HC 1048-III Health CommitteeWritten evidence from NHS North Lincolnshire Directorate of Public Health (PH 142)

1.0 Thank you for inviting responses to the Health Committee on Public Health. Please find enclosed a summary of NHS North Lincolnshire’s Public Health Directorate concerns about the proposed changes to Public Health.

2.0 Summary

2.1 We agree with the Public Health white paper and the Faculty of Public Health that there are three domains of public health:

Health protection (infectious diseases, environmental hazards and emergency planning).

Health improvement (lifestyles, inequalities and the wider social, economic and environmental influences on health).

Health services (service planning, commissioning, audit, efficiency and evaluation).

2.2 We share the same concerns as the Faculty of Public Health, Royal Society for Public Health, and Association of Directors of Public Health (http://www.fph.org.uk/uploads/Letter%20to%20David%20Cameron.doc) with regards to the proposed changes to Public Health in England and that these concerns have been overshadowed the other changes to the NHS.

2.3 We have particular concerns about the proposed reforms in the following areas:

Lack of standard setting and professional regulation of public health specialists if employed by local authorities.

Fragmentation of the public health system. One of the three domains of public health - health services (service planning, commissioning, audit, efficiency and evaluation), is integral to commissioning of health services. It will be very challenging for this aspect of the public health function to be delivered from a local authority setting yet to separate this from the rest of the Public Health workforce may lead to fragmentation of the public health system.

The “health premium” proposal is flawed and unworkable.

3.0 Lack of Standard Setting and Professional Regulation

3.1 Public health specialists are generally members or fellows of the Faculty of Public Health, all are required to be on the Specialist Register. This gives the public reassurance in their professional standing, Continuous Professional Development, qualifications and training and sets the rigorous standards which all members of the profession are required to meet.

3.2.1We are concerned that, as plans currently stand, public health specialists employed by the Local Authority will not be mandated to be above this quality line. Public health is a professional undertaking with defined competencies and standards in order to protect the public’s health. Not mandating that public health specialists require this status puts the health of the population at risk.

3.2.2There is also a significant risk that failure to require that Directors of Public Health in particular, but also other Public Health specialists are properly trained and registered, will result in significant inequity across the country, as some Local Authorities will wish and be able to recruit properly trained experts, whereas others may not.

4.0 Health Services Public Health Specialists

4.1 Health services public health is a vital domain of Public Health and makes a major contribution both to improving the health of the population, and reducing health inequalities. Many Public Health consultants who undertake this work are first: qualified doctors, undertaking junior medical jobs before higher specialist training in public health; nurse consultants or from other areas of clinical practice with substantial clinical experience. This together with an additional five years training with associated additional professional qualifications and study, gives them a broad and deep understanding of the NHS and the health needs of the population.

4.2 Public health specialists’ input into commissioning of health care is integral to daily working. No-one else has the academic rigour and practical experience of commissioning nor the understanding of the health needs of the population, the evidence base, and is able to balance complex interrelated disease pathways with health economics within the context of finite monies to pay for services.

4.3 A population perspective to health service planning has been integral to the NHS for decades now and has ensured rationing of finite resources in a fair and equitable manner. Public Health specialists have worked alongside GPs, hospital specialists, nurses, other clinicians, social care and NHS managers for years to ensure a multiprofessional clinical input into commissioning.

4.4 It has been suggested that GP commissioners would be able to buy health needs assessments from local universities in order to make commissioning decisions. The reality is that commissioning is a hugely complex juggling act. Public health specialists provide leadership and strategic direction as well as managing health service quality improvement projects and programmes. Universities may be able to complete one off needs assessments – but they won’t be in a position to ask the right questions of providers at contract meetings about PH issues or to interrogate the evidence routinely to check that change is heading in the right direction. Commissioning support units will be expected to provide this monitoring support to GPs – but without PH expertise within those units we are not convinced this will happen. The process needs to be local enough and responsive enough to allow commissioners to report on potential PH performance issues as they arise.

4.5 The developing GP commissioning consortium in North Lincolnshire recognise that they do not have the time nor the skills of balancing the needs of a whole population with the evidence base, reducing inequalities, and commissioning services which offer value for money. They like all other GP commissioners in the country are keen to have public health support in the future. It will be extremely challenging to directly influence NHS commissioning from within the Local Authority, as is currently planned

5.0 The “Health Premium”

5.1 In our view the “Health Premium”, as described in the Public Health White Paper and associated consultation document, is not workable for the following reasons.

5.2 There are no outcome measures that are sufficiently robust as overall measures of population health (and hence health inequality, and reduction in health inequality) that are sufficiently responsive at local level in a relatively short space of time, to be a valid tool for this purpose.

5.3 Even if there were, the mechanism would need to take into account other factors on health and health inequalities at population level. For example, economic changes in an area which health services cannot influence. Another example would be the impact of population change, in particular immigration and emigration, both in and out of a district as well as internally, within a district. If these sort of factors are not taken into account, local areas will end up being penalised, or rewarded, simply because of the impact of population change on local health indicators. At present, the impact of immigration and emigration is completely undefined, though real.

5.4 Even if the above problems were overcome, we cannot conceive of any additional incentive that this proposed mechanism would deliver However there is a real danger that if implemented, the “health premium” would end up further disadvantaging already disadvantaged districts, since they are the ones least likely to be able to attract it, through no fault of their own.

June 2011

Prepared 28th November 2011