The Government plans major changes to the public health system in England. These will affect all three domains of public health: health protection (addressing environmental threats to population health); health improvement (tackling health inequalities and lifestyle issues impacting on health and wellbeing); and healthcare public health (applying public health expertise to the provision of healthcare services).
Although the Coalition Government has undertaken to increase NHS spending in real terms, increasing demand for healthcare and slower growth in resources means that the NHS faces an unprecedented financial challenge. An active public health policy represents an opportunity to address this situation by easing the pressures created by rising demand.
Under the Government's planned public health reforms, the Secretary of State for Health will, for the first time, be under an explicit statutory duty to take appropriate steps to protect the public from dangers to health. We welcome this, but recommend that the Secretary of State should be under a duty to reduce inequalities in relation to public health, as he will be in respect of healthcare under the Health and Social Care Bill.
A Cabinet Sub-Committee on Public Health has been created. We welcome this too, but recommend that it should have a clear remit to scrutinise the public health impact of policies across government.
The Chief Medical Officer (CMO) will become the "professional head of the public health profession", leaving the NHS Medical Director to provide professional leadership in respect of providing healthcare. We recommend, however, that the CMO should perform both these roles.
A new dedicated public health service, Public Health England (PHE), will become operative from April 2013 as an Executive Agency of the Department of Health (DH), bringing together hitherto disparate public health functions into one national body. Some would prefer PHE to be constituted as a Special Health Authority. The Committee believes that the principle that PHE must be visibly and operationally independent of Ministers is more important than the precise bureaucratic formulation.
The Government has indicated that PHE will have "sub-national hubs", in some (as yet undefined) alignment with the sub-national structures of the NHS Commissioning Board and the Department for Communities and Local Government. This does not seem to us adequate. The Committee believes that PHE needs a clear structure of regional accountability, along the lines currently provided by the regional structure of the Health Protection Agency.
Major new responsibilities for public health will also be assumed by local authorities, relating to all three domains of public health. The Government argues that local variations in public health call for local solutions; and that local government is ideally suited to address the wider determinants of health, given its existing role in providing a broad range of services that impact on those wider determinants. We broadly welcome the new public health role for local authorities, but take issue with some aspects of the Government's plans.
We find that the lack of a statutory duty on local authorities to address health inequalities in discharging their public health functions is a serious omission in the Government's plans.
All Directors of Public Health (DsPH) will by law be jointly appointed by local authorities and the Secretary of State (with this function being exercised through PHE), and located within, and employed by, local authorities. We recommend that these appointments should be subject to a statutory appointments process, involving an Advisory Appointments Committee, and accredited by the Faculty of Public Health, as is currently the case in respect of DsPH within the NHS.
The Committee believes it should be a statutory requirement that DsPH be appointed at chief officer level, reporting directly to the council Chief Executive. Also, any local authority wishing to terminate the appointment of its DPH must be required by statute to have the Secretary of State's approval.
Councils will have a "convening role" in respect of public health, NHS and social care, as well as other council services and wider public sector responsibilities. Central to this role will be Health and Wellbeing Boards (HWBs) and the Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies that will be formulated through them by local authorities and Clinical Commissioning Groups (CCGs). We recommend there should be a statutory requirement for upper-tier authorities to involve lower-tier authorities in the work of the HWBs.
Instead of the top-down frameworks previously used to drive targets and performance management, progress in public health will be measured through the Public Health Outcomes Framework. We welcome this but are disappointed that the first NHS and Social Care Outcomes Frameworks have been finalised before the Public Health Outcomes Framework. We recommend that outcomes data must be sufficiently localised and detailed to reflect accurately trends and patterns in the health of the public. Datasets must be of an adequate size to be able reliably to detect relevant characteristics of populations at the appropriate level, including at sub-local authority level. Data should also, as far as possible, be capable of disaggregation regarding the full range of protected characteristics under the Equality Act 2010.
The Government has suggested that the current spend on public health services could be over £4 billion, but it has not explained how this figure was arrived at. We believe that this policy confusion is undermining confidence in the Government's public health strategy and making service planning impossible.
The DH states that 2009-10 will be the historic baseline for future public health allocations. The Department must make clear how the actual level of funding will relate to this baseline. We seek reassurance that, in setting the public health budget both nationally and locally, the DH will take account of objective measures of need.
The DH states that, in the current reduction of NHS management and administration costs, frontline public health services are being protected, but we have heard evidence to the contrary. The Department has also failed to give a convincing account of its distinction between frontline and non-frontline spending in public health services.
Two parts of the ring-fenced PHE grant to local authorities (the recurring fixed "baseline allocation" for health improvement; and funding for mandatory services) will be allocated according to a needs-based formula. We note that the DH has asked the Advisory Committee on Resource Allocation to support the development of this. We are concerned by the government's decision to reduce the weighting for health inequalities in Primary Care Trust allocations for 2011-12 from 15% to 10%, which seems likely to impact on the future allocations formula.
The third part of the grant to local authorities will be the proposed "Health Premium". Authorities will only receive this additional funding for health improvement (over and above their fixed "baseline allocation") if they make progress in improving the health of their local population. We are concerned about the proposed introduction of the Health Premium. We believe there is a significant risk that, by targeting resources away from the areas with the most significant continuing problems, it will undermine their ability to intervene effectively and thereby further widen health inequalities.
Ring-fencing allocations risks encouraging local authorities to see only spending from the ring-fenced budget as relevant to public health and runs counter to a "place-based" approach. Even with ring-fencing, there is a risk of local authorities "gaming" the system and effectively raiding their public health allocations by "redesignating" services. The Committee therefore proposes that the ring-fenced public health budget should operate for no more than three years.
We welcome the Government's public commitment to evidence and intelligence as fundamental elements of the public health system. The Government's plans for PHE do have the potential to improve the public health information and intelligence function, by integrating and streamlining the work currently done by several bodies. However, we have concerns about some aspects of the DH's approach.
The work of the Public Health Observatories (PHOs) is an extremely valuable part of the public health system. While the Government has promised to continue the work of Observatories, there is a great deal of uncertainty, especially following the substantial cuts to their funding that have been made in the current financial year. We are concerned to hear that three of the Observatories, in London, the North East and the North West, face particular risk of closure. We recommend that Ministers clarify their plans for individual PHOs as a matter of urgency to ensure that this important resource is not lost before PHE is established.
We welcome the intended continuing role of the National Institute for Health and Clinical Excellence (NICE) in evaluating the effectiveness and cost effectiveness of public health interventions. However, the Committee was surprised to learn that NICE's Public Health Interventions Advisory Committee has yet to meet this year, having previously met on a monthly basis. Ministers should make clear exactly what role NICE will play in future in respect of public health and how that role will be fulfilled.
Healthcare public health is a core part of the public health service. Its role is to bring public health skills and knowledge to bear on the commissioning of healthcare services, helping ensure their quality, safety, efficacy, effectiveness, value for money and accessibility. However, the Government's initial proposals were widely seen as downgrading the role of public health in the commissioning of healthcare services. It has now been clarified that DsPH and their teams will provide public health expertise, advice and analysis to CCGs, HWBs and the NHS Commissioning Board; and this will be one of the mandated public health services that local authorities must commission or provide. However, this is not enough. The local DPH should be a member of the Board of each CCG. There should be a qualified public health professional on the NHS Commissioning Board; and the Board should routinely take advice from qualified public health professionals when commissioning decisions are being taken.
PHE will secure the provision of public health services: through local authorities; through the Commissioning Board; or by commissioning or providing services itself. We see a danger that this will produce a lack of coordination and cohesion in public health services, compounded by the definition of the mandated services which will be the responsibility of local government. The Committee recommends that these distinctions be reviewed.
The Government's plans will make significant changes to arrangements for dealing with public health emergencies, such as major disease outbreaks, at local, regional and national levels. We welcome the updated and enhanced powers that the Bill gives to the Secretary of State in the event of an emergency. We also welcome the clarification given about the role that DsPH will play locally in emergency preparedness, response and resilience; at the same time, PHE will need a clear leadership and coordination role when public health emergencies cross local boundaries. There is an important need for "surge capacity" at the supra-local level in the event of an emergency; the Committee recommends that PHE take responsibility for ensuring that this capacity exists through coordination of local authority structures.
In his report on the arrangements for regulating public health professionals, Dr Gabriel Scally recommended that there should be statutory regulation of the profession, with the Health Professions Council regulating public health specialists as an additional profession, to accommodate specialists who are not members of a regulated healthcare profession. The Government, however, was sceptical, stating that its preferred approach was to ensure effective and independently-assured voluntary regulation. In view of the rising proportion of public health specialists that do not have a medical or dental background, the Committee recommends that the Government review its opposition to Dr Scally's proposal.
The Government has promised that a detailed Public Health Workforce Strategy will be developed by autumn 2011 to support effective transition to the new system. However, uncertainty has inevitably been created by the transition to new structures; this is undermining morale and causing people with valuable skills to leave the profession. Uncertainty around staffing issues must be resolved as quickly as possible. It is also important that the public health specialty is fully integrated into the Government's forthcoming proposals for healthcare workforce planning, education and training.
We welcome the Government's acceptance of the key principles of the Marmot Review on health inequalities. However, we are unclear why the Government only endorsed five of the six policy objectives outlined by Marmot, omitting that of securing a healthy standard of living for all.
As regards the national policy dimension of health improvement, the Government is taking an approach that it says marks a break with the "nannying" of the past. Drawing on the concepts of the "ladder of intervention" and "nudging", it says that it will aim to make voluntary approaches work before resorting to more intrusive, regulatory measures. A key vehicle for this "escalator" approach is the Public Health Responsibility Deal, based on voluntary agreements with business and other partners. The Committee does not oppose the exploration of innovative techniques such as "nudging", where it can be shown, following proper evaluation, to be an effective way of delivering policy objectives. The Committee were, however, unconvinced that the new Responsibility Deal will be effective in resolving issues such as obesity and alcohol abuse and expect the Department of Health to set out clearly how progress will be monitored and tougher regulation applied if necessary. Those with a financial interest must not be allowed to set the agenda for health improvement.