Letter from the Co Chairs, Southwark Health
Alliance, to the Clerk of the Committee (PH 20A)
REQUEST FOR AN UPDATE FROM THE SOUTHWARK
HEALTH ALLIANCE REVIEW OF SPECIALIST HEALTH PROMOTION AND PUBLIC
Further to our telephone conversation, please
find enclosed a summary update of the Southwark Review of Specialist
Health Promotion and Public Health Resources. We are currently
feeding back the results of the review and consulting on potential
re-configuration options. This consultation will continue into
the New Year.
We would welcome the opportunity to share with
you the outcome of the consultation. Both the Local Authority
and Health Authority are facing significant "modernising"
challenges and we believe that a strengthened and locally accessible
Specialist Health Promotion and Public Health Resource will help
us deliver the increasingly tough health improvement objectives
and targets that we have set in Southwark. Our review is also
reinforcing the value of "public health alliance" partnerships
in providing strategic co-ordination in health improvement in
area based initiatives, of which Southwark has a high number.
We would like to emphasise our view as expressed
in our submission that health promotion and public health are
at a pivotal point nationally. The Southwark review is confirming
to us what we need and what works. We hope the Health Committee
will consider this when making its national recommendations.
Thank you for contacting us for this further
1 December 2000
We are writing to you as joint Chairs of the
Southwark Health Alliance to assist your work in reviewing the
future of public health and health promotion. We hope that the
Committee will find this brief submission helpful. We would be
pleased to supply more detail. We would be delighted to receive
the Committee's comments on this submission.
The two communities of Health and Local Authorities
have a shared responsibility for leadership at Borough level on
public health, public protection and health promotion. Locally,
the Health Authority and Health First, the specialist health promotion
agency commissioned by the Health Authority, have been the principal
source of health promotion and public health expertise. However,
there are well established arrangements by which this expertise
is shared with the Local Authority and voluntary sector community.
The Southwark Health Alliance which has been pivotal to partnership
working on public health issues and health improvement is currently
undergoing review in order to better meet new challenges.
Recent Government proposals relating to both
the NHS and local government have created a need at a local level
to re-think how public health and health promotion expertise can
be strengthened to support the challenging "modernising"
agenda. Southwark partners in considering and implementing the
Government proposals, are beginning to recognise the potential
transmutation of the Health Authority into a sub-regional body
focussed on performance management of PCGs/PCTs and specialist
commissioning, and the general priority given to improvements
in clinical primary care. Simultaneously, the Local Authority
is prioritising the establishment of the Local Strategic Partnership,
while giving careful consideration to how it can best utilise
its power to promote well-being and fulfil its duty of community
planning. Additionally, our specialist health promotion agency,
Health First, is considering its role in relation to the Health
Southwark's Health and Local Authorities are
now consulting their partners on the precise form that any revised
organisational arrangements might take. This may well involve
the pooling of public sector health promotion budgets and the
strengthening of the public health function which is currently
based at the Health Authority in new configurations over the next
year or so.
This submission covers:
our starting pointwhat we
mean in Southwark by public health and health promotion;
the importance of distinguishing
health promotion planning or strategy from operational activity;
the organisational arrangements up
to now, and the reasoning behind them;
our views on why that position is
what any new organisational arrangements
might look like.
The key messages from the Southwark review of
public health and health promotion are:
the roles of organisations are changing
as structures change in response to the national agenda;
there is an increasing role for the
local authority in the wider health agenda in particular in relation
to inequalities, regeneration and probity;
public health expertise is required
to inform this, with increasing demands made on current public
there is a cogent case for strengthening
links between public health and local authorities and increasing
public health and health promotion support and public health skills
at a local authority level. However, public health still needs
to be a part of a coherent public health function and maintain
professional accountability for example via local or regional
in practice, the public health function
will also need to link with local health agencies to ensure the
effective use of resources in relation to health needs and effective
A shared view of public health and health promotion
Health promotion is about causes, not symptoms.
Current thinking is that the roots of ill-health and health inequality
lie in social ills such as poverty, poor housing, weak educational
systems, general environmental issues such as pollution, as well
as in individual behaviours such as poor nutrition, bad parenting,
and life style "choices" from drug taking to lack of
exercise. Changing individual behaviours and tackling some of
the contextual social ills is seen as the long term solution to
many health concerns. Such preventative work is better and cheaper
than costly clinical intervention further down the line. It follows
that the best health promotional work is not at the point of clinical
intervention but is further up stream than that.
With the above in mind, Southwark partners consider
health promotion as one of the core components of the public health
function. Components of the public health function will also include,
amongst other things, surveillance and assessment of the population's
health, managing knowledge and getting research into practice,
developing and influencing policy and informing on priorities
in health and health care.
Distinguishing health promotion strategy from
We find it helpful to draw a distinction between
the co-ordination, planning or strategy around health promotional
activity and the doing or delivery of health promotional work.
Leaving to one side for a moment the individuals
whose health we are trying to improve, many public, private and
voluntary institutions and possibly individuals have a stake in
and a useful contribution to these activities. They need to be
involved for at least two reasons. Firstly, we need to pool their
insight and knowledge in order to get the best possible view of
the local determinants of ill health and of the best way of intervening.
Secondly, many of the institutions are sovereign bodies, and will
need to be party to the discussions and be convinced by them if
they are to change their own behaviour or priorities to help affect
the health of the community.
In our view the strategy or co-ordination of
health promotion activities and of the various stakeholders that
contribute to them needs a clearly defined focus. In some ways,
it hardly matters who holds that co-ordinating role, so long as
it is clear and they are equipped for it. However it is helpful
to be clear where the primary accountability for co-ordination
lies. In Southwark, the review establishes that this lies with
the Health Alliance, demonstrating the important role that a healthy
alliance partnership plays in ensuring strategic co-ordination,
especially in areas where there are high numbers of area based
initiatives (there are at least nine in Southwark, including HAZ,
Education Action Zone, mini EAZ, Surestart, New Deal for Communities,
SRBs, Employment Action Zone, Sports Action Zone).
What follows in this submission is not concerned
here with the delivery of health promotion activities or interventions,
except to say that will continue to be shared among many partners,
and will continue to be a balance between one off projects and
complex programmes, between short and long term work, between
opportunistic and planned, and so on.
The position up to now
It would be fair to say that for some years
the prime responsibility for public health and health promotion
have rested with health authorities and their predecessor organisations.
Most recently, Directors of Public Health under the aegis of their
Health Authority have led this process.
In Southwark, the Health Authority has of course
recognised that the pivotal role of both the Local Authority and
the voluntary sector. That led to the establishment of the Southwark
Health Alliance in 1993 with the Chair shared between the two
Authorities. This shared arrangement has served Southwark well.
It has allowed us to develop and initiate a series of programmes
to shift health outcomes, and led to a broader contribution (from
non-health service organisations) to the Health Improvement Programme
and (from non-local authority agencies) to the Local Authority
Community Plan than might otherwise have been the case.
We need to emphasise the role of the voluntary
sector. They are key partners in the planning and the delivery
of health promotional activity. Local organisations have been
vigorous contributors to both the strategy and the delivery of
The position for the future
We think that the time is ripe for a rethink
of the institutional relationships in this field. In broad terms
our views are that:
The Health Authority, tasked with
the establishment of PCG/PCTs, is in a transitional phase. Current
indications from the Department of Health and elsewhere is that
Health Authorities will amalgamate into sub-regional structures
with a monitoring and review role, and a specialist commissioning
PCG/PCTs on the other hand, have
three objectives: to develop primary care, to undertake local
needs assessments and to commission services. It is clear from
the range of targets and the broad managerial ethos emerging from
the Department of Health that the improvement of primary care
is their overriding priority. PCG/PCTs will have a powerful role
to play, and a strong interest in, broad health promotional issues.
But they will have less influence on the determinants of ill health
than some other bodies. And it is probably not realistic to expect
that they will lead on the whole gamut of health promotion activity.
There is some concern that the health
promotion expertise currently provided by Health First and valued
by the Local Authority and the voluntary sector may be lost or
become less accessible in any potential realignment with regional
health promotion resources such as with the Health Development
Agency. The Southwark review is showing that easy access to locally
based expertise will play an important role to ensure that health
issues are addressed in an evidence based manner in major area
The Local Authority, in the meantime,
is finding its remit extended significantly. Local authorities
are being given the powers and the duty to integrate health issues
into the wider processes of community planning at Borough level.
Change to the political system will accentuate this. The emergence
of individually accountable and powerful local politicians in
a Cabinet or as Mayors, and the expansion of the scrutiny function
of local authorities to embrace health, will have an impact. Together
these issues are forcing local partners to re-think how the public
health function can be strengthened in order to better provide
specialist and expert public health support to the Local Authority.
As if to re-enforce this trend, the
system of Public Service Agreements may allow Councils that can
demonstrate that their Local Strategic Partnerships are effective
and exceeding Government targets may have access to un-hypothecated
funding, and a release from at least some of the burdensome and
over-prescriptive planning frameworks imposed from the centre.
Finally, but not least Southwark
partners have to some extent recognised that the Local Authority
is well placed to integrate health promotion with their wider
educational and regeneration roles; regeneration in Southwark
is of course particularly active. It is a route to public and
private funding on a scale that dwarfs any other conceivable source.
The above is making us re-consider the organisational
arrangements that underpin public health and health promotion
and to look at ways to strengthen that activity during the transitions
of the next few years.
FOR PUBLIC HEALTH
AND HEALTH PROMOTION
It follows from this that the current arrangements
for public health and health promotion may have to change. For
a variety of reasons, the Health Authority may not be able to
sustain the energy it puts into Borough based health promotional
work, and in any case must integrate its work with the evolving
PCG/PCTs as well as support the potential demands on public health
resources from the emerging Local Strategic Partnership. The Local
Authority, on the other hand, is challenged by the duty of well-being
and the powers of community planning to facilitate that integration.
Both communities have an interest in strengthening the Borough's
strategic or co-ordinating capacity in health promotion and in
public health expertise.
The practical issue we must now face is whether
and how to combine the limited budgets of time, money and energy
Southwark partners hold in different ways. We already pool resources
to fund both strategic and operational activity. Perhaps we need
to pool more in order to be certain that the longer term and sometimes
diffuse work around public health and health promotion hold its
groundand preferably advancesthrough the organisational
turbulence of the foreseeable future.
We have therefore initiated a consultation process
with the relevant partners in public health and health promotion
in Southwark to test their views. On the whole they share our
view that it is time for change and that there must be some more
formal pooling of effort between the two authorities, and that
we must work to integrate our efforts with the wider strategic
Our consultation is not yet concluded but might
encompass the establishment of a core health promotional team,
organisationally equidistant between the health and local authorities,
with a remit to force the pace on health promotion strategy and
commissioning and to integrate that with the local strategic partnership.
In addition, there is a need to strengthen local public health
expertise in order to support the Local Authority's additional
roles around health improvement and scrutiny. This may involve
change to the current public health arrangements which are primarily
Health Authority based. Funding these developments may involve
some hard choices for both the Local and Health Authorities. There
are other options, although the status quo is probably not one
The Southwark consultation continues into January
2001 and we will welcome the opportunity to update the Health
Committee on the outcome.
1 December 2000