loyalty may manifest in a small way through DPHs introducing themselves as the DPH for the area and not the council. And it may be used in a bigger way as a force for encouraging leadership across the system.
There is no inevitability that modern DPHs will lead across the system. However, there are great opportunities for DPHs to work across organisational and sectoral boundaries and work with communities using their unique skills and experience.
Public health was a foundation of local government tackling risks to health in the 19th century and DPHs are now best placed in local government to take a leading role in tackling the modern risks and underlying determinants that contribute to health inequality, injustice and disability. That can only be achieved by joint leadership, working with elected members, GPs, public sector organisations and their communities.
Tim Allison, honorary secretary, Association of Directors of Public Health