HC 1048-III Health CommitteeWritten evidence from Sheffield City Council (PH 125)

Executive Summary

1. We welcome the transfer of PH to local authorities as we think local authorities can do more than the NHS to address the root causes of ill-health and inequalities. We are clear that the transfer of public health responsibility to local government is a positive change and will enable local authorities to utilise their broad service responsibilities to improve public health outcomes for communities and address the wider determinants of ill health.

2. We also feel that the development Health & Wellbeing Boards (HWB) will be a powerful mechanism which will strengthen relationships between commissioners of health care, social care and public health and support the delivery of better health outcomes for communities in Sheffield.

3. However, we are concerned about the implications of centralising health protection arrangements. We feel that isolating one element of emergency planning from wider local arrangements and operating it at a national level which are delivered by all local partners is dangerous and not in the interests of local people. We feel a system of emergency planning should be integrated at a local level—police, local government, fire and rescue, and NHS.

4. We feel it is important that duties should be agreed with GPs to ensure they are accountable to local people for their PH contribution and the outcomes they bring.

5. GPs should have a statutory duty to work with councils on public health, as should Public Health England (PHE).

6. HWBs are essential in the new system and should have the ability to engage with PHE at local level and hold it to account for its effectiveness (limited to locally determined priorities).

7. The Public Health White Paper published by Government in November 2010, does not include any clear designation of responsibility for local population health. Our view is that this should be assigned to Local Authorities and be the responsibility of the Leader of the Council.

8. The suggestion of greater flexibility for PHE in commissioning services conflicts with the localist principles of the Government and we feel that commissioning for public health is best placed at local level (particularly as the emphasis should be placed on spending the majority of public health funding at the local level).

9. There remains a fundamental lack of clarity about the dual accountability of Directors of Public Health (DsPH). We feel DsPH should be accountable to the local council only and local authorities should be trusted to determine how public health leadership is provided in the area and to whom the DPH reports. Dual accountability adds complexity and undermines local democratic accountability for public health decision making.

10. To minimise the risk that public health expertise is lost in the transition, there needs to be better understanding of the TUPE arrangements to enable PCT staff to transfer to councils and/or GP consortia. Whatever arrangements are determined by the council and GPCC, DsPH need to be Member appointments given their status and grading.

11. Greater acknowledgement that many councils have excellent information and research capabilities which can be used for public health related work, indeed a combination of Council and PCT expertise will build centres of excellence, working closely with universities.

12. The focus of the Outcomes Framework, the ringfenced budget and the Health Premium should be addressing the causes of ill health (as set out by Sir Michael Marmot).

13. The formulas used for calculating the public health budget allocation should be “Utilisation” and “Population health measures” (the latter taking within-District inequalities into account).

14. We have serious concerns about the proposed Health Premium. We feel that the Health Premium should be awarded on the basis of progress made and improvement on baseline position, rather than absolute improvements. This would mean that the premium mechanism would recognise the distance travelled by those areas with the biggest health inequalities challenges. Otherwise, there is a danger that areas with greater levels health inequality may struggle to make sufficient progress to access the Premium.

15. We note there is a professional lobby amongst some PH specialists to remain outside local government, at least for their employment. We are strongly against this as it would negate the council’s responsibility and democratic control of the PH system.

Creation of Public Health England within the Department of Health

16. We have concerns that creating Public Health England as a part of the Department of Health will undermine its independence and hence authority as a source of independent public health advice. We believe that its credibility would be enhanced by establishing it as an independent organisation, similar in status to the current Health Protection Agency.

17. PHE should be required to work with Local Authorities, as should NICE. NICE has done little work with Local Authorities and this requires development to build relationships and understanding which is fundamental if there is to be an effective and efficient delivery of public health services. PHE will have research and information responsibilities but we feel PHE and local authorities need closer relationships with the research and analysis expertise available in universities, not just through academic public health departments, many of which have focussed on a narrow agenda of health services and behaviour. We need to draw upon eg. Departments of Politics, Environmental Science, culture, too. Local and national systems for this are required to facilitate the development of research hubs.

18. We believe that the commissioning of public health services by GPCC and local authorities working together would more effectively meet the needs of communities if it was done at the local level. At present, the proposals contain areas where the commissioning of services is over complicated and ultimately undermined by the centralisation of elements of public health provision. For example, we do not understand the rationale for PHE commissioning public health work for under 5s and HVs—all of this should be done by councils and the GPCC working together.

19. We do not feel that the case has been made to justify greater PHE flexibility and this may conflict with the localist principles of the Government.

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

20. Both the Health Protection Agency and the National Treatment Agency for Substance Misuse undertake vital roles within the Public Health system in England.

21. The NTA has been a key partner and stakeholder in the development of effective treatment and recovery systems. If the National Treatment Agency and the regional support teams to partnerships are abolished; our local partnerships will seek assurance that the positive benefits that the NTA has provided are not lost. We would recommend that a thorough impact assessment is carried out on the decommissioning of the NTA.

22. We are concerned about Emergency Planning being led by PHE. Local Emergency Planning must be embedded across local agencies. We feel that one element being led from a national organisation will severely disrupt our ability to address local emergencies, we consider such an arrangement to be dangerous. In fact we need integration at a local authority level of all services who are “level one responders”. We believe that emergency planning is an key local responsibility, currently co-ordinated through local resilience forums. It is crucial that there is clear local NHS leadership for emergency planning and that public health has an integral role in local resilience forums, local authorities and the NHS.

The public health role of the Secretary of State

23. In light of the importance of effective health services to the health of the public, we believe that the current duty imposed on the Secretary of State to provide comprehensive health services should not be amended, as is currently proposed in the Health and Social Care bill.

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)

24. There remains a fundamental lack of clarity about the dual accountability of Directors of Public Health (DsPH). We feel DsPH should be accountable to the local council only and local authorities should be trusted to determine how public health leadership is provided in the area and to whom the DPH reports. Dual accountability adds complexity and undermines local democratic accountability for public health decision making.

25. It needs to be recognised that the public health proposals from Government are as much about councils developing their new leadership role and responsibilities in public health as they are about the physical transfer of public health expertise from the NHS.

26. The role of Public Health England in the appointments process for Directors of Public Heath needs to be clarified.

27. To minimise the risk that public health expertise is lost in the transition, there needs to be better understanding of the TUPE arrangements to enable PCT staff to transfer to councils and/or GP consortia. Whatever arrangements are determined by the council and GPCC, DsPH need to be Member appointments given their status and grading.

JSNA

28. Duties should be developed to ensure that strategic leads and commissioners (including GPCC) “have regard” to the JSNA to inform health commissioning decisions.

29. JSNAs must be used to inform local planning. In addition to being agreed by the local Health and Wellbeing Board, they should be approved by the Council’s Cabinet or local Community Assemblies (which are Sheffield’s devolved local area committees).

30. Any guidance or best practice for the JSNA should require local authorities to have regard to the other assessments we are required to complete to understand the wider determinants of health (eg Local Economic Assessment, Child Poverty Needs Assessment, Join Strategic Intelligence Assessment, Housing Market Assessment). It is crucial that greater linkage is developed between such assessments in order to address the wider determinants of health, as identified by the Marmot Review.

Joint Health and Wellbeing Strategy (JHWS)

31. A locally agreed Health and Wellbeing Strategy is potentially an important driver for public health improvement and the wider development of health and social care services in an area. This must be informed by specialist public health input through the JSNA, the views of local communities, wider needs assessments and profiling (Local Economic Assessment, Joint Strategic Impact Assessment, community profiles). Local commissioners of health, public health and local government services including social care must be held to account for commissioning services which contribute to the implementation of the Strategy.

Arrangements for public health involvement in the commissioning of NHS services

32. Local councils and GPCC should be left to agree the best mechanisms and arrangements for this, the Council will need public health experience for its role in the commissioning of local and social care services, as with GP consortia. The role of PH in these services’ commissioning requires greater clarity and definition.

33. Effective, efficient and accessible health services make a vital contribution to public health and reducing health inequalities. “Health services public health” is the contribution that public health expertise makes to ensuring that health service provision is optimised, and is one of the three strands of public health activity (the other two being health improvement and health protection). It is vital that health services commissioning undertaken by GP Commissioning Consortia is informed by public health expertise, and that there are effective arrangements at local level to achieve this. This could be effected in a number of ways: eg by GPCC employing PH consultants, by seconding PH consultants from Local Authority PH teams, or by GPCC commissioning such input from elsewhere.

34. The resourcing of this element of PH activity needs clarification. If it is deemed to be within the GPCC “running costs”, then GPCCs should be mandated to demonstrate that they have used the resource to access the relevant expertise

35. Effective mechanisms for ensuring that Dental Public Health advice is available to commissioners of dental services must also be established. Current proposals are that Dental Public Health should be a responsibility of local authorities, yet all commissioning of Dental services is to be done by the NHS commissioning board. IT is not clear how they will access Dental PH advice.

Arrangements for commissioning public health services

36. We feel that local authorities are best placed to commission local public health services but where Government are insistent on PHE commissioning services, there must be a clear, complementary commissioning approach between local authorities and PHE.

37. We have concerns about where the responsibility for commissioning some public health functions has been allocated in the White Paper. In particular, we feel it is unnecessary to separate the commissioning of public health services for children, as the White Paper states that responsibility for commissioning of services to the under 5s will rest with PHE. This adds unnecessary complexity to the commissioning of public health services for children and families and will undermine “whole household” approaches to improving family wellbeing.

38. We feel that sexual health services including TOPs, DV support, support for families with multiple problems should be commissioned by GPs advised by local authorities and sometimes by joint commissioning.

39. The Public Health White Paper suggests that the majority of public health activity should be spent on local services. Therefore, we feel it should it follow that services should be locally commissioned, adhering to the Government’s commitment to localism. We believe that local authorities are best placed to commission public health services which are informed by and meet the needs of local communities to improve public health outcomes and tackle health inequalities. The fundamental benefit of empowering local authorities with the responsibility for public health is that local authorities are able to influence and address the wider determinants of health and embed public health priorities in all local government services. This will be inherently weaker if a complicated commissioning arrangement between central (PHE) and local (councils, GPs and Health & Wellbeing Boards) is pursued.

40. We believe that public health outcomes can be enhanced if they are commissioned locally by local authorities and GP Commissioning Consortia working together. For example, we feel:

GPCC should commission contraception services.

LAs and GPC should commission nutrition services and support.

GPCs should commission NHS health checks.

41. We believe that local authorities should be empowered to provide or commission:

work to address inequalities (especially financial inclusion);

housing;

nutrition/food;

all children’s PH activities; and

substance misuse services—prevention (GPC should commission treatment services).

The future of the Public Health Observatories

42. It is crucial that the considerable public health information and intelligence expertise currently in PCT public health departments is not lost. There is a real danger of this with the uncertainty about employment, TUPE arrangements etc. Some PCTs currently have excellent expertise in research and analysis but Equally there is good knowledge and skills available in PHOs. There should be a split between national and regional level intelligence work that PHOs would be well placed to undertake but that local intelligence work should be the responsibility of the local authority.

43. We would like the Government to give greater recognition of the ability and important role of local authorities in providing district and sub-district level public health information and analysis. Local authorities are uniquely placed to combine public health analysis with wider intelligence and analysis and PHE would find such local focus almost impossible to provide to each local area.

44. As with the wider PH proposals, there is an opportunity here to unite the considerable information and intelligence expertise in PCTs with the research and intelligence functions in local authorities. This would support the further development of comprehensive evidence-based commissioning in public health whilst capitalising on the wider demographic and socioeconomic expertise in local authorities.

45. Greater acknowledgement that many councils have excellent information and research capabilities which can be used for public health related work, indeed a combination of Council and PCT expertise will build centres of excellence, working closely with universities.

The structure and purpose of the Public Health Outcomes Framework

46. The outcomes framework must not act as a top down performance mechanism - that would be a barrier to improvement and undermine localised target setting, innovation and delivery of outcomes

47. We feel that in order to ensure the outcomes framework drives public health improvement, Government needs to:

ensure geographical aggregates are appropriately aligned and reflect relevant performance/lead arrangements;

indicators should be relevant to stakeholders (ie members of the Health & Wellbeing Board) and applied appropriately (ie the indicators align to actions that can be taken by the relevant agencies involved);

make trend data available (and if not available consider re-engineering historical data to facilitate this);

consider the organisational degree of overlap;

prioritise local (small) area level analysis; and

that relevant local PH intelligence staff can access the necessary data (ie will ex-NHS staff based in a local authority be able to access what is currently categorised as NHS data?). As the proposals currently stand, access to data is a considerable barrier to integration of these public health services and we feel that the Department of Health need to be actively trying to address this issue.

48. Focus must be on addressing the root causes of ill health and not just behaviour change. Behaviour change is an important part of the approach to tackling health inequalities and support people to make positive health choices. However, addressing the root causes of ill health, as set out by Marmot, is fundamental to advancing health equality.

49. In our response to the Government’s consultation on the Public Health Outcomes Framework, we suggested that the Department for Health should consider the following in order to strengthen the outcomes framework:

Base the domains on the categories, indicators and evidence contained within the Marmot Report.

Distinguish clearly between intra and inter district differences (and don’t use them interchangeably).

Consider all axes of inequity.

Definition of deprivation (presume this will need to be re-based from Census 2011).

Baseline clearly defined so measuring change from baseline rather than a general improvement (eg measure change in the slope as well as size of the gap).

Consider level of challenge faced within individual areas.

Ensure indicator, performance measure and actions that can and should be taken are aligned.

Measures should be more strongly focused on health inequalities.

More economic/income indicators (including around stability/quality of employment).

Arrangements for funding public health services (including the Health Premium)

50. It is crucial that major local authorities and particularly those with the largest populations suffering some of the worst health inequalities (eg. the eight Core Cities) are able to work directly with Government and the Department to develop the allocation formula and health premium. This is particularly important in the context of the other significant financial and structural changes that are currently being delivered in the public sector as a whole.

51. Further, we also believe that Government must fully consult Directors of Public Health, Local Authorities, academics with expertise in health inequalities and public health informatics experts in the development of the public health budget formula and the Health Premium.

52. We feel that linking health improvement budgets to progress on the public health outcomes framework would be an effective mechanism to incentivise further achievement and also may provide additional resources to support greater progress.

53. The health improvement budget should be based on need to ensure that areas with the biggest challenges are sufficiently resourced.

Health Premium

54. We have reservations about the proposed Health Premuim. It will be a significant challenge to identify a measure of health that is sufficiently robust and responsive to be used as a measure of health inequality at local level and which would respond quickly enough to Public Health activity. Moreover, even if one such were found, the other factors that impact on health inequality (such as widening socioeconomic inequality, internal and external migration etc) are likely to be as influential as any PH activity, so that the Health Premium would not be a fair mechanism for rewarding such activity.

55. There is a danger that those areas with the largest health inequalities will not be able to demonstrate the necessary progress to access the Premium. If the Government decides to implement the Health Premium, then it should be awarded on the basis of progress made and improvement on baseline position, rather than absolute improvements. This would mean that the premium mechanism would recognise the distance travelled by those areas with the biggest health inequalities challenges. Otherwise, there is a danger that areas with greater levels health inequality may struggle to make sufficient progress to access the Premium

The future of the public health workforce (including the regulation of public health professionals)

56. Integrated training and co-development is essential to developing future generations of flexible, informed professionals for whom integrated working is the norm.

57. We feel that further attention needs to be paid to future specialist training arrangements for public health, not only around medical education but also across other professional disciplines and areas of expertise. We are concerned that the proposed dissolution of the Deanery structure and replacement with what are essentially ad hoc arrangements funded by a levy from the employers of specialists (in this case, local government and PHE) will not lead to sufficiently robust and high quality arrangements for PH specialist training in the future. Whatever future arrangements are reached with regard to funding training, it is essential that local government is recognised as a suitable training location.

58. In this workforce context too, we would support the retention of the General Social Care Council to provide specialist regulation for social workers and other social care staff, rather than the proposed merger with the Health Professions Council in or after 2012. While we believe strongly in service integration, we believe that this is most effective when it is the product of joint working between professionals with their own specialist skills, areas of expertise and professional perspectives, and this in turn is best supported by specialist professional regulatory and training bodies, especially in the context of the current Social Work Reform programme and the Munro report.

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

59. We welcome the recognition of Sir Michael Marmot’s work in the Public Health White Paper and feel that the proposals for health and public health present a real opportunity to address the wider determinants of health.

60. However, we feel that the Marmot report’s findings could be used more explicitly, helping to shape the Outcomes Framework and wider Government priorities. As the new PHE is expected to work across Government, we would welcome the development of a cross Government approach to tackle the socioeconomic determinants of poor health rather than seeing it siloed in the Department of Health.

June 2011

Prepared 28th November 2011