HC 1048-III Health CommitteeWritten evidence from London Directors of Public Health (PH 154)

Executive Summary

1. We recognise the need for change within the public health system and welcome the opportunity to consider how public health could be strengthened. We are particularly conscious of the current economic climate and we want to play a full part in creating effective, efficient and integrated public services that prevent ill-health, protect against disease and tackle health inequalities.

However, we have fundamental concerns about the current proposals which we feel may have an adverse effect on these goals and fragment rather than integrate the public health system at a time in which cohesion is needed most.

2. Directors of Public Health need to be authoritative, work in a setting where their advice and outputs can be independently trusted, and work across organisational boundaries on all the 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); and

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

3. Directors of Public Heath need to be mandated to challenge local decisions affecting the public’s health and ensure Local Authorities and the NHS are fully cognisant of evidence and population need in the planning of local services. To do this, Directors of Public Health need to be supported by an adequately resourced local public health team which is part of a broader, integrated public health system. We are concerned that the current proposals would fragment, diminish and narrow local public health functions; positioning Directors of Public Health as part of Local Authorities with a primary focus on health improvement. We are concerned that the vital and unique role local public health has in relation to health protection and health services will be lost and the ability of public health professionals to influence across local systems will be reduced. We are also concerned that such close alignment with the Local Authority may reduce the impartiality and independence of Directors of Public Health and their teams.

4. London’s public health workforce has historically faced significant resourcing challenges and it has taken considerable time and effort to develop, recruit and retain the talented resources we now have. We are deeply concerned about the impact the current proposals will have on the workforce and feel urgent action needs to be taken to reduce the period of uncertainty and halt the potential erosion of public health skills from the Capital. We believe that consolidating the public health workforce into Public Health England (PHE) would provide the best opportunity to safeguard the workforce, maximise expertise and develop a coherent, integrated and flexible system. PHE could develop mechanisms to second expertise to localities to work with the full range of organisations that need to work together to improve the health of the population including Local Authorities, the NHS Commissioning Board and GP Consortia.

5. We welcome the creation of PHE and the potential this offers in terms of national leadership and coordination an integrated system of public health. We feel the consolidation of the Health Protection Agency (HPA) and Public Heath Observatories into PHE must be undertaken in a manner which does not adversely affect their national and international reputations, their resourcing and their ability to provide independent and authoritative services. In order to achieve this we believe PHE must be independent of the Department of Health and have a national role in all three domains of public health. We believe PHE would be best constituted as a Special Health Authority and the employing body of all public health professionals in England. This model has been widely proposed in other responses from across the public health system including the Faculty of Public Health, The HPA, and in the Lancet.

The future role of local government in public health

6. Local Authorities have a vital role to play in improving and protecting the health of their local populations and we welcome the intention to strengthen public health’s role in this. We recognise that Local Authorities will face some difficult challenges on the deployment of scarce resource and we are committed to supporting Local Authorities to make decisions in light of the best available evidence on effectiveness and population need. However, as Directors of Public Health we have equal concern to ensure that the same goals are achieved in local NHS systems. We are concerned that this duality of focus is not adequately recognised in current proposals which heavily align Directors of Public Health with Local Authorities. It is not clear if, and how, Directors of Public Health will relate to the local NHS and the broader remit of health protection and health services.

7. Local Authorities can and ought to play a role in public health which extends beyond health improvement; to both health protection and health service planning. We are concerned that current proposals too narrowly define the role of Local Authorities in public health and reduce local accountability for health protection and health service planning. The move of Directors of Public Health to Local Authorities only makes sense if mechanism can be developed to ensure they have the highest possible level of influence across the spectrum of Local Authority and NHS activities and do not narrow the focus of local public health to health improvement. To enable this Directors of Public Health should be:

either employed by PHE and seconded to Local Authorities or be jointly appointed by PHE and Local Authorities;

accountable for the three domains of public health: health protection, health improvement and health services;

accountable to the Chief Executive of the Local Authority and have access to councillors and elected members;

mandated to work across the local health and social system;

empowered to challenge, assure and support decisions made that affect health; and

supported by a properly resourced, professionally trained team.

8. Whilst the proposals clearly indicate that there will be Directors of Public Health at a local level, there is little clarity on how this role will be supported and resourced. At the very least, there must be a core minimum set of appropriately trained and accredited public health professionals supporting an agreed set of functions. It is vital that Directors of Public Health have an adequately resourced public health team to if they are to effectively discharge their public health functions.

9. The recent exercises to identify the public health budget need to be repeated within the Local Authority to establish a baseline. We are concerned to learn that many Local Authorities have been considering cost shunting current schemes onto the new ring-fenced Public Health budget which they are proposed to receive in 2012–13. It is currently unclear what, if any, conditions will be attached to ring-fenced public health budgets, but we are concerned that at a time when Local Authorities are making considerable savings, public health funding could be used to supplement other financially challenged schemes or services. This could lead to a reduction in overall public health spending at a local level with obvious detrimental effects on public health outcomes. Public Health monies should not be used to get services up to baseline - rather Public Health monies should be used to complement and enhance core services so as to enable local people to be better able to use them in a health improving way.

10. Health and Wellbeing boards offer potential to be an integrating and aligning force between the NHS and Local Authorities. However, in order to achieve this, the formal powers of Health and Wellbeing Boards need clarifying and strengthening. In particular, the role of Health and Wellbeing Boards in relation to the Boards of GP Consortia, the NHS Commissioning Board and the Board of Local Authorities need definition. To ensure Health and Wellbeing Boards can fulfil their potential it is recommended that they are:

accountable for delivering a comprehensive joint needs assessment for the local population which is utilised in strategic planning and commissioning;

have a formal role in signing off GP Commissioning plans. In the spirit of true partnership, the Boards should also play a similar role in relation to signing off Local Authority commissioning plans; and

accountable for the three domains of public health: health protection, health improvement and health service.

Arrangements for public health involvement in commissioning of health services

11. Public health plays a critical but much overlooked role in the commissioning of health services. The competencies required to effectively commission services align more closely with the competencies of public health specialists than they do with any other professional group. Key tasks, such as assessing need, planning and designing care in line with evidence and appraising investment and disinvestment decisions, are all fundamental public health skills. The role that public health can and needs to play in relation to the commissioning of health services must therefore not be underestimated or undervalued. It is disappointing and concerning that the current proposals do not clearly define what, if any, relationship public health will have to the commissioning of health services. We feel that public health must have a strong and well-defined role in relation to both the National Commissioning Board and local GP Consortia. As a minimum, formal mechanisms need to be established to ensure health service commissioning is cognisant of public health advice and all commissioning entities have a qualified public health professional on their Board.

12. National as well as local experience suggests GP consortia will need and want considerable support in their new commissioning roles, especially in relation to health intelligence. Much of this support is currently provided from within public health teams in Primary Care Trusts, together with regional Public Health Observatories and the broader public health system. The current proposals do not address this significant public health role and we are concerned that left unrecognised, a range of alternative providers could be brought in to support GP Consortia in these areas. Not only is this likely to be at great financial cost but it is also likely to be variable in terms of quality and approach and may exacerbate inequities in the provision of services. We are concerned to ensure public health continues to play a vital role in GP Commissioning which we feel requires:

well-resourced public health teams organised locally, regionally and nationally that work together to support GP Consortia in an efficient and responsive way;

Directors of Public Health providing oversight of, and input into, GP consortia commissioning, supported by additional resources and expertise held within PHE. Directors of Public Health should quality assure public health input into local GP Consortia, if not be the direct provider of services;

that the population size of GP consortia should be based on evidence of effectiveness, as should decisions as to whether services are commissioned and delivered nationally, regionally or locally. Consortia should be encouraged to develop structures for stable joint commissioning where these would best serve their population; and

that GP Consortia adopt boundaries which match or fit within existing Local Authority boundaries—enabling a relationship with one Local Authority and Director of Public Health and their team.

13. The range of organisations requiring public health support and input is likely to rise, especially considering many GP Consortia cover smaller geographical areas than that of former PCT’s. In order to support the range of organisations requiring public health support, it will be imperative to operate from a position of critical mass. Diluting or fragmenting local teams between organisations will not give the breadth and depth of skills that can be brought to bear by a team and will risk spreading scare resource ever more thinly. We believe PHE ought to become the employing body of public health professionals to help mitigate these risks and create a more independent and flexible resource base.

Arrangements for commissioning public health services

14. There is increasing complexity in the commissioning and provision of health and social services, including the commissioning and provision of public health services. The range of providers offering public health services continues to grow and, perhaps more challengingly, the range of commissioners of public health services is also set to grow under the new proposals to include GP Consortia, the NHS Commissioning Board, PHE, Local Authorities as well as a range of other, smaller organisations. We are concerned that without simplification and coordination there is a very high risk that localities will not have sufficient oversight of the mix of services provided locally and will find difficulty in assessing if and how the services adequately address population need. In addition, multiple commissioners and providers are likely to create fragmentation and confusion for patients and the public and ultimately be less safe and effective than a more collaborative and integrated system.

15. Public Health intelligence is an integral function that underpins all three domains of public health. The current proposals alternate between positioning this as a core function of public health and a service that can be commissioned like others. We recognise that some public health intelligence services can be commissioned but the majority need to remain embedded within the core public health system.

The future of the Public Health Workforce

16. In order to provide effective strategic leadership for public health, the public must have confidence that the Director of Public Health and his or her team is able to provide informed, independent and professional advice. As currently drafted, both the public health White Paper and the Health and Social Care Bill would allow someone to be appointed as a Director of Public Health without the relevant training or qualification required by the Faculty of Public Health, the UK standard setting body for public health. Public Health professionals give advice and take decisions that impact on the lives of many thousands of people and we strongly oppose any erosion of the current requirements regarding registration and qualification of the public health workforce. We feel it essential that Directors of Public Health, specialists and consultants in public health are appropriately trained and accredited under the current Faculty system.

17. There is currently considerable uncertainty as to which public health functions will transition to which organisations in the new system and a fear that local public health teams may be fragmented. Local public health professionals are concerned that they may be forced to sub-specialise in one area of public health and potentially face the deskilling impact this could have. It is also unclear if organisations “receiving” public health functions, such as Local Authorities, will have any obligation to employ public health staff currently employed within Primary Care Trusts. There is therefore considerable anxiety about the future of the public health workforce and an understandable concern that local redundancies may be a possibility. There have already been de facto cuts to local public health as NHS colleagues have handed over functions to public health departments previously covered by other departments with no funding to support these, such as immunisations (often previously led by primary care); infection control (often previously led within nursing or governance teams) and emergency planning.

18. The public health workforce has a major role in sharing its competencies with other health professionals, notably in General Practice, Acute and Community Trusts and Local Authorities. This capacity and capability building role helps ensure that health improvement, well-being and addressing the determinants of health is integral to the role of all health professionals and organisations and not the sole responsibility of a discrete group described as the “public health workforce”. It is important that this role is recognised and supported and that reforms in other parts of the NHS and local government make clear the responsibilities of every organisation and health professional to public health.

The future of public health observatories

19. Public Health Observatories provide a critical service to local public health teams and must be transitioned to PHE in a manner which allows them to continue to do so. Health intelligence plays a vital role in informing decisions that affect the public’s health and assuring patients, the public and the health and social care system of the rationale, evidence and outcomes of those decisions. Independence and impartiality in the work of Public Health Observatories is therefore paramount and we are concerned that unless PHE is established independently from the Department of Health, these defining features of good health intelligence will be lost.

Managing the public health transition

20. The changes proposed by the White paper on public health represent the biggest reform and reorganisation of the public health system in a decade. In order to transition to new arrangements effectively, there must be a clear, coordinated plan in place that ensures transitions happen in an equitable way across the country. Across London we are already beginning to see the development of a fragmented public health service with slightly different models in each Borough depending on historical and financial positions.

Dr Peter Brambleby, Director of Public Health for CroydonDr Quentin Sandifer, Director of Public Health for CamdenDr Jackie Chin, Director of Public Health for EalingDr Ruth Wallis, Director of Public Health for LambethDr Hilary Guite, Director of Public Health for GreenwichDr Ann Marie Connolly, Director of Public Health for SouthwarkDr Angela Bhan, Director of Public Health for BromleyDr Val Day, Director of Public Health (Interim) for Sutton and Merton

June 2011

Prepared 28th November 2011