HC 1048-III Health CommitteeWritten evidence from the Royal College of Nursing (PH 128)

1.0 Introduction

1.1 The Royal College of Nursing (RCN) issued a full response to the Department of Health’s White Paper consultation on public health, Healthy Lives, healthy future and its corresponding documents on the Outcome Framework and Commissioning in March 2011. In these responses the RCN stated that it welcomed the renewed focus upon public health and that a new Public Health Service would be established with a focus on disease prevention and evidence based approach to improve health behaviour. However, the RCN has many concerns with the proposals for public health, not least the pace of change and the lack of mandated nurse involvement in commissioning of all health care services, including public health.

2.0 Executive Summary

2.1 It is vital that clearer lines of responsibility and accountability are mandated between the various actors and agencies created by the reforms. There must be clear mechanisms by which the tax payer can hold ministers to account, as well as those responsible for commissioning, delivering and overseeing care.

2.2 The RCN supports the focus on outcomes if it is sufficiently flexible to allow for local responses, whilst providing a robust public health framework to allow for comparisons and bench-marking. It is important that as well as high level outcomes there are also intermediate and short term outcomes in order to measure progress over time.

2.3 Nurses have an invaluable insight into the practical issues of service delivery, including advice on value for money, efficiency, and effective and quality care provision.

2.4 RCN members are overwhelmingly concerned that the allocated grant to Local Authorities would not be protected despite Government assurances. Coterminosity with local authority boundaries would alleviate many of the complexities of funding arrangements.

2.5 The Health Premium will require careful planning and the results of piloting should help inform decision making of future premium allocations. Rewarding those who demonstrate the greatest gains may disadvantage those localities with fluctuating populations, which mean that there is a steady influx of disadvantaged people whilst the more affluent leave the locality.

2.6 Health and Wellbeing Boards have the potential to offer a central platform for all concerned and if adequately prepared and supported, should facilitate joint commissioning arrangements.

2.7 The RCN welcomes the Government support for the Marmot review but believe that in the period since February 2010 there could have been more proactive work carried out by the Government to reap the benefits of the Marmot Review Team’s recommendations.

2.8 Public Health Observatories (PHOs) provide invaluable information in regard to the health of the nation. PHOs have been able to present national and local statistics providing valuable information as the basis for policy and strategy to tackle health inequalities and public ill health.

3.0 Overview of Reforms

The RCN strongly urges the Government to adopt a phased approach to implementing new arrangements. This includes a full evaluation phase, sharing best practice and building on what is already known about good commissioning and delivery of services.

3.1 The RCN is also concerned about the pace of change in these times of financial constraint, and in particular how the move to Public Health England and Local Authority responsibility will impact upon the coherence of public health services. The transition will necessitate the integration of staff, systems and cultures if it is to succeed. The RCN believes that the proposed timetable is too ambitious and urges that appropriate support mechanisms are in place to support staff during the transition and that sufficient time is allowed for the new systems to become embedded.

3.2 The RCN Frontline First campaign has shown the effect the efficiency savings are having upon the NHS workforce, with 40,000 posts already earmarked for removal. Such cuts to the workforce cannot fail to effect standards of care and service.

4.0 Role of the Secretary of State

The RCN is uneasy with the proposed arrangements of accountability including that of the Secretary of State within the Health and Social Care Bill. It is vital that clearer lines of responsibility are mandated between the various actors and agencies created by the reforms. Questions remain over the transition of the Department of Health to the Department of Public Health, local government responsibilities, and with the governance arrangements of Public Health England.

4.1 There must be clear mechanisms by which the tax payer can hold ministers, as well as those responsible for commissioning, delivering and overseeing care, accountable for government funded services. As the proposals currently stand the RCN does not believe the system is sufficiently robust.

5.0 Outcomes Framework

The RCN supports the focus on outcomes within a framework that is sufficiently flexible to allow for local responses, whilst providing a robust public health framework to allow for comparisons and bench-marking. This approach should help to ensure that populations across England are not disadvantaged through poor commissioning, poor delivery or inappropriate allocation of resources. Consideration should be given to outcome accountability and how shared responsibility will be managed between the NHS, Public Health England, Local Authority, GP Consortia, individuals, government and industry.

5.1 It is important that high level outcomes also have intermediate and short term outcomes in order to measure progress over time. The introduction of an outcomes framework will need time to embed and to produce reliable outcome data. Given that health outcomes may not change significantly in the short term, consideration should be given to the development of intermediate indicators.

5.2 Outcomes should reflect the presence of health and wellbeing in the population, and not only the absence of disease or mortality. Outcomes should be rooted in the wider social determinants of health, and health protection outcomes should include inequalities and prevention indicators.

5.3 Public engagement and ownership are critical to the success of the public health agenda. Without public awareness, understanding and ownership, change is unlikely to be achieved. Nurses working in the community can play a key role as community champions and ambassadors. Nurses are also often the first point of contact for early intervention with individuals who, for example, smoke, have alcohol dependency issues and who are obese. This is one of the reasons why the RCN asserts that nurses should be involved at every stage and level of the design, commissioning and implementation of health services including public health.

5.4 Evidence suggests that a focus on early year’s development and positive family experience is vital to a lifetime of good physical and mental health. A holistic service including midwives, practice nurses, the family nurse partnership programme, health visiting services and Sure Start centres play a key role in this. Outcome measures should take into account the progression from early years development to long term overall population health and recognise the role that nursing services can play in this.

6.0 Commissioning

RCN members surveyed as part of the RCN’s White Paper response overwhelmingly (81%) expressed the view that they lacked confidence that the voice of nursing would be taken account of in commissioning arrangements. Many senior nurses have gained considerable commissioning experience while working within Primary Care Trusts and this talent must be retained in the new public health arrangements and NHS. Nurses with experience of working in the community have an understanding of community health issues, the primary prevention of disease, and issues relevant to child and adult health. Such experience, knowledge and skills will be essential within the new commissioning and public health arrangements and that the unique perspective of nursing expertise in public health leadership and commissioning will provide a holistic view of the patient and the care pathway.

6.1 The RCN has previously stated its concern that increased localism may lead to fragmentation of public health services between different localities, exacerbating the “postcode lottery”. With an increasing number of commissioning groups being established with their own boundaries and patient populations, this is further increased. The NHS is currently well placed to take a strategic overview of health inequalities and identify need across a wide area. The RCN believes the proposals as they stand will not allow for this strategic oversight, and the reforms must change to reflect this.

6.2 Nurses have an invaluable insight into the practical issues of service delivery, including advice on value for money, efficiency, and effective and quality care provision. For example, health visitors, midwives and school nurses are an excellent public health resource and should be used to inform commissioning and to work closely with local public health teams.

6.3 Nurses are well placed to stand back and view care pathways, take a holistic perspective on clinical issues and effectively support commissioners in service design. The shift from a target-driven to an outcomes-driven public health service cannot happen without significant involvement of nurses in commissioning. There should be high level nursing involvement during the design, development and delivery of any reforms to healthcare services and healthcare commissioning. Nursing leaders play a pivotal role in helping to close the gaps between hospital, community and social care and hold vital skills and knowledge which should be harnessed within commissioning arrangements. This will help ensure the delivery of integrated and seamless care to patients.

7.0 Funding and Public Health England

Respondents to an RCN member survey at the time of the Public Health White Paper expressed support for the creation of Public Health England and the proposal for ring fenced budgets to be the responsibility of Public Health England. However, a number of concerns were also highlighted. These included concern that the allocated grant to Local Authorities would not be protected (76%).

7.1 At this time of financial constraint across the public sector, the RCN is concerned that although public health funding has been ring fenced, responsibility for allocation of that budget has moved to the Local Authorities. Local Authorities’ budgets are facing a reduction by 25% over the next four years. There is a real risk of this budget being squeezed and services outside of the remit of public health being funded out of this budget. This must be guarded against with detail of how ring fencing this budge will happen in practice.

7.2 Many PCTs are currently having to manage overspend, which could leave the new commissioning consortia vulnerable. The scale of cuts to existing PCT commissioning, quality improvement, information management and technology, finance and HR functions, will also leave commissioning consortia vulnerable and less equipped to take over their proposed roles. This is likely to prove a risk to business continuity for the local health economy, in terms of providing a service to the local population.

7.3 In considering the partnership of commissioning consortia and their role as public health providers and advisors to the Health and Wellbeing Boards and Local Authorities, it must be noted that commissioning based purely on the general practice ‘list’ will not capture the needs of the whole population as it will also include socially excluded people. The RCN is also concerned that with the advent of “any willing provider” and ability to register with a GP of their choice, the normal geographical boundaries upon which data is collected and decision on need made, will in future be flawed.

7.4 In order to aid effective commissioning and allocation of resources, consideration should be given to the alignment of consortia with local authority boundaries or their ward boundaries. Local Authorities have significant insight about their populations, which they use to inform local public service provision, and it is sensible to integrate this existing knowledge with general practice intelligence. Coterminosity with local authority boundaries would alleviate many of the complexities of funding arrangements.

7.5 If public health is seen to be separated from the wider NHS functions then there is a danger that there will be budgetary tensions between public health and the NHS over who funds what services.

7.6 In social care such tensions have been seen to ultimately have a detrimental impact on the care patients receive. Care staff have to manage the issues that delays in funding create, such as bed blocking, as well as having to deal with the time-consuming “assessment industry” and form-filling that is a result of the funding divisions. The RCN urges the Government to carefully consider how it will ensure that such problems do not become a feature of the new public health structure and associated frameworks. There is risk attached to the proposed separation of the public health budget from the NHS. It is important that both Local Authorities and the NHS also continue their good work in addressing public health issues, disease prevention and health promotion and play a significant ongoing role outside of the ring-fenced budget.

8.0 Health Premium

The Health Premium will require careful planning and the results of piloting should help to inform the robust decision making of future premium allocations.

8.1 Whilst the RCN welcomes the recognition that the Health Premium needs to incentivise health improvements across a local authority’s population so that inequalities are reduced as overall health improves, we have some concerns over its application.

8.2 Rewarding those who demonstrate the greatest gains may disadvantage those localities with fluctuating populations, which mean that there is a steady influx of disadvantaged people whilst the more affluent leave the locality. Therefore the formula for the premium must be sensitive enough to calculate for gross inequalities both in variance of population and variance of capability and capacity of the public health team. There is also a need to consider all aspects of public health in the various communities. Rural communities may be more static than those within urban areas, especially major inner city areas, where population movement and migration is a factor.

8.3 Health Premiums need to be designed to reflect the often long-term nature of improvements in addressing inequalities.

8.4 The Health Premium must apply to the greatest health need within a locality, and cannot be a blanket measure as each locality will have different challenges. The structure of Health Premium should:

Incentivise the provision of services which are targeted toward the hard to reach.

Reward multi-sector integration and collaboration.

Tackle areas where crime is a problem for local people.

Target areas where people historically die prematurely.

Be evidence-based on the research evidence for achievable public health intervention.

Target intergenerational cycles of deprivation through a focus on children and young people.

9.0 Health and Wellbeing Boards

HWBs will need to retain impartiality and independence from competing commissioning and provider forces. They do however, have the potential to offer a central platform for all concerned and if adequately prepared and supported, should facilitate joint commissioning arrangements.

9.1 With the development of HWBs the RCN believes the Government must build on examples of best practice of established and successful joint working between Local Authorities and the local NHS through existing joint strategic needs assessments. Acknowledgement of the different cultures of the NHS and local government should not be under estimated, and plans to assist and support the development of a shared culture and professional language would be helpful.

9.2 The RCN welcomes the proposal that 15% of the GP Quality Outcomes Framework is aligned to public health, however, we are concerned that there appears to be no guarantee that “advice” from the HWB and Directors of Public Health (DsPH) relating to public health imperatives will have to be addressed, or sanctions applied if they are not.

10.0 Marmot Review

The RCN notes the Government’s support for the report by the Marmot Review Team, Fair society, healthy lives, the independent review of health inequalities in England. We agree that tackling health inequalities must remain a top priority. The recommendations made by the Marmot Review Team go well beyond the traditional parameters of health care and the health service, and recognise the importance of wider social, environmental and economic policies. Local Authorities will be well placed, if appropriately funded, to tackle certain social and environmental factors which contribute to health inequalities. However, the RCN believes that the responsible departments within the national Government must also ensure that proposed reforms to the labour market and welfare system do not worsen health inequalities.

10.1 Cuts to housing benefit, incapacity benefit and welfare could have an impact on the health and wellbeing of some of the most vulnerable members of society. Whilst it is recognised that some individuals misuse the benefits system, there are many who genuinely depend on it to maintain a minimum standard of life and ensure a minimum standard of health.

10.2 If cuts are made to the funding of Local Authority projects which are targeted in these areas, which is a likelihood given the current economic environment, we could feasibly see the aggravation of local and national health inequalities.

10.3 Whilst empowerment, “nudge” and social marketing all have a role in encouraging voluntary behaviour change, population approaches and national regulation can be both extremely effective and sometimes necessary (eg the banning of smoking in public places and the compulsory use of safety belts). The RCN notes that although the focus of the Public Health White Paper is on evidence based practice and service design, the evidence base for “nudge” is weak.

10.4 The RCN welcomes the Government’s support for the Marmot review but believes that in the period since February 2010 there could have been more proactive work carried out by the Government to reap the benefits of the Marmot Review Team’s recommendations.

11.0 Directors of Public Health (DsPH)

DsPH will have a critical role in the leadership and management of public health services, and initiatives. They must retain the authority and independence to advise and guide public health decisions. It is concerning that there remains a lack of clarity regarding the decision making capacity and autonomy of DsPH and the RCN recommends that these posts should function at director level within Local Authorities. In order for the Directors of Public Health (DsPH) to fulfil their role there must be a direct line of accountability to from the Director to Local Authority Chief Executive level.

11.1 The Faculty of Public Health is generally accepted as the “guiding body” for public health and that the voluntary UK Public Health Register is the Nursing and Midwifery Council or General Medical Council regulatory equivalent. Public health is a speciality that embraces many disciplines including nursing. Applicants for consultant or director of public health positions (including nurses) must demonstrate that they are registered and that they meet Faculty standards. Interviews for these posts must follow the same standards regardless of the discipline of the candidates. The RCN agrees that any candidate that meets these standards is eligible for appointment to consultant or director of public health positions and that these posts should have equity in pay and conditions of employment.

12.0 Public Health Observatories

The RCN is concerned for the long term future of PHOs beyond the Government commitment to funding up until 2011–12. PHOs provide invaluable information in regard to the health of the nation.

12.1 PHOs have been able to present national and local statistics providing valuable information as the basis for policy and strategy to tackle health inequalities and public ill health. Without this sound information it will become more difficult to formulate effective policy and improve health outcomes. As well as the uncertainty around the future of PHOs, national trend data including indicators to demonstrate the effectiveness of behaviour change strategies is being lost as the “Place” and “Tell us” surveys are discontinued.

12.2 The NHS Information Centre has also announced that it plans to stop funding the General Lifestyle Survey run by the Office of National Statistics. This survey provides data on smoking and alcohol consumption attitudes and behaviour, two of the most damaging public health problems within society today.

June 2011

Prepared 28th November 2011