HC 1048-III Health CommitteeWritten evidence from NHS Knowsley Public Health Directorate (PH 16)

The following provides an overview of issues for consideration as part of the inquiry into public health. These issues are highlighted along with potential solutions in order to suggest ways that current proposals can be improved.

Summary

There is a risk that the current specialist public health advisory roles located throughout health trusts and other organisations will be lost if public health is removed in its entirety from the NHS. The future location of public health within local authorities and the Department of Health risks leaving the NHS to further embed its role merely as an illness service.

The training and development of the public health workforce should remain with the Deaneries as is the case with other speciality training schemes.

NHS organisations and local authorities should be required, through the powers of the Health and Wellbeing Board to jointly make data available and produce strategic needs assessments and performance monitoring of health and wellbeing strategies. This will strengthen the joint accountability for improving the health of the population beyond caring for the vulnerable.

The proposed fragmentation of leadership and commissioning for children’s services needs to be resolved with local areas maintaining control for designing and implementing systems that are integrated and meet the needs of local families.

1. Links Between Public Health and NHS Commissioning

Public health leadership is well established as a central support to the commissioning of health services. This has been essential for the development of evidence, needs assessment, intelligence and outcome feedback. Separating the development of a new public health system from the discussion about reforms to health and social care may lead to lost opportunities to integrate functions to better achieve efficiencies and improved outcomes. It was notable that the “Pause, Reflect, Listen, Improve” listening exercise was based on the future NHS model without public health and there was no reference to public health even under the “Advice and Leadership” topic. Specific consideration needs to be given to how public health leadership can be retained within the new health and care system, possibly through retaining employment within the NHS of public health staff.

The web channel on health and care changes on the Department of Health website is titled “Modernisation of health and care” rather than NHS reform, highlighting the barrier of regarding the NHS as a static entity dealing with “health” or “ill-health” rather than as part of a complex system. We would suggest that a return to the aims of improving health, care and wellbeing outcomes through modernisation may clarify possible relationships of health system elements and the role of public health as part of that system.

2. Role of Public Health England

Public Health England (PHE) is expected to form through taking on the functions of other existing agencies including the Health Protection Agency, and the Public Health Observatories (PHOs). If PHE becomes part of the Department of Health, this could cause adverse constraints for these two functions in particular, the independence of their advice and expertise that is relied upon, and the generation of income from supplying knowledge and expertise.

Health Protection

The structures through which health protection will be delivered and the accountabilities within those structures are not clear which is concerning given that these proposals form the majority of the specification of PHE. The responsibilities of local health protection units and Directors of Public Health (DsPH) need to be specified more completely, both for ongoing health protection work and emergency situations. DsPH must have the power to require any agency to respond if needed in preparation for or during incidents. This is particularly the case for when surge capacity is required from NHS organisations as part of a public health response.

Public Health Observatories

Public Health Observatories (PHOs) located in universities are a valuable academic link and take both a regional perspective and a lead on agreed areas of public health intelligence. Nationally, public health information needs to be more closely linked to the Information Centre which will process inputs and outputs relating to the NHS and Social Care Outcomes Frameworks. PHOs provide input at all stages of the population health commissioning cycle and its subsets. Clarification on what resource would be available through the PHOs for local authorities and NHS bodies would be necessary. The reduction in funding for PHOs and the loss of expert staff through uncertainty will result in a lack of capacity for an already scarce resource just as GP Consortia and Local Authorities need intensive support.

If the NHS is to become a “health” service rather than an “ill-health” service then the logic of removing a population prevention and protection function from it is not apparent, particularly if part goes to the Department of Health and part into Local Authorities, breaking the NHS link in two directions.

Public Health Leadership

PHE has been proposed as a “national” public health service but currently has only specified roles for the agencies that are to form it, and for Directors of Public Health. It is unclear how PHE expects to fulfil its national leadership role for the whole of public health across the three domains of health improvement, health protection and health services, or what its relationship would be with the National Commissioning Board. PHE needs to be established as an NHS body such as a Special Health Authority to fully utilise its specialist public health functions.

3. Public Health Workforce

Wherever their working location (public health specialists have roles in universities and trusts and may in future work in other areas in addition to local authorities and consortia) the public health workforce should have access to appropriate training, development and leadership. There is also a danger that DsPH could become an isolated specialist function in local authorities if they are not able to retain and call upon designated public health trained staff. Without this, it would be difficult maintain an overview of population health needs, outcome performance, intelligence and evidence to inform the role of public health advisor to a wide range of partners.

The separation of roles between PHE (national leadership and population based issues) and local authorities (local needs and solutions) could be managed effectively by employing all public health staff in PHE and then deploying them to where relevant issues are best addressed. As an example, many issues that need to be addressed in local authority areas will be common across bigger footprints and may be better addressed in collaboration through pooled resources and influence. This would also facilitate sharing resources when surge capacity is required. Maintaining the centralised coordination of the specialist training programme within this structure would also be beneficial to enable experience to be gained through placements across all public health delivery agencies, managed by the existing Deanery network.

4. Role of the Director of Public Health

Directors of Public Health will oversee and direct work in all three areas of public health. The DPH role is that of the linchpin of the local NHS, social care and public health system, bringing structures together and making them stronger by their presence. In order to fulfil the “Vision of the role of the Director of Public Health” (Annex A Healthy Lives, Healthy People) the following will need to be implemented:

The DPH must have the skills and knowledge required to fulfil the vision for the role which can be assured through the current specialist registration and appointments process. By maintaining these standards, it will be clear that appointed DsPH will have abilities across all the 10 public health competencies

In order that the DPH is able to influence strategically they should have accountability to the Chief Executive, executive team membership and direct access to elected members and their executive group.

The DPH must be able to express professional, independent views as the advocate for the health of the local population and advisor to the Health and Wellbeing Board.

The DPH must have sufficient resources including professionally trained staff with the knowledge and skills to deliver strategic public health advice and plan and implement public health programmes across the three public health domains.

5. Function of Health and Wellbeing Boards

Health and Wellbeing Boards (HWBs) should be the driving force behind needs assessment, prioritisation and collaborative commissioning for local population health and wellbeing. They will work towards the integration of NHS services, social care and public health in its wider social and environmental context, with the aim of achieving improved health and wellbeing outcomes. HWBs should also include the strategic responsibility for health protection and reducing health inequalities. A Health, Care and Wellbeing Strategy should set out how the outcomes are to be achieved. Commissioning plans should then set out the specifications for the services to deliver the outcomes and how resources will be used. The HWB should be charged with ensuring the commissioning plans meet the expressed needs within the population through the use of locally determined evaluation and performance management.

Partners should be mandated to fully engage with the remit of the HWB. Local authorities should be given powers to engage support of the NHS Commissioning Board if there is an issue with compliance from partners to their role or an unresolved dispute regarding the contribution of commissioning plans to the health and wellbeing needs of the population. This includes ensuring that GPCC are responsible for contributing to public health outcomes.

6. Understanding Needs

Joint Strategic Needs Assessment

The Joint Strategic Needs Assessment process has been a joint responsibility of Local Authorities and Primary Care Trusts. Much of the input to JSNA will have been public health expertise and capacity. The Strategic Needs Assessment process should not be “Joint” in name, but through the requirement on all parties to engage. The current proposal to share responsibility for ensuring the process is undertaken between GP Commissioners and Local Authorities with a lead role for the DPH needs to be underwritten with a requirement for any health and social care funded body to contribute information and expertise, and for Local Authorities to be able to contribute the same in relation to economic, social and environmental determinants of health.

Public Health Intelligence

Public health intelligence is the driver for evidence based commissioning for population health and is required at national and local level. Public health provides strong tools for assessment, such as asset based approaches, impact assessment and participatory research. Public health also takes a population view of consultation, engagement and involvement, recognising that health, care and wellbeing are whole population issues, rather than just the population accessing services. Sufficient resource and capacity needs to be retained both in PHE and at local levels to ensure this collation, analysis and interpretation of data can continue to be available. It is essential that the reforms do not block existing access to data from its widest sources that are key to the development of local intelligence that informs commissioning. Robust transfer of data between health and local authorities needs to be established.

Public Health Outcomes

The Public Health Strategy for England and the Public Health Outcomes Framework were both issued for consultation some months after the proposals in Liberating the NHS and the NHS and Social Care Outcomes Frameworks. The government has yet to respond to the public health consultations, but the initial NHS and Social Care Outcomes Frameworks have both been finalised. The outcome frameworks to deliver population health have therefore been agreed prior to consideration of wider issues, not only the determinants of health, but international and global priorities such as demographic change and health threats. One outcomes framework with associated responsibilities for implementation would be preferable.

The result of the Strategic Needs Assessment process that engages all relevant bodies should be a strategy that is owned by the local authority and its population. The strategy should describe the activity that is to be prioritised, the evidence for it and what it aims to achieve.

7. Public Health Involvement in Commissioning

Public health involvement in commissioning must be recognised at all levels from the National Commissioning Board to GP consortia, with a requirement for all commissioners to seek and take account of public health advice. The expertise of public health in commissioning of health services should be highlighted.

Responsibility for Public Health commissioning should originate at local authority level through the DPH. PHE should be positioned in order that it can act on behalf of DsPH to drive national level action in order to give power to local authorities or achieve whole population level interventions where these are more cost effective and publicly acceptable. DPH should have the power to invest the ring fenced public health budget collaboratively to achieve economies of scale where local interventions are less effective or cost efficient.

Anomalies such as the divide in children’s commissioning must be resolved. Local areas should determine what the needs of the local population are and then be able to utilise the expertise of commissioners on a large scale (through PHE and NHSCB), where local commissioning is less effective or standardised services and procedures are required

8. Public Health Budget

The proposal for a ringfenced public health budget holds out the illusion of dedicated funding for population health activity but is a tenuous concept with no indication of what it might have to fund and who might be able to access it. If local authorities are to embrace their population health responsibilities, it must be clear that any ringfenced budget is funding the transition of a public health service, while core funding will be used to deliver outcomes. Public Health departments should be asked to list essential public health delivery functions for sustainable inclusion in local authority responsibilities, rather than list what a (possibly time limited) ringfenced budget should fund. There is also a risk that the ringfenced budget will be further reduced by public health departments having to contribute towards Local Authority on-costs, for items such as Accommodation, HR and Finance support. These have not been included in any consideration of PH current expenditure as they are generally absorbed within PCT costs.

Public health funding proposals offer perverse incentives, literally in the case of the health premium. Premiums should be attracted to populations with the worst health and wellbeing without performance conditions. Evidence of collaborative use of premiums directed through the HWBs would be more appropriate.

Considerable efforts have been made by health and wellbeing partnerships to maximise the impact of health inequalities funding such as Neighbourhood Renewal Fund and single budgets such as Area Based Grant on population health and wellbeing through public health delivery programmes. The 2010-11 in year savings requirements and abolition of Area Based Grant caused the loss of exactly those partnerships and integrated programmes that the Public Health White Paper exhorted public health to develop on its publication three months later. It is concerning that the government appeared unable to recognise the impact withdrawal of Area Based Grant would have for health and wellbeing commissioners across the health economy. Consideration needs to be given to how with reducing resources and increasing demands for care from vulnerable individuals, sufficient resources can be made available to local authorities to fund preventive programmes. This is especially the case where individuals and families living in deprived areas or vulnerable groups require more than just information and access to services in order to make healthy choices.

June 2011

Prepared 28th November 2011