HC 1048-III Health CommitteeWritten evidence from the Allied Health Professions Federation (PH 151)

1. Introduction

1.1 The Allied Health Professions Federation (AHPF) is a federation of twelve Allied Health professional bodies representing over 130,000 professional members across the UK of whom 84,000 work in the NHS in England. (See Appendix for full list of member organisations).

1.2 The purpose of the AHPF is to promote the value of Allied Health Professionals (AHPs) and integrated professional working. The AHPF believes that AHPs, as key specialist clinicians, are an essential part of the health and care workforce who are well placed to deliver high quality care to patients, clients and service users across the whole of the health and social care sectors. The AHPF also believes that in the emerging health and social care environment and in particular in the developing public health arena there will be a need to involve AHPs in all spheres of decision making. Therefore maintaining and developing professional expertise over time will be important to ensuring the sustainability of the system.

1.3 The AHPF is uniquely placed to draw on the expertise and experience within the professional bodies in order to inform and engage with consultations, issues and opportunities impacting upon Allied Health Professionals across the health and social care sectors.

1.4 This consultation response has been put together on behalf of the whole of the AHPF. It has deliberately been confined to broader comments. Individual professional bodies have submitted separate responses where a profession specific response adds value to the consultation process.

2. Overview of Recommendations

2.1 There should be an Allied Health Professions Director in Public Health England.

2.2 AHPs should have a guaranteed role in commissioning services across the whole of the local decision making process including the clinical consortia, the Health and Well Being Boards and the local public health structures.

2.3 AHPs should be involved in joint strategic needs assessments and developing joint health and wellbeing strategies.

2.4 Whilst public health is focused on prevention it is important the link to intervention services is clear.

2.5 It should be highlighted that many services, whilst not supporting prevention or cure, are based on rehabilitation and increasing quality of life eg stroke services.

2.6 It is essential that the establishment of new commissioning bodies within the broader public health remit result in greater coordination and integration of AHP services in order to safeguard access for vulnerable groups.

Further Comment

3. Leadership

3.1 The new central Department of Public Health will provide vital input to the overall well being of the nation. It will require AHP input at the highest level and consideration should be given to mandating an Allied Health Professions Director at the same level as the Nurse Director already announced.

3.2 In the current DH structure the senior allied health professional role (Chief Health Professions Officer) reports to the chief nursing officer effectively putting AHPs under the nursing umbrella. The AHPF believe that it is inappropriate for the top level AHP representation to remain under nursing for these reasons:

Nursing and AHP roles have diverged over the years and now occupy very different niches within health and social care with different professional needs and capabilities.

The sheer volume of nursing related activity driven by staff numbers could inadvertently take priority over AHP professional initiatives.

3.3 We would welcome early guidance to clarify the role of Public Health England. At present there seems to be potential for confusion in the lines of accountability between the directors of public health within local government and Public Health England. The AHPF hopes that Public Health England will take the lead responsibility and determine clear direction for the public health agenda at both the national and local level.

3.4 Top level accountability to government must remain the remit of the Secretary of State for Health.

3.5 The AHPF recognises that the ageing UK population is placing an increasing burden on health and social care services across the UK. Therefore the Secretary of State has a vital leadership role to ensure that long term strategies which improve the overall health of the population and prevent avoidable ill-health are put in place at national and local level, and are adequately funded.

4. The Future Role of Local Government in Public Health

4.1 The AHPF is concerned that services may become disjointed under the new plans. It is vital that when public health, currently undertaken by the NHS, is transferred to local authorities, there is no resultant fragmentation in service commissioning. For example early years services will continue to be funded from local authorities under public health funding however this has an overlap with health care intervention. Interventions such as screening programmes need to be commissioned as a whole programme without a potential separation of the screening element or universal public health services from the assessment and intervention elements, including rehabilitation (often health, education and social care).

4.2 In the transition period AHPs will have an increasingly important role to play as the responsibility for public health moves to local authorities. AHPs are well placed to act as integrators of care and can often help form the “bridge” for patients between hospital clinicians and GPs or community-based health and social care services.

4.3 AHPs preventative and early intervention work is often funded by local authorities. Against the backdrop of local authority budget cuts the AHPF is concerned that this new public health responsibility will be under threat. This will impact upon some of the most vulnerable people in society.

5. The Future Role of Directors of Public Health

5.1 Public Health Directors will require access to allied health professional expertise and input to exercise their role. It is essential that the Directors of Public Health are aware of the range of services that AHPs provide in preventative care and the potential impact in other areas such as mental health, social and emotional development and reducing inequalities.

5.2 Given this important role of AHPs in integrating care, and the key contribution that they can make to improving public health, a wider clinical involvement in strategic planning, joint strategic needs assessment development and decision making will help deliver better, cost effective outcomes for patients and for public health.

5.3 It is essential that when Directors are appointed they are fully apprised of the risks within their local population where AHPs have particular expertise.

6. The Role of Health and Wellbeing Boards

6.1 Allied Health Professionals have an important role in many aspects of care including improving public health and wellbeing, reablement, management of long term conditions, providing integration across health and social care and delivering care within the education and justice contexts. In order to make informed decisions Health and Wellbeing Boards, Directors of Public Health, the NHS National Commissioning Board, commissioning consortia and other commissioners will need a wide range of skills and must have broad representation from a range of healthcare professionals. AHPs should be guaranteed a place at all levels in the new NHS structures.

6.2 AHPs are in a unique position as the only clinical professions able to combine knowledge and skills from all areas of health, social care and education. Their involvement in commissioning provides innovative ideas for redesigning services, integrating teams and sectors and delivering the QIPP agenda. The inclusion of AHPs on Health and Wellbeing Boards and other commissioning structures will ensure that commissioning across a pathway is identified, designed and implemented in a co-coordinated way.

6.3 Health and Wellbeing Boards must not operate separately from the work of the NHS. Their role is integral to health promotion. There are different cultures across health and local government and there is a risk that a lack of health representatives will prevent close health scrutiny and result in further fragmentation of services and patient pathway delivery.

6.4 While we welcome the establishment of Health and Wellbeing Boards, the Bill currently appears to grant them insufficient powers to join up commissioning effectively between the NHS and local authorities.

7. Joint Strategic Needs Assessments (JSNA) and Joint Health and Wellbeing Strategies

7.1 As it stands there is little to encourage local authorities or partner commissioning consortia to consult with appropriate individuals. Given the importance of ensuring integrated working, particularly with regard to services for children or vulnerable adults, there should be a duty to consult with appropriate health professionals who work across sectors such as education, health and public health and who have expertise with regard to children and vulnerable adults.

7.2 Correct membership of the Health and Wellbeing Boards is essential as they are vital to ensure that appropriate health and social care provision in line with the Joint Strategic Needs Assessment is planned and provided for as well as providing scrutiny to local budget allocation.

7.3 In developing the joint Health and Wellbeing Strategies the workforce should include AHPs. AHPs are the third largest health care group. Their involvement and input is crucial to all commissioning decisions.

7.4 At the local level much can be achieved by AHPs contributing to the development of the local Health and Wellbeing Strategies, agreeing priorities and delivery mechanisms designed to deliver best outcomes for communities. This joined up approach across health and local government will help to align priorities and services according to patient need, ensuring that public services are responsive to meet patient need. Often AHPs are the key individuals in identifying and providing expertise in areas of health inequality or vulnerable groups.

8. The Integration of Public Health and the Commissioning Process

8.1 There is an underpinning assumption that GPs and GP practices have a good understanding of public health and the needs of the population they are serving. Building the capacity to address public health commitments will need to be a priority for consortia. This may need to be specifically incentivised through Public Health England and the National Commissioning Board.

8.2 The AHPF calls for AHPs to have a guaranteed role in commissioning services and to be named as part of the workforce to contribute to the JSNA. AHPs are woven into the fabric of public health in this country. They are in the vanguard of creating a service based on people being healthy rather then a service based on fixing ill-health.

8.3 The AHPF recommends that Consortia board members be appointed against a series of competences needed for commissioning—which includes the ability to understand and commission evidence based public health interventions. It is likely that to achieve this Commissioning Consortia boards will need to be made up of a wide range of professionals who can demonstrate the breadth of experience, knowledge and expertise across health and social care commissioning pathways. This should include AHPs.

8.4 Commissioning should be undertaken on the basis of whole pathways of care and not for individual single elements of care. Commissioning pathways should include where relevant population and prevention aspects.

9. The UK Wide Context

9.1 AHPs are already represented at a strategic level across Northern Ireland and Scotland. In Northern Ireland the commissioning structure for health and social care services includes AHPs. The Health and Social Care Board operates through five commissioning groups and each has representation from allied health professionals. In Scotland community health partnerships and community health and care partnerships include representation from allied health professionals at Board level. The AHPF fully endorses the representation of allied health professionals at a strategic level and recommends that this is adopted into the English health and social care system without delay.

10. The Future of the Public Health Workforce including Regulation of Public Health Professionals

10.1 The future of the public health workforce is at risk from a lack of understanding of professional roles by commissioners, by fragmentation of education and training and by localised workforce decisions which will marginalise smaller professional groups.

10.2 We are concerned that a model with plurality of providers will destroy the pipeline of future clinicians so that the model fails in five to 10 years. How will the longer term implications of potential damage to the education and training of future clinicians be addressed and resolved?

10.3 The AHPF supports any process that ensures the development of regulated professional expertise leading to enhanced clinical outcomes, experience and safety for patients. The allied health professions are regulated by the HPC and this or similar models should be in place for other public health professionals.

10.4 Due to the likely increased choice in providers under Any Qualified Provider, registration would provide assurance to the service user that the professional meets the relevant standards for their training, professional skills, scope of practice, conduct behaviour and health.

11. The Marmot Review and Health Inequalities

11.1 The Marmot review “Fair Society, Healthy Lives” was clear that health inequalities result from social inequalities and that there is a need for action to tackle the social determinants of health inequalities.

11.2 The Marmot Review showed that poor health in adulthood is strongly related to poverty and to factors in early childhood that affect development. What happens during the early years has lifelong effects on many aspects of health and well-being—from obesity, heart disease and mental health, to educational achievement and economic status. Marmot identified as a priority objective reducing inequalities in the early development of physical and emotional health, and cognitive, linguistic and social skills—and put giving every child the best start in life as the review’s highest priority recommendation.

11.3 There is a concern about ensuring that health inequalities are not increased. In the current transition phase there is already evidence of increased rationing. For example one GP consortia is only commissioning one assessment session and one treatment session of physiotherapy (even though this is not evidence based). In the future if there is not effective initial commissioning regulated professionals will need to challenge such practice to prevent them breaking their codes of practice.

11.4 The AHPF is concerned that the Government proposals in the Health and Social Care Bill will not improve health inequalities. Involving the private sector in the responsibility deal has been helpful in supporting change but “nudging” people into change risks widening health inequalities by only influencing those who are ready to change. For example the removal of the cap on the amount of money that Foundation Trusts can generate from private patients has the potential to reduce choice for poorer patients and exacerbate health inequalities.

12. The Structure and Purpose of the Public Health Outcomes Framework

12.1 There are now three aligned frameworks the NHS Outcomes Framework, the Outcomes Framework in Adult Social Care and the new Public Health Outcomes Framework. We are concerned that there may be a risk of a fragmented approach to public health, with some health inequalities “falling through the gap” between the NHS, Public Health, social care and other sectors.

12.2 Building the capacity to address public health commitments should be a priority for consortia. The AHPF supports the proposal that incentives and drivers for GP activity should be specifically designed with public health concerns in mind, and that a proportion of the current value of QOF be devoted to evidence based public health and primary prevention indicators.

12.3 Public Health Outcomes framework should consider the overall lifestyle and reasons for health behaviour not just one aspect of a person’s life eg obesity.

12.4 Some public health outcome measures can take years to implement and need sustained action. Both long term and short term targets are required. Additionally budgets must be allocated accordingly, with recognition that the resultant savings from interventions may be seen in different education or welfare areas.

12.5 We recommend that the outcomes should be aligned to and reflect the Marmot 6 priorities through the life course.

12.6 We would welcome more qualitative evidence being considered as part of the evidence for public health interventions.

June 2011

APPENDIX

The Allied Health Professions Federation (AHPF) member organisations are:

The Society of Chiropodists and Podiatrists (SCP);The Society and College of Radiography (SCoR);The Royal College of Speech and Language Therapists (RCSLT);The College of Paramedics (COP);The Chartered Society of Physiotherapy (CSP);The British Association of Occupational Therapists/ College of Occupational Therapists (BAOT, COT);The British and Irish Orthoptic Society (BIOS);The British Association of Prosthetists and Orthotists (BAPO);The British Dietetic Association (BDA);The British Association of Drama Therapists (BADT);The British Association of Art Therapists (BAAT); andThe Association of Professional Music Therapists (APMT)

Prepared 28th November 2011