HC 1048-III Health CommitteeWritten evidence from Jude Williams (PH 112)

This short submission is making the case to:

increase the assessment of public health work in provider trusts as part of the remit for the Care Quality Commission (CQC) (points 2 to 6);

utilise the full range of local government functions to improve health and reduce health inequalities through the support of the “in-house” public health team (point 7);

support the introduction of the Health and Wellbeing Boards, and Health and Wellbeing Strategies based on JSNAs, whilst addressing the need for the board to influence GP Commissioning and visa versa. Ensure the crucial role public health staff could play in this integration including use of the Annual Director of Public Health’s Report (point 8 and 9);

review the idea of a premium and how that would operate (point 10);

monitor the impact of the changes on health inequalities (point 11); and

ensure there is cohesive national support in place for health inequality work going into the future, for both GP Commissioning Consortia and local government (point 12).

1. To give some context to this submission, I worked in the Department of Health (DH) up to 2003. Just before leaving I took a key role in writing the standards for public health, included as one of the seven domains in Standards for Better Health (2003), the quality standards for the NHS. I then became Head of Public Health at the Healthcare Commission for six years (2003–09), up until the time it was closed down and its functions were taken into the Care Quality Commission. Over the past two years I have been deputy head of the Health Inequalities National Support Team, which ceased to exist at the end of March 2011.

2. At the Healthcare Commission, I established a small public health team and we developed criteria (in consultation with key stakeholders) for use in core and developmental standards-based annual assessment of all healthcare organisations in England. We ran this assessment process for five years. We assessed the impact of this work and found a noticeable improvement of the quality and quantity of public health work being undertaken by all healthcare organisations.

3. PCT trusts improved their public health planning, partnership and engagement, commissioning and service delivery. Provider trusts improved their public health work, particularly in relation to incorporating one-to-one lifestyle advice in the work of their frontline staff, improving their own staff’s health and an increased participation of partnerships with a focus on health improvement and emergency preparedness. About 30 provider trusts even established public health experts within their staffing. This included, for example, taking the opportunity to do prevention among patients and families of patients to reduce recurrence of diseases, unintentional injury, excess drinking etc. As this work developed, trusts then recognised that “it makes good business sense”.

4. Unfortunately there is currently very little focus on public health in CQC and therefore the driver for more provider trusts to take up this, or a similar approach, has reduced considerably. Whilst it is easy to see how other safety and quality of care issues are their top priorities, if we are to ensure the NHS plays an important role in preventing disease and improving health in the future there needs to be some focus on public health within the national inspectorate and the assessment process. NICE, with their new standard setting duties could be key in supporting CQC in this task.

5. The proposed move of public health teams to local authorities is bold and holds great potential for improvements in health and health inequality outcomes, particularly in relation to the broader determinants of health—provided adequate resources continue to be allocated to this function. It would be a great loss if this were at the expense of losing the NHS potential to maximise the health gain that could be reaped from all their healthcare activity and their large staff groups. Ensuring that CQC has a greater role in relation to public health would help to prevent this.

6. In addition to our assessment work the Healthcare Commission undertook a series of national reviews and reports on public health issues such as obesity (report jointly produced with Audit Commission and National Audit Office), sexual health, tobacco control, unintentional injury and Are We Choosing Health?—a review of the impact of 10 years of public health and related policies. By shining a light on specific public health issues we were able, as an independent inspectorate, to consider the issues in order to drive improvement.

The next six points will focus on health inequalities (and therefore drawing on experience gained from the last two years of working in the Health Inequalities National Support Team):

7. A focus on health inequalities brings together health improvement work and access to diagnosis and treatment—ensuring access to health care and health improvement to the most vulnerable. It is important to reap the benefits of the public health team moving to local government, both in relation to the wider determinants of health and in utilising the local government’s deep reach into communities allowing them to support those with the poorest health access necessary health treatment and care (including lifestyle advice).

8. The concept of Health and Wellbeing Boards offers a positive opportunity for health promotion and health inequality interventions that have impact in the short, medium and long term. The development of a Health and Wellbeing Strategy, informed by the Joint Strategic Needs Assessment (JSNA), should be seen as an opportunity to refresh local partnerships. The detail of how the board will influence the GP’s commissioning agenda and visa versa must, however, be strengthened. Otherwise the whole system for delivering population health gain and tackling health inequalities could break into silos.

9. It is important that the move of the public health team to local government doesn’t leave health care commissioning by GPs separated from local Health and Wellbeing Strategies and public health support. Public health staff could be key to this integration but would need greater imperatives than voluntary agreements to ensure they could become effective throughout the country. The Director of Public Health’s Annual Public Health Report could maintain its independence and have a legislative duty to fully report on how the population’s health and health inequalities are improving or deteriorating in light of the local Health and Wellbeing Strategy, and how that relates to the commissioning and provision by all partners in the area. This could be an important component of local accountability necessary in the commissioning and provision of services by GPs.

10. I have concerns about the proposed financial premium based on areas achieving improvement in their life expectancy. This currently appears to give little recognition of where areas are starting from—those that have delivered well in the past might be unable to raise their game as much as previously poor performing areas. It also takes little account of some areas with more transient populations or those suffering the worst impact from the changing economic climate.

11. The impact of the changes on health inequalities between and within local authority areas needs to be closely monitored over the next few years so that adjustments can be made to delivery systems if figures are worrying, albeit acknowledging the difficulty in separating the impact of system failure from the overall public sector cuts.

12. The wide range of public health NSTs closed last March (2011), including the one with a specific focus on health inequalities. I understand that The Healthy Communities Team in LGID is also scheduled to close in the autumn. It will be important that there is cohesive national support in place for health inequality work going into the future, for both GP Commissioning Consortia and local government, with some degree of independence from central government departments. In that way, some of the past models and resources can be used in the new system and as the system develops new learning can be shared between areas.

June 2011

Prepared 28th November 2011