HC 1048-III Health CommitteeWritten evidence from National AIDS Trust (PH 111)

A. Introduction

1. NAT (the National AIDS Trust) welcomes the inquiry of the Health Select Committee into Public Health.

2. NAT is the UK’s leading charity dedicated to transforming society’s response to HIV. We provide fresh thinking, expert advice and practical resources. We campaign for change. All our work is focused on achieving four strategic goals:

effective HIV prevention in order to halt the spread of HIV;

early diagnosis of HIV through ethical, accessible and appropriate testing;

equitable access to treatment, care and support for people living with HIV; and

eradication of HIV-related stigma and discrimination.

3. This submission addresses issues in the order set out in the Committee’s call for evidence. We comment only on those areas where we have, we trust, relevant points to make on the basis of our work. In particular NAT is concerned to ensure:

the continuation of the independent high-quality surveillance and analysis currently undertaken by the Health Protection Agency;

clarity on the distribution of responsibility for public health, with particular attention to the role of the NHS;

arrangements which provide consistent comprehensive sexual health and HIV services across the country;

an Outcomes Framework which genuinely incentivises the broad range of actions necessary for public health; and

an adequately resourced ring-fenced public health budget with agreement as to how this fund should complement other resources which have a public health impact.

B. Summary

4. The creation of a specific body responsible for public health has real potential for bringing about improvements to public health. However it is important that comprehensive surveillance and a full analysis of data required by both local and national service providers and decision makers continues to be carried out to the high standard currently delivered by the Health Protection Agency (HPA).

5. It is also important that Public Health England retains a degree of independence from Ministerial intervention. Public Health England must be able to make decisions about the best course of action for public health based on evidence and expertise. The data collected and collated by Public Health England must remain as publicly available and accessible as it currently is under the HPA.

6. We have some concerns about whether the political nature of local government will impact on the commissioning of unpopular or controversial issues, such as HIV and sexual health.

7. Greater clarity is needed as to how at the local level the NHS (for example GP practices) can be required to address identified public health need. This is also important for funding responsibility.

8. NAT strongly recommends that Public Health England develop a new national programme for HIV prevention which will allow for research, information exchange and the development of materials to support vital local HIV prevention work.

9. It is vital that the essential elements of an open-access sexual health service be specified by Public Health England so that the same level of service is available across the country.

10. All commissioners and providers of public health services must, in respect of their public health responsibilities, take a “whole population” approach and not discriminate within the local population on the basis of residency status.

11. NAT recommends that the Government retain and develop further a broad and indicative range of public health outcome indicators. We particularly call for the retention in the final Framework of the late HIV diagnosis indicator which will be key to improving the health of HIV positive people and reducing onward transmission.

12. Both in their needs assessments and then in the planning of services, local authorities should be required to demonstrate attention to all key elements of public health (including HIV and sexual health) and to the diversity of the local population (to avoid simply an aggregated or majoritarian approach, which misses concentrations of severe need).

13. There is value in having a ring-fenced budget for public health separate from the NHS and provided to Local Authorities to protect long-term investment in public health from the immediate demands of acute care, however there is also a danger it will act as an artificial “cap” on public health investment where previously there was flexibility within a single local PCT budget to meet treatment and health improvement needs.

14. It would be useful to have clarity as to what should be funded from the local authority health improvement budget, what funded from Public Health England monies allocated elsewhere and what funded from other budgets as part of a wider obligation to promote public health

C. The Creation of Public Health England and the Abolition of the Health Protection Agency

15. The creation of a specific body responsible for public health has real potential for bringing about improvements to public health. By bringing together all strands of public health Public Health England will have the ability to see the bigger picture, to consider issues within the wider context, ie how sexual health and HIV relates to education, to drugs and alcohol, to understanding of risk, etc. This wide-angle lens could bring better integration and more joint working which can only be beneficial.

16. However it is important that comprehensive surveillance and a full analysis of data required by both local and national service providers and decision makers continues to be carried out to the high standard currently delivered by the Health Protection Agency (HPA). It would be very helpful if the Committee sought assurances over continuing funding for effective surveillance, that such surveillance will be directed according to public health need rather than political considerations, and that analysis is also undertaken by Public Health England at the national level to identify needs and possibly effective interventions—this is essential for an impactful public health response.

17. It is also important that Public Health England retains a degree of independence from Ministerial intervention. If it is to be part of the Department of Health it will be important to include appropriate safeguards. The current independence of the HPA enables it to carry out its functions without undue influence from Government. It is important that Public Health England is able to make decisions about the best course of action for public health based on evidence and expertise. It is also important that the data collected and collated by Public Health England remains as publicly available and accessible as it currently is under the HPA.

D. The Future Role of Local Government in Public Health

18. We are not opposed in principle to an increased role for local government in public health. Indeed it has the potential to allow for greater integration into wider wellbeing issues such as housing, education and social care. However we have some concerns about whether the political nature of local government will impact on the commissioning of unpopular or controversial issues, such as HIV and sexual health.

19. It is currently not clear how responsibility for public health will be distributed between the different structures, people and processes proposed in the reforms, such as Directors of Public Health, Health and Wellbeing Boards, HealthWatch, Public Health England, the NHS Commissioning Board and GP Consortia (to name only the key ones). In particular it is important to ensure that the NHS works both to address acute ill-health, and also to prevent future ill-health and promote good health. Greater clarity is needed as to how at the local level the NHS (for example GP practices) can be required to address identified public health need. This is also important for funding responsibility, to which we return at the end of this submission.

20. The Joint Strategic Needs Assessment and the Health and Wellbeing Strategy must take account of more than just those areas included in the Public Health Outcomes Framework. As further discussed below, they must also consider the needs of vulnerable groups in the area and health issues specific to the local population (for example HIV prevention needs in areas of high prevalence, or areas with large high risk populations). They should also consider how to ensure that fragmented commissioning structures don’t affect the provision of integrated and effective services.

E. Arrangements for Commissioning Public Health Services

21. Public Health England should retain and develop a role to commission certain public health programmes at a national level. It would be useful for the Committee to explore with the Government appropriate health areas for such national work. NAT’s view is that such national programmes are particularly important where it appears unlikely that there will be the will or expertise at the local level to meet relevant need. In particular, HIV is a condition which requires a sensitive and complex response, which may not affect many people in some areas but which at the national level is a serious public health threat, and which is vulnerable to prejudice. NAT strongly recommends that Public Health England develop a new national programme for HIV prevention which will allow for research, information exchange and the development of materials to support vital local HIV prevention work.

22. Undoubtedly there should be some public health services which should be mandatory. The Government used open-access sexual health services as an example of the type of services that should be mandatory in the white paper and we agree with this. However it is unclear what is meant by and included in these services. It is vital that the essential elements of an open-access sexual health service be specified by Public Health England so that the same level of service is available across the country. Comprehensive services must include (but not be limited to):

(a)rapid, open-access sexual health services (which must include GUM, contraception and abortion),

(b)specialist and reference services for STI microbiology,

(c)submission by local services of the range of data required for national and local surveillance to ensure public health strategic planning if informed by current evidence of need,

(d)and, according to need, community based HIV and STI prevention interventions and testing services.

There must be guidance as to the content of comprehensive sexual health services to ensure consistency and clarity across the country. NAT are concerned at reports that the Government wish to keep to an absolute minimum Public Health England “mandates” or requirements imposed on local authorities as to how they commission public health. But inconsistency is unacceptable when dealing with services which are meeting acute ill-health, such as STI infection, or are addressing the spread of infectious disease in a population.

23. While the majority of the focus of public health appears to be falling to local government it must not be forgotten that GPs still have a role to play in commissioning services relevant to public health. However we are concerned about the definition of the responsibility of GP consortia and how that relates to public health—para.4.50 of the Public Health White Paper reads, “As NHS commissioners, GP consortia will have responsibility for the whole population in their area, including registered patients, unregistered citizens and visitors requiring urgent care”. This is an inadequate remit to encourage the engagement of GPs on “the health of the local population as a whole” particularly in relation to an infectious disease such as HIV which affects people irrespective of their citizenship or residency status. We know of no definition of public health which limits its scope to a particular category of citizens in a particular locality. It is vital that all commissioners and providers of public health services, in respect of their public health responsibilities, take a “whole population” approach and not discriminate within the local population on the basis of residency status.

F. The Structure and Purpose of the Public Health Outcomes Framework

24. The emphasis on outcomes in public health is welcome. NAT has concerns over the desire of the Government to reduce significantly the number of public health outcomes from those in their draft consultation document. It should be noted these are not targets but simply collected, published and accessible data (much of which is already available) on the basis of which local populations and stakeholders are meant to consider performance. Given that fact, a limited number of outcomes far from providing real autonomy at the local level, in fact unnecessarily constrains the breadth and flexibility with which local councils can consider need and services. Furthermore, to reduce the number of outcomes for the sake of reducing them, rather than having as many outcomes as is necessary to ensure equitable and high quality public health provision—has the potential to hamper attempts to improve health. NAT recommends that the Government retain and develop further a broad and indicative range of public health outcome indicators.

25. We do also have concerns at the end of national targets for achievement locally. In NAT’s experience these have been effective in raising standards across the country (for example in reducing waiting times for GU services). Particular attention needs to be paid to how to incentivise local effective investment in public health given that (with the exception of STI treatment) the direct costs of ill-health arising from the neglect of public health will not be borne by local authorities themselves but by the NHS (in the current system PCTs to a degree pay for the consequences of failures in health promotion by increased secondary care bills).

26. In the Government’s draft consultation document there were three sexual health related outcome indicators relating to teenage pregnancy, Chlamydia diagnosis and late HIV diagnosis, all of which are welcome. NAT particularly calls for the retention in the final Framework of the late HIV diagnosis indicator which will be key to improving the health of HIV positive people and reducing onward transmission.

27. We note, however, that there is no currently proposed public health outcome indicator relating to the promotion of safer sex behaviour and the reduction in HIV and STI incidence. One reason for this is simply that it is difficult to identify nationally relevant and available data which could be used for this purpose. But this then highlights a limitation to relying solely on such indicators to incentivise appropriate local health promotion. Available indicators may not map comprehensively onto known public health need. In the absence of a relevant indicator what encouragement will there be for local authorities to invest in HIV prevention in most at risk communities such as gay men and African communities, already too often stigmatised or neglected? In addition to the Public Health Outcomes Framework, Public Health England will need to put in place some essential requirements for, and components of, acceptable and effective public health work at the local level in the mandate given to local authorities. Both in their needs assessments and then in the planning of services, local authorities should be required to demonstrate attention to all key elements of public health (including HIV and sexual health) and to the diversity of the local population (to avoid simply an aggregated or majoritarian approach, which misses concentrations of severe need).

G. The Arrangements for Funding Public Health Services

28. There is value in having a ring-fenced budget for public health separate from the NHS and provided to Local Authorities to protect long-term investment in public health from the immediate demands of acute care, however there is also a danger it will act as an artificial “cap” on public health investment where previously there was flexibility within a single local PCT budget to meet treatment and health improvement needs.

29. The danger is especially serious if there is an underestimate of the real costs of public health need and an inadequate ring-fenced budget. NAT has heard concerns as to how public health expenditure has been estimated for the purposes of the planned ring-fenced budget. There are questions as to the boundaries between treatment and care on the one hand, and public health interventions on the other. The NHS and local authorities already fund interventions which have an important public health impact but which are not directly identified as “health improvement”. It will be important that such interventions continue to be funded from outside the specific health improvement ring-fenced budget. There is a danger of arguments between various agencies or bodies as to who (or which budget) is responsible for funding particular public health interventions. It would be useful to have clarity as to what should be funded from the local authority health improvement budget, what funded from Public Health England monies allocated elsewhere and what funded from other budgets as part of a wider obligation to promote public health. Within the HIV sector, for example, there has been debate as to who under the new arrangements would fund HIV testing in primary care in high prevalence areas.

June 2011

Prepared 28th November 2011