You've Consolidated. Do You Know Who Your Local Health Director Is?

In the summer of 2012, the General Assembly enacted a law that authorized boards of county commissioners in North Carolina to consolidate county human services departments and boards. In the months since, twenty counties have taken actions under G.S. 153A-77. The exact actions have varied from place to place, but the most common action has been to create a consolidated human services agency (CHSA) combining the former county departments of health and social services, and sometimes other human services departments or functions as well. There are presently 17 CHSAs in North Carolina that include both public health and social services, as this map shows. North Carolina law requires counties to assure that public health services are available to their residents, a duty that is satisfied by the creation of a CHSA that includes public health. State law also creates the position of local health director, requires the person in that position to meet minimum education and experience requirements, and assigns quite a few powers and duties to that person. Traditional county health departments and multi-county district health departments are headed by a local health director who meets the statutory qualifications for the position and carries out the statutory powers and duties. However, a CHSA is led by a consolidated human services director--a position that is also created by statute but has its own powers and duties and is not subject to the education and experience requirements for a local health director. When a county creates a CHSA that includes public health, what becomes of the local health director? That is actually a multi-part question that is not entirely answered by law. What happens to the position of local health director is one thing, but what happens to the powers and duties of a local health director is another.  Local health directors In a traditional health department, the local health director is appointed by the board of health and is responsible for administering the department and exercising powers and duties prescribed by law. The minimum education and experience requirements for a local health director are set out in G.S. 130A-40. In general, the local health director must have education and experience in medicine, public health, or public administration related to health.  The powers and duties of a local health director come from multiple sources of law. The main statute is G.S. 130A-41, which charges the local health director with administering local public health programs, enforcing state public health laws and local public health rules, investigating disease outbreaks, ordering isolation or quarantine when authorized by law, abating public health nuisances and imminent hazards, employing and dismissing health department employees, advising local officials of public health conditions, and more. While extensive, this list is not exhaustive. Other powers and duties appear elsewhere in the statutes, many in Chapter 130A but quite a few elsewhere. For example, a local health director:

• Serves as the local vital records registrar (G.S. 130A-94)
• Is responsible for organizing countywide rabies vaccination clinics at least annually (G.S. 130A-187)
• Oversees environmental health programs in which the local health department has duties specified in statutes, such as on-site wastewater permitting (G.S. 130A-335)
• Approves the local jail medical plan (G.S. 153A-225)
• Is one of several local officials responsible for supervising the relocation of graves (G.S. 65-106)
• Ensures that certain defendants referred by the district attorney are tested for sexually transmitted infections and that the victim and specified others are notified of the results (G.S. 15A-615)

This is not a complete list of duties under state law, and the local health director also has duties arising from contracts or federal laws. For example, as a condition of receiving state and federal funds, the health director must sign an annual contract with the North Carolina Department of Health & Human Services. The contract, called the "consolidated agreement," promises that the county will comply with a number of laws (such as federal non-discrimination laws) and be subject to oversight and monitoring by the state Department. Consolidated human services directors A CHSA is administered by a consolidated human services (CHS) director who is appointed by the county manager with the advice and consent of the CHS board (or the county commissioners, if they have assumed the powers and duties of the CHS board).   He or she administers the department as well as exercising powers and duties prescribed in G.S. 153A-77, the consolidation statute. There are no minimum education and experience requirements for a CHS director in state law; however, the director clearly needs to be someone who is prepared to administer a local agency that carries out numerous state and federal programs and typically has a relatively large budget and staff compared to other local departments. If the CHS director does not have the statutory qualifications to be a local health director, then he or she must appoint a person who has those qualifications and is approved by the county manager [G.S. 153A-77(e)]. If the CHSA includes public health, the CHS director acquires most of the powers and duties of a local health director. More on this in a moment. What happens to the position of local health director in a county with a CHSA? The law has very little to say about this and the practice may vary from place to place. One thing that is clear is that each local public health agency--whether it is a traditional health department or a consolidated human services agency--must have someone who has the statutory education and experience requirements to be a local health director. It may be the CHS director, but if the CHS director does not have the statutory credentials, then he or she must appoint someone who does. What happens to the powers and duties of the local health director in a county with a CHSA? When a CHSA includes public health, the CHS director acquires the powers and duties of a local health director, with the limitation that the CHS director's hiring/firing decisions and executive responsibilities are subject to the oversight of the county manager. This occurs automatically as a result of statutes that transfer local health director duties to a CHS director when a CHSA is created [G.S. 130A-43(c); 153A-77(e)]. In addition, the CHS director has the powers and duties set out in G.S. 153A-77(e). Some of these appear to overlap with local health director duties, while others reflect the CHS director's role as the administrator of other human services programs carried out by the CHSA. Although the CHS director acquires the powers and duties of a local health director, he or she might not be the person who exercises them.  The powers and duties of a local health director that appear in G.S. Chapter 130A may be delegated to another person (see G.S. 130A-6). In many counties with CHSAs, the CHS director has delegated those powers and duties to the person he or she has appointed who has the qualifications of a local health director. However, the law does not require this delegation and it may be that some CHS directors retain some of the powers and duties and delegate others. So who is the local health director in a county with a CHSA? There is a complicated answer and a more practical answer. Starting with the complicated answer: One way of looking at it is to say that the CHS director is the local health director. G.S. 130A-2 defines "local health director" as the administrative head of the local health department, and G.S. 130A-43 specifies that a CHSA that includes public health "shall have the responsibility to carry out the duties of a local health department." On the other hand, G.S. 153A-77 requires the CHS director to appoint someone with the qualifications of a local health director. The statute does not assign that person a role or title, but it seems reasonable to assume the purpose for requiring the appointment is to have someone who has the education and experience requirements for a local health director to serve in the local health director role -- and this may be achieved if the CHS director delegates health director powers and duties to that person. The more practical answer is that the North Carolina counties that have formed CHSAs have all identified someone who is serving as the local health director. A full list is available on the website of the North Carolina Association of Local Health Directors. In a few counties, the CHS director is identified as the local health director, and in some cases those individuals have the statutory qualifications of a local health director. However, most counties that have formed CHSAs to date have identified someone other than the CHS director to serve in the local health director role.