Conclusions and recommendations |
The Secretary of State for Health
1. We welcome the Government's intention to give greater prominence and priority to public health policy, whilst also emphasizing that "public health is everybody's business". We also welcome the new emphasis on the public health role of the Secretary of State for Health and the embodiment of this in new statutory duties in relation to health protection and statutory powers in relation to health improvement.
2. We do not understand why the Secretary of State's new statutory duty to reduce health inequalities under the Bill appears to apply only to the exercise of his functions in relation to the health service. We recommend that the Bill be amended to make it clear that the Secretary of State's duty to reduce health inequalities applies in the exercise of all his functions, including those applying to public health.
3. The creation of the Cabinet Sub-Committee on Public Health, chaired by the Secretary of State for Health, is a significant step forward in developing a much-needed cross-departmental approach to public health. We recommend that its remit should be defined to include consideration and publication of evidence-based health impact assessments prepared by each department of state on policies within its sphere of responsibility.
The Chief Medical Officer
4. We welcome the continuing role of the Chief Medical Officer (as the Government's principal medical advisor) in respect of public health, particularly the production of an independent annual report on the nation's health. However, we have concerns about the devolution of the Chief Medical Officer's broader duties relating to healthcare to the NHS Medical Director. The NHS Medical Director is a management role within the NHS; the role of the Chief Medical Officer has traditionally been to provide a professional voice on healthcare issues which is independent of NHS management; the Committee regards this as important function which is not recognized in the new arrangements.
Public Health England
5. The Government's case for combining within Public Health England a range of public health functions currently carried out by several organisations appears to rest on the perceived need to streamline a system that is currently fragmented. While acknowledging "considerable strengths" in the current system, the Government argues that it can still be made to work better. The Committee does not disagree with this view but sees the main case for change in the need for an independent voice for public health at the heart of government.
6. Public Health England must be - and, just as importantly, must be perceived as being - independent of the Government. Only in this way will it maintain the reputation for independence and evidence-based expertise, as well as the important trading activities, of the Health Protection Agency and some of the other bodies which Public Health England will succeed. We, therefore, welcome the Government's decision that Public Health England will not, as originally planned, be constituted as an integral part of the Department of Health.
7. It is important that the Government ensures that the arrangements for the new body provide it with sufficient guarantee of its independence. The Committee believes that the principle that Public Health England must be visibly and operationally independent of Ministers is more important than the precise bureaucratic formulation.
8. We are concerned at the lack of clear plans for Public Health England to be established at the regional level. The idea of "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 does not seem to us adequate. The Committee believes, in particular in view of the sensitivity of its health protection responsibilities, Public Health England needs a clear structure of regional accountability, along the lines currently provided by the regional structure of the Health Protection Agency.
Local government and Directors of Public Health
9. We welcome the new public health role planned for local authorities, leading in health improvement, and the emphasis that this places on tackling the wider determinants of health. We also welcome the new role envisaged for Directors of Public Health, as public health leaders in local communities, located within local authorities. However, several concerns have been raised with us about the details of implementation.
10. 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. We recommend that the Health and Social Care Bill be amended to rectify this.
11. Some witnesses have argued that local authorities need additional regulatory powers to allow them to achieve public health improvements in their area, including, for example the ability to extend the scope of the ban on smoking in enclosed public places or set a minimum price per unit for alcohol. The Committee recommends that these proposals be the subject of further public consultation.
12. We endorse the joint appointment of Directors of Public Health by local authorities and the Secretary of State (through Public Health England). We recommend that, in addition, 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 Directors of Public Health within the NHS.
13. The Government argues that the involvement of Public Health England in the appointment of Directors of Public Health will be sufficient to ensure that those appointed are appropriately qualified and trained. The Committee does not agree; it believes that there should be a statutory requirement for Directors of Public Health to be a member of an appropriate professional register.
14. The Committee believes that Directors of Public Health should be appointed at chief officer level, reporting directly to the council Chief Executive. The Government says that it "expects" Directors of Public Health will be appointed at this level, but there will be no sanctions that can be applied if they are not. We recommend that this be laid down as a statutory requirement in the Health and Social Care Bill.
15. We endorse the plan for Directors of Public Health to be, under statute, mandatory members of their local Health and Wellbeing Boards. We also welcome the proposed statutory obligation on Directors of Public Health to prepare an annual report, which the local authority must publish.
16. We are concerned that, in fulfilling their role, Directors of Public Health should be free to speak out, if necessary to criticize their local authority, without inhibition or restriction. We, therefore, recommend that any local authority wishing to terminate the appointment of its Director of Public Health must be required by statute to have the Secretary of State's approval.
17. We are concerned that too little attention is paid in the Government's plans to the role of lower-tier authorities. Given their areas of responsibility, in particular in the commissioning and provision of social housing, there should be a statutory requirement for upper-tier authorities to involve them in the work of the Health and Wellbeing Boards.
The Public Health Outcomes Framework
18. We welcome the Government's intention to measure progress in improving the health of the population by reference to outcomes rather than process targets; and we endorse the overall Outcomes Framework that has been outlined for public health.
19. There is a good case for having a single, integrated Outcomes Framework for public health, the NHS and adult social care. It is disappointing in this regard that the first NHS and Social Care Outcomes Frameworks have been finalised before the Public Health Outcomes Framework.
20. We recognise the need to minimise data collecting burdens. However, 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. This must include levels below those of local authorities, so that inequalities within authorities' areas are detected. Data should also, as far as possible, be capable of disaggregation regarding the full range of protected characteristics under the Equality Act 2010.
The overall public health budget
21. Healthy Lives, Healthy People stated that early estimates suggested that the current spend on services for which Public Health England will be responsible could be over £4 billion. More than 12 months later the Government has been unable to provide any detailed explanation as to how this figure was arrived at, or - more fundamentally - which services will in future be the responsibility of Public Health England. The Committee believes that this policy confusion is undermining confidence in the Government's public health strategy and making service planning impossible.
22. The Department of Health is currently compiling its definitive baseline public health expenditure, with the intention of publishing it later this year. When it does so, it must show in detail exactly how this figure has been arrived at. The Department must clarify whether it intends to make any adjustments to the baseline, relating to factors such as localised underspending and the impact of the reduction in management and administration costs occurring since the baseline year.
23. The Department of Health must also make clear how the actual level of funding for public health will relate to the historic baseline. We seek reassurance from the Department that, in setting the public health budget, it will take account of objective measures of need. This must apply in respect of both the national budget and allocations to local authorities.
24. Although the Department of Health states that, in the current reduction of NHS management and administration costs, frontline public health services are being protected, we have heard evidence to the contrary. Furthermore, the Department has failed to give a convincing account of its distinction between frontline and non-frontline spending in public health services. Unless it can do so, the suspicion will remain that it is an arbitrary distinction and that public health services are suffering, and will suffer, in consequence of the cuts that are being made.
Local public health budgets
25. 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%.
26. 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.
27. Although many witnesses welcomed the proposed ring-fencing of public health budgets transferred to local authorities, and the Committee understands the short-term attractions of this approach, it does not believe it represents a desirable long term development. Ring-fencing 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, which would allow the wider determinants of health to be more effectively addressed. Furthermore, even with ring-fencing, there is a risk of local authorities "gaming" the system and effectively raiding their public health allocations by "redesignating" as public health spending services that they are already providing from other budgets.
28. The Committee therefore proposes that the ring-fenced public health budget should operate for no more than three years. During that period it should be a statutory duty of Directors of Public Health to certify that the ring-fenced budget is used appropriately for public health purposes.
Public health evidence and intelligence
29. We welcome the Government's public commitment to evidence and intelligence as fundamental elements of the public health system. The Government's plans for Public Health England do have the potential to improve the public health information and intelligence function, by integrating and streamlining the work currently done by several bodies. We look forward to the results of the Department's Working Group on Information and Intelligence for Public Health in this regard.
30. The work of the Public Health Observatories 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 Public Health Observatories as a matter of urgency to ensure that this important resource is not lost before Public Health England is established.
31. We welcome the decision to create a new School for Public Health Research (within the National Institute for Health Research) and a Policy Research Unit on Behaviour and Health. We also welcome the Government's indication that the National Institute for Health and Clinical Excellence will continue to have a function in respect of evaluating the effectiveness and cost effectiveness of public health interventions.
32. Against that background the Committee was surprised to learn that the Institute's Public Health Interventions Advisory Committee has yet to meet this year, having previously met on a monthly basis. The Committee believes that Ministers should make clear as soon as possible exactly what role the Institute will play in future in respect of public health and how that role will be fulfilled.
Public health and NHS commissioning
33. Public health expertise is an indispensable part of commissioning NHS services. With the NHS facing major financial challenges, these functions are more important than ever. Yet Healthy Lives, Healthy People was widely seen as downgrading the role of public health in the commissioning of healthcare services. In its response to the Future Forum and in the consultation response the Government outlines changes to its plans intended to provide reassurance on this count, but we do not believe these are enough.
34. In its earlier report on commissioning the Committee recommended that the local Director of Public Health should be a member of the Board of each local commissioning body (now Clinical Commissioning Group). This remains our view.
35. The Committee also believes there should be a qualified public health professional on the NHS National Commissioning Board, and that the Commissioning Board should routinely take advice from qualified public health professionals when commissioning decisions are being taken.
Commissioning public health services
36. There is a danger that the involvement of local authorities, Public Health England and the NHS Commissioning Board in various facets of public health commissioning will produce a lack of coordination and cohesion in public health services. This danger is compounded by the definition of the mandated services which will be the responsibility of local government which, for example in sexual health services and child health services, creates a dysfunctional division between services which need to be coordinated. The Committee recommends that these distinctions be reviewed.
Emergency preparedness, response and resilience
37. 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 Government's decision to delay the implementation of its new arrangements for health protection until April 2013, lessening the potentially disruptive impact on preparations surrounding the 2012 Olympics and allowing further transition time.
38. We further welcome the clarification given in Healthy Lives, Healthy People: Update and way forward about the role that Directors of Public Health will play in emergency preparedness, response and resilience. The Government must specify which bodies will be designated as Category 1 responders under the Civil Contingencies Act 2004.
39. Public Health England will need a clear leadership and coordination role when public health emergencies cross local boundaries - which they will often do.
40. 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.
Regulation of public health professionals
41. There is widespread support for the recommendation in Dr Gabriel Scally's report that non-medically qualified public health specialists should be subject to statutory 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 this proposal.
The future of the public health workforce
42. The uncertainty caused by the transition to the new public health system is inevitably having an unsettling effect on the workforce, which is undermining morale and causing people with valuable skills to leave the profession. The structures will rely for their effectiveness on the availability of motivated and committed professional staff; it is therefore important that uncertainties around staffing issues are resolved as quickly as possible.
43. It is also important that the public health specialty is fully integrated into its forthcoming proposals for healthcare workforce planning, education and training.
44. Finally, we attach importance to the future role in the workforce of public health academics, particularly in their role in the Public Health Observatories. The importance of academia as a career option within public health should not be ignored.
The national policy dimension
45. We welcome the Government's acceptance of the Marmot Review principles of "proportionate universalism" and the "life course approach". However, we are unclear why the Government only endorsed five of the six policy objectives outlined by Marmot. Ministers have recognized the importance of the social determinants of health, and committed themselves to address health inequalities, so it is not obvious why Healthy Lives, Healthy People did not explicitly endorse the importance to public health of securing a healthy standard of living for all.
46. We regard the idea of the "ladder of intervention" as no more than a restatement of a principle that is fundamental to a free society.
47. Against this background we do 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. Partnership with commercial organisations has a place in health improvement. However, those with a financial interest must not be allowed to set the agenda for health improvement. The Government cannot avoid its responsibility for constantly reassessing the effectiveness of its policy in delivering its public health objectives.