Health and Social Care Bill

Memorandum submitted by the Association of Directors of Public Health (HSR 43)

The Association of Directors of Public Health (ADPH) is the representative body for Directors of Public Health (DPH) in the UK. It seeks to improve and protect the health of the population through DPH development, sharing good practice, and policy and advocacy programmes. www.adph.org.uk

 

ADPH has a strong track record of collaboration with other stakeholders in public health, including those working within the NHS, local authorities and other sectors. We have worked closely with colleagues in local authorities – particularly Directors of Adult Social Services (DASS) and Children’s Services (DCS) – and with IDeA (now LGID) developed work on effective joint working in local authorities between DPH, DASS and DCS (Leading Together Better) [1] .

ADPH has submitted detailed responses to consultations on the NHS White Paper, draft Health & Social Care Bill and Public Health White Paper; submitted and presented evidence to the Health Select Committee and other Parliamentary Groups/Committees; and made direct representations to the Secretary of State for Health. ADPH President Frank Atherton is also a member of the Future Forum.

In this submission we raise areas of concern that we believe require urgent consideration and clarification in relation to Parliament’s consideration of the amendments to the Health & Social Care Bill.

1. Overview – public health and local government organisations

The Health and Social Care Bill represents a major restructuring, not just of health care services, but also of local authority responsibilities in relation to public health, health improvement and health protection and the coordination of health and social care. Recognising this fundamental change and the opportunities - and risks - that it presents for improving the health of the public, ADPH along with eight organisations [2] representing public health specialists and local government have joined to discuss the Bill. All involved recognise the important role that local authorities have to play in improving the health of the public and are keen to develop effective working relationships – and in doing so are calling for:

· urgent clarification on funding arrangements for public health;

· safely managed transition arrangements which avoid the loss of vital expertise;

· a clearer picture of what functions go where, minimal direction from the centre and early resolution of very complex resource issues;

· and most importantly that no action should be taken that threatens or undermines the good work that already takes place across the country on integrated health and social care delivery.

2. Protecting and promoting the health of the local population

We believe that local authorities should be responsible for protecting and improving the health of their populations at all times, including during outbreaks and emergency situations. Public Health England should support local authorities in doing this, and local authorities should be required to use the skills and expertise of public health specialists to deliver health and wellbeing for their local population.

However we are very concerned that neither the Health & Social Care Bill (nor the Public Health White Paper) articulate these responsibilities clearly. This puts the public at serious risk, particularly in emergency or epidemic situations. We believe that the following responsibilities are so important that they should be defined in primary legislation:

· Local authorities should be responsible for protecting and improving the health of their populations at all times, including during outbreaks and emergency situations.

· Public Health England should support local authorities in discharging this responsibility.

· Local authorities should be required to use the skills and expertise of public health specialists to deliver health and wellbeing for their local population.

3. Public Heath England

Public Health England (PHE) can only effectively operate as a national public health service if it encompasses all three domains of public health:

- Health protection (infectious diseases, environmental hazards and emergency planning);

- Health improvement (lifestyles, inequalities and the wider social, economic and environmental influences on health); and

- Health services (service planning, commissioning, audit, efficiency and evaluation).

PHE should operate as a supporting organisation which can:

· provide independent scientific evidence-based advice to national and local government, the NHS and the public on all matters relating to the maintenance, improvement and protection of health;

· offer expertise to the NHS Commissioning Board (NCB) in support of its role in providing national leadership in commissioning for quality improvement, commissioning national and regional specialised services, and allocating NHS resources;

§ provide effective, expert and adequately-resourced specialist PH capacity to support the work of local DsPH and their teams;

§ provide independent scientific evidence-based advice and guidance to the devolved nations where they are unable to access this locally;

§ generate revenue from external consultancy and academic research funding.

We are concerned that:

- there is a lack of definition on the role and status of Directors of Public Health (DsPH) within PHE – this requires clarification, including in relation to the health protection functions of DsPH locally;

- clarity is required on the mechanisms for public health input to the NCB;

- there must be clear lines of accountability, communication and access between PHE, commissioning groups, NHS and DsPH working within local authorities.

Specialist public health capacity (including specialists working across the domains of health improvement, health protection, healthcare public health, and public health intelligence/analysis) should be consolidated into PHE. The specialist capacity can then be deployed to provide public health input to all parts of the health and social care system; commissioning groups, LAs, NCB, and NHS-funded provider organisations.

Health protection

ADPH has been working with the HPA to develop solutions to key local health protection issues. The initial phase of this work was recently completed and the outcomes report has been widely circulated.

PHE and the NHS will need to liaise closely with public health agencies in the devolved administrations to ensure that cross border support remains robust in relation to UK health protection issues.

Capacity for emergency preparedness and response must be maintained within the new structures – and robust interim arrangements to ensure a stable transition.

Clarity is vital over which part of the system will lead responses to incidents at local and sub-national/supra local or regional levels.

There needs to be clear agreement on the roles and responsibilities for DsPH and local health protection units, including assurance that health protection work carried out in second tier local authorities is connected with coordination and planning mechanisms organised at the top tier of local government.

4. Role of the Director of Public Health

Directors of Public Health (DsPH) are the frontline leaders of public health working across the three domains of health improvement, health protection, and health care service planning and commissioning. Directors of Public Health must be enabled - through primary legislation - to provide oversight and influence across all these determinants of health within local authorities, the NHS and primary care, and other appropriate sectors and agencies in order to secure the improving health of their population.

DsPH should be jointly appointed by LAs and PHE and should have a contractual relationship with both. However the supporting HR framework and clarification of terms/conditions and accountabilities are urgently needed.

DsPH will need clearly defined responsibilities and powers and the professional status and enablement to express an independent view in order to provide advocacy for the health of the population. This is analogous to the requirement for local authorities to appoint a suitably qualified officer responsible for the proper administration of its financial affairs in section 151 of the Local Government Act 1972.

DsPH will require a well-resourced, professional and co-located Public Health team providing the skills and experience to input to local service planning and commissioning, and to deliver Public Health programmes and advice across the health economy, supported by access to high quality local and national data and scientific evidence base.

ADPH strongly believes that:

· A DPH should be an individual trained, accredited, and registered in specialist public health;

· There should be a statutory requirement for top tier Local Authorities to appoint a DPH with the appropriate professional training and accreditation;

· The DPH should be recognised as the principal adviser on all health matters to the local authority, its elected members and officers, and its Health & Wellbeing Board, on the full range of local authority functions and their impact on the health of the local population as stated in Annex A of the PH White Paper;

· The DPH should work at corporate/strategic director (top team) level as a full executive member of the corporate leadership team with direct access to the local authority Cabinet and councillors – influencing and working alongside other Local Authority Executive Directors and normally reporting or accountable to the CEO or equivalent;

· The professional status of the DPH and ability to express an independent view in order to advocate for health improvement and reducing health inequalities within their local population and act for the protection of the local population - and the independent DPH annual report - must be protected;

· As the principal advisor to a Health & Well Being Board, a DPH should not relate to more than one Board. However, we recognise that where local arrangements lead to a shared Board, then it may be appropriate for one DPH to work to this Board.

· DsPH should:

o be appointed jointly by the local authority and PHE, through a statutory appointments process which mirrors the existing Advisory Appointments Committee process for DsPH and Consultants/Specialists in Public Health – and accredited by the Faculty of Public Health (as is currently the case);

o have a formal contractual relationship and role with PHE;

o have their employment terminated only with approval of both the local authority and the Secretary of State for Health.

The Public Health system across Local Authorities, PHE and the NHS must facilitate and promote seamless movement of public health professionals across different settings, as part of a normal career path.

5. Health & Wellbeing Boards

ADPH welcomes amendments to strengthen Health & Wellbeing Boards and believes that local commissioning plans should be subject to scrutiny and comment by the Health and Wellbeing Board – and to greatest effect would also be signed off by the Board.

The Director of Public Health should act as a principal advisor to the Health and Wellbeing Board for public health advice across the three public health domains of health improvement, health protection, and health care service planning and commissioning.

It is important that in two tier authorities the existing health and wellbeing partnerships continue to work together for the health and wellbeing of the local population. We believe that District Authorities should have specific roles and duties for the improvement and protection of health.

6. Commissioning

ADPH welcomes the Government’s commitment that Public Health principles and practice should influence all parts of the NHS. The NHS Commissioning Board should therefore be required to appoint a Director of Public Health with a national remit and to be a full member of its Board.

Commissioning Groups should be required to work through and with Directors of Public Health to ensure their decision-making is underpinned by expert, professional public health advice.

We welcome the Government’s commitment that commissioning groups will have a duty to promote integrated health and social care around the needs of users, and Government’s acceptance of the Future Forum recommendation that commissioning group boundaries should not normally cross those of local authorities. However, we would welcome clarification of the changes in the Health & Social Care Bill that will enact this commitment.

In order to promote coherent response to emergencies, commissioning groups should assume similar responsibilities as category 1 responders under Civil Contingency Act that have previously applied to Primary Care Trusts.

Commissioners should be required to demonstrate the use of a strategy covering high quality, universal services, targeted services for communities of interest at greater risk especially deprived communities and tailored services for people with multiple and complex needs. This should be underpinned by evidence base, public health intelligence and needs assessments.

7. NHS Commissioning Board

Clarity is required on the mechanisms for public health input to the NHS Commissioning Board and Clinical Senates. These should be clearly defined in the Health & Social Care Bill.

The NHS Commissioning Board should be required to appoint a Director of Public Health with a national remit and to be a full member of its Board.

8. Provider organisations

To fully realise the transformational change envisioned in the Health & Social Care Bill, we believe there is a need to extend public health influence within provider organisations. We believe that there are huge benefits that derive from having a public health lead working within Trusts.

We would welcome measures that would enable and encourage provider trusts to work with local authorities in improving the health of the population.

For example, we have in the past expressed concerns over the accumulation of excessive financial reserves in Foundation Trusts, and suggested that above a capped level of reserves, an annual proportion of the reserves could be spent on initiatives agreed locally as providing health gain for the population.

In 2010 ADPH surveyed its members on progress with the introduction of Transforming Community Services, and results from this survey highlighted that:

- Care must be taken that in any re-organisation the impact on public health services should be assessed – this is particularly true for emergency planning and response.

- Where possible there should be a named public health lead in community services.

- public health expertise should be readily available to provider services where no public health lead is in place.

9. Regulatory organisations

In strengthening the role of the Care Quality Commission, and developing the role of Monitor, we would wish to see clear lines of public health input into both organisations, and specifically:

- public health expertise and input at a high level within the Care Quality Commission to ensure a strong population perspective in quality regulation;

- public health expertise and input into Monitor to ensure effective use of resources in support of the prevention agenda health improvement and a reduction in health inequalities.

10. Health inequalities

We welcome that the Bill includes new duties on the Secretary of State, NHS Commissioning Board and commissioning groups to have regard to the need to reduce health inequalities. These duties should reflect the broader role of the NHS in promoting public health as a provider, commissioner and major employer, with equivalent duties on the Secretary of State and local authorities in respect of their ro les in promoting public health.

July 2011