HC 1048-III Health CommitteeWritten evidence from Dr Andrew Clark and Dr Cathy Read (PH 120)

Executive Summary

There remains a lack of clarity about what central government expects from local authorities and where accountability lies. This is a key issue in the wider localism debate and we suggest should be addressed in this context.

We believe the transfer of public health expertise into local government should increase capability and boost the confidence of local authorities in their ability to tackle complex issues of public health and wellbeing. It also presents an opportunity for local communities, through the council, to support the whole of primary care to be more accountable.

We believe it is important that the director of public health is a direct report to the chief executive.

Public health teams within primary care trusts currently can play a leading role in improving clinical pathways and clinical services. Moving public health expertise into local authorities could create gaps elsewhere. This needs to be acknowledged and addressed, either by building capacity within the NHS or accessing those skills in local authorities, or possibly, Public Health England.

We believe the proposed transfer of commissioning responsibility for NHS Health Check Programme and for sexual health services carries significant risks to success.

The proposed outcomes framework is very important. Key to its successful operation will be the selection of the correct contemporary proxy indicators for future improved health outcomes of less or delayed onset of diseases and much better management of those with established morbidity. Reliable data collection is an issue to resolve.

The link between public health adult social care and NHS outcomes is useful. It would also be useful to have an equivalent framework for children and young people.

Relatively few of the proposed indicators in the consultation document are available at a geography lower than local authority. Wherever possible, indicators in the outcomes framework should be available at a lower level as this is potentially more useful to health and wellbeing boards.

A considerable amount of the approach set out by Sir Michael Marmot is recognisable in Government policy but policy development and implementation of supporting initiatives does not appear to be even across the key objective areas.

Dr Andrew Read and Dr Cathy Read

1. Andrew Clark trained at the Middlesex Hospital in London. He was a GP principal in a group practice, a GP tutor and a District Health Authority Board GP member. As Senior Medical Officer in the NHS Executive his main role was supporting the development of the national GP contract, focussing on changes to GP out-of-hours care. He has worked as a consultant and director of public health, including time as the Public Health Director of the North West Cervical Screening Quality Assurance Reference Centre. Currently Deputy Director of Public Health for NHS Yorkshire and the Humber, his role includes the provision of public health support for performance management and professional advice to the serious untoward incident team. He is the SHA clinical lead for the national screening programmes, the NHS Health Check programme and specialist public health aspects of health protection.

2. Cathy Read FFPH has 15 years experience of public health in the Yorkshire region. She is currently Consultant in Public Health at NHS Yorkshire and the Humber, focusing on health inequalities and sexual health. She previously held various jobs in medicine and spent 10 years working as a journalist and editor. She has contributed to research on social capital and health and access to health care and is an Honorary Senior Clinical Lecturer at Sheffield University.

The Public Health Role of the Secretary of State

3. The stated intention to focus on cross-government action for public health is welcome, particularly if this is informed by the full scope of the Marmot Review and is not limited in practice to issues like obesity—important though this is. It will be interesting to see how the cross-cabinet committee mechanism and the new public health focus of the Department operate in relation to the reform of the benefits system, and informs policy development in key public health issues such as alcohol, food and transport for example.

4. On accountability, there remains a lack of clarity about what central government expects from local authorities and ultimately responsibility. We are aware this is one of the knotty problems of the whole “localism” debate and is exercising many others, including the Public Accounts Committee and the Communities and Local Government Committee. We note that the latter has suggested the development of a constitutional settlement as a potential way forward and suggest that the respective roles and responsibilities of the Secretary of State and local authorities in relation to public health should be part of these discussions.

The Future Role of Local Government in Public Health

5. The move to return leadership to local authorities is welcome. We believe it strengthens capacity and capability to respond to the challenge, particularly in relation to action on health inequalities. Having a much-enhanced level of public health expertise in-house should offer greater scope for more systematic action on the social determinants of health as well as in relation to the commissioning and scrutiny of clinical services.

6. We believe the knowledge, skills and expertise of directors of public health and their teams can make a positive contribution to the functioning of the wider council—techniques such as health needs, health impact assessment and equity assessments, for example, their approach to the use of evidence of effectiveness, evaluation skills, their knowledge and understanding of clinical environments.

7. We believe this should increase capability and boost the confidence of local authorities in their ability to tackle complex issues of public health and wellbeing. It also presents an opportunity for local communities, through the council, to support the whole of primary care to be more accountable in a way that has simply not been possible before, in respect of their service provision, use of resources such as hospital planned and unplanned referrals and prescribing costs and practice population outcomes in early diagnosis and long term condition management.

8. Given the sensitivity and complexity of the above we are very concerned that some of this potential is much less likely to be realised if the director of public health does not have sufficient seniority to access and influence lead members and chief officers across the organisation. We believe it is important that the director of public health is a direct report to the chief executive.

9. In relation to joint strategic needs assessment and effective health and wellbeing boards and strategies, we would like to draw attention to a small but significant data issue. It will be a real advance if public health teams can have access to up-to-date outcome data from practices. One regular frustration is reliance on “old” QOF data for planning, which was devised as payment system for GPs. In public health terms an important element of securing better health will be much better outcomes in populations with long term conditions such as diabetes, cardiovascular, and respiratory diseases etc. We are aware of some exciting pilot work in Lancashire and the Black Country and elsewhere. In these areas practices are using common software in relation to long term condition management and mid life health checks that supports better management by the practice, allows their primary care trusts to undertake data analysis at population level and offers great prospects for improved planning and management support systems for people with long term conditions within individual communities.

10. While we believe there is a need for greater clarity on local to national accountability, we are also aware of much debate around accountabilities to and between member of health and wellbeing boards. Equally important will be how the local health and social care providers interact and support each other. This includes the very important contribution from the voluntary sector and unpaid carers. The presence of Health Watch England will add to this.

Arrangements for Public Health Involvement in the Commissioning of NHS Services

11. Most GPs are not trained in public health and most of their professional career is spent dealing with individuals and their health problems. Their previous involvement in NHS commissioning such as GP Fund holding has usually been centred on commissioning of specific procedures such as hernia repair, hip replacements etc. At the time these systems were evolving into a broader more population approach to NHS commissioning through GP Multifunds, Primary Care Groups and Primary Care Trusts. However none of these commissioning models have been significantly public health focussed. They have not been required to and so are not used to taking a population focus. In our experience in Yorkshire and the Humber, GP consortia members recognise this and initial thinking is that they will probably look to the director of public health for some level of advice and support.

12. What is probably less widely seen is the contribution public health teams within primary care trusts currently make to improving clinical pathways and clinical services. eg diabetes management in Barnsley, circulatory disease in Sheffield, the earlier detection of lung cancer in Doncaster and glaucoma in Leeds.

13. Moving all public health expertise into local authorities could create gaps elsewhere. This needs to be acknowledged and addressed, either by building capacity within the NHS or accessing those skills in local authorities, or possibly, Public Health England (PHE). In addition, the source of specialist public health elements of the, so far, largely unspecified GP Consortia Commissioning Support provision. However there are real risks to maintaining the speciality’s current high quality and value for money by dispersing a relatively scarce public health expert resource in this way.

14. It would be sensible if best use was made of accredited public health specialists in local PHE and in the DPH teams to cover these areas. In this regard it is so far unclear how the NHS Commissioning Board (NHSCB) and DH Policy teams will be obtaining its specialist public health expert advice.

15. This analysis indicates that best economies of scale and maintenance of a wide range of high quality public health specialist expertise to support commissioning in these different arenas could well require joint appointments between PHE and Local Authority Public Health Teams. This would build on existing examples of effective integrated commissioning such as Sheffield’s commissioning group for long term conditions, which draws on expertise from public health, working with acute and primary care, or the neighbourhood adult health teams, which integrate commissioning for health and adult social care in Leeds.

Arrangements for Commissioning Public Health Services

16. We do believe the proposed transfer of commissioning responsibility for NHS Health Check Programme and for sexual health services carries significant risks to its success.

17. The NHS Health Check is a new and complex universal system to prevent, or delay the onset of, or diagnose early vascular diseases in the target population. It is essentially a systematic case finding programme very analogous to the current national screening programmes. Commissioning strategies to deliver a cost effective and safe service are still in their infancy. Commissioning the NHS Health Check Programme, in a manner that gets it successfully and safely established, should remain within the purview of the NHS Commissioning Board at least until the completion of full roll-out in 2017.

18. The proposed fragmentation of sexual health commissioning runs counter to considerable recent efforts and some success in integrating sexual health provision. Fragmented commissioning is not efficient and could result in either duplication or gaps in service for vulnerable people. These are highly specialised clinical services which local authorities do not have experience of commissioning. If they are going to buy in services they may duplicate effort where supra-local authority commissioning could be more efficient. From our experience even specialist PCT staff have benefited from a range of intermediate tier level support and strategic leadership from the HPA, SHA, NCSP and DH. Sexually transmitted infections do not respect local authority boundaries and it is critical to have a supra local authority perspective a swell as understanding variation within a local area. Services must be open access and universal and not subject to the preferences of local politicians facing difficult funding decisions. This would erode the founding principles of the NHS, worsen health inequalities and would almost certainly breach the requirements of the Equalities Act as some of those most vulnerable and able to benefit from appropriate outreach services belong to the protected groups. In our experience strong local sexual health networks which are clinically led are critical to making progress and controlling sexually transmitted infections. A commissioning model which harnessed this energy and expertise would strengthen rather than weaken the current approach. If Public Health England were given responsibility for sexual health and delegated this locally to an appropriate commissioner, meeting specified quality standards, then this could get around concerns that some local authorities may not do the job well.

The Structure and Purpose of the Public Health Outcomes Framework

19. We welcome the principle and regard it as very important, while appreciating that this is an area where there is much work to be done. The key, in our view, is for the selection of the correct contemporary indicators for future improved health outcomes of less or delayed onset of diseases and much better management of those with established morbidity. A key issue to be resolved is how to reliably collect the necessary data.

20. The link between public health adult social care and NHS outcomes is useful. It would be useful to have an equivalent framework for children and young people, reflecting the significance of services and actions to improve their health and development, the contribution improvement here will make to the reduction of inequalities and reflect the role of the directors of children’s services in local health and wellbeing boards.

21. Relatively few of the proposed indicators in the consultation document are available at a geography lower than local authority. We would like to suggest that, wherever possible, indicators in the outcomes framework should be available at a lower level eg post code, as this is potentially more useful to health and wellbeing boards, in understanding and reducing inequalities within their areas. This approach could also create a stronger link between local strategies and the outcomes framework nationally.

22. We have been able to produce profiles on the wider determinants of health for each upper tier local authority in Yorkshire and Humber, containing slope indices of inequality. These show the degree of inequality within a locality on the topic and where inequality is relatively greater. Indicators covered include all age, all cause mortality, early years foundation stage development, child poverty, educational achievement at GCSE, long term unemployment, job vacancies, civic participation, housing condition and fuel poverty.

23. Again we believe the potential of GP systems to support and complement this “lower level” analysis is significant. Such an approach could well be found to be of great importance to GP consortia as they tackle their health improvement programmes to secure the very significant reductions in planned and unplanned care that the NHS QIPP programme demands.

Arrangements for Funding Public Health Services

24. We are pleased at the recognition that, in the past, public health has often been “raided” to fund other parts of the NHS, but we are aware of the anomaly of ring fencing when the direction of travel is generally to remove ring-fences from local authority budgets. More worrying is the potential that the ring-fenced budget alone is seen as the public health budget, rather than the transfer of what we calculate the NHS currently spends on direct public health services and not reflecting local authority spend on the wider determinants such as housing.

25. These are all public health programmes based on population based data, hence the importance of public health expertise in its commissioning.

The Future of the Public Health Workforce

26. Many colleagues have a role in public health but we believe it is important that the high quality of public health specialist expertise is maintained and improved. The mandatory nature of professional accreditation for specialist public health practice must be maintained. This needs to continue to be delivered by current regulatory processes being used by whoever employs the public health specialist. PHE should have responsibility, along with the Faculty of Public Health, for assuring the high quality of specialist public health practice through common recruitment processes as well as regular appraisal and revalidation systems.

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

27. Sir Michael Marmot presented his findings to senior leaders in local government and the NHS across Yorkshire and the Humber. His arguments struck a strong chord with many and over the following months many have used the full Marmot framework to take forward their work on inequalities. These include Barnsley, Calderdale, Rotherham, and Sheffield.

28. The Government stated that the public health white paper set out how it wished the Marmot Review evidence to be taken forward. A considerable amount of the approach set out by Sir Michael Marmot is recognisable in Government policy, for example the cross government working and the focus on social justice. Some recommendations of the review have emerged as prominent elements of policy, for example, the welcome expansion of health visitor numbers and the roll out of the Family Nurse Partnership programme.

29. However, policy development and implementation of supporting initiatives does not appear to be even across the key objective areas. For example, we have heard local evidence about the increasing numbers of families under financial stress and increasing numbers experiencing fuel poverty. A recent study by Salford University, on behalf of Leeds City Council, found that on measures such as level of indebtedness, ability to save, use of non-mainstream credit, areas with average levels of household income surveyed in 2010, were found to be more financially excluded than deprived areas studied in 2004.

June 2011

Prepared 28th November 2011