HC 1048-III Health CommitteeWritten evidence from Dr Bruce Laurence (PH 12)

These are personal views and do not represent those of any organisation to which I am affiliated.

Summary of Points: Dr Bruce Laurence, FFPH Acting DPH NHS Derbyshire, Writing in Personal Capacity.

1.Public health staff are being forced to undertake highly complex organisational change at a time when they should be focusing on core business. One way to minimise loss of time would be to ensure that the specialist public health workforce are employed in a single organisation and seconded to others as appropriate.

2.Public health training is threatened by this upheaval and needs protecting

3.The importance of second tier authorities has received little recognition in the policy documents so far.

4.The importance of the major role of PCTs in emergency planning and response and in major health protection programmes needs more consideration.

5.Public health funding is very complex and there are major risks for many important services as well as public health employees in trying to identify an appropriate budget. The health premium should not unduly skew organisational focus and a way of managing this is suggested.

6.The DPH needs to have sufficient power to act as a strong voice for the public’s health.

7.The Health and Wellbeing board should have clear and defined powers in relation to commissioning.

8.Consortia need to be resourced and encouraged to take a public health informed view of commissioning and in particular to impact on health inequalities.

Some comments on the proposed changes to public health in England. These are my personal views and not that of any organisation to which I am affiliated.

1. Impact of Organisational Change

1.1 During these times of financial hardship the need for a strong public health voice within local communities to ensure that services to deprived communities are protected is more important than ever. It is therefore the worst possible time to undertake a wholesale reorganisation of the public health function within the health sector and doubly so because the health sector itself is under such pressure both from its financial constraints and from its own fundamental restructuring. While there are some exciting opportunities associated with the move of health improvement functions to local authorities, which are in many ways a natural home for many public health functions it is a dangerous time to uproot public health from the NHS and thrust it into an entirely new arena. This is exacerbated because LAs are under extreme pressure themselves and in many cases also restructuring in response to these pressures.

1.2 It is well recognised that it has taken PCTs and predecessor organisations up to two years to find their feet after previous relatively modest reorganisations. This is far more fundamental and disorientating than anything that has gone before and it seems likely that, at a time when we should be rigorously focused on delivery of health outcomes and improving efficiency, we will be massively distracted for at least two but more likely up to three years.

1.3 As an acting DPH I have major concerns as to how I will be able to successfully engineer the transfer of a large team into any or all of one upper tier LA, eight second tier authorities, five GP consortia and Public Health England. Some members of that team already in some cases have joint appointments between the NHS and upper or second tier authorities. Since the GP consortia and PHE are themselves only in the earliest stages of existence and since the terms and conditions of staff transfer and the overall budget are all unknown any planning that I can do is hedged round with uncertainty. All this has to be done in a PCT that has just become a cluster with another PCT and is spinning off most of its staff to GP consortia while losing others to voluntary redundancy. It should be noted that there are a very great number of contracts that will need to be reviewed and possibly unpicked and remade when we understand where responsibilities lie and what budgets are available and that this work will have to be done at a time when the commissioners and other support staff with whom we have previously worked are largely aligning themselves to emerging GP consortia or in some cases, looking to exit the service.

1.4 I labour the point to show what a complex piece of change management will have to be undertaken because of an unprecedented organisational change that will not only have uncertain benefits, not having ever been piloted, but that all political parties specifically agreed would not happen in their election manifestos. As faithful public servants, I and my colleagues will endeavour to work within the policies laid down for us, but it is difficult to find anyone locally who thinks that the benefits are likely to outweigh the costs of this upheaval.

1.5 The county council is, however, very positive about the transfer, and the GP consortia also interested in ensuring a public health input to planning and this is the bright spot in an otherwise difficult picture.

1.6 Fragmentation of the public health workforce will weaken its ability to work in any of its specialist areas. One solution to this would be to keep all elements of the specialist workforce within a special health authority or executive agency. This would also get around the considerable problems associated with transferring NHS staff to LAs. This transfer is problematic for LAs who are themselves losing staff through redundancy and public health staff themselves are hugely fearful of what this might mean for their own conditions of employment and pensions. People are already so concerned that they are looking for and taking other jobs outside of the sector.

1.7 Part of what makes the ph workforce successful is the synergy between different parts of the agenda and this is also weakened when people work more narrowly in multiple organisations with their own particular interests. Through public health profession having its strong root and substantial critical mass in the NHS it has been able to work effectively in partnership with a wide range of other organisations. A fragmented workforce will be far less effective while a unified one may have a chance of maintaining essential functions into the future. This would still leave an exceptionally challenging task but would make it rather easier in the short term and bring benefits in the long term.

2. Public Health Training

2.1 There will potentially be severe consequences for public health training. The NHS has long understood and accepted its heavy responsibility for training all types of health staff, but consortia and local authorities will not necessarily see it as their responsibility to ensure the workforce of the future and trainers forced down narrower career pathways will struggle to provide a wide and balanced training experience for trainees. It may be argued that these agencies will appreciate the need to keep a flow of well trained professionals coming through the ranks, but in practice this long term aim will not feature highly on their long lists of pressing and urgent priorities. There needs to be clear guidance in order to protect this function and ideally strong deaneries should be maintained that can champion this at regional and local levels.

3. Two Tier Authorities

3.1 The second tier authorities are highly involved in public health work and there is very little in the policy documents that suggests that there is much understanding of this point. It is important not only that the ph budget is ringfenced but also that the DPH has sufficient power over its use that it can be channelled to whichever organisation is best able to use it whether that is upper or lower tier LA, NHS, voluntary agency etc. Clearly it is up to DsPH and colleagues to learn to swim more skilfully in the local political environment but there are special challenges for those working in two tier authorities.

4. Emergency Resilience and Response and Health Protection at Local Level

4.1 One area of personal interest is emergency planning. I have seen the importance of the PCT coordinating the local health service response to an emergency such as the flu pandemic and promoting the planning and exercising that ensures that such a response is fast and effective. I am fearful that there is nothing in current policy that gives any assurance that this essential local work will continue.

4.2 I have also observed how much work there is undertaken by ph staff in PCTs that ensures the quality of core health protection programmes such as immunisations and screening. There seems to be a belief that this can be managed entirely by a national commissioning body and those who deliver the service on the front line in practices or hospitals. PCT staff are those who ensure high levels of vaccination and screening uptake, look at uptake across different groups and performance by practice, ensure that changes in screening programmes are implemented locally, and respond to untoward incidents. All this requires a lot of hard work by people with a sufficiently local focus to know the players on the ground and the characteristics of local systems. Where exactly this local work is hosted should be left up to local discretion. Also on the subject of health protection, it is important that it is seen in an integrated way across a health community. I would suggest that each locality should have a local health protection board chaired by the DPH that brings together major local health protection stakeholders such as PHE, consortia and major providers of relevant services.

5. Health Premium and Public Health Funding

5.1 Health premium. This should not be so large that it devastates local services where there has been poor performance. It must also not skew local activities too much towards indicator activities. I suggest that it is based on quite a wide range of outcomes so that a particular problem with one outcome or other does not affect the premium too much. I also suggest that the actual indicators to be used are kept secret till the end of the year and till the data is in so that people don’t chase the indicators but are obliged to work across the whole spread of priority areas. I realise that this is rather a radical idea but time and again I see massive effort put into things that are more important because of their target value than their health value.

5.2 There is another problem around funding which is that ph work in PCTs and the NHS has developed over decades based on a very mixed funding model and with money for particular projects and sub-projects being put together and supplemented from a variety of recurrent and non recurrent pots coming down both via the NHS and other organisations and partnerships. Furthermore ph work is done in a vast array of providers in the NHS (primary and secondary care and mental health services), LAs at both tiers, voluntary sector organisations, community groups, and other statutory agencies. The current exercise in identifying “public health expenditure” and the huge variance seen across different local authorities shows not only that this is almost unfathomably complex but also that there are – probably- great variances in what is actually spent between different areas. There are also major differences in the size of public health workforces in different areas. Therefore significant problems will be faced in practice whether funding is based on current expenditure or on some capitation based formula.

6. Role of the DPH

6.1 The role of the DPH is important. I don’t really believe that a DPH will ever be totally independent of political or institutional interests, or if he/she was it would mean that they were so detached from the major stakeholder organisations as to be rather sidelined. However a degree of independence needs to be maintained and this may best be done by making PHE their primary employer with a joint appointment process with the LA and also giving them some level of authority with GP consortia eg having them as a statutory board member. To some extent the independence of the DPH to challenge local decision making on behalf of the community is a matter of culture and the way in which central authorities express the role of the DPH and support or undermine DsPH when they do challenge vested interests. Within the LA they need to sign off on the use of the ph budget and also, very crucially they need to sign off on the commissioning plans of GP consortia on behalf of the Health and Well-being board. There should also be some guidance from the centre that supported the need for the DPH having a sufficient rank within the LA that gave them the influence that they will require to establish PH priorities alongside all the other LA priorities. Otherwise there is a danger that PH priorities will be put second to much longer established ones.

7. The Health and Wellbeing Board and Protecting Health Service Rights for Vulnerable People and Groups

7.1 The H&WB needs to have some clear and defined authority regarding GP consortium plans. This means in particular some power to ensure that consortia take responsibility for a defined geography and that no vulnerable communities or individuals can be left without access to primary and secondary healthcare. It must be enshrined in guidance that if a practice chooses to remove someone from its list or not to register someone who requests it, the responsibility of ensuring that that individual receives a full range of health services lies with the consortium covering that geographical area. Where geography is not clear there must be a process by which this allocation can occur without vulnerable people being bounced around from practice to practice.

8. Public Health Advice to GP Consortia

8.1 Consortia will have essential roles in ensuring equitable access to a full range of services, for maintaining primary care’s role in health promotion and health protection and for reducing local health inequalities. They will also need to make the most efficient use of their resources. The best consortia will see that they have an important role in supporting local communities in improving their own health and wellbeing. As consortia will inevitably struggle to establish their basic governance structures and then take on the mighty task of commissioning the basic health services these other functions could easily be neglected. The best way of ensuring that consortia plans were well developed from a public health perspective would be to encourage consortia to obtain ph advice in the planning stage. This could be done through them employing their own ph capacity or through them accessing expertise from a central ph employing body on a secondment or contractual basis. The role of public health expertise in commissioning at a local level has been much neglected in policy guidance to date. This is a serious oversight particularly at a time when with the commissioning function in the throes of radical change there is a great risk of costs running out of control in the time between the PCTs falling away and the consortia really getting up and running. A good understanding of the evidence base for treatments and the cost effectiveness of different approaches is more important than ever.

8.2 The NHS is an essential service in managing and reducing health inequalities and particularly the primary care services and this is recognised in the proposed new duty on the Secretary of state to have some duty in this regard. The Health and well-being board needs to be able to demand of consortia that they are managing health inequalities in tangible, evidence based and effective ways. Once again having public health expertise available to consortia may be the most direct way of ensuring this planning but the duty needs to be emphasized in the guidance to consortia.

9. These are some of the issues that I have with emerging public health policy. There are positive elements to creating a strong public health England and to working more closely with local authorities, but there are also numerous concerns and an uncertain and demoralised workforce is being asked to take on an ever more complex and demanding task of change management that could be a major distraction from its primary roles of protecting and improving population health, informing effective commissioning of health services and reducing health inequalities in England.

June 2011

Prepared 28th November 2011