Public Health: Accounting for Healthy Lives

Introduction Following the Health and Social Care Act 2012, public health in England has been reimagined, with a £2.7 billion ring fenced grant being provided to local authorities by Public Health England (PHE), the newly created statutory body. The Department for Communities and Local Government’s ‘localism’ agenda and PHE’s loose statutory levers have, ostensibly, ‘returned public health home’, put ‘public health back into the heart of local communities’, and democratised public health (Department of Health, 2011; Local Government Association, 2014). For public health professionals this has meant establishing their professional legitimacy outside of the NHS for the first time since 1974, in an environment that is being redefined by austerity. My research project follows the actors across institutional boundaries as new calculative techniques are formulated and a new community of practice emerges. By tracing the key inscription devices, the complex network of translations, and the conflicting accountabilities in two case study locations my project maps the resultant narratives around how public health comes to matter. Literature review I have reviewed a wide range of literature through my research project to date, these can be grouped into the recent public health literature (Day et al., 2014; Caron et al., 2014; Phillips and Greene, 2015); the qualitative accounting literature on local government (for example, Llewellyn, 1998; Goddard, 2004; Arnaboldi and Lapsley, 2008; Murray, 2011) and on the health (for example Samuel et al., 2005; Kurunmaki and Miller, 2008; Jarvinen, 2009; Fischer and Ferlie, 2013); the wider public sector literature on new public management (NPM) (Hood, 1991; Hood, 1995; Lapsley, 2009; Power, 2012) and value for money (Alwardat et al., 2015); studies and theoretical work developing actor network theory (Latour, 1999; Latour, 2005; Callon, 1998; Czarniawska, 2004; Justensen and Skaerbaek, 2010; Justensen and Mouritsen, 2011; Skaerbaek and Christensen, 2014) and science and technology study inspired new materialisms (Barad, 2007; Boll, 2014); literature on accountability (Stewart, 1984; Muligan, 2000; Roberts, 2009); and literature on the various forms of professional identity including the interactions between the medicalised and accounting professions (for example, Jarvinen, 2009; Fischer and Ferlie, 2013). Public health in the UK has evolved for over 150 years through the various Public Health Acts through to the transfer of public health into the NHS in 1974, and through the progressive rounds of reforms that saw the introduction of primary care trusts in 1998 (Nuffield Trust, 2016) and then their abolition in 2013 (Local Government Association, 2014). The huge social and economic value of public health is discussed in the Marmott review (Marmot and Bell, 2012), while more recent research evaluating the current arrangements give a mixed picture of the advantages and disadvantages of the transfer to local government. Phillips and Greene (2015) conduct one of the few qualitative studies to date, finding that there were a range of complex accountabilities to line managers, politicians, and to residents; that traditional wellbeing activities are dependent on local expertise and more qualitative forms of knowledge, which is in contrast to the more scientific 'evidence based’ forms of knowledge in the medical profession and at PHE. Other studies have drawn on broad survey data of directors of public health or cross sectional interview data (Caron et al., 2014; Day et. al, 2014) while the National Audit Office (NAO) have reviewed the processes nationally (NAO, 2014). My research contributes to this by focusing on the financial structures and management accounting in practice, as they emerge in a new and complex multi-agency arrangement. My project will develop the limited accounting literature on local government in the UK, and also on the wider health literature touched on above. It will link its findings to concepts of new public management (Hood, 1991; Hood, 1995; Lapsley, 2009; Power, 2012); building particularly the links to the professional identity and accountability in an actor network theory framework. Two key accountabilities will be professional accountability and financial accountability; which will be discussed in relation to the accounting and professionalism literature, but also crucially with reference to one of the key controversies in Latour’s Reassembling the Social (Latour, 2005), the concept of ‘groups’ under radical (re)construction. In my context these will also play out against political accountabilities and the statutory accountability to PHE. I will draw on the key conceptual sources above, analysing my results from an actor network theory perspective, discussing the extent to which professional bodies, accountability levers, and other calculative devices can be said to ‘act’ in this complex network. Theoretical framework and methods My central research questions, on which my first paper will focus, are: - To what extent do the various calculative devices for public health commissioning and interventions shape or conflict with the multiple ‘giving of account’? - For whom are these calculations constructed, mobilised, and translated in this network? By focusing on a unique empirical opportunity to see public health in local government under (re)construction, these research questions will make both empirical and theoretical contributions to the wider debates on NPM, management accounting in the public sector, and the construction of professional identity. In more recent actor network theory research we have seen a shift towards multiple centres of calculation (Justensen and Mouritsen, 2011), towards more complex and localised networks of translation as opposed to linear or narrative translations (Latour, 2005, pp.21), and a distinction between matters of fact and matters of concern (Latour, 2005: pp.87). By following two case study unitary authorities, this research paper will map the unfolding battle for the superiority of various ways of knowing and being, and map how financial evaluations are continually being mobilised in this context. Initial results and conclusions Following my first round of 15 interviews across my two case study locations, PHE, private sector consultancy firms, and the third sector, as well as observations of health and wellbeing boards, this project will suggest three initial findings: Firstly, the multi-agency nature of public health, the change of institutional environment, and the wider austerity context, create tense boundary problems and an inherent conflict between ‘bringing public health into everything we do’ (Department of Health, 2011) on the one hand and protecting budgetary independence and professional identity on the other. Secondly, the focus on outcomes, measurability, and scientific rigour, of the public health profession are consistent with some elements of wider NPM reform, but crucially do not currently align monetary returns on investments with inputs, which creates potential for shocks when ring fencing of public health grant monies is removed in a context of deep austerity. Finally, calculations and constructions of ‘matters of fact’ nonetheless play a crucial role in legitimising and aligning complex public health interventions, and counter to wider health accounting literature (McGivern et. al, 2015) mobilisations that emphasise ‘social returns’ and broad concepts of wellbeing are central, in some cases overriding short term cost focused decision making. I organised the University of Birmingham’s conference ‘Public Health: Healthy lives out of austerity’ on the 11th February 2016, which included a focus group session of 40 public health practitioners. In 2016 I plan to conduct a second round of interviews extending my initial data and findings. List of References: Alwardat, Y. A., Benamraoui, A., and Rieple, A. (2015) ‘Value for Money and Audit Practice in the UK Public Sector’ International Journal of Auditing, 19 (3), pp. 206-217 Arnaboldi, M., and Lapsley, I. (2008) ‘Making Management Auditable: The Implementation of Best Value in Local Government’ ABACUS, 44 (1), pp. 22-47 Barad, K. (2007) Meeting the Universe Halfway: Quantum Physics and the Entanglement of Matter and Meaning Durham: Duke University Press Boll, K. (2014) ‘Representing and Performing Businesses: A segmentation model in action’ Journal of Cultural Economy, 2014, Vol.7(2), p.226-244 Callon, M. (1998) ‘An essay on framing and overflowing: Economic externalities revisited by sociology’ The Sociological Review, 46 (1), pp.244-269 Caron, R., Hiller, M., and Wyman, W. 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