HC 1048-III Health CommitteeWritten evidence from the Public Health Directorate, NHS Rotherham (PH 119)

Please find below the collective submission for evidence from the Public Health Directorate within NHS Rotherham. We welcome the opportunity to express our opinions to the Committee and consider the points which follow.

The Creation of Public Health England within the Department of Health

1. We support the creation of Public Health England, but feel that it would be a stronger and more effective organisation if it were independent of the Department of Health. The Health and Social Care Bill is aiming to reduce political micromanagement and ministerial influence in NHS decision making, but establishing Public Health England within the Department would appear to go counter to these aims.

2. We support the proposal made by McKee etc al (The Lancet, 28 February 2011 doi:10.1016/S0140-6736(11)60241-9) to establish Public Health England as a special health authority or an arms length body and for all existing public health staff to be employed within Public Health England with some seconded to work within local authorities. Employment of the existing non medical public health workforce by Public Health England would help ensure the continuity of skills and expertise developed over many years in the NHS, avoid the public health workforce being split into silos and create a workforce that is more flexible and responsive to local need.

The Abolition of the Health Protection Agency and the National Treatment Agency for Substance MisuseThe Public Health Role of the Secretary of State

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):

3. We support a greater involvement of the local government in public health activity, but in the same way as Public Health England should be free of political interference, so should local public health teams. By transferring public health staff contracts to an independent Public Health England and then second the most appropriate people into the local authority would ensure a greater level of independence and that public health professionals can continue to advocate for the improved health of the population, regardless of the current political control within the authority.

4. The Director of Public Health must retain an influential role in decisions about public health activity and how the ring-fenced grant can be spent. It is important, therefore, that this post is given sufficient authority. Whilst we support the joint appointment of DsPH between Public Health England and the local authorities, we do not feel that in time of significant organisational change, that all DPH posts should automatically be re-recruited, but that contracts be transferred and the joint appointments process be applied as an when DPH posts become vacant. If there is a concern that this process could allow ineffective postholders to remain in place, then robust processes should be developed so both employing organisations understand their responsibilities for addressing individual performance management.

5. We support the establishment of Health and Wellbeing Boards as the strategic body to direct public health priorities. We feel that clinical representation from GP consortia should be mandatory (guidance requires consortia representation, but doesn’t specify that it include a clinician).

6. The Health and Social Care Bill requires commissioners to “have regard” to the JSNA and health and wellbeing strategy, but we feel that this is too imprecise; a commissioner could legitimately claim to have “had regard” to the documents and still ignore their content. The board should have sufficient authority to demand explanations from commissioners when decisions do not follow the requirements of the JSNA or joint health and wellbeing strategy and require their attendance before the local authority’s scrutiny committee. We believe there must be a clear process of signing off both Social Service and GP commissioning plans.

7. The whole of NHS and Social Care funding needs directing to Public Health not simply service provision.

8. The local Health and Wellbeing Strategy should provide an important framework for how the ring-fenced public health grant can be spent to ensure continuity and strategic direction during transition. It would also remove the risk of the grant being diverted to uses with no clearly defined role in improving public health and the reduction of health inequalities.

Arrangements for Commissioning Public Health Services

9. In almost all areas of public health there is a split between elements best commissioned by Local Authorities, those best commissioned by the NHS and those best commissioned by the Commissioning Board. It will be hard to identify where the boundaries should fall between the different commissioners, and could easily result in tensions between commissioners as they attempt to provide a fair, equitable and effective balance of services and outcomes. For example, who is responsible for commissioning pharmaceutical provision required to support a public health programme (such as nicotine replacement therapy for stop smoking services, or long acting reversible contraception for sexual health services) and would its funding sit within the public health ring fence?

10. Further clarity around the future location emergency planning function is needed. Whichever body is responsible for local emergency planning needs to have qualified officers to develop the plans and arrangements and assist the commissioners so that contracts are robust during an emergency. Qualified emergency planning staff need to review contractors’ emergency and business continuity plans to ensure they are resilient, compliant and aligned to the business continuity regulations.

The Structure and Purpose of the Public Health Outcomes Framework

11. The most important indicators are those that have the greatest potential to reduce health inequalities. Whilst some will be relevant across the Country, it could be argued that a local authority should be measured on a proportion of locally determined indicators. The final framework should be a compilation of mandatory indicators with a selection of optional indicators to reflect the local need identified within the JSNA.

12. The proposed domains encompass the key areas of public health and reflect health inequalities. A point for clarification regards which organisation with public health responsibility will be leading on, and responsible for the commissioning of activity for each domain.

13. The proposal to share the domain on preventable mortality is a valid suggestion which will require the wider NHS workforce to focus on the prevention agenda, the use of the Prevention and Lifestyle Behaviour Change Competence Framework would be a useful framework for considering in relation to the wider workforce being capable and competent to support this agenda.

Arrangements for Funding Public Health Services (including the Health Premium)

14. Public Health Services:

The Director of Public Health must retain an influential role in decisions about how the funding can be spent during the transition period, and beyond in conjunction with a robust Health and Wellbeing Strategy providing the strategic framework for continuity and negating the risk of funding being diverted to uses with no clearly defined role in health improvement and the reduction in health inequalities.

15. Public Health funding should be retained for health improvement and reduction in health inequalities and not used to bolster existing local authority public health provision, for example environmental health and trading standards enforcement.

16. The Health Premium:

The premium could be structured so that the different outcomes attract different levels of premium, with significantly larger sums associated with the indicators that are more challenging, but demonstrate progress towards reducing health inequalities.

17. The allocation of health premium could also be linked to the delivery of targeted high impact interventions that tackle some of the key issues exacerbating health inequalities in particular communities, based on the needs identified in the JSNA.

18. A note of caution, linking outcomes and the health premium needs to be considered and managed to avoid non-incentivised issues becoming devalued. There is a concern that incentivising some indicators could be to the detriment of others. Similarly, if the JSNA identifies key local priorities for which there is no indicator, consideration needs to be given to how this is addressed.

The Future of the Public Health Workforce (including Regulation of Public Health Professionals)

19. Avoid the loss of significant public health expertise (particularly in the sphere of health improvement / health promotion) which is feared as a result of the abolition of PCTs. The public health workforce has already been depleted through the process of reducing management costs in PCTs and could not be further reduced without having a detrimental effect on its ability to carry out the necessary activity. Capacity to deliver will be challenged if we can’t recruit and develop our talent.

20. Recognition needs to be given to the wider Public Health Workforce for their skills and professionalism. There is a concern that in the proposed transition to Local Authorities the public health workforce could be seen as surplus to requirements, the Local Government Association response the Public Health White paper made it apparent that the budget was an attractive proposition, not the workforce.

How the Government is Responding the Marmot Review on Health Inequalities

21. We would hope to see cross party support for the aims expressed it the Marmot Review.

June 2011

Prepared 28th November 2011