HC 1048-III Health CommitteeWritten evidence from the NHS Alliance (PH 11)

Executive Summary

The Alliance welcomes the creation of Public Health England and the transfer of Directors of Public Health (DsPH) and health improvement functions to local authorities but we have a number of concerns about the overall coordination and delivery of public health functions at both national and local level.

We believe DsPH need to put more focus on the skills of persuasion, public engagement, facilitation and leadership and less on the analysis of problems. The responsibility for providing information and benchmarking data to inform local commissioning should remain with sub-national Public Health Observatories that should be co-located with outposts of the National Commissioning Board.

DsPH need to have a continuing role in commissioning NHS services and they should sit on GP Consortium Boards. In time all GP Consortia should have a GP with a specialist interest in public health who works closely with the DsPH.

There are too many outcome measures and too much focus on separate outcomes for public health, social care and the NHS. There should be more work on developing shared outcomes for older people, long term conditions and mental health. This would help to drive effective partnership working and pooling of budgets to address local priorities. Health and Wellbeing Boards should rank outcomes in priority order depending on local needs identified in the Joint Strategic Needs Assessment (JSNA) and the local strategy should focus on addressing the highest priorities.

There should be more focus on public health as everyone’s responsibility and less on public health as the responsibility of a professional workforce. This will require new ways of working if the wider health and social care workforce is to see every contact as a public health opportunity.

Rather than look for new resources public health needs to get better at identifying and developing local assets to support the delivery of public health outcomes. This should include a systematic approach to providing support for voluntary and community organisations that promote participation in leisure and voluntary activities and that develop and maintain supportive social networks and nurturing relationships for vulnerable individuals (NICE Guidance on Behaviour Change).

There should be more investment in recruiting, training and supporting local people to take on the role of motivating and championing change within their communities. It is not clear from the current proposals how the training and support of such individuals is going to be funded or who will provide it. We believe this needs a systematic approach with Health and Wellbeing Boards working closely with their local voluntary and community sector who have the reach into and trust of marginalised groups that is not always the case with the statutory sector. Investing in this approach is an important way of addressing inequalities.

1. We welcome the creation of Public Health England within the Department of Health and more importantly welcome the formation of a cross government cabinet sub-committee on public health that hopefully will ensure an integrated approach across all government departments.

2. There is merit in the abolition of the Health Protection Agency and the National Treatment Agency for Substance Misuse and of making the functions of these organisations part of the remit of Public Health England. These functions require national leadership and expertise, and they also require local delivery and engagement. We also believe however that there is a case to be made for a sub-national framework for some of these functions. This need not necessarily be around geographical regions but could be around groupings of common interest. There is for instance an effective core cities network for the eight largest cities outside London and similarly there could be a rural areas network and a network for smaller towns. These areas have different needs and issues and this sort of approach could lead to better benchmarking of like with like.

3. The Secretary of State has too often functioned as the Chair of an organisation responsible for health care delivery rather than the Chair of an organisation responsible for the nation’s health. Given the challenges of demographic change, long term conditions and behaviourally determined problems such as obesity and alcohol, we welcome the shift to a much greater focus on public health. There is a lot of exhortation to partnership working and shared budgets at local level, the Secretary of State needs to take a leadership role in driving partnership working and shared budgets for public health, both across government departments through the cross government cabinet sub-committee, and across the silos within the Department of Health.

4. The future role of local government is crucial for the success of the proposed new arrangements. We broadly welcome the location of Directors of Public Health (DsPH) in local authorities but we have some concern about the breadth of the role and about DsPH being servants of two masters – Public Health England and their local authority. We believe that the balance of this relationship needs to be in favour of the local authority and that this needs to be made clear in any job description.

5. Getting the right person in post will be critical and as well as recommending that a representative of local GP Consortia should sit on the interview panel for these posts, we also hope that there will be an emphasis on the soft skills of persuasion, public engagement, facilitation and leadership as well as the more technical skills of health protection, data analysis, evidence and evaluation. We would also hope that the Public Health England representative on these panels will be there to ensure that candidates meet the appropriate professional standards, leaving the final choice of candidates to local panel members.

6. Statutory Health and Wellbeing Boards are an essential component of the proposed changes. Their role should be to develop the overall strategy for the local health and social care economy through the Joint Strategic Needs Assessment and the Joint Health and Wellbeing Strategies. The Board will need to build relationships with local providers and local commissioners and will need to have excellent communication systems across the local health and social care economy and with patients and the wider public.

7. The Board with the Director of Public Health will need to produce a local action plan with clear priorities that outlines how the joint strategy is going to be delivered and how it will be monitored against agreed outcomes.

8. One way of ensuring that local providers sign up to the local Health and Wellbeing Strategy and the action plan would be for Health and Wellbeing Boards to establish an arms length local Provider Forum that would provide a vehicle to ensure that local providers are engaged in the cost effective re-design of a locally integrated and collaborative approach to service delivery that meets local strategic objectives and the needs of the local community. DsPH would then have a key role in providing data, information and evidence to bridge between the Health and Wellbeing Board and the Provider Forum. Membership of the Provider Forum should include the voluntary and community sector as well as statutory providers, private sector and not-for-profit social enterprises.

9. The role of HealthWatch on Boards is problematic. The Alliance believes there are three separate elements of public and patient involvement: wider engagement and participation of the public in how NHS money is spent and what NHS services cost; scrutiny and quality assessment of existing services; and advocacy for marginalised and disadvantaged groups. We are not convinced that all of these can be done by a single body and we are also not convinced that HealthWatch should be a core member of the health and wellbeing board. We believe that the core function of HealthWatch should be local overview and scrutiny and this is reinforced by the proposal that Health Watch should be led by a statutory committee within the Care Quality Commission. This will place Health Watch in the position of having to scrutinise itself for decisions made collectively by the Health and Wellbeing board.

10. The proposed arrangements for public health involvement in commissioning NHS services are very weak and there is no direct responsibility other than the statement that DsPH will work in partnership with other local government colleagues, and partners such as GP consortia, the wider NHS, early years services, schools, business, voluntary organisations and the police, to achieve better public health outcomes for the whole of their local population. The Alliance believes that DsPH should be represented on GP Consortia and that they should be using data to work with GP Consortia in order to develop transparent and accessible ways of demonstrating how NHS funds are spent, about how savings can be made and about how local communities can be supported in taking more responsibility for their own health.

11. An additional way of strengthening the link between public health and consortia would be for the Royal College of GPs to work with the Faculty of Public Health to produce a training programme for GPs with a specialist interest in public health. Over time it would then be possible to require that all GP consortia have a GP with a specialist interest in public health who works directly with the DPH.

12. A further concern about the proposed new arrangements and in particular the proposals for the public health outcomes framework is that; firstly there are a very large number of outcomes and; secondly DsPH and their local authorities will inevitably focus on health improvement outcomes and primary prevention. We are in favour of outcome measures but we believe that the local strategy will need to set priorities in response to local needs and we would also prefer a model in which there is a small number of required outcomes that are shared across the local health and social care economy. These outcomes should focus on older people, long term conditions and mental health. These are the issues that make the greatest demands on health and social care and we believe that shared outcomes in these areas will encourage local partnership working between public health, adult social care and GP Consortia so that they learn how to work together effectively.

13. There should still be separate outcome measures for Public Health, Adult Social Care and the NHS but these should also be prioritised in response to local needs. During the set-up and development phase Health and Wellbeing Boards should be encouraged to focus on shared outcomes in order to encourage the development of effective partnership working.

14. The proposed arrangements for commissioning public health services follow a number of different strands with commissioning routes through Public Health England, local authorities and the national commissioning board and GP consortia. While the Alliance accepts that national screening and immunisation programmes will need to be commissioned at national level, we would prefer to see a more joined up approach to commissioning public health at local level. At the end of the day poor uptake of national programmes is usually do to local circumstances and can only be addressed at local level.

15. Similarly when Public Health England decides to fund national campaigns, the evidence suggests that these will have more impact if they are done in tandem with local campaigns which highlight where further local information and services which support the campaign can be accessed.

16. If public health commissioning is going to translate into effective local public health delivery there needs to be a much more systematic approach to public health delivery through the development of existing local assets that include all primary care providers and the local voluntary and community sector.

17. GPs, dentists, pharmacists, community nurses, health visitors, optometrists, and allied health professionals will need to ensure that every contact is a potential public health opportunity. In addition opportunities need to be created for primary care professionals to take on additional public health roles. These should include “healthy living pharmacies”, health checks, early intervention for alcohol problems, smoking cessation, falls prevention and opportunities for GPs to acquire expertise in public health as GPs with a specialist interest.

18. NICE Guidance on Behaviour Change recommends among other things that support should be provided to local organisations that promote participation in leisure and voluntary activities and that develop and maintain supportive social networks and nurturing relationships. There is increasing evidence that activities and supportive social networks are good for health, particularly the health of older people and for people with mental health problems. This is very much the role and remit of the voluntary and community sector. We need to move towards the social prescribing of activities that support and build sustainable social networks, particularly for isolated and vulnerable older people and for people with mental health problems.

19. Local health and social care economies need to find systematic ways of developing a range of quality assured social prescribing activities that include physical activity, healthy eating/cooking skills, befriending, welfare rights, arts and health and volunteering opportunities. This probably needs to be done through a single contract with a lead provider who has sub-contracts with a range of smaller local providers. We also need to find proportionate and robust ways of testing these models so that we can demonstrate that over time they save money rather than just ad to costs. Part of this model will also need to include the development of local peer support through health trainers or health champions who are recruited from and work within local communities. A project funded by the NHS North East Innovation Fund and done in collaboration with the national Diabetes Year of Care Project, local GP Consortia and a voluntary sector provider, HealthWORKS Newcastle has recently produced a guide to commissioning such activities to support self-care for long term conditionswww.diabetes.nhs.uk/year_of_care/commissioning/thanks_for_the_petunias__a_guide_to_developing_and_commissioning_nontraditional_providers/

20. Public Health Observatories should continue to have a role in the new NHS architecture. For each observatory, this should include one or more specialist areas together with a sub-national responsibility for providing information and comparative benchmarking data to support local commissioning. The North East Public Health Observatory currently has a national lead role in mental health and offender health as well as providing important regional information. The Alliance assumes that the National Commissioning Board will need to have sub-national outposts and it would make sense if the observatories and the Commissioning Board outposts were co-located.

21. The Alliance believes that a transparent outcomes based approach is the best way forward and we welcome the proposal to establish a range of national indicators under the five domains of: health protection and resilience; tackling the wider determinants of health; health improvement; prevention of ill health; and healthy life expectancy.

22. We do however have some concerns about the diagram on p14 of the Transparency in Outcomes document that shows only a very small central area of “shared local health and wellbeing issues for joint approaches” with much larger areas representing the individual responsibilities of Public Health, Adult Social Care and the NHS. We believe there should be a much greater focus on developing shared outcome measures for the local health and social care economy. Arguably the greatest threat to financially viable and sustainable public services is an ageing population and the projected increase in long term conditions. This needs to be a joint responsibility of all of the services and funding streams with pooled place-based budgets held by Health and Wellbeing Boards.

23. This will require work on the development of new outcome measures in order to track and benchmark progress. These measures should be framed around the themes of preparation for old age, active old age, vulnerable old age and dependent old age. What is being done about maintaining physical health and preventing the development of long term conditions in mid-life (local prevalence of Type 2 Diabetes), what is being done to promote active old age, including volunteering opportunities (number of volunteers over 65), how do we better identify and support vulnerable old age so that it does not become expensive dependency (criteria for and measurement of number of vulnerable older people) and how do we maintain and prevent progression of dependency (number of dependent older people living at home).

24. The added value of such an approach is that it will drive partnership working and prevent demarcation disputes between funding streams about who pays for what. A similar approach also needs to be taken to mental health with more shared outcome measures and pooled budgets for delivering mental health outcomes which is the other major area in which Public Health, Adult Social Care and the NHS need to work together.

25. Finally, in terms of the total number of indicators, we are not averse to a large national number of indicators which are collected centrally and which allow local areas to benchmark themselves against areas with similar demographic characteristics. We would however like the indicators to be seen as a menu from which local areas choose a limited number which have been identified as high priorities from their JSNA and their local health strategy. We believe that this will reflect the fact that different areas have different needs and that a focus on delivering a limited number is more likely to be successful. The only additional indicator that we would like to see is a measure of the willingness of the local system to pool separate budgets for joint activities. This is probably the most significant measure of effective partnership working.

26. Despite a ring-fenced budget, funding is still likely to be a problem. This can be addressed by setting clear local funding priorities and by ensuring that there is a public health contribution to reducing costs and demands for expensive NHS services.

27. The use of the health premium as an incentive to address inequalities is an over-simple approach to a complex problem and may have perverse consequences with areas being rewarded or penalised for getting better or worse as a result of changes in their population baseline or in local circumstances rather than as a result of anything the local area has or has not done.

28. There is a tension between public health as everyone’s responsibility and public health as the responsibility of a professional workforce. We endorse the need for a well regulated professional workforce but at the same time we believe there is a need to both re-examine the core skills of this workforce and to look at ways of extending public health skills to other professional groups and to the wider community through peer support and community health champion models.

29. The current professional competencies place too much focus on collecting and analysing data and trying to produce evidence for action and not enough focus on engaging front line staff, communities and local people and in persuading them to take action and to change the way we live. If public health rhetoric is to be turned into delivery of cost-effective outcomes there needs to be more emphasis on the softer skills of facilitative leadership, effective partnership and persuasion and this should be recognised in the competencies framework.

30. In terms of wider dissemination of public health skills, the potential of GPs with a specialist interest in public health has already been mentioned in paragraph 11. We also believe there is an increasingly important and cost-effective role for community health trainers and for volunteer community health champions. These models depend on recruiting, training and supporting local people to take on the role of motivating and championing change within their communities. It is not clear from the current proposals how the training and support of such individuals is going to be funded or who will provide it. We believe this needs a systematic approach with Health and Wellbeing Boards working closely with their local voluntary and community sector who have the reach into and trust of marginalised groups that is not always the case with the statutory sector.

31. Addressing inequalities in an economic recession is not easy. Investing in providing opportunities for people to acquire training and skills as volunteers and peer support workers (see 30 above) is one small way of addressing this. We welcome the focus on improving healthy life expectancy, rather than life expectancy and we also welcome the notion of proportionate universalism. Nationally more poor people live in non-disadvantaged areas than in disadvantaged areas and we need to invest in improving the gradient for inequalities rather than just focusing on the most disadvantaged individuals or areas.

June 2011

Prepared 28th November 2011