HC 1048-III Health CommitteeWritten evidence from NHS Bristol’s Public Health Directorate (PH 162)

We welcome the opportunity to submit evidence to the Health Select Committee for its inquiry into Public Health.

We have made extensive comments previously about the proposed health reforms. We attach our previous consultation responses to the white paper, “Healthy Lives, Healthy People”, and supporting documents on the public health outcomes framework, funding and commissioning routes, and regulation of public health professionals.

We wish to make additional comments under some of the headings, as requested.

The Creation of Public Health England within the Department of Health

The independence of Public Health England 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. A previous example of this advocacy role was the successful lobby for legislation for banning smoking in public places.

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)

Role of the DPH

The duties and responsibilities of Directors of Public Health outlined must be supported by relevant powers in the legislation. For example, the Director of Public Health should have control over the budget for health and wellbeing.

Role of the Health and Wellbeing Board

The PCT, as current local leaders of the NHS, co-ordinates system wide improvements in services, such as reconfiguration of services for patients with heart attack or stroke, or the location of a new hospital. The PCT works closely with partner Primary Care Trusts and NHS Trusts/Foundation Trusts, local clinicians and patients, as well as wider stakeholders to deliver such changes across the whole health system. In the new commissioning arrangements it is not clear what the mechanisms will be for ensuring effective system wide change.

The Health and Wellbeing Board can effectively take on this function. In order to do this its role needs to be strengthened to enable the Board to be seen as having this overall local leadership role. The Health and Wellbeing Board must be central to the new health and care landscape locally such that it can effectively facilitate system wide improvements and can enable integrated working between primary and secondary care and between commissioners and providers.

Under the current proposals the Health and Wellbeing Board has the unique feature in the future health and care system of including elected members and being a committee of the council, giving it democratic accountability. This feature can strengthen is leadership role in the health and social care system locally, but only if the Health and Wellbeing Board is given sufficient powers. The Health and Wellbeing Board must be given power to take decisions about budget spends and mutually hold commissioners to account. In particular, its authority locally must not be undermined by the NHS Commissioning Board or any one member organisation of the Health and Wellbeing Board.

Arrangements for Public Health Involvement in the Commissioning of NHS services

(i)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 specialists bring technical expertise in health intelligence, needs assessment, equity audits, critical appraisal of evidence of effectiveness and cost-effectiveness, advice on disinvestment, evaluation of services, and development of care pathways. In order to ensure these skills are available to GP commissioning consortia, it should be mandatory for the Director of Public Health (or their nominee) to have a seat on each of the GP Commissioning Consortium Boards. This would be in their role as technical lead for the specialty of public health (quite separate to their role in local government).

(ii)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.

   The Bristol Commissioning Model (attached as appendix) helps to illustrate how commissioning of children’s services needs to be carried out in an integrated manner, with a focus on health and well-being. The Bristol Model draws on the evidence base, linking care pathways and interventions/service delivery with commissioning decisions, population investment and outcomes. It demonstrates opportunities for commissioning and delivering in a much more aligned/integrated way—in the short, medium, and longer term—to achieve better and more sustainable outcomes.

The Future of the Public Health Workforce

(i)Public Health covers all three domains of public health (health protection, health service public health, and health improvement), and Public Health England may need to be the employer for the whole public health workforce to prevent fragmentation.

(ii)What support and training will there be for Public Health practitioners? How will this be funded and coordinated? We would like to see this clearly set out in both national guidance and in local arrangements. There is a danger that this area will be left unfunded and unmanaged, as regional structures disappear and local structures emerge. This is an issue for the wider public health workforce, currently employed in a range of health improvement/public health roles in the voluntary sector, the local authority and the NHS.

(iii)We face unprecedented challenges because of the combined impacts of resource depletion, environmental degradation, and the economic shocks that are predicted to arise from “peak oil”. This has substantial implications for transport, food, jobs, health and healthcare. It is therefore essential that the proposed changes to public health services and associated changes to health services more generally, do not disrupt essential local workforce and service delivery capacity. There is a need for simpler systems that are both robust and resilient for times of hardship.

June 2011

APPENDIX

Prepared 28th November 2011