HC 1048-III Health CommitteeWritten evidence from the Centre for Public Scrutiny (PH 15)

Introduction

This submission is informed by our responses to consultation documents issued in 2010: Healthy Lives, Healthy People: Our strategy for Public Health in England; Funding and commissioning routes for public health; and Transparency in Outcomes. The submission draws on our experience of supporting scrutiny programmes, our work with local councils and their partners and findings from our Health Inequalities Scrutiny Programme, which has helped councils and their partners to understand public health issues and respond to some of the health inequalities that exist in their communities.

Summary

Handing councils responsibility for public health sits well with their community leadership role. But principles of transparency, inclusiveness and accountability need to be embedded so that solutions to problems are “co-produced” between councils and citizens.

We welcome health and well-being boards – they could be crucial to the success of the health reforms if they can generate a commitment to real partnership working. We think they should become the health and social care commissioning boards for their areas.

The Health and Social Care Bill should be amended so that current health scrutiny powers are not diluted, especially in relation to greater executive influence and restriction of referrals of service changes. Health scrutiny is a cornerstone of constructive accountability arrangements across healthcare, social care and health improvement.

We support the approach to improving the health of the population set out in the white paper. Empowering individuals to make healthy choices and giving local communities the tools to meet their own health needs have been themes of our national public health programme that we have been running for the last two years.

District Councils have a vital role to play in public health, given their role in housing, planning, regulation, environmental health and leisure. Not enough detail has been set out about the role of district councils in tackling inequalities.

Reducing inequalities is complex but not impossible. We have demonstrated through our programmes the value of scrutiny, which can be a powerful tool in the development of joint strategic needs assessments, health and well-being strategies and commissioning plans.

About CfPS

CfPS is an independent charity which promotes transparent, inclusive and accountable public services by influencing policy and providing a range of practical support. The Centre is widely regarded as the leading national voice for public scrutiny and accountability. We work across government (for example with the Department of Health, Communities and Local Government, Home Office, Department of Work and Pensions), with the Local Government Group and with stakeholders across primary and acute care.

Why Scrutiny and Accountability Are Important

Good scrutiny and accountability involves different people in different ways – citizens, patients and service users, elected representatives, inspectors and regulators. Four mutually reinforcing principles need to be embedded at every level:

constructive “critical friend” challenge;

amplifying the voices and concerns of the public;

led by independent people who take responsibility for their role; and

driving improvement in public services.

What do we mean by “overview and scrutiny” and “holding to account”?

The language of “overview and scrutiny” can give a misleading impression of what the function can achieve. For example, “holding to account” is not always about reacting to decisions that have been made, it is much more than this – it is about influencing every part of the business cycle, as illustrated in the diagram below:

We have a wealth of evidence that scrutiny works, right across the public sector (for example our Good Scrutiny award winners for 2010 and shortlisted entries for 2011). This indicates that “non-executives” are able to work in creative and imaginative ways, providing value for local people.

This submission builds on our policy papers “The Anatomy of Accountability” and “Accountability Works!” These argue for a joined up approach that links “non-executives” together at local level and encourages the development of “co-production” ie professionals, the public and their representatives finding solutions to problems together. The need to improve outcomes at a time of economic challenge makes this an imperative.

Local Councils and Public Health

The Centre supports the proposals to transfer public health responsibilities to local councils. Local councils have the wider remit needed to tackle inequalities and improve health through non health services.

The vision that Healthy Lives, Healthy People sets out for the role of the Director of Public Health in local government includes identifying health inequalities and developing and implementing local strategies to reduce them. This is an extraordinarily complex and difficult assignment the success of which will require ownership and active engagement by the whole of local government, and most importantly of councillors.

All councillors will have a concern to see health inequalities being effectively tackled by the Director of Public Health but health scrutiny councillors will have a particular opportunity to help ensure health inequalities remain (or become) a central concern rather than a marginal interest of the council. In achieving this, health scrutiny can make a unique contribution to helping shape how local authorities and the Directors of Public Health in particular develops and implements the strategies for tackling health inequalities.

The local vision for health and well-being boards will be crucial. Restricting the local agenda for Boards to healthcare and social care will not enable councils, Boards or DsPH to tackle the “Marmot” challenge effectively – they must treat public health equally alongside health and care services. The co-ordination role of Boards provides an opportunity to connect needs assessments to practical health and well-being strategies and commissioning plans that are driven by needs and aspirations of citizens. It will be important for Boards to take a proactive view to membership – for example, it will be important to include leaders in education and business on Boards.

Three principles need to be embedded into the operation of health and wellbeing boards and to the wider reforms so that they can successfully deliver improvement – transparency, inclusiveness and accountability. Arrangements for Healthwatch and extended scrutiny powers for councillors will help promote “intelligent involvement” at each stage of the commissioning cycle, combining the benefits of participatory and representative democracy and balancing professional judgement and public opinion. Accountability for quality and outcomes needs to be matched by accountability for “responsiveness” – the extent to which Boards listen, understand and change.

District Councils

Many of the wider determinants of health are influenced by District councils, as they have statutory functions such as housing, leisure, planning, regulation and environmental health. District Councils are also closest to their communities.

It will be important for each local area to determine how they engage with the different tiers of government, some top tier areas already do this well, however for others it may need to be encouraged. It is also important to recognise all tiers of government (parish and town councils and community and neighbourhood fora) and the unique perspective that they can bring to public health.

Data and Intelligence

A large amount of data and information already exists about public health, healthcare and health services – however much of this data and information is either not used or not used properly. The growth in detailed performance management arrangements led to a generation of data and information being collected to satisfy those regimes alone, with the focus on process rather than outcomes. We welcome the shift to measuring outcomes but the wealth of data that exists already should not be lost. Without proper arrangements in place to gather and make sensible use of data and information there is a risk that patients and the public will not have access to useful information to inform choice or to hold commissioners and providers to account.

Public Health Observatories have played a key role in holding and interpreting data about the state of public health, health inequalities and outcomes for patients. This kind of information will be vital if health inequalities are to be tackled.

One of the most effective of ways making data available in an accessible form is by having a sufficiently developed Joint Strategic Needs Assessment (JSNA) – that has a broad remit and takes account of the wider health determinants. It needs to be a holistic assessment of the well-being of the population together with their health and care needs and be developed and informed by relevant local partners and citizens themselves. If it is to inform a sustainable health and well-being strategy that can drive commissioning plans, a JSNA needs to be “co-produced” between professionals and citizens. Such an approach will help to tackle the “Nicholson challenge” and the “Marmot challenge” together.

The JSNA not only needs to present an analysis and interpretation of local data, it also needs to tell the story of the community itself. This has been a particular strength of our Scrutiny Development Areas. Most of the Scrutiny Development Areas developed creative and innovative ways to understand communities and the issues affecting their health. – using scrutiny as a magnifying glass – getting to understand issues holistically.

An overarching principle should be that information is transparent, presented in ways that local people can use to make judgements about how health and wellbeing boards, commissioners and providers are working to improve health and wellbeing generally and the safety, quality, value and responsiveness of services. The key is to provide information in ways that people can find it, understand it and use it. This is especially important in the drive to help people set higher aspirations for their health and well-being and providing opportunities for them to fulfil these through enhanced life chances.

Scrutiny – an Effective Public Health Tool

The current “health scrutiny” powers represent the strongest model of democratic accountability in public services. They enable councillors to engage with commissioners, providers and patients and the public across primary, acute and tertiary care at every point in the commissioning cycle in creative and innovative ways. Councillors have shown that they can operate very successfully locally and across boundaries (particularly when tackling service reconfiguration and health inequalities).

Scrutiny can make a uniquely valuable contribution to a council’s strategic approach to health inequalities. In many places, health scrutiny councillors and Directors of Public Health work well together on a range of specific health inequalities issues and in future this should come to represent practice everywhere. The respective perspectives that the public health professionals and councillors bring to health inequalities are complementary and each can learn from the other.

Public health often focuses on “deficits” – problems, needs and deficiencies - that characterise communities experiencing health inequalities. But local councillors are aware of the social capital, community resources and resilience that frequently characterises challenged communities. So a scrutiny inquiry can highlight community assets around which communities can build their future.

Because health inequalities are complex, deep-rooted and not quickly solved, it can be difficult to persuade decision makers to invest resources to tackle them. Scrutiny inquiries can be an effective way to focus wider attention on issues and strengthen the evidence-base for investment.

Learning From the CfPS National Public Health Programme – Summary

This programme is defining the added value of scrutiny reviews in tackling Health Inequalities.

Over the last two years, 47 local councils in total have been using the scrutiny process to understand and respond to local health inequalities. Each of the areas has sought ways to develop innovative solutions to deep seated inequalities.

The causes and effects of health inequalities are complex. And tackling them is not easy. One of the last places you might look to find solutions is in a local overview and scrutiny committee. However these committees probably contain some of the most qualified people to help public services understand the issues that their communities face – locally elected councillors. The Centre recognised this “expert” role and set out to demonstrate the active and vital role that “scrutiny” can have in helping its partners understand issues so that gaps in inequalities can be narrowed.

What was different about this programme is that it is not focused on satisfaction with operational services, but focused on unpicking the “causes of the causes” of health issues. Each of the SDAs worked with different partners to focus on a different local challenge, including mental health, geographical health inequalities and the effect that poor housing has on health.

Funding and Commissioning

Under current plans, Health and Wellbeing boards will be responsible for the production of the Joint Strategic Needs Assessment and Health and Wellbeing Strategy. They will also have a crucial role in determining commissioning plans – we think this can be strengthened to increase democratic legitimacy and local accountability. To exercise this function effectively, funding will be required. However the public health budget will be allocated to the local council and not the health and wellbeing board. Therefore the relationship between health and well-being boards and the NHS Commissioning Board will be crucial, along with robust local accountability arrangements to ensure that Boards have the resources needed to make a difference and that they are subject to scrutiny about the investment they are making and the outcomes they are achieving. This will need to extend across the healthcare, social care and health improvement aspects of the work of Boards. Council Leaders will also need to be accountable for their approach to improving inequalities in their areas.

Commissioning works best where patients are involved in their own care, local communities are able to influence service design and delivery, and governance arrangements are established in ways that demonstrate they are open and accountable. Our ideas about this are set out in more detail in our paper with the NHS Alliance “Towards transparent, inclusive and accountable GP Commissioning”.

New arrangements for commissioning through the NHS Commissioning Board and GP consortia need to have health improvement at their heart alongside service improvement. Only in this way can the “Nicholson challenge” and the “Marmot challenge” be tackled together.

The Health and Social Care Bill needs to be strengthened to provide a “backstop” against which to judge transparency, inclusiveness and accountability in the new system can be judged, but what would make the system work is good relationships between GPs, councillors and communities at practice, neighbourhood and area level. Relationships between Consortia, Health and Well-being Boards and the NHS Commissioning Board would need to emphasis and facilitate local decision-making, in line with the Coalition’s principle of localism.

Our framework for public service accountability, “Accountability Works for You,” will enable commissioners and providers to demonstrate their commitment to transparency, inclusiveness and accountability in every aspect of the commissioning cycle.

CfPS’ March 2010 guide about Practice based Commissioning would be a useful learning tool for the future. It highlights areas where Commissioners could be held to account during transition and in the longer term:

understanding needs and aspirations of communities;

their capacity to change the status quo;

supporting long term conditions; and

improving health and well-being.

Transparency, Accountability and Involvement

Transparency and accountability need to be threaded through arrangements for funding and commissioning. The documents highlight the accountability arrangements for Public Health England and local authorities; however these need to be strengthened so that the arrangements emphasise and facilitate local decision-making. The performance management arrangements for DsPH between councils and Public Health England need to be clearer and DsPH should appointed as members of the council senior management team.

Transparency in Outcomes

A large amount of data and information already exists about public health, healthcare and health services – however much of this data and information is either not used or not used properly. Providing information to help people understand public health gives them a powerful tool to take part in discussions and debates about how services work and how they are responding to people’s needs. It is about giving people information about services, performance and outcomes but also about how they can influence change.

Giving people information could lead to greater involvement but there needs to be a balance between giving information directly and pointing people to sources of information that they can analyse themselves.

Making data available without commentary or context setting would also provide challenges. In order to be fully transparent, data needs to be meaningful. Considering ways of visualising data for local people would be one way of helping with this challenge.

Greater transparency about the way councils, health and wellbeing boards, commissioners and providers work together, how services are performing and how services can be improved is likely to lead to greater involvement from patients and the public

Relationship With Other Outcome Frameworks

The existence of three overlapping outcome frameworks for the NHS, Public Health and Adult Social Care does not seem to simplify the system – and could be a burden on local councils and their partners. Whilst the three frameworks are overlapping and complementary, CfPS supports the development of a single framework that ensures all partners are working together on the same priorities.

With any framework it will be important to recognise the different aspects of local government in an area. It is not enough to simply say that district councils will be able to play their role. The framework needs facilitate this by ensuring that information is broken down for individual neighbourhoods that are meaningful to local people, providers and commissioners. The contribution that District Councils can make to achieving good local outcomes needs to be more robustly recognised.

June 2011

Prepared 28th November 2011