HC 1048-III Health CommitteeWritten evidence from HK Consulting (PH 121)

HK Consulting specialise in strategic commissioning and partnerships between the NHS, local authorities and wider voluntary and private sector partners to drive improvement. We welcome this opportunity to submit evidence to the Health Select Committee’s inquiry into public health.

1. Executive Summary

HK Consulting broadly support the Government’s proposals that place responsibility for local health and wellbeing and the reduction of health inequalities within local government, and are strongly supportive of the Government’s proposed role for the Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategies. HKC agree public health is a vital but often neglected aspect of the National Health Service; the financial constraints on public sector spending, coupled with an ageing population mean that it is more important than ever to identify opportunities for early intervention, effective methods of prevention, and innovative investment and delivery mechanisms.

HKC does however have concerns about local partners’ ability to realise the full potential of the process without adequate support and capacity. The level of current development and capacity building support offered to the new leaders through transition appears inadequate compared to the scale of the challenges. Our experience shows that without effective leadership and support, this new opportunity to address entrenched health inequalities and poor outcomes through the development of new partnerships is unlikely to be properly exploited.

2. Joint Strategic Needs Assessments

2.1 HKC supports the new central role of the Joint Strategic Needs Assessment to public health investment but has concerns about how ready public health teams are—especially in light of organisational changes—to realise the system-wide expectations now placed on them and the JSNA.

2.2 Through their JSNA, a leading cohort of areas have created shared, evidence based strategic priority setting processes through their JSNAs, asked tough questions about poor outcomes and system failure, driven real change across public services demonstrated by improved outcomes. Many areas have shown sophisticated high-level needs assessment are not only manageable but realise tangible benefits across the wider statutory and non-statutory sector, extending beyond the traditional realms of health and social care.

2.3 In contrast, a significant number of areas have struggled to provide quality insight into poor outcomes and local priority issues around health and wellbeing. The JSNA has struggled to connect with existing strategic planning and commissioning processes and has little or no impact on decision-making outside traditional health and care settings. This is often a result of poor leadership, limited resources, and siloed working, and historically was exacerbated by competing demands of divergent regulatory frameworks.

2.4 HKC considers this is a critical time for public health where the opportunity to lead a process that helps to drive s real change and tackles the most persistent of health inequalities is waiting to be seized. However, low morale and a reduction of capacity and status of many public health professionals brought on by organisational change may make the local JSNA and Joint Health and Wellbeing Strategy (JHWS) processes a poisoned chalice for those “in the day job”. Without the necessary tools, learning processes and improvement programmes, the increasingly contentious and political nature of priority setting processes may prove overwhelming for officer-level staff. It is clear the Department of Health, national improvements agencies and others need to continue to provide support to help areas to fully realise the opportunities of the new system.

3. Public Health Observatories

3.1 HKC considers public health observatories to be an integral part of the public health service and recognises the key role they play in collecting the data, intelligence and evidence base that form such an integral part of the strategic approach needed to address persistent health inequalities. HKC is concerned about the reduction in the core contribution for each observatory and the removal of funding for the Association of Public Health Observatories.

3.2 A reduction in funding would impact on skills and capacity of public health observatories to support public health delivery, encourage the perverse consequence of the duplication at a local level and miss big picture analysis. There is also a danger the skills and capacity of Public Health Observatories in developing specialised public health best practice and evidence of effectiveness will also be lost.

4. Public Outcomes Frameworks

4.1 Policy makers must remain cautious that outcomes frameworks across health, social care and public health do not become a goal in themselves and tick box exercise; a lesson from the past is that siloed national level assessment frameworks ride roughshod over the necessary “give and take” at the heart of robust local partnerships and integrated working. There must therefore be crystal clarity that local priority setting generated by quality JSNA/JHWS processes have clear parity with national targets where there is an incontrovertible local narrative. However, in HKC’s view the fundamental question of local versus national persists; government and policy-makers must show absolute commitment to recognising legitimacy of local decision-making alongside national outcomes frameworks.

4.2 Further, HKC considers the importance of alignment between of the Outcomes Frameworks for adult social care, the NHS and public health to be paramount to guard against competing interest and divergent criteria across the system. HKC understands that different services face competing priorities and accountability structures and it is important the new outcomes frameworks are sufficiently complementary so as to support and facilitate enhanced integration and shared priorities. There must be sufficient interplay between the public health outcomes framework and the NHS and adult social care frameworks to allow partners to work together in an effective and innovative way.

5. Responding to Marmot

5.1 HKC considers the new and central role for the JSNA and JHWS and the duty to commission with regard to them will help progress the recommendations of the Marmot Review. The increasingly prominent role of the community and voluntary sector in the JSNA/JHWS processes should ensure the voice of hard-to-reach and seldom heard groups is heard and considered in strategic planning and commissioning.

6. Conclusion

6.1 HKC supports the Government’s view that persistent health inequalities are best addressed via strategic commissioning informed by a JSNA and JHWS. It is right the strategies are produced by a health and wellbeing board that brings together all health, public health and social care commissioners to agree overarching priorities and subsequent actions.

6.2 HKC is, however, concerned that policy-makers are pushing ahead with a process that transfers greater decision-making and public budgets to the local level without any evidence of a clear risk management strategy (ie mapping the strengths and weakness of the proposed new system and its leaders, logging the major likely risks and identifying the necessary investments and actions to mitigate them, such as priority areas for skills enhancement.) We believe this would be unthinkable in any equivalent restructuring in industry. It is our view that the current development and capacity building support offered to the new leaders through transition is inadequate and, unless addresses, risks another decade of failure to tackle poor outcomes and persistent health inequalities.

June 2011

Prepared 28th November 2011