HC 1048-III Health CommitteeWritten evidence from Professor John Ashton, Director of Public Health, NHS Cumbria (PH 135)

Executive Summary

Public Health England should be the focus for all public health activity ensuring no fragmentation across the three domains of public health. All public health staff should be employed by this body with structured arrangements between commissioning organisations and local government underpinning the approach.

There must be clear line of sight from national to local arrangements for health protection and strategic planning of health protection arrangements should be embedded into the Joint Health and Wellbeing Strategy.

Public health is the business of all of government and each department needs to adopt a public health/prevention orientation.

Health and Wellbeing Boards are the primary focus for democratic accountability in health in the local area and must have powers to sign off GP Consortia Plans for the local area.

Public health involvement in the commissioning of NHS services should be mandatory with strong relationships between Public Health England and GP Consortia.

Oversight of all public health commissioned services needs to be from within the same organisation ie Public Health England.

High quality intelligence and communications with good locality structures provide the best way of achieving evidence led solutions, applying more effort in areas of greater need and reducing health inequalities. A reduction of this capacity would be a retrograde step.

Localities should be given the freedom to determine their own outcomes in respect of health and wellbeing in accordance with an assessment of needs and assets.

Health premiums should not be inadvertently rewarding areas of affluence where improvements would be made anyway. This would serve to widen the inequality gap.

The proposed ring-fenced budget is generally welcomed but should be defined clearly and protected to deliver against those defined areas. The budget should also be sufficient to meet the purpose.

Credible independent expert public health professionalism should be maintained through specialist training and knowledge

The Marmot review into health inequalities must be understood across all government areas

1 The creation of Public Health England within the Department of Health

1.1 The three domains of public health (health protection, health improvement and health services) are the central pillars to an effective system. Public Health England as currently proposed runs the risk of fragmenting these three domains. Much has been done in recent times to achieve joined up thinking, strategic oversight, performance management and effective co-ordinated delivery. To improve this approach all three domains must remain together within the remit of the new body. The range of agencies involved in public health under the proposals is complex and potentially confusing for both the general public and the partners who need to be engaged in order to be effective.

1.2 Public Health England acting as the overarching structure using secondment arrangements could work in the following areas:

Health protection (infectious diseases, environmental hazards and emergency planning)—local Health Protection Units could be established as part of public Health England.

Health improvement (lifestyles, inequalities and the wider social, economic and environmental influences on health)—local teams working in both tiers of local government but responsible to Public Health England.

Health services (service planning, commissioning, audit, efficiency and evaluation)—Public Health England secondments into locality commissioning teams.

1.3 To enable this to take place Public Health England must be established as a special health authority or as an executive agency.

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

2.1 A key strength of the HPA has been the robust arrangements for centralised expert advice and handling of national issues, but in our experience this has been to the detriment of their provision of local services. In Cumbria, as described in our 2011 Director of Public Health Annual Report, we have established a strong in-house Health Protection Team. This would usefully serve as a national model.

2.2. With regard to the National Treatment Agency, allowing local areas to determine their own responses to their own problems is the most effective way to tackle substance misuse. Integrating the NTA into Public Health England makes an important and necessary link between substance misuse, prevention, harm reduction and recovery.

2.3 There must be clear “line of sight” from national to local arrangements for health protection. Local health protection and emergency planning arrangements should not be moved upwards from the Director of Public Health to leave responsibility only for those functions that are the responsibility of the local authority.

2.4 The strategic planning of local health protection must be integrated into the Joint Health and Wellbeing Strategy, based on the Joint Strategic Needs Assessment.

3 The public health role of the Secretary of State;

3.1 The public health focus of the secretary of state is of extreme importance. Not only will this serve to ensure that prevention is adequately resourced and that health care systems adopt a prevention orientation, in addition the secretary of state can influence in other areas of government. With a true public health and prevention focus this could mean acting as an effective advocate for public health in the following areas: housing, environment, alcohol/licensing, tobacco control, transport policy, crime and education. Public health is therefore the business of all of government as much as it is the business of all of society.

4 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)

4.1 Local government has influence over many of the determinants of health and is a suitable setting to deliver health improvement through the range of services it provides. However as previously described this potentially fragments the three key domains of public health. Public Health England as the employing body for all public health staff could second public health teams to local authorities (potentially at all levels in two tier areas) to influence change within the context of all three domains and not restricted to the area of health improvement as currently described.

4.2 Future systems must not be fixated on the provision of personal services. Whilst the White Paper introduces the idea of transferring some public health services into local government, it is in the area of public health leadership where maximum effect can be achieved. Local authorities who embed public health principles in their organisations can integrate these principle with their community leadership role to mobilise the assets of citizens and other sectors to improve and protect population health.

4.3 A focus on leadership rather than service delivery is further important as many of those services are no longer directly provided by local authorities (eg Housing, transport, recreation, schools, food and water hygiene. Therefore the place to influence and mobilise services in the future should be the Health and Wellbeing Board which itself should not be solely the under the remit of local authorities. Whilst the democratic accountability through elected member representation is welcomed there is a need to develop multiple local methods of accountability to diverse constituents of interest.

4.4 The Director of Public Health must be able to give independent professional advice across all three domains having direct accountability to the Chief Executive of the upper tier local authority and direct access to the political leadership in the authority.

4.5 The power to sign off local commissioning plans must first sit with the Health and Wellbeing Board who will have the most accurate view on whether those plans satisfy the Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategy. These two key documents must influence and drive the commissioning of services in the local area and must demonstrate to the local population that local need is being addressed. We must ensure that alongside any assessment of need there is an emphasis on the need to map assets so that we do not simply design and shape services to address need but that needs are met through mobilising the assets within communities.

4.6 There needs to be understanding of how public health outcomes are linked to other agreed outcomes in related areas such as economic development, regeneration and sustainability. The close links between health, worklessness, deprivation and environmental factors must not be lost through silo working in Health and Wellbeing Boards. Strong links will be necessary with the Local Enterprise Partnerships and other bodies engaged in regeneration in areas where health inequalities are wider.

4.7 Two tier local government gives particular challenges. It would be helpful if guidance also reflected the complexities of working within such a structure although the freedom to determine arrangements locally is welcomed.

5 Arrangements for public health involvement in the commissioning of NHS services

5.1 Public health involvement in commissioning should be mandatory and any commissioning organisation should demonstrate how it has taken account of specialist public health advice and available intelligence. This should run right through the system from national down to locality arrangements. There is not enough public health involvement in commissioning and proposals which divert staff into either local government or Public Health England will make that even more difficult to achieve. We have to also ensure that any future system enables us to be much better at using public health skills to performance manage and evaluate any commissioning changes.

5.2 Public health teams are hubs of partnership working for health in a given area linking clinical expertise to the work of a range of organisations who work in complementary and directly related fields. There are significant opportunities not realised in the proposals for GP consortia related to the development of Community Oriented Primary Care and Asset Based Community Development through more explicit collaborative approaches between Local Government and Primary Care. Public health teams are well placed to lead this agenda and to ensure its integration into wider commissioning objectives.

5.3 Whilst Public Health England can deliver on the prevention agenda, it cannot do it alone. Health services need to adopt a strong prevention orientation throughout their commissioning cycles to enable demand for health care to be managed into the future, therefore strong relationships need to be built and maintained between Public Health England and GP Consortia.

6 Arrangements for commissioning public health services

6.1 The proposals as they stand place the commissioning of public health services within a range of leadership structures from local government, Public Health England, the GP consortia and the NHS Commissioning Board. There is need for proper co-ordination of all aspects of public health to ensure need is met, assets are mobilised in an efficient way and duplication does not occur.

6.2 There would be far less risk to any of the above if all aspects of public health services had a direct co-ordinated relationship within Public Health England

7 The future of the Public Health Observatories

7.1 Intelligence is the lifeblood of any good public health system. Observatories have given a rich picture of the health of our communities at a range of spatial levels that simply would not be possible within localities. This high level population view has enabled comparison between similar areas and has led to the sharing of good practice which in turn has led to better outcomes for communities.

7.2 The development of Public Health Observatories at regional and local level, together with the range of products that have informed organisations and systems have been of immense value. This approach enables us to target scarce resources, particularly in areas of greater inequality. Public health expertise in evidence based decision making and prioritisation is key to ensuring services are efficient and commissioned according to need and evidence of what works. We consider it essential that future approaches will contain no less than what currently exists in terms of the focus on intelligence. It is critical that the expertise built up through intelligence networks at all levels is not lost. It is also essential that any future arrangement builds on the good relationships established between observatories and their constituent public health departments.

7.3 Observatories have proved their worth to the public health and wider partnership system; they are objective, knowledgeable and trusted sources of expertise. Without the range of high-quality expertise and support from public health observatories, much of the work carried out by practitioners and, indeed, local authorities, policy makers and the wider community would not be carried out without a sound evidence base. This will be even more important in a system where enhanced Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies are driving the agenda.

7.4 Effective public health intelligence must work hand in hand with high quality localised communications. The role of communications in effecting lifestyle behaviour change is significant as is the role in major emergencies, pandemics and other issues associated with protection of our communities’ health. Social marketing and health information need to be targeted and specific to ensure maximum uptake of public health messages therefore locally directed communication arrangements using very specific knowledge of our communities, are essential.

8 The structure and purpose of the Public Health Outcomes Framework

8.1 There are a large number of indicators mentioned in guidance received to date. Past experience has shown that it can be difficult to maintain focus on that number across the range of agencies we will need to work with. We would therefore hope to be able to prioritise a smaller set of indicators based on the issues identified through the JSNA process in Cumbria.

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

9.1 The proposed ring-fenced budget is generally welcomed but should be defined clearly and protected to deliver against those defined areas. The budget should also be sufficient to meet the purpose. The definition should be clear about which elements are inside and outside the scope of the budget.

9.2 Whilst broadly supporting the proposals for a system which stretches performance, there are some elements of concern in the health premium proposal. Previous experience from developing Local Area Agreements has shown that pump priming new initiatives and tying in reward elements has helped partners maintain focus. We believe however that any health premium system must be focused on reducing inequalities rather improving performance or rewarding good performance. It should also not require an onerous data collection approach nor reward improvement that occurs as a result of broader changes (eg overall increases in affluence in some parts of the country)

9.3 Good performance is harder to achieve in deprived areas which may exacerbate the gap in health inequalities. Even in more affluent rural areas issues like screening may suffer from reduced uptake due to geographical sparsity and access to services. Future systems should enable areas with particular difficulties such as these to be prioritised to improve faster.

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

10.1 The public has a right to be confident in public health regulation and procedures. Specialist Public Health professionals are involved in decisions which affect morbidity and mortality which require a defined and regulated skill set. Whilst it makes sense to assert that “public health is everyone’s” business and that many interests can become involved in improving health, this requires specific specialist leadership which must be developed within a formal framework and regulated through an agreed system of continuous professional development. Statutory regulation is the most effective way to ensure this takes place.

10.2 The importance of credible public health advice cannot be underestimated. This can only be maintained through specialist training and knowledge which the general public can respect and have confidence in. This is especially important in health protection and crisis situations but is equally important across the other domains of public health.

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

11.1 The Marmot Review gave a comprehensive picture of health inequalities and how organisations should work much further upstream to tackle inequality. Concepts such as the health premium may serve to widen inequalities especially with elderly and vulnerable groups. Other areas of government policy need to understand Marmot to ensure that their policy areas do not inadvertently widen inequality. Tackling health inequalities is the business of all of government not just the Department of Health and as such Marmot needs to be understood across all departments.

12 Conclusion

Public health professionals are committed to protecting and improving health and wellbeing and reducing inequalities. There is recognition of the need to work with many different organisations to achieve our agreed outcomes but the key to success is in leadership and ensuring that leadership is as easy to understand and engage with as possible. Fragmenting the leadership and service provision of public health across multiple organisational boundaries is at best confusing and at worst will not help local areas to deliver on their agreed outcomes.

This “once in a generation” chance to reform public health may undermine the successes achieved in recent times in developing partnerships, collaborating and working towards a single system for public health. Due consideration must be given to keeping the three domains of public health together to ensure that public health thinking and a prevention orientation permeates through all parts of the system.

June 2011

Prepared 28th November 2011