HC 1048-III Health CommitteeWritten evidence from County Councils Network (PH 167)

CCN

1. The County Councils Network (CCN) is a cross-party special interest group of the Local Government Association which speaks, develops policy and shares best practice for the County family of local authorities, whether unitary or upper tier. CCN’s 38 member councils, with over 2,500 Councillors, serve 24 million people over 45 thousand square miles or 87% of England.

2. CCN works on an inclusive and all party basis, and recognises that member authorities must have the right to respond to their communities in different ways. We seek to make representations to government that can be supported by all member authorities.

Introduction

3. CCN welcomes the opportunity to submit evidence to the Health Select Committee on the issue of Public Health. In our response we highlight key issues for member councils arising from the proposals set out in the Public Health White Paper and the Health and Social Care Bill. As a special interest group (SIG) of the LGA CCN firmly endorses the overall response submitted by the LGA.

4. CCN strongly supports the general direction of the proposals to return to councils a leading role in improving, promoting and protecting the health of their local communities. We welcome the commitment to move from a centralist approach focusing on processes to a more localist approach focused on achieving improved health outcomes. This transfer of responsibility for improving public health to local authorities is a welcome return to the historic role played by local government in the area of health improvement and health inequalities. There is considerable synergy between local authorities’ current activities that already contribute to improving health outcomes (for example sustainable travel, promotion of cycling and walking, and healthy schools) and the responsibilities that will be transferred.

5. Whilst CCN welcomes the localist intentions we have concerns that details do not fully match the rhetoric. In a number of areas, from the functioning of Health and Well-being Boards (HWBs), to the roles of Public Health England (PHE), the NHS Commissioning Board and the Director’s of Public Health (DsPH), and the ability for identifying and including local priorities and allocating resources at the local level, CCN believes that there needs to be a significant shift of power and resources to a more local level.

The Role of Local Government in Public Health

Health and Wellbeing Boards

6. CCN strongly supports the creation of Health and Wellbeing Boards (HWBs) and are pleased to see that the Government has put them on a statutory footing in the Bill. The HWBs must have clear and sufficient legal powers to provide local leadership and a strategic framework for the coordination of health improvement and addressing health inequalities in an area. It is important for Health and Wellbeing Boards to be able to identify their own locally appropriate outcomes through the development of a robust and inclusive Joint Strategic Needs Assessment (JSNA) process and to set out the direction of their plans through the Joint Health and Wellbeing Strategy (JHWS). We therefore very much welcome the government’s commitment to place a duty on GP Consortia and HWBs to this effect and that there is a clear acknowledgement that the JSNA needs to be an integral part of the process.

7. However it is not clear how they will work with other commissioners to ensure the most co-ordinated commissioning of health and social care for communities. CCN believes that for this to happen HWBs need to have equality in statute with the National Commissioning Board and for the relationship between PHE and HWBs to be equally defined.

8. CCN calls on the Health Select Committee to recommend that, following the recent “Listening exercise”, the role of the boards is not watered down, that they have sufficient teeth, are able to do the job effectively and that local decisions are not undermined by national priorities.

Public Health England

9. CCN have a number of concerns about the role and responsibilities of Public Health England (PHE) and its relationship with local authorities. It appears that the majority of public health services will be commissioned by PHE with very little being delegated to local government. The current proposals provide no satisfactory rationale for PHE to retain commissioning responsibility or for continuing to include them in the primary care contract for general practitioners (GPs). It is also not clear how PHE will make a significant impact on health improvement and health inequalities if it does not seek innovative ways of improving services. CCN is also concerned that whilst there are clear lines of accountability of PHE to the Secretary of State for Health there is little reference to accountability to councils or communities at the local level. CCN believes that the government should also more clearly define the relationship between PHE and HWBs and resolve issues of local accountability.

Directors of Public Health (DsPH)

10. Current proposals suggest that DsPH will be “strategic leaders for public health and health inequalities in local communities”. This fundamentally misunderstands the role of elected members (particularly Cabinet) in providing strategic direction and also has the potential to miss opportunities to join up public health services with other related services in a locality. This will be even more important during the current period of deficit reduction and resulting reductions in public sector funding.

11. The majority of DsPH in CCN member councils are already jointly appointed by the PCT and local authority and therefore we welcome the formal transfer of this role to councils. However under the current proposals there are significant accountability issues - with the DPH being jointly appointed by PHE and local authority, professionally accountable to the Chief Medical Officer and able to be dismissed by both the local authority and the Secretary of State for Health. CCN firmly believes that the DPH should be locally accountable for their record on health improvement and health inequalities and that this is best achieved by being fully accountable to the local authority.

12. The transfer of public health responsibilities and staff to local authorities will also create a number of complex employment issues. It is in councils’ interests that local government should have the flexibility to manage this effectively and we will be seeking clarification on this matter, as the employment implications are considerable – especially at the time when councils are seeking to maximise efficiencies.

Multi-tier Areas

13. CCN believes that in multi-tier areas District councils will have a complementary role to play in improving health outcomes given their statutory responsibilities for housing, planning, environmental health and leisure. CCN member councils in multi-tier areas are already engaging with District councils in their area and CCN strongly believes that it must be a matter for local areas to determine the best way for districts to be involved in the operation of Health and Wellbeing Boards (HWBs) and how they can contribute to this agenda.

Arrangements for the Funding of Public Health

14. The Secretary of State for Health has indicated that total public health funding will be “about £4 billion”. However it is not clear whether this is sufficient funding at the national level as there is a distinct lack of reliable data on current spending on public health and health improvement nationwide. The Department of Health admitted to the Health Select Committee that it “does not collect detailed information (on expenditure on public health and tackling health inequalities) because of local discretion on how funding is spent”.

15. There are also issues about how funding will be allocated between PHE and local government, and what evidence will be used to make this decision. The Audit Commission has indicated that the responsibilities to be taken on by PHE will cost more than £2 billion which could mean that less than half the funding allocated to public health will find its way to local authorities. CCN urges the government to ensure a fair share of funding for the delivery of this important agenda for which councils are going to be ultimately accountable.

16. Equally as important are significant questions about how funding will be distributed between upper-tier local authorities, either based on historic levels of funding or a new funding formula. Distributing funds based on historic levels of expenditure could be significantly hampered by the lack of reliable data at national and local levels. This could be compounded by the possibility that some PCTs may classify prevention spending differently and, following the announcements about a ring-fenced public health grant, offer misleadingly low estimates of their spending on public health. There is also considerable risk of “asset stripping” on the part of PCTs prior to the handover to local government in 2013. This could lead to councils receiving less funding to fulfil new public health responsibilities than is currently spent by the PCT. This will be difficult to track and is of significant concern to local government.

17. CCN believes it is essential that local authorities have sufficient financial resources so that they can take on these new functions and deliver real improvements in health for the communities to which they are responsible. Whilst we very much welcome the commitment that local authorities will receive additional resources, CCN has genuine concerns that the proposal for ring-fenced funding will limit the ability for local partners to pool resources at the local level, thereby constraining improved co-ordination and the design of effective and efficient services which really deliver improved health outcomes at the local level.

18. If the Government insists that public health funding is ring-fenced we would urge the Government to develop a funding formula and the level of allocations to individual councils in partnership with experts from CCN member councils, alongside wider local government representatives, including Directors of Children’s and Adult Services and the Society of County Treasurers.

19. CCN also welcomes the Government’s commitment to the “Health Premium” as a means of rewarding improved outcomes. However we would want to ensure that there was a balance between financial rewards and the resources to support communities with the greatest challenges in relation to health improvement.

20. There are many unanswered questions in relation to the “Health Premium” including whether rewards will relate to national or local outcomes, which authorities will be eligible and what will be the qualifying criteria. CCN urges the Department of Health to provide greater clarity on operation and funding allocation of the “Health Premium” and work with local authorities to ensure that it will be used to maximise improvements in health and wellbeing.

Public Health Outcomes Framework

21. CCN firmly supports the focus on improving health outcomes and addressing health inequalities and fully endorses the Government’s support for the “life course” framework set out in Sir Michael Marmot’s report which considers the wider determinants of public health encompassing both Starting Well – focusing on maternal and child health, and Developing Well – focusing on child and adolescent well-being. CCN agrees that significant improvements in public health can only be achieved through addressing the “causes of the causes” as expressed in the Marmot report.

22. In our Manifesto CCN set out our view that there should be an alignment of outcomes frameworks for public services in a locality. The current proposals introduce yet another separate outcomes framework and whilst the government has indicated the public health outcomes framework will be linked to separate NHS and Social Care Outcomes Frameworks, CCN believes that this is a missed opportunity to align performance frameworks more closely and reduce the burden on local authorities.

23. Within the context of the current proposals CCN urges the government to ensure that the Public Health Outcomes Framework is not overly prescriptive, thereby limiting the ability of local councils to respond to the public health needs of a particular area which they are best placed to understand. The framework needs to leave room for Health and Wellbeing Boards to identify their own locally appropriate outcomes through the development of a robust and inclusive Joint Strategic Needs Assessment (JSNA) process and to set out the direction of their plans through the Joint Health and Wellbeing Strategy (JHWS). It is essential that these local priorities are not undermined or overridden by national imperatives set by PHE and/or the Secretary of State.

Conclusion

24. The Government’s proposals represent a major restructuring over a number of years, not just of public health but also of councils’ responsibilities in relation to health improvement, and coordination of health and social care. 

25. CCN is fully committed to a localist agenda and reiterates our view that public health should be a local service, directed by local government and not simply a national public health service hosted by local government, and that without compelling evidence to the contrary decisions should be devolved to the local level.

26. However, as outlined in our response, we do have a number of concerns about resources, the role of local authorities and national agencies in relation to public health and the lack of joining up between the NHS, public health and adult social care.

27. We trust that the Health Select Committee will take account of our concerns and recommend that the Government addresses these issues as health and social care policy is further developed over the coming months.

28. We would welcome the opportunity to address the Committee as part of your important inquiry or provide further information on any aspect of our response.

June 2011

Prepared 28th November 2011