Select Committee on Health Written Evidence


Memorandum by the NHS Confederation (WP 74)

INTRODUCTION

  1.  The NHS Confederation welcomes the new public health White Paper "Choosing Health" and, in particular, its emphasis on dealing with the preventable determinants of ill health eg smoking, obesity.

  2.  The NHS Confederation is a membership body that represents over 93% of all statutory NHS organisations, including Primary Care Trusts (PCTs), across the UK. Our role is to provide a voice for the management of the NHS and represent the interests of NHS organisations. We are independent of the UK Government although we work closely with the Department of Health and the devolved administrations.

  3.  Our evidence sets out our general views on the Public Health White Paper but then concentrates on the specific questions posed by the Committee.

OVERALL VIEW

  4.  Health is not purely the province of health care organisations and it is only by facilitating the use of a range of different approaches and the expertise of all stakeholders that the public health agenda can be delivered.

  5.  The Confederation believes that it is important to stress that the key delivery vehicle for health improvement is local partnership; both strategic in terms of the planning and delivery of services by the wider health and social care community; and personal between health and other professionals and the individual or local community.

  6.  The NHS Confederation endorses a model which encourages policy and planning around public health to be joined up at all levels including between government departments (for example referencing the impact of changes to licensing laws as part of the overall alcohol strategy) in order to gain maximum benefit from the work done in local partnerships.

  7.  The NHS Confederation believes that the worsening trends in health inequalities have been as a result of long term health differentials and will require long term solutions delivered in a stable environment where developments are part of a consistent programme of action. To this end, it would strongly urge a cross party approach to public health, enabling the delivery of this agenda to continue in line with the available evidence and good practice models irrespective of party political changes.

  8.  The NHS Confederation also advocates a balanced approach to the twin health improvement vehicles that is to say; of technological advance in healthcare; and the building of health capacity and personal responsibility for health through health promotional advice, empowerment and support for self care. It believes that there are sometimes false perceptions of the relative impacts of each element, whereas, in reality, each is required in different proportions at different stages in the individual's health journey, delivered using pathways of care which join the two together across NHS and other organisational boundaries.

  9.  Whilst all NHS organisations have a responsibility to promote health, PCTs were developed specifically with a remit to lead health improvement within local communities. This responsibility is of equal importance to other areas of work eg their commissioning responsibilities and was re-iterated in "Shifting the Balance of Power" (2001) and strengthened through the development of public health structures with Board level accountabilities within each PCT nationally.

  10.  PCTs are alone amongst NHS organisations in their responsibilities with regard to health equity auditing and assessing the health impact of local industrial and other developments. These responsibilities require a significant depth of knowledge about the local communities served and their differential health status and aspirations.

  11.  The NHS Confederation believes, therefore, that these requirements mitigate against the enlarging or merging of PCTs without the development of strong underpinning locality structures which enable responsiveness to and intelligence of local issues to be maintained.

IN RESPONSE TO THE COMMITTEE'S QUESTIONS

Question 1—Whether the proposals will enable the government to achieve its public health goals?

  12.  The NHS Confederation remains committed to an absolute ban on smoking in public places. However, it believes that this will need to be through a staged approach with continued support from smoking cessation services. In a recent poll of Chief Executives, smoking was spontaneously raised as one of their top three overall concerns. We believe that the implementation of an outright ban would be very challenging in the short term. The Confederation, therefore, supports the proposals on smoking outlined in the White Paper, with the proviso that this is a first step towards a total ban in public places.

  13.  There is evidence that access to work and educational attainment are major health determinants and any proposals which encourage getting individuals into or back into work are to be welcomed. The Confederation, therefore, supports the emphasis on work related health, both in general and in the NHS in particular, and believes that, with occupational health support as outlined in the White Paper, this is essential to ensuring healthy futures.

  14.  The NHS Confederation believes that there is a genuine problem with the levels of sexual health services available across the country for all age ranges. We would urge a more radical approach to the existing under-capacity including the use of Alternative Personal Medical Services (APMS) and independent sector procurement where appropriate. We believe that the proposed 48 hour waiting target for specialist Genito-Urinary Medicine services (GUM) is a step forward and that, if the rapid increase in sexually transmitted disease is to be halted, there must be a full review of service to improve access in appropriate settings and to improve the speed of diagnosis and treatment.

  15.  The NHS Confederation also supports the work which will build on the National Alcohol Harm Reduction Strategy (2004), particularly around auditing access to treatment services, the programme for improvement for treatment services and approaches to targeted screening and brief intervention in primary care.

  16.  The Confederation supports the use of Local Strategic Partnerships as vehicles for building community capacity for health through the development of Local Public Service Agreement (LPSA) targets which relate to local health inequalities. By drawing down pooled resources, the partnership can then allocate these to cross agency, joined up and community based projects. The proposal for the development of accredited Health Trainers, drawn from local deprived communities, is similarly welcomed as a way of building empowered and informed local communities, aware of the health choices available to them.

  17.  There is a need to build on models which focus positively on health, rather than perceiving it as an absence of illness. Whilst welcoming proactive health checks, we believe that there is a need to ensure that these do not encourage a continued focus on ill health. We would therefore suggest that the content of such checks uses a "wellbeing model" rather than one which stresses the need to screen for potential ill health.

  18.  However, these initiatives will not overcome distortions in community perceptions of risk and the consequences of risk taking behaviours, particularly in the young. For example, parents seeking to protect their children by driving them to school but failing to recognise the risk of low exercise levels. Developments based on the Canadian SmartRisk model are therefore also supported by the Confederation as a method of developing informed personal health choices.

Question 2—Whether the proposals are appropriate, will be effective and whether they represent value for money?

  19.  The NHS Confederation believes that the White Paper proposals are, in the main, appropriate and will form an effective basis for the achievement of the Public Service Agreement (PSA) targets to which they relate.

  20.  Existing evidence shows that the highest savings in terms of quality of life are achieved where cheap, positive health advice and support can be used to effect and/or support change.

  21.  We therefore particularly welcome the tobacco control initiatives outlined in the White Paper as representing long term value for money.

  22.  Similarly, the use of Pedometers and the encouragement of young people to exercise through walking buses and sports initiatives in schools are examples of cost effective and wholly appropriate proposals.

  23.  Personal Health guides will also represent value for money but only when linked to other patient held records and to the development of the National Care Record and Healthspace through the National Programme for Information Technology (NPfIT).

  24.  It is to be hoped that the Health Direct support line will be part of existing systems (eg NHS Direct) and will not represent another call centre based service with a separate infrastructure as has been the case with local GP referral centres etc.

Question 3—Whether the necessary public health infrastructure and mechanisms exist to ensure that proposals will be implemented and goals achieved?

  25.  The delivery of the White Paper principles and the related PSA targets will require the commitment of the whole workforce and not just the specialist public health teams in PCTs, Strategic Health Authorities, Government Offices and Local Authorities.

  26.  There has been a rapid expansion of specialist public health roles, particularly into primary care over the past three years but it is important to place these in the context of the changes in the traditional roles of the wider non-specialist workforce and to consider the fitness of the existing vocational programmes to train public health consultants towards the wider remit of Directors of Public Health.

  27.  The NHS Confederation does not believe that increases in overall staffing will be necessary to deliver the public health agenda. However, there is a need to improve public health skills across a range of professionals through multi-professional education programmes so that health improvement takes its place as core business across the NHS and other statutory partners.

  28.  Whilst recognising the shortfalls in specialist public health professionals outlined in the White Paper, the NHS Confederation also would emphasise the need for strengthening the effectiveness of public health management programmes. This will need to be embedded in such a way as to ensure that the skills of both existing and new specialists, both medical and non-medical, are fit to support the necessary changes which the White Paper will bring.

  29.  It is essential that work continues through the National Institute of Health and Clinical Excellence (NIHCE) to ensure that effective and consistent measures of improvement are available for those initiatives highlighted in the White Paper. This will enable continuous audit of progress against nationally agreed standards so that health improvements can be objectively assessed.

  In summary, the NHS Confederation believes that the White Paper forms a firm basis from which to tackle, through partnerships and improved education and support arrangements, the existing inequalities in health.





 
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