Health and Social Care Bill

Memorandum submitted by the UK Faculty of Public Health (HRS 50)

About FPH

1. FPH represents the specialist public health workforce in the UK. We are committed to ensuring that public health operates at the very highest of professional standards, underpinned by a strong evidence base. We work closely with a wide variety of organisations and sectors, including government, to promote and deliver lasting improvements in health and wellbeing.

2. FPH has submitted comprehensive responses to the Government’s proposed reforms in Healthy Lives, Healthy People. It was a leading signatory on a letter to the Prime Minister outlining concerns around the proposed reforms. FPH has also submitted evidence to the Health Committee Inquiry into Public Health and has given oral evidence to the committee (FPH President, Professor Lindsey Davies 17/5/11) – all available from www.fph.org.uk Our position has been formed through extensive consultation with our members and other public health and health organisations.

Summary

3. In its various responses to government consultations and inquiries FPH has consistently called for the following to be implemented in order to ensure a public health service that is fit for purpose and which supports people to achieve good health and wellbeing:

§ responsibility and accountability for protecting and improving people’s health to be firmly with local authorities at all times;

§ Public Health England to be established as an NHS body or, failing that, an executive agency, providing independent and trusted advice, and employing all public health specialists;

§ all three domains of public health (health services, health improvement and health protection) to be embedded throughout the system, including commissioning structures;

§ qualified and registered directors of public health to be positioned as influential, strategic leaders for health, responsible for managing the ring-fenced public health budget, protecting and improving the health of the public, and providing public health advice and expertise locally, including to clinical commissioning consortia;

§ local authorities to be supported by expert, embedded public health teams;

§ the statutory regulation currently in place for public health specialists who are doctors or dentists to be extended to cover those from other backgrounds;

§ the continuance of public health training alongside other medical specialities to ensure the long-term viability of the profession;

§ effective public health practice through a detailed understanding of the local context, dependent upon good working relationships, built on trust and mutual respect;

§ a sustained period of stability to enable the new system to deliver the ambition of the reform.

Public Health England as an executive agency

4. FPH has consistently called for Public Health England (PHE) to be established as an NHS body or, failing that, an executive agency of the Department of Health (DH). This is to ensure that the new organisation is viewed by and has the confidence of the public, professionals, and government, as an independent, authoritative and trusted source of evidence-based public health support and advice. The original proposal, in Healthy Lives, Healthy People, to establish it within the DH raised significant concern within the public health profession that the new organisation would not be viewed as sufficiently independent.

5. The Government’s commitment to establish PHE as an executive agency of the Department of Health (DH) is a helpful step in the right direction. However, PHE as an executive agency will still be part of the civil service, so a new way of working will need to be developed to secure professional independence and public confidence.

6. Establishing PHE as an executive agency should also mean that the important commercial and grant-funded research activities which the Health Protection Agency and public health observatories undertake are allowed to continue. This should be enshrined in the structural guidance/framework that is developed to support PHE’s creation.

Protecting the public through a robust registration and appointments process

7. Protecting people’s health and wellbeing is of paramount importance. The system of registration and revalidation for medically qualified doctors, particularly post-Shipman, underlines the need for a professional workforce that is closely regulated and monitored. Public health specialists, whether employed as consultants or as directors of public health (DPHs), make decisions which affect the lives of hundreds or thousands of people at a time. For this reason, FPH has consistently called for the statutory regulation of all senior public health professionals – including those from backgrounds other than medicine and dentistry. It has also pushed for a robust appointments process – such as that which currently operates – to ensure the protection of the public and in the interests of the employer.

8. The NHS Future Forum recommended that the "registration by an appropriate national body should be compulsory for non-medically qualified public health staff" – which we would interpret as covering all public health professionals working at specialist level ie. at consultant grade and above. FPH was extremely disappointed to find that in its response to the Forum’s report, the Government ignored the issue entirely.

9. At FPH’s annual conference on 4 July 2011, Secretary of State Andrew Lansley was challenged on the registration and appointments issue. His response was that because directors of public health would be jointly appointed by local authorities and the Secretary of State for Health this should provide a sufficient level of scrutiny. FPH disagrees; the current appointments process for consultants and DPHs, which has stood the test of time, is designed to ensure that only the most qualified and appropriately trained individuals are appointed to senior public health posts, where decisions are made about the health and wellbeing of large numbers of people. Most public health specialists are employed currently in the NHS, in a well-regulated system. Under the new arrangements, the range of potential employers will increase substantially. Statutory registration – and revalidation – will become all the more important in the new context to secure for all employers the confidence that their staff have achieved and are maintaining a high standard of professional practice and behaviour.

10. The extension of the current NHS statutory appointments process to cover local authorities is a second key component of the necessary professional regulatory system. This process is used for all clinical and public health consultant appointments in the NHS, and has also been used extensively for joint appointments between local authorities and primary care trusts.

11. An extension to the current statutory instrument – rather than the creation of new legislation – and an explicit requirement for it to cover appointments within local authorities (as well as the NHS) and to include a representative of the Secretary of State on the appointments panel, would be all that was required to protect employers and the public.

12. The Bill as it currently stands does not even require a DPH to be qualified in public health. It should do. FPH is deeply concerned that this issue remains unresolved

13. If the DPH and the population they serve are to be confident that they are able to provide professional views on health and health needs honestly and openly – even when this might sometimes require them to call into question the activities of prominent local organisations – then a degree of protection is required. Medical officers of health, in similar positions in the past, could not be dismissed without the agreement of the secretary of state. This provision was rarely used but was of great value in avoiding precipitate or unreasonable action. FPH would strongly support its inclusion in the revised Bill, which currently requires only that the Secretary of State is consulted and gives no power of veto.

Public and patient involvement

14. FPH supports the strengthening of public and patient involvement in decision-making about their health and wellbeing, through the inclusion of an amendment to the Health and Social Care Bill to make it an explicit duty that the public is involved in identifying local needs and developing strategies to meet those needs . This involvement will also provide an important scrutiny and accountability function.

Ensuring capacity and skills within the public health workforce

15. FPH continues to be made aware of the continued ‘drip drip’ loss of public health posts and specialist expertise either through the loss of such posts or through people leaving the specialty as a consequence of the uncertainty and lack of detail around their future role.

16. FPH has written to Secretary of State Andrew Lansley seeking his personal assurance that all appropriate measures are and will be taken to secure capacity within the public health system – particularly as the period of transition to the new system has been extended. In his reply, Secretary of State refers to the development of a workforce strategy which is due for publication in the autumn. However, this does not address the current, immediate problem of the continued loss of public health skills. These letters can be read at www.fph.org.uk

17. FPH welcomes the retention of the deaneries and the continuation of specialist public health training through the current mechanisms of the deaneries. However, of key concern is what will happen to public health specialty registrars who are about to or have recently completed their training . Currently, there remains a recruitment freeze within the NHS, including public health posts. This presents the real danger that highly skilled, keen and committed individuals will be lost from the system – as well as the investment in training them. The successful implementation of the new system will depend heavily on the skills and enthusiasm of newly qualified staff, replacing those who are retiring early or moving to other careers. In this temporary period of job stagnation, transitional arrangements and funding are required urgently to provide an employment ‘bridge’ between the end of the normal training period and appointment to a permanent post to avoid the loss of vital public health skills.

18. Whilst FPH welcomes the proposed retention of the deaneries and the continuation of specialist public health training through this current mechanism, until Health Education England is fully established, levels of training funding to support the highly successful public health specialty registrar recruitment and training programme must continue.

Public health leadership

19. Government will be publishing "non-legislative proposals on how to ensure that public health professionals, in partnership with NHS commissioners, play a key role in providing leadership to drive improvements in quality and patient outcomes and to reduce health inequalities." FPH welcomes this. We believe that public health expertise should be embedded in every aspect of the new public health, NHS and commissioning structures, and that there should be certain requirements of the DPH.

20. Central to this will be a strong, independent, influential DPH, supported by a skilled public health workforce. The DPH will be the strategic leader for public health in their area, providing – through their annual report – independent analysis of the health needs of their local population and, equally important, a critique of how well those needs are being met and what more is required. The original Bill stated that the DPH should produce an annual report on the health of their population but there is no explicit duty for the report to also describe the population’s health needs, and the extent to which these are being met. This remains unchanged and should be rectified within the new Bill.

21. The DPH must also be positioned with influence and authority in the local authority, able to influence all areas of the authority’s work as a member of the authority’s most senior executive committee, with direct accountability to its chief executive and direct access to its cabinet and councillors.

Strengthening local commissioning structures

22. FPH, and other public health and health organisations, have called for the strengthening of the role of health and wellbeing boards (HWBBs) to provide challenge and sign-off to local commissioning plans, ensuring that they are aligned to the joint strategic needs assessment, local health and wellbeing strategies, and address the actual health needs of their communities.

23. FPH welcomes the commitment from the Government to strengthening the role of HWBBs – particularly in providing scrutiny and challenge to local commissioning plans; though we are disappointed that they will not be given the power of veto, only the power to refer back plans for further amendment and development.

24. The Government has decided, in response to the recommendations of the Future Forum (acting on concerns raised with regards to the need for multi-professional input into the commissioning process – something which FPH has consistently highlighted with regards to the need for specialist public health input), to strengthen local clinical networks and create clinical senates – to promote a more integrated approach to health and care provision. Public health representation on these networks and senates is vital to supporting the development and delivery of a seamless and integrated system, and we welcome the explicit reference to the involvement of public health specialists in clinical senates to support this.

25. The creation of clinical senates, and the strengthening of clinical networks, adds another dimension to the development and provision of health services, locally and nationally, in addition to NHS and foundation trusts, NHS Commissioning Board, PHE, Monitor and the Care Quality Commission. All of these organisations must work together to deliver a coherent, efficient and patient centred health service. A clear vision for how these will work together in practice, setting out accountabilities and responsibilities will be required.

26. FPH also welcomes the explicit reference to the need for "commissioners...to work with public health experts, and in line with public health guidance". However, we are concerned that the Government has not specified that there should be a public health specialist in the constitution of the clinical commissioning consortia governing body. Further detail is required on how this will work in routine commissioning practice. The Future Forum also recommended that the governing body of each commissioning group should also have multidisciplinary representation on it to ensure that commissioning decisions were fully informed and appropriate for their local population. Public health and health organisations have strongly recommended this body should include specialist public health advice. FPH was therefore disappointed that, whilst the Government explicitly stated that the governing body should contain a nurse and a doctor, there would be no duty on these bodies to have public health specialist representation.

27. Commissioning consortia need to understand fully the principles of population health and apply these across all the areas of health needs assessment, assessment of evidence of clinical effectiveness, understanding of ‘best buys’ for health gain, and to influence priority setting, and service monitoring, They also need to understand the preventive and protective public health services that they must provide support to or work in partnership with. These competencies are those of public health specialists and these capabilities must be enshrined in the governing bodies of clinical commissioning consortia.

Strengthening national commissioning structures

28. The Government has published its vision for the new NHS Commissioning Board, Developing the NHS Commissioning Board. In its response to the Future Forum recommendation, government committed to strengthening the involvement of a wide range of multidisciplinary professions in the commissioning of local health services – as we describe above. However, FPH is extremely disappointed that practically no mention of the importance of public health in commissioning is made in the proposals for the structure and function of the NHS Commissioning Board. The national arrangements do not therefore reflect requirements at the local level.

29. The third domain of public health – health services [1] – provides vital input into the commissioning of health services for populations. Public health specialists working in this field provide critical expertise, skills and knowledge on the effective commissioning and delivery of health services for their local population. The failure to include any reference to, or explicit need for public health specialist expertise to be employed within the NHS Commissioning Board at strategic (or indeed at any) level is of great concern to FPH, particularly as the board will have responsibilities relating to emergency planning, and that it may deliver "preventative and public health services" and commission "services of behalf of PHE" (Developing the NHS Commissioning Board, 2011). This omission demonstrates that there is still a significant lack of understanding of the importance of health service public health in the development, delivery and evaluation of NHS services. This omission should be urgently addressed to ensure specialist public health input on the national commissioning board for the NHS.

Timescale for transition

30. In its response, government recognised the concern over the pace of change and has set out plans for an extended transition period. It states that there will be "no two tier system". However, the proposal is that all GP practices will either be operating fully as clinical commissioning consortia, or in shadow form with commissioning for local services undertaken by the local hub of the NHS Commissioning Board – if it is up and running in time. The NHS Commissioning Board itself will not be fully operational until 2013 (though will undertake duties from 2012). Some areas are already undertaking commissioning and establishing health and wellbeing boards. It is important – for the health and wellbeing of the public – that differences in readiness for the system do

not result in disruption to the provision, access and continued care of the public.

Information, intelligence and research

31. Innovative public health practice that delivers real outcomes is based on sound evidence, information and intelligence, and research. FPH welcomes the commitment from the Government to strengthen these – including through an explicit duty to be placed on the Secretary of State to promote research, and it is important that the research functions of organisations such as the Health Protection Agency, are strengthened following their move into PHE.

32. FPH has highlighted the importance of the work carried out by public health observatories (PHOs) in relation to research, information and intelligence gathering, analysis and interpretation. FPH welcomes the recognition by government of this important role played by PHOs and we urge that England’s world-renowned system of surveillance is built on and strengthened in the new arrangements.

July 2011


[1] Health service public health is the area of public health which specifically relates to the planning, efficiency, audit and evaluation of health services. Public health specialists working in this field provide critical expertise, skills and knowledge on the effective commissioning and delivery of health services for their local population. They have the specialist training required to interpret the huge amounts of information and data received on their local population, their health needs and the various services provided for them. Their understanding of the geography of health needs can be utilised to direct the planning and commissioning (and, where appropriate, decommissioning) of services to meet those needs. Their management training and experience enables them to inspire, lead and deliver change in systems and organisations.

Prepared 19th July 2011