Written evidence from the Association
of Directors of Public Health (COM 47)
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.
The ADPH welcomes the opportunity to input to
the Health Select Committee Inquiry into Commissioning.
This submission follows consultation and involvement
with our members—Directors of Public Health—in England,
along with input from members in the other UK countries, who have
valuable experience of other structures and ways of working.
ADPH will also be submitting responses to the
NHS White Paper and related documents. We recognise that the NHS
White Paper and the structural changes it heralds in England raise
huge opportunities for public health, but with such changes there
are also risks. In this submission, we seek to highlight key issues
that we believe will need to be addressed to ensure real improvements
in commissioning, health care services and outcomes and the reduction
of health inequalities.
1. THE ROLE
OF PUBLIC
HEALTH IN
COMMISSIONING
Public Health oversight of and public health
input to commissioning at all levels will be essential to achieve
real improvements in population health outcomes and the reduction
of health inequalities.
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.
Also needed is the demonstration of excellence
in managed entry of new drugs, technologies and public health
interventions. We recommend the promotion of Health Impact Assessment
(HIA) and Health Equity audit as necessary components in commissioning
service change (capital or design) alongside equality and diversity
impact assessment.
Perhaps the greatest challenge to the new NHS
will be how to put prevention at the heart of commissioning. Given
that the new structure will put health care and prevention into
separate organisations with different outcome frameworks, geographical
boundaries, cultures and systems for accountability, there are
considerable risks.
The combined cost to the NHS of smoking, alcohol
and obesity has been put at £11 billion, roughly 10% of the
NHS budget, with half of that cost attributed to smoking alone.
Failing to engage primary care effectively in preventative medicine
will impose burdens to the public in terms of ill-health, consortia
in terms of a heavier work load and the NHS as a whole in terms
of unaffordable costs. Ensuring that the two new services (public
health and health care) work together effectively must be of the
highest priority. Current proposals for the NHS Outcomes Framework
should be reviewed to include specific public health indicators.
Consortia should be encouraged to adopt boundaries
which match or fit within existing local authority boundaries.
Consortia governance structures should include a dedicated place
for public health. Effective joint planning and integrated delivery
should be a requirement placed on both consortia and the new Public
Health Service.
Urgent consideration will need to be given as
to how best to structure and maintain clear lines of accountability,
communication and access between the Public Health Service and
both Public Health teams working within Local Authorities and
the GP consortia.
2. NATIONAL ISSUES
2.1 Public Health Service
We believe that the Public Health Service should
provide public health expertise and input to commissioning, including:
— evidence-base advice and support function
with input into GP consortia commissioning and service quality;
— strategic expertise and input into specialist
commissioning;
— public health expertise into the NHS
Commissioning Board to support its role in providing national
leadership in commissioning for quality improvement, commissioning
national and regional specialised services, and allocating NHS
resources; and
— public health input to prescribing and
medicines management.
The above being supported by its wider remit
which should necessarily include:
— information and intelligence functions—observatories;
cancer registries etc;
— screening and other QA programmes;
— scarce resources—such as dental
PH; infection control etc;
— Public Health input to regulatory organisations/functions;
— Public Health input to provider organisations/Trusts;
— Health Protection national functions;
emergency planning;
— Investment in the Public Health workforce
(specialist and practitioner)—both practice and development;
— Investment in the Public Health academic
function; and
— a remit to promote full understanding
by politicians (national and local) of the DPH role and all key
Public Health functions.
As highlighted above, urgent consideration will
need to be given as to how best to structure and maintain clear
lines of accountability, communication and access between the
Public Health Service and both Public Health teams working within
Local Authorities and the GP consortia.
2.2 NHS Commissioning Board
Public health expertise will be required by
the NHS Commissioning Board to support its role in:
— providing national leadership in commissioning
for quality improvement;
— commissioning national and regional specialised
services; and
— allocating NHS resources.
Commissioning of national and regional specialised
services: The NHS Commissioning Board must ensure that consortia
work in close collaboration with Directors of Public Health and
the Public Health Service and Local Authorities to ensure that
specialised services are delivered at the appropriate geographical
level. Where joint commissioning structures are established to
provide more effective and efficient services for large population
areas, the Commissioning Board should ensure that Directors of
Public Health are involved to ensure that population health gain
is maximised.
Ensuring effective local commissioning: The
Commissioning Board should ensure that local commissioning is
undertaken with due regard to public health and preventative medicine
and with the active involvement of Directors of Public Health.
Governance of GP consortia: Effective delivery
of public health outcomes is as important an issue as reporting
and audit. Consortia should demonstrate to the Commissioning Board
that they and their constituent practices have proper processes
in place to ensure that they are playing an active and evidence
based role in population health improvement and prevention of
illness.
Consortia should be expected to develop commissioning
plans which reflect population need as identified in the Joint
Strategic Needs Assessment. The National Commissioning Board should
use an assessment of the extent to which needs are addressed within
the performance assessment of Consortia.
The Commissioning Board should hold consortia
responsible for ensuring that GP practices discharge effectively
the preventative health aspects of primary care; and the Outcomes
Framework should incentivise these functions.
Commissioning outcomes framework: A commissioning
outcomes framework should include key public health indicators
including those for long term conditions and lifestyle factors
such as tobacco and alcohol.
3. LOCAL ISSUES
Locally, the Director of Public Health should
provide oversight and the Public Health team input to GP consortia
commissioning, supported by additional resources and expertise
held within the Public Health Service.
We believe that GP consortia should work closely
with Local Authorities and that local commissioning plans should
be subject to scrutiny and comment by the Health and Well-being
Board—and to greatest effect would also be signed off by
the Board.
Directors of Public Health will also commission
health improvement services through the proposed local ring-fenced
public health budgets.
3.1 GP consortia
To support effective commissioning decisions
that will bring real improvements in population health and a reduction
in health inequalities, GP consortia will require access to and
clear lines of communication with:
— Health and Well-being Boards;
— well-resourced and professional local
Public Health teams, including public health commissioning expertise,
that are co-located with the DPH, 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;
— cross-agency/sector needs assessments
(JSNA);
— Public Health information and intelligence
providing relevant and timely intelligence; and
— the national Public Health Service
for evidence-based advice to support commissioning and service
quality.
Effective commissioning: Whether a service is
commissioned and delivered nationally, regionally or locally is
a decision which should be based on the evidence of effectiveness.
Consortia should be encouraged to develop structures for stable
joint commissioning where these would best serve their population.
These will often include city-wide and regional commissioning.
These commissions should be made on a time-scale that will allow
stable service planning and delivery.
Ideally consortia boundaries should be contained
within one local authority—enabling a relationship with
one Local Authority Director of Public Health and public health
and social care teams.
In setting priorities and in measuring success,
commissioners require access to good, standardised data to describe
their populations and compare them with those around them. This
"benchmarking" is an important commissioning function.
Good benchmarking data and tools are emerging, available at PCT
and Local Authority levels. However, if consortia are not coterminous
with Local Authorities and the boundaries of consortia shift over
time as practices join or leave, then effective benchmarking becomes
less feasible.
Reducing inequalities in health: Health inequalities
will only be reduced with action on the wider determinants of
health. Many of these are affected through Local Authority based
services and commissioning (eg Planning, Housing etc). Tackling
the main social and behavioural drivers of health inequalities
is something that can only be done in collaboration with Directors
of Public Health within Local Authorities. Smoking, for example,
is the largest cause of health inequalities, accounting for half
the difference in life expectancy between richest and poorest
in society. Effective collaboration with the new Public Health
Service will be crucial in reducing inequalities and dislocation
between the services will be potentially disastrous. Robust structures
will be required to ensure that consortia are active and effective
partners in the planning and delivery of public health measures,
particularly those geared to reduce health inequalities.
3.2 The role of the Director of Public Health
in Commissioning
Directors of Public Health will be responsible
within their defined population for the delivery of:
— measurable health improvement;
— Health Protection including emergency
response;
— oversight of and support for health and
care service planning and commissioning; and
— reduction of heath inequalities.
To successfully deliver this they will require
the authority to have oversight and influence across: Local Authorities;
the NHS—including primary care; and other agencies and sectors,
to ensure a population approach across all the determinants of
health. It is essential to align the responsibilities, power and
authority of Directors of Public Health to achieve these outcomes.
The core purpose of the Director of Public Health
is to act as an independent advocate for the health of the population
and to provide leadership for its improvement and protection.
As such it should be a high-level statutory role bridging Local
Authority and NHS responsibilities for health and well-being for
a defined population. As the leader of the local Public Health
System, DsPH should ensure that better health outcomes are delivered
through the provision of authoritative influence across all the
Directorates within the Local Authority; the NHS; voluntary organisations
and the business and industry sector.
Directors of Public Health will also commission
health improvement services through the proposed local ring-fenced
public health budgets.
In support of their role, Directors of Public
Health (DPH) will need well-resourced and professional Public
Health teams, including public health commissioning expertise,
that are co-located with the DPH, 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.
3.3 Health and Well-being Boards
Local commissioning also relates to proposals
within the NHS White Paper for local democratic legitimacy in
health, and so below we highlight some issues relating to the
remit of Health and Well-being Boards:
— The remit of the Boards should explicitly
include the three public health domains of health improvement,
health protection, and health care service planning and commissioning.
— Scrutiny of local commissioning plans
should rest with Health and Well-being Boards—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 Well-being Board
for public health advice across the three public health domains
of health improvement, health protection, and health care service
planning and commissioning.
We believe it would be beneficial to establish
Boards early (in shadow form) to maximise early learning.
It is important that in two tier authorities
the existing health and well-being partnerships continue to work
together for the health and well-being of the local population.
We believe that District Authorities should have specific roles
and duties for the improvement and protection of health.
4. KEY AND
IMMEDIATE ISSUES
OF CONCERN
The process of transition itself carries risks,
and it will be important to recognise and mitigate those risks
to ensure the longer term success of the new commissioning arrangements.
The most serious and pressing concern is the
impact of current (and future) local financial savings and consequent
risks to public health capacity and capability to support effective
commissioning—as a depleted service will be unable to respond
effectively to public health priorities and support the new commissioning
arrangements.
ADPH has significant concerns that the loss
of local public health capacity and capability will seriously
risk the success of the reforms envisioned in Liberating the NHS.
This is an issue that needs to be recognised by government and
urgently addressed by PCTs, Local Authorities, SHAs and GP consortia
as they work together on transition.
October 2010
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