HC 1048-III Health CommitteeWritten evidence from Lancashire County Council (PH 115)

Clarity is urgently needed around the role and accountabilities of Public Health England compared to local authorities.

Close working relationships with other Government Departments that have an impact on population health will be required if Public Health England (PHE) is created within the DoH.

For the local public health system to work effectively, the three domains of PH need to be integrated at the local level with the ability to set local priorities.

The proposed dual accountability of DsPH to local authorities and PHE for different elements of their role is a matter of concern to the County Council.

It is important that DsPH have the capacity to fully integrate within local authorities and are able to influence the use of wider local authority budgets to maximise their impact on health outcomes.

Proposals for how Health and Wellbeing Boards (HWB) would be implemented in two tier local authority areas does not seem to have been considered.

The statutory role of HWB would need to allow sufficient flexibility to enable all partners to agree a local model.

The Health Bill needs to include a statutory requirement for JSNA data to be shared.

Joint Health and Wellbeing Strategies should be underpinned by statutory powers.

The three domains of public health integrated within the local authority would prevent fragmentation of the public health function and promote efficiency.

Local authorities are best placed to commission all children’s public health.

GP Consortia boards should not replace the HWB.

The County Council has significant concerns about the loss of regional expertise should PHE take on the role of the Regional Public Health Observatories.

Children with additional needs and mental health issues need further consideration in the PH Outcomes framework.

The County Council would like to see the population health measure approach used to determine the allocation of PH resources with a district level population based formula.

Incentivisation needs to be on as small a geographical area as possible.

Action to address health inequalities needs a cross-departmental approach to address the wider determinants of health.

1. The creation of Public Health England within the Department of Health

Lancashire County Council (LCC) believes that bringing public health into local government provides important opportunities to align action to improve health status with local authority responsibilities in relation to the wider determinants of health. The creation of PHE within the Department of Health could make it difficult to facilitate a similar approach at a national level, lead to silo working and dilute the potential opportunities created by the reforms. If PHE is created within the DoH, concerted efforts will be required to ensure close working relationships with other Government Departments that have an impact on population health and influence the work of local authorities.

Clarity is urgently needed about the role and accountabilities of Public Health England compared to local authorities.

2. The abolition of the Health Protection Agency and the National Treatment Agency for Substance Misuse

The County Council welcomes the streamlining of public health agencies at a national level and the consequent opportunities to align national programmes. However the county council believes that for the local public health system to work effectively, the three domains of public health (health protection, health improvement and health and social service quality) need to be integrated at the local level with the ability to set local priorities. This will require strong local relationships with Public Health England’s health protection and substance misuse functions.

3. The public health role of the Secretary Of State

The county council supports the change to the role of the Secretary of State for Health in terms of its wider responsibility and shift of focus to tackling health inequalities and (together with local authorities) protecting and improving public health.

4. The future role of local government in public health (including arrangements for the appointment of Directors of Public Health; and the role of Health and Wellbeing Boards, Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies)

Lancashire County Council warmly welcomes the proposal to transfer responsibility for public health to local authorities and is confident that with support from a Director of Public Health (and his/her team) it can exercise this role effectively.

The county council recognises the influences its own functions have on health outcomes, such as: educational attainment, transport and economic development and in response to this we have recently appointed a Cabinet Member for Health and Wellbeing, (whose portfolio includes oversight of the organisation’s developing public health function). We also recognise the significant impact that functions of district council partners have on health, through housing, planning, environmental health and leisure provision.

5. Arrangements for the appointment of Directors of Public Health

The joint appointment of the DPH between the county council and PHE will provide the local authority with specialist public health expertise to ensure it maximises the impact of its services and commissioning on population health and wellbeing. It will also enable public health skills and tools to be used to improve the effectiveness of wider local authority interventions. This will require the three domains of public health to remain integrated at the local level.

The proposed dual accountability of DsPH to local authorities and Public Health England for different elements of their role is a matter of concern to the county council and we seek clarity on how this will work in practice.

Local authorities will need the support and skills of public health professionals in order to carry out our new responsibilities and capitalise on the opportunities to integrate public health with our existing responsibilities. We will need to be assured that this will be prioritised by the DPH under the proposed arrangements. It is therefore important that DsPH have the capacity to fully integrate within local authorities and are able to influence the use of wider local authority budgets to maximise their impact on health outcomes.

Local authorities will need to be fully involved in the appointment of the DPH. We should be free to decide for ourselves the most appropriate location for the DPH within the organisation to ensure s/he can provide strong leadership and influence across the full range of local authority decisions that impact on population health and wellbeing.

6. Role of Health and Wellbeing Boards

Lancashire County Council supports the establishment of a Health and Wellbeing Board (HWB) and agrees with the proposed role and remit of the Board. We also agree that it should be established on an upper tier local authority footprint, as this is the most appropriate level to enable integration of social care, public health and NHS commissioning plans. We agree that the Board should be established on a statutory basis and, given its system management role, its levers and governance will have to be as robust as possible.

The White Paper’s proposals for how HWBs would be implemented in two tier local authority areas does not seem to have been considered: for example a county-wide HWB, whilst essential for providing a strategic oversight and aligning commissioning priorities, would have a very large membership if it were to involve all relevant partners. It might also be perceived as being distant from some of our local communities. We therefore welcome the opportunity to design our own health partnership system that can carry out the functions of a HWB, and which has the Board at its heart.

The Board should take a cradle to grave approach to health and ensure that links are made to existing arrangements, eg Children’s Trusts, in order to be able to fulfil its role of joining up commissioning plans. Both tiers of local government in Lancashire make a significant contribution to, and impact on, health. Whilst we agree with the statutory role of the HWB it would need to allow sufficient flexibility to enable all partners to agree a local model that can operate effectively to meets the needs of the people in Lancashire.

7. Joint strategic needs assessments

We welcome the centrality of the JSNA to the role of the HWB, and the proposed duty on GP commissioning consortia to contribute to its production.

In Lancashire we have a particular approach to health intelligence which aims to develop a culture of intelligence, make intelligence widely available, and empower commissioners and communities to use the intelligence to inform decisions.

A good JSNA should consider the needs of different equality and diversity groups (beyond those enshrined in legislation). The Health Bill therefore needs to include a statutory requirement to share data, including individual data, as necessary across partners to overcome any additional unnecessary barriers to effective integrated working.

8. Joint Health and Wellbeing Strategies

Lancashire County Council fully supports the proposal to develop Joint Health and Wellbeing Strategies (JHWS). The county council is well placed to build on the good practice already in place in Lancashire and has been working with partners to improve health and reduce health inequalities for some time. The JHWS will provide a vehicle to escalate this to the levels needed to create better health outcomes for all. We feel that this responsibility should be underpinned by statutory powers (with minimal statutory requirements) with a duty to cooperate for all partners to ensure the alignment of priorities. This will also help to ensure that key partners such as GP consortia work closely with local authorities when identifying their commissioning priorities.

9. Arrangements for public health involvement in the commissioning of NHS services

The county council would like to see the three domains of public health, including support to NHS commissioning, integrated within the local authority public health function. This will prevent the fragmentation of specialist public health skills needed to support all domains (eg intelligence, research and development and social marketing) and will maximise efficiency. It will also enable health improvement and health protection measures to be integrated into NHS commissioning.

10. Arrangements for commissioning public health services

A number of the proposals for the commissioning of public health service create considerable risk of system fragmentation. For example we are very concerned that the proposals that children’s public health interventions for the under 5’s are commissioned by the NHS commissioning board, yet those for school age children be commissioned by local authorities, will undermine the potential to streamline services for the 0–19 population. Local authorities are best placed to commission all children’s public health and to align it with our wider responsibilities for children and young people. Local authorities are also better placed than the NHS commissioning board to commission public health for those in prison or custody to enable integration with offender management programmes and our wider community safety responsibilities.

11. GP Consortia

Consortia will need access to specialist public health advice to inform effective public health commissioning. This should be provided through an integrated local public health service based within local government.

We support the suggestions from some quarters to increase transparency and democratic legitimacy in relation to consortia decision making. One way of doing this might be to include elected members on consortia boards. However, we feel strongly that even with the membership of elected members, GP consortia boards should not replace the HWB, whose role is to manage the whole health and wellbeing commissioning system, rather than make decisions about which NHS services should be commissioned.

If they are to have elected members of their boards, consortia will need to clearly understand members’ constitutional responsibilities (what individual councillors can and can’t commit to on behalf of their local authority). Their main role should be to reflect the views of the authority and to act as community champions, based on their detailed knowledge of, and legitimate advocacy role in relation to, their constituents. Members of the consortia boards will need support to achieve this understanding, and elected members will need support in order to effectively apply their democratic role to health service commissioning.

Consortia should be required to demonstrate that they are acting in partnership with local authorities in order to be established and approved by National Commissioning Board. It is vital that the consortia maintain an appropriate level of engagement with local government and other partners, including involvement in the Health and Wellbeing Board. Individual local authority representatives on the commissioning consortia boards will aid this, but should not become a substitute for it.

12. Health and Wellbeing Boards

Led by Local Authorities, the HWBs (with membership from Local HealthWatch), will play a vital role in supporting local authorities, consortia and the NHS Commissioning Board to make effective commissioning decisions informed by public insight. Seldom heard groups need support to contribute to the commissioning process. The contribution of children and young people will be essential in articulating their health needs.

13. The future of the Public Health Observatories

The County Council has some significant concerns about the loss of regional expertise should Public Health England take on the role of the Regional Public Health Observatories.

There are potential resource implications about PHE’s capacity to respond and provide the technical expertise and high quality intelligence about the health of local populations. Having this level of skill and expertise at a regional level is ideal as it is concentrated enough to have the expertise but local enough to understand local issues, to influence regional policy and improve understanding amongst local clinicians and commissioners of population health.

The County Council is also concerned that PHE will not provide the breadth and depth of data to inform local intelligence operations. We have already seen the removal of, and reduction in, data provision due to the government’s proposals and actions. We fear that the shift to PHE will resulted in a similar reduction in the data made available to us.

14. The structure and purpose of the Public Health Outcomes Framework

We feel that the public health outcomes framework has limited focus on issues related to children and young people. Although, there are some domains where outcomes for children and young people are included, this is not true across all domains and is particularly concerning for children and young people with additional needs. We also feel that mental health is not explicitly reflected as a priority within the five domains identified for the outcomes framework.

15. Arrangements for funding public health services

In determining the allocation of public health resources, focus should be on population need, rather than the way resources have been used previously. We would strongly advocate that the population health measure approach is adopted to determine the allocation of public health resources. However as deprivation is a key determinant of health need we would prefer a district level population based formula which is sensitive to variations in deprivation in large areas such as Lancashire. This approach would not penalise deprived areas who have effectively improved health outcomes to date, and would reflect a focus on wider determinants of health.

Local Authorities working with partners through the Health and Wellbeing Board should have the flexibility to spend any health premium awarded on any activity that they consider will improve their priority health outcomes and reduce health inequalities.

Incentivisation through the health premium needs to be based on as small a geographical area as possible, otherwise the shortcomings of the spearhead system will be replicated i.e. small pockets of deprivation in otherwise affluent areas will be forgotten. A purely geographical approach to incentivisation will not reduce inequalities between population groups which fall within the definition of, “protected characteristics”. Indeed, financially rewarding areas with better health can be perverse, as it is those areas with the highest level of need that will need the greatest capacity to improve the public’s health.

The county council welcomes the possibility of the Health and Wellbeing having responsibility for any place-based budgets for health improvement. We feel that the use of the ring-fenced public health budget should not be limited to a narrow definition of “public health” but should be able to be used to fund action to address the wider determinants of health. It will be critical to the success of new structures that public health principles are embedded in all services that contribute to health outcomes at the commissioning level.

16. The future of the public health workforce

Lancashire County Council believes that the integration of training between the NHS and local authority staff whose role involves social care, health policy and strategy or primary prevention is essential in order to support integration of public health into health and care delivery and to improve outcomes for communities, service users and patients.

The transfer of responsibilities for public health to local government, which we fully support, will create significant training requirements for existing public health and local government staff as well as elected members. The professional training requirements of public health staff operating within a local government environment will need to be addressed, as will equity of access to public health training for staff currently within local government. This is likely to be challenging in current financial circumstances.

Lancashire County Council agrees with the Local Government Information Unit that in terms of advice and leadership the skills of all public health, social care and associated local authority professionals need to be recognised, as well as those of the medical profession. In Lancashire for example we have recognised that wherever it is located, public health provides an essential bridge between local authorities and the NHS, which must not be lost as a result of the new arrangements. We are happy to report that many of our emerging GP consortia recognise the value of public health skills to support their commissioning responsibilities, particularly their ability to provide a population perspective and advice on primary prevention of ill-health.

17. How the Government is responding to the Marmot Review on health inequalities

The government should recognise that action to address health inequalities needs a cross-departmental approach and it must support interventions within the NHS and those that address the wider determinants of health—such as housing, working conditions and early childhood education. In our view this is not well reflected in Healthy Lives Healthy People.

The Government must also commit to long term investment in initiatives to tackle health inequalities as these do not produce instant returns. It is imperative that politicians continue to support the reduction of inequalities as a goal, even if the outcomes might not be achieved within a political term.

June 2011

Prepared 28th November 2011