HC 1048-III Health CommitteeWritten evidence from Directors of Public Health from the South West of England (PH 158)

1. Overview—concerns for the Public Health system

All 14 Directors of Public Health in the South West of England welcome the opportunity to provide the Select Committee with evidence for its Inquiry into Public Health.

Whilst welcome, the “listening period” in the passage of the Health and Social Care Bill has heightened concern in respect of many aspects of the proposals for public health in England, and anxiety about the future exists across the public health workforce. The evidence that is enclosed will, we hope, ensure that the Select Committee is armed with the knowledge to scrutinise the Health and Social Care Bill to achieve the best configuration of public health expertise to support health improvement and the reduction of health inequalities in England.

2. Specific issues identified by the Committee

This submission deals with all the issues identified by the Health Select Committee, drawing on the knowledge and expertise of all the Directors of Public Health from the South West of England, and is a joint submission. What follows is an examination of those issues and the opinions of these senior public health professionals.

2.1 The creation of Public Health England within the DH

We do not consider this to be a good idea. Public Health England (PHE) needs to be arms length so it can be seen to be independent and free of political influence.

The independence of PHE is essential, and the public health workforce should remain independent of the civil service. Public health needs to be free to have an advocacy role in such situations as those exemplified by the successful lobby for legislation for banning smoking in public places. Independence would allow PHE to speak authoritatively to the public on a variety of issues, and doubts exist as to whether being part of the DH will promote this. The credibility of the public health advice given by specialists comes both from respect for their professional training and knowledge, and from the integrity and credibility that arises from working for an impartial and independent organisation. We suggest alternative models of: an arms length body; a special health authority or an executive agency. There exists a range of opinions on whether PHE should employ all consultants and specialists in public health.

Public Health England can only effectively operate as a national public health service if it encompasses all 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). The Consultant Public Health workforce is particularly concerned about revalidation (a requirement for professional re-registration) and whether this will be possible in the new arrangements as revalidation requires Public Health Consultants to work across all ten areas of public health competence.

The establishment of PHE could embody the devolution principles of the Coalition Government so that only those things that cannot be delivered locally should be addressed at the national level. It is therefore important to make sure attention is paid to the links between PHE and local PH teams, who should have some involvement in the design of the PHE.

There exists a range of opinion across the UK's senior public health workforce as to whether DPHs should be employed by PHE and seconded to local authorities, or employed by them directly. The recommendations of the Association of Directors of Public health (ADPH) are noted.

2.2 The abolition of the HPA and the NTA for Substance Misuse

This represents a good opportunity to bring resources and functions together at a local level, although there are current concerns about the distance of the HPA from local PH teams and whether or not the suggested new arrangements would improve this relationship. In particular we would want the DPHs to be responsible for health protection but would be deeply concerned if this was not accompanied by the effective resources to support them. The public health system has worked best when it is all part of the same organisation. Since the establishment of the HPA as a separate organisation, we have coped by working very hard across organisational boundaries to ensure that systems and services are safe and that together we are resilient.

The response to H1N1 influenza within the South West clearly illustrated that working together on the response was only possible because we all understood the system and we were skilled at operating across the whole spectrum of health protection and health service response. We were able to redirect a wide complement of staff to the task in hand and respond quickly and effectively. We are as yet, unable to see how this sort of response would work in the new system or indeed whether the operational delivery of the full range of public health practice has been taken into account. There are very genuine concerns about ensuring that we keep the full range of emergency response around health protection safe through this period of transition. If health protection is separated from the local role of the DPH the outcome would be to seriously undermine public health services including response to emergency or epidemic situations.

DPHs welcome the challenge of tackling substance misuse and would wish it to be explicit that prevention of both alcohol and substance misuse is part of their role in the future. There are concerns regarding pressures on local drug and alcohol treatment services with the removal in many areas of Supporting People grants.

2.3 The public health role of the Secretary of State

We welcome the proposed new duties on the Secretary of State (and National Commissioning Board and Commissioning Consortia) to have regard to the need to reduce health inequalities. However these duties are narrowly drawn, only applying to the role of the NHS in providing services to patients. The duties should reflect the broader role of the NHS in promoting public health as a provider, commissioner and major employer. The accountability of the Secretary of State for public health must be clear and it is vital that the Secretary of State retains ultimate responsibility.

2.4 The future role of local government in public health

We are supportive of public health residing in local government with this local public service being the right mechanism for promoting population health across all the determinants of health. That said, any legislation must ensure that a critical mass of public health skills is retained to deliver core public health functions; and that action on core national outcomes is not seriously distorted by local politics. This can be achieved by ensuring that the commissioning objectives and budget allocations are clearly mandated by PHE.

There are risks to the specific arrangements for health service response to major incidents and health protection emergencies. The current components of health protection delivery should integrate with local authority public health teams, which could also bring together environmental health, service public health and health protection under one management at a LA level. This does of course require more structured arrangements in two tier authorities.

It is essential that there is ring fencing of the budget going to the local authority for the additional public health functions being transferred.

2.4.1 Arrangements for the appointment of Directors of Public Health

The Director of public health (DPH) will need to be appointed jointly and have direct accountability to the Local Authority Chief Executive. They should be appointed by means of a statutory process and an Advisory Appointment Committee (AAC). They should have the independence and increased protection such as that afforded to Section 151 officers within local government, and they should be difficult to remove without good cause. The duties and responsibilities of DPHs must be supported by relevant powers in the legislation. For example, they should have control over the budget for health and wellbeing. The DPH will require strong links with Public Health England.

We note that, whilst proposed for DPHs, there are also no equivalent duties on the Secretary of State or on local authorities in respect of their roles in promoting public health, and we would welcome these.

2.4.2 Health & Wellbeing Boards/JSNAs

Health and Wellbeing Boards (HWBs) need to focus strongly on the Joint Strategic Needs Assessment (JSNA). The HWB needs to be able to hold people to account. Its primary function is not to be a commissioning body; its focus is on health, and as such they should consider local health protection arrangements.

The HWB should take on the role of co-ordinating system wide improvements in services, such as reconfiguration of services or the location of a new hospital. In order to do this the role needs strengthening through appropriate powers so it is seen to have an overall leadership role for health and social care locally. Ultimately, HWBs need power or else they will be of little use.

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

Current proposals need attention as they are inadequate and do not reflect the very significant contribution public health professionals make across many sections of the NHS. Public health influence on local health service commissioning is almost absent in current proposals with the only link being through the HWB and the requirement for NHS commissioning to “have regard to the JSNA”. A more integrated approach is needed between public health and health service commissioning, to ensure that disinvestment has minimal adverse population health impact. One approach may be to place requirement on local public health teams to provide direct public health advice to commissioning consortia and that appropriate budget is included in the transfer of budgets from the NHS to local public health teams.

How public health relates to Commissioning Consortia is not yet clear and thought should be given to this so that public health is able to ensure evidence based commissioning through the JSNA and based on available research evidence. The skills, knowledge and experience of public health specialists who can deal with healthcare public health is absolutely essential for ensuring that commissioning decisions are based on evidence of best-value, fairness, efficiency and effectiveness at national and local level. Public health brings a population perspective and technical skills that need to be set out clearly in any memoranda of understanding between public health teams and Commissioning Consortia.

Public health commissioning input currently comes from senior staff who make contributions across the breadth of public health domains and as such it will be vital to ensure that legislation promotes and enables this contribution while ensuring that the public health workforce at a local level remains as a coherent whole. Public Health expertise and input should be mandatory and part of the accreditation of commissioning bodies.

In order to ensure PH skills are available to Commissioning Consortia it should be mandatory for the DPH (or their nominee) to have a seat at each of the Commissioning Consortia in their capacity as technical lead for public health; quite separate from their role in local government.

2.6 Arrangements for commissioning public health services

The current proposals concern us as they have the potential to fragment aspects of commissioning (& service delivery) across organisations. This area needs more work to ensure a clear coherent line of sight across commissioning arrangements within a given programme of work or set of outcomes.

If any particular commissioning arrangement is providing an inadequate service, Public Health England will be able to change the funding and commissioning route, subject to contractual and other constraints. Individual commissioners will manage contracts with providers to achieve the best possible outcomes. GP practices are currently the preferred provider for a range of public health services under the GP contract, such as childhood immunisations, contraceptive services, cervical cancer screening and child health surveillance. These arrangements will continue and will be funded from the public health budget. However, there may be a case for Public Health England and local authorities in the future to have greater flexibility to choose how such services are commissioned, as circumstances change or if services can be better delivered another way.

All the evidence around the quality, effectiveness and outcomes of services and for safeguarding argues for a coherent, joined up and integrated approach to children’s services. It is essential that there are smooth transitions between the NHS and social care, between primary and secondary care, and between children’s and adult services. Commissioning of children’s services is very fragmented in the current proposals and there is risk that this will result in incoherent services. There is also a high degree of a risk around safeguarding, in the absence of clear guidelines about who is responsible for commissioning effective safeguarding. To ensure the comprehensive commissioning of a seamless Healthy Child Programme we feel consideration should be given to commissioning key services from the same source. Current plans are for GP's to commission maternity, the NCB to commission increases to health visiting numbers and local authority to commission school nursing and health visiting services. Commissioning of children’s services needs to be across both consortia and LA as much of work is preventive.

2.7 The future of the Public Health Observatories

The new system must ensure that all those working in public health have access to timely, comprehensive and appropriate data and analysis to inform their decisions and advice. The reforms could result in disruption of existing flows of data and the loss of analytical expertise. Arrangements for maintenance of the public health observatory function and for ensuring access to health service data at local and national levels need urgent clarification. The Public Health Observatories between them deliver an essential service. It is very important to continue this, but they must remain independent of politics and be outward facing organisations, closely linked to and informing the work of PHE and local Public health teams. An alternative model could be to bring them into a national intelligence service in which —if regional outposts were to remain, they should demonstrably serve local population and needs.

2.8 The structure and purpose of the Public Health Outcomes Framework

The Outcomes Framework is a useful construct. It provides an essential measurement to ensure we close the gap in life expectancy and health outcomes and continue to improve the health of the population with a focus on increasing healthy life expectancy for all. Reliable data and information are essential to the understanding of health needs, modelling of future scenarios and assessment of impact and efficacy. This is relevant both for service planning and design and for the recognition of and response to hazards and outbreaks. The Framework does however need refinement. We suggest a significant reduction in the number of indicators while ensuring they are robust enough for local collection, analysis and action. We particularly support the linkage of population level health outcomes to social and health care outcomes, ensuring that care pathways can link up.

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

There is insufficient clarity in current proposals to understand this. However we must ensure through this process that the NHS is open and transparent about public health resource allocation returns and these are properly scrutinised and align clearly with programmes & outcomes. There is a danger that the health premium may widen inequalities if it is not tied into tackling inequalities. It is vital that public health budgets should not be able to be asset-stripped by local authorities.

The proposals in the White Paper will cause a great deal of confusion around what a proposed public health budget would cover. Public health work should continue to be an integral part of the services provided in primary care, and will continue to be funded from within the overall resources used by the NHS Commissioning Board to commission these services. This includes public health activity carried out by GP practices as part of the essential services they provide for all patients, preventative services provided by dentists under their NHS contracts, and services provided under the community pharmacy contractual framework (CPCF). The CPCF includes provision of prescription-linked healthy lifestyle advice and participation in public health campaigns, which will both need to involve close liaison with the relevant public health experts.

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

There must be statutory regulation for all Consultants in Public Health, regardless of primary qualification, on a par with other specialties, for example in pathology where not all pathologists are medically trained. This is essential to maintain standards and protect the public. We thus fully accept and strongly support the recommendations of the Scally Report.

We particularly support statutory regulation so that the titles of senior public health professionals can be protected. It is extremely important that the public can be sure that their DPH is fully trained and qualified to carry out the duties of their post.

The DPH must be a Consultant in Public Health and have a team of Consultants in Public Health to support them in their role. Current proposals risk local public health teams becoming relatively junior, non-specialist health improvement teams with no link to health services or health protection. Public Health covers all three domains of public health (health protection, health service public health, and health improvement) and PHE will have a key role in professional formation and development.

We look forward to seeing the workforce proposals that the Department of Health is developing for the new system. We would wish them to promote the highest standards of training and expertise to ensure that England continues to have one of the best public health systems in the world.

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

The current proposals do not represent an explicit response by Government to the Marmot Review, and as such are a missed opportunity. It can be read that the current proposals contain too much reliance on personal behaviour change approaches rather than the macro measures around income, regulation and upstream / societal changes proposed by the Marmot Review.

3. Conclusion

We, all 14 Directors of Public Health for the South West of England, are responsible for improving, protecting and restoring the health of more than five million people. We believe that the future public health system for the country needs to be well designed in order to meet not just national objectives but also to meet the needs of local populations across England. In order to build the very best system we believe that the starting point and foundation should be the creation at a local level of a dynamic, highly professional public health structure, based in Local Authorities and with strong continuing links to the NHS, that can deliver the needed improvements in the health of local communities and neighbourhoods.

We would be very happy to amplify and add to any component of this submission upon request.

June 2011

Prepared 28th November 2011