HC 1048-III Health CommitteeWritten evidence from the Health Statistics Users Group (PH 153)

The Health Statistics Users Group exists to bring together producers and users of official health statistics. It has over 300 members who are statisticians and data analysts working in the NHS locally, regionally and nationally, in local and national government, universities, statutory and voluntary organisations and consultancies throughout the UK. It provides a regular forum for users and providers of health information to discuss the availability of, access to, and use of health, health services and social care statistics. Further information about the Group is found at www.hsug.org.uk. It is a member of the Statistics Users Forum, hosted by the Royal Statistical Society.

This submission is based on discussions at a workshop on the White Paper “Healthy lives, healthy people: our strategy for public health in England”, held on 25 March 2011, to inform the Group’s response to the consultation on that White Paper and two related consultations on “Funding” and “Transparency of outcomes”. We have a particular concern for Public Health Intelligence, which includes the data needed to inform the development of public health, the metadata which define the data and how they are derived and collected and the staff who have the skills to analyse and interpret the data.

Our response to the consultation on the White Paper is appended, together with responses produced in collaboration with the Public Health Action Support Team (PHAST) to the consultations on “Funding” and “Transparency of outcomes”. This response was drafted by Margaret Eames, Sylvia Godden, Richard Willmer, and Alison Macfarlane, who together with the Group’s chair, Deana Leadbeter, would be willing to elaborate on any of these points further.

Summary

In our response we have considered each of the 11 areas set out for the Inquiry. Our response has been based on the following key points:

1. There is a need for an integrated role between Public Health England and the national commissioning board to ensure the probity of health commissioning. For budgetary and ethical reasons we would ask the Select Committee to seriously review and clarify the function of GP consortia . The provider and commissioning function of GP consortia must be separated for financial, ethical and accountability reasons.

2. The success of Public Health in the future will depend critically on the availability of, and access to reliable public health information and intelligence. Also it depends on the NHS capacity to effectively analyse and interpret it in order that there is a proper evidence based approach to Public Health. Organisational arrangements and responsibilities should reflect this. In particular:

(a)There should be a coherent Public Health Intelligence strategy in place, set and overseen by Public Health England covering each local authority and GP Commissioning consortium—for the whole country, with accountability for health care outcomes overviewed by the local DPH. This must ensure that the underpinning health evidence for a population continues to be collected and analysed at Local Authority level, and at GP practice level, so that GPC commissioners and other commissioners of healthcare provision are locally held accountable for health outcomes, as indicated in the White paper. (This is not included in the NHS “Information revolution” white paper-nor clarified in other White papers).

(b)Responsibilities for Information & Intelligence, nationally, regionally and locally (including the analysis of local authority, Hospital and GP practice data) should be agreed as part of this strategy. Some consultation would be helpful regarding where these functions are best performed. The future and position of organisations should be considered in the light of this work.

(c)Existing flows of information in the system should not be lost in transition by default as PCTs disappear and functions change.

(d)It is vital the population based approach to public health is not lost in the changes and that there are responsibilities for defined populations. It is vital that NHS boundaries be aligned with local authority boundaries so that commissioning and planning services are conducted in an efficient and effective way.

(e)Existing staff capacity in the NHS to analyse and interpret I&I should not be lost.

3. Public Health England should take a lead role now in ensuring these things happen.

Main Issues for Consideration by the Inquiry

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

1.1 Public Health England should not be located within the Department of Health as it should be independent and perceived as such by the public. We support the views that it should be an arm’s length body, established as a Special Health Authority in the NHS. It should oversee the transition to the new arrangements with sufficient time to ensure that essential datasets and skilled staff are retained and relocated and that access to other key data are maintained for public health purposes.

For local public health departments and observatories this would have the benefits of:

(a)Enabling staff with scarce public health analytical and intelligence skills to be retained in the NHS.

(b)Maintaining access to NHS data sources through existing arrangements with the Office for National Statistics, the NHS Information Centre and other organisation without disruption.

(c)Establishing a model in which the independence of the public health function is more likely to be retained rather than being compromised by local cost pressures.

(d)Permitting easier access to training and development, and the continuation of established formal and informal Public Health networks. For example having a central employing organisation would make it easier to arrange placements for public health trainees, to share and exchange skills and to keep up to date with professional knowledge.

1.2 Public health started as a local authority function in the nineteenth century and remained in local authorities from 1948 to 1974, as a component of the tripartite NHS. There is a good case for local public health departments to be physically located in local authorities but with staff employed by Public Health England within the NHS.

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

For similar reasons, these organisations should remain independent of government and their functions should continue within an independent Public Health England.

3. The public health role of the Secretary of State

The Public Health role is welcomed and the Secretary of State should take a stronger lead in championing the role of Public Health England and ensure that public health evidence is used to ensure that GPs and other health professionals commissioning services do so in a way which is linked to the need to improve public health. The Secretary of state should also own the role of public health in overseeing outcomes from commissioning by GP consortia.

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 Moving public health functions to local authorities provides an opportunity to coordinate existing local authority health functions and those transferring from primary care trusts. There is, however, a risk that roles and responsibilities for public health will become fragmented and that the NHS and the commissioners will not see it as a key part of their role. It is vital this does not happen.

4.2 If Local government actions in public health are to be effective, the populations for whom GP consortia are responsible should align with local authorities boundaries. The Director of Public Health is responsible for the public health of the whole population of all ages and the wider determinants of this, so should be accountable to the Chief Executive of the local authority, rather than the head of adult services, as currently proposed.

4.3 The future location of public health analysts currently working locally in primary care trusts should be clarified. These key staff have been ignored in documents which have so far mentioned only those working in regional public health observatories. “Equity and Excellence” refers to directors of public health, leading public health in local authorities and having “a team”. This should include public health analysts.

4.4 To ensure the continuing availability of public health intelligence at a local level, it is essential to address practical issues in good time, including information governance requirements for continuing access to data, and transfer of software and data, including historic data.

4.5 Arrangements for training and retaining established networks still have to be developed. The Health and Wellbeing Boards appear to be the only structure so far outlined for enabling public health intelligence and evidence to be used in the commissioning decisions of GP consortia. Public health intelligence specialists play an essential role in preparing Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies.

4.6 Currently Public Health Intelligence has strong links with commissioners in primary care trusts. These are essential to ensure that plans are aligned with the needs of the needs of the population for which they are responsible. if GP consortia are not coterminous with any one local authority or if there is more than one consortium within a Local Authority area, these keys links will be broken.

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

5.1 Proposals to date lack any strategy for the continuation and development of meaningful, robust, and cost effective health statistics. This endangers the future ability of public health teams to measure health outcomes and does not acknowledge the key role of local public health intelligence in documenting trends and variations in health, based on stable, well defined local geographical populations in England. This builds on the population of PCTs, most of which became coterminous with local authorities, or clusters of local authorities in 2007. Such health measures are essential to keep commissioners accountable by measuring the health outcomes of health care provided to a population on a regular basis.

5.2 The NHS White papers, “An Information revolution” and “Healthy People, Health Lives” and related papers have failed to show any understanding of the needs of public health intelligence at a local level. The commissioning of health services for the population should clearly indicate outcomes, and trends. To allow “free” geographical boundaries for commissioning is likely to cause chaos, and incur much further expense in terms of irregular units of data collection and analysis.

5.3 We agree with the statement in the letter from Faculty of Public Health President Lindsey Davies to the Prime Minister that “To ensure that the health needs of the whole population are appropriately and adequately addressed and that resources are used to best effect then GP (commissioning) consortia must be responsible for defined geographical population which is coterminous with local authority boundaries”.

5.4 In the appended paper we have summarised how cost effective local collection of public health intelligence can be managed, and how this is critically important for protecting the public’s health and preventing poor commissioning of health care in future. This is instrumental in reducing local inequalities in health, and informing both local and national public health policy.

5.5 Ethically there should be a distinction between the provider function of GPs and a body which will commission on behalf of the GP commissioners. We believe there should be a close communication and an accountable link between public health intelligence and commissioning bodies so that local commissioning can improve in response to health outcomes and, in the future, local public health evidence.

6. Arrangements for commissioning public health services

To inform the commissioning of public health services, there should a public health intelligence team as part of a well-qualified and adequate public health workforce located in the local authority under the Director of Public Health This should be employed by Public Health England.

7. The future of the Public Health Observatories

7.1 The Observatories currently perform a vital function at regional level in making public health intelligence available and used. They have considerable skills that should not be lost to the system. The proposed information and intelligence strategy should identify roles required at regional level and judge the future of the observatories on that basis. The observatories should be retained in the interim, liaise with and given the role of ensuring an orderly transfer to new information and intelligence arrangements within Public Health England.

7.2 Public health intelligence is not restricted to public health observatories. Local and regional have complementary roles. Much local knowledge is needed for correct inference about the causes of changes in local population health outcomes from year to year and this is often not known at regional level.

7.3 Good training in statistical methodology and modelling is needed, and the observatories have taken on a leading role in this, with modules taught in each region. It is important that this function continues.

8. The structure and purpose of the Public Health Outcomes Framework (PHOF)

8.1 Setting up an outcomes framework is welcomed, but it will be important to ensure that systems are in place to capture and make available relevant and appropriate data. The framework should be tested before being rolled out.

8.2 We have heard from grassroots public health intelligence staff, that much valuable data collection or analysis, possibly including jobs, may be cut from April 2012. We believe Public Health England should take a critical role now in reviewing current data collection and analysis, and for protecting and developing the public health intelligence workforce.

8.3 It is important to ensure that data are not lost in transition in the way that much hospital data and information were lost in 1993 when as a result of the abolition of regional health authorities, regional computer centres were closed, hospital data lost and key NHS statisticians were made redundant and lost to the NHS. Indeed seen in most national trend charts, 1993 then became “Information year zero” for monitoring population health for England, despite some valiant attempts at the time to save the previous hospital data. The historic statistics and data were not valued by political decision makers then, except in Scotland.

8.4 We should learn the lessons now from this. It is essential that the NHS and GP consortia do not suffer losses in public health intelligence that requires them to start yet again at information year zero in 2013. No new information system has been planned or costed so far, but this would be needed if GP consortia are not coterminous with local authority populations. Although some demographic and primary care data can be mapped in several ways, this is only one component of the public health intelligence. To change the whole current Public health information system would be very costly across England and a great waste of taxpayers’ money.

8.5 Much of these data could be crucial to the proposed Public health outcomes framework. We need to preserve these services which complement the regional observatories and are producing the evidence which protects the population’s health locally. PHE could ensure the key public health datasets, and reports are protected from the possibility of being cut by local health service managers, who do not appreciate their significance, simply to achieve short-term financial gains.

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

As currently designed, the Health Premium would not necessarily be fair, due to variable case-mix (severity of cases) in different hospitals, and variable GP diagnostic load. Rewards through publicity of good outcomes such as high level of smoking cessation in hard to reach, high smoking attributable mortality areas might be more appropriate.

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

It is very important that regulation of all public health staff is put into place including the recognised register for defined specialist Consultants. Since 2005 non-medical public health staff have become an essential part of the public health workforce.

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

11.1 The government should understand the importance of the local authority population boundary for public health intelligence data collection and for commissioning. Data about the wider determinants of health, mentioned in the Marmot review, including housing, unemployment, education, transport and green spaces are also collected at local authority level. Social care data (likely to become part of a shared health and social care programme budget in future) are also measured and monitored through the JSNA on the local authority populations. Unless all the data are collected within the same units of analysis then they will not be able to measure the effect of factors such as housing, transport on the outcomes of health.

11.2 Whilst the clustering of GP practices to form GP consortia for providing GP/Primary care health services in a collaborative way may be more cost-effective and could be within a “free boundary”, the commissioning function will not work without a coterminous boundary with the local authority because the information required, should fit with other data. To constrain local GP commissioning to the local authority population boundary for measuring health outcomes would be the least costly, most accountable strategy for the NHS and would facilitate long term trend analysis. Commissioners (to include Public Health specialists, GPs, Hospital experts, and finance staff) could be accountable to several GP clusters besides the DPH of the local authority (if the local authority contains a jigsaw of GP consortia), but the local authority unit would remain the best way to examine health outcomes robustly, to be able to incorporate wider determinants of health in models and to progress genuine health improvements.

11.3 We have described a way forward to make the GP consortia model work in the attached papers. Most of London’s shadow GP consortia are now coterminous with the local authorities because they can see the financial benefits of using the currently existing public health intelligence for a smooth handover of the commissioning structure to a new GPC commissioning body with a bridge to public health intelligence in the local authority.

June 2011