HC 1048-III Health CommitteeWritten evidence from The Cheshire and Merseyside Directors of Public Health (PH 168)

1.0 Introduction

The Cheshire and Merseyside Directors of Public Health (C&M DsPH) operate as a federation to maximise their capacity to promote and protect health and reduce inequalities across Cheshire and Merseyside, via the Public Health Network (ChaMPs). The C&M DsPH work together in association with the Cheshire and Merseyside PCT CEO Board and as independent advocates for public health.

The C&M DsPH are the driving force behind the leading edge Public Health Network that was established in 2003 and serves the 2.4 million people of Cheshire and Merseyside. The C&M DsPH are the Network executive and collaborate with a multi-disciplinary Board that includes Local Authority, NHS, Health Protection and Academic representatives to oversee the delivery of a comprehensive public health programme outlined in an annual Business Plan, underpinned by a Five Year Strategy.

The C&M DsPH via Public Health Network has established robust partnerships and effective strategic working at all levels including the Merseyside and Cheshire footprints. There is a strong history of developing influential partnerships and collective lobbying for change when necessary including the successful collaboration on smokefree places. With the emergence of the Liverpool City Region – Safer Healthier Communities Board and the Cheshire and Warrington Commission – Health and Wellbeing Board the C&M DsPH, via the Network, provide both Boards with professional leadership and have influenced their strategic direction specifically relating to their current joint priority of alcohol. The unique position of the Network to serve two similar Local Authority led collaborations has meant shared learning and a powerful association between the two health focused Boards, welcomed by the lead Local Authority CEOs.

Following the White Paper Equity and Excellence: Liberating the NHS the C&M DsPH are developing a new managed system for public health across Cheshire and Merseyside. The system will build on the successful ChaMPs Public Health Network model with enhanced pooling of public health resource to achieve efficiency savings and maximise collaborative advantage.

2.0 Overview - Concerns for the Public Health System

The C&M DsPH recognise that the proposed reforms raise opportunities for public health and welcome the increased formal role of Local Authorities (LAs) in the health agenda and integration of local DsPH into LAs. However, England needs an integrated system for delivery of public health outcomes, and we are concerned that there is a significant risk that the proposals could have adverse effects on fragmentation:

of the public health workforce across a number of organisations;

of commissioning and finance responsibility for public health programmes;

and loss of clarity on accountability, particularly in the area of health protection; and

of well-functioning national public health training scheme.

The C&M DsPH think that LAs should be accountable for improving and protecting the health of their population at all times (with support from Public Health England). However, in order to ensure a coherent system-wide approach to public health, the Health & Social Care Bill should place a statutory duty on all health and social care bodies (including NHS funded providers) to cooperate in efforts to improve and protect heath and in responding to public health incidents and emergencies.

3.0 Specific Issues Identified by the Committee

3.1 The creation of Public Health England within the DH; the abolition of the HPA and the NTA for Substance Misuse

Public Health England (PHE) 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).

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

PHE should operate as a supporting organisation which can:

provide independent scientific evidence-based advice to national and local government, the NHS and the public on all matters relating to the maintenance, improvement and protection of health;

offer expertise to the National Commissioning Board (NCB) in support of its role in providing national leadership in commissioning for quality improvement, commissioning national and regional specialised services, and allocating NHS resources;

provide effective, expert and adequately-resourced specialist PH capacity to support the work of local DsPH and their teams;

provide independent scientific evidence-based advice and guidance to the devolved nations where they are unable to access this locally; and

generate revenue from external consultancy and academic research funding.

It is unlikely that these aims can be achieved if PHE becomes a fully-integrated part of the Department of Health. It should be established as an NHS body which would:

facilitate the employment of public health staff by PHE;

enable pooling of scarce and specialist public health capacity;

enable the continuance of external income streams that currently support national health protection activity; and

facilitate the separation of science from policy and therefore re-enforce the independence of DsPH and health protection for the populations’ health and protection.

The C&M DsPH are also concerned that:

there is a lack of definition on the role and status of DsPH within PHE – this requires clarification, including in relation to the health protection functions of DsPH locally;

clarity is required on the mechanisms for public health input to the NCB; and

there must be clear lines of accountability, communication and access between PHE, commissioning consortia, NHS and DsPH working within local authorities.

Specialist public health capacity (including specialists working across the domains of health improvement, health protection, healthcare public health, and public health intelligence/analysis) should be consolidated into PHE. The specialist capacity can then be deployed to provide public health input to all parts of the health and social care system; Commissioning Consortia, LAs, NCB, and NHS-funded provider organisations.

3.1.1 Health Protection

The C&M DsPH feel that capacity for emergency preparedness and response must be maintained within the new structures – and robust interim arrangements to ensure a stable transition. Clarity is vital over which part of the system will lead responses to incidents at local and sub-national/supra local or regional levels.

The C&M DsPH also feel that there needs to be clear agreement on the roles and responsibilities for DsPH and local health protection units, including assurance that health protection work carried out in second tier local authorities is connected with coordination and planning mechanisms organised at the top tier of local government.

The C&M DsPH agree that PHE and the NHS will need to liaise closely with public health agencies in the devolved administrations to ensure that cross border support remains robust in relation to UK health protection issues.

3.2 The public health role of the Secretary of State

The C&M DsPH welcome proposed new duties on the Secretary of State (and NCB 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.

There are also no equivalent duties on the Secretary of State or local authorities in respect of their roles in promoting public health.

3.3 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)

The C&M DsPH agree that:

DsPH are the frontline leaders of public health working across the three domains of health improvement, health protection, and health care service planning and commissioning. DsPH must be enabled - through primary legislation - to provide oversight and influence across all these determinants of health within local authorities, the NHS and primary care, and other appropriate sectors and agencies in order to secure the improving health of their population.

Over the past year Local Authority funding and functions have been reduced dramatically and this contraction will continue over the next few years. Some Local Authorities are looking to defray their reductions and staff costs through public health funding. This brings a number of risks including diluting public health skills, downsizing programmes and potential loss of influence and effectiveness. The DsPH question whether this is the most appropriate time for Local Authorities to take on responsibility for the public health function without robust safeguards being in place.

If the transfer of PH continues DsPH should be jointly appointed by LAs and PHE and should have a contractual relationship with both. However the supporting HR framework and clarification of terms/conditions and accountabilities are urgently needed.

DsPH will need clearly defined responsibilities and powers and the professional status and enablement to express an independent view in order to provide advocacy for the health of the population. This is analogous to the requirement for local authorities to appoint a suitably qualified officer responsible for the proper administration of its financial affairs in section 151 of the Local Government Act 1972.

DsPH will require a well-resourced, professional and co-located Public Health team providing the skills and experience to input to local service planning and commissioning, and to deliver Public Health programmes and advice across the health economy, supported by access to high quality local and national data and scientific evidence base.

The C&M DsPH strongly believe that:

A DPH should be an individual trained, accredited, and registered in specialist public health.

There should be a statutory requirement for top tier Local Authorities to appoint a DPH with the appropriate professional training and accreditation.

The DPH should be recognised as the principal adviser on all health matters to the local authority, its elected members and officers, and its Health & Well Being Board, on the full range of local authority functions and their impact on the health of the local population as stated in Annex A of the PH White Paper.

The DPH should work at corporate/strategic director (top team) level as a full executive member of the corporate leadership team with direct access to the local authority Cabinet and councillors – influencing and working alongside other Local Authority Executive Directors and normally reporting or accountable to the CEO or equivalent.

The professional status of the DPH and ability to express an independent view in order to advocate for health improvement and reducing health inequalities within their local population and act for the protection of the local population - and the independent DPH annual report - must be protected.

As the principal advisor to a Health & Well Being Board, a DPH should not relate to more than one Board. However, we recognise that where local arrangements lead to a shared Board, then it may be appropriate for one DPH to work to this Board.

DsPH should:

(a)Either be appointed jointly by the local authority and PHE or through a single national organisation, through a statutory appointments process which mirrors the existing Faculty of Public Health process including the statutory establishment of an Advisory Appointments Committee.

(b)If a joint appointment with the Local Authority have a formal contractual relationship and role – which could be honorary – with PHE; if a single national organisation have a formal contractual relationship and role with the Local Authorities.

(c)If a joint appointment with the Local Authority has their employment terminated only with approval of both the local authority and the Secretary of State for Health.

HR guidance to clarify employment/contractual issues - and professional accountability issues for DsPH and their teams – is urgently needed. There is an immediate and transitional risk of loss of PH professional staff and expertise through uncertainty and staff concerns over the implications of potential transfer out of NHS employment.

Clarification of the resources that will support the DPH role in local authorities is urgently needed.

Funding for DPH and PH team development will be crucial to support effective transformational change.

3.4 Health & Well Being Boards/JSNAs

The C&M DsPH feels that the powers granted to Health and Well Being Boards are weak and there is a risk that health and social care integration may be more difficult to achieve.

The Boards have not been granted sufficient powers to meet the expectation that they will join up commissioning between the NHS and local authorities. The interface between GP consortia and local authorities will be critical in ensuring that services meet the full range of local population health needs. However, while Consortia must consult Boards in drawing up their commissioning plans, there is no requirement for Consortia to have regard to the views of the Board.

Health and Wellbeing boards must have the power to sign-off local commissioning plans, ensuring that they are aligned with the joint strategic needs assessment and address the identified needs of the population.

In two tier authorities existing health and well-being partnerships should continue to work together. District Authorities should have specific roles and duties for the improvement and protection of health and the reduction of health inequalities.

The C&M DsPH strongly believe that the JSNA must:

be asset-based, wide-ranging and thorough and include qualitative “citizen” views (not just service-user or patient views);

include preventative and health protection issues; and

be the basis for all local commissioning.

3.5 Arrangements for public health involvement in the commissioning of NHS services; arrangements for commissioning public health services

The C&M DsPH agree that public health oversight of and input to commissioning will be essential to achieve real improvements in health outcomes and the reduction of health inequalities.

The proposed reforms:

lack clarity over who will be responsible for providing “local system leadership” and planning services across GP consortia boundaries following the abolition of SHAs/PCTs;

include few requirements on the governance of consortia;

do not require GP consortia to promote integration between health and social care – an omission that will be exacerbated by lack of co-terminosity between consortia and local authorities; and

do not appear to place a duty on GP consortia to promote and protect the health of their local health population.

Locally, the DPH should provide oversight and the Public Health team input to GP consortia commissioning, supported by additional resources and expertise held within PHE. GP consortia should be required to work through and with DsPH to ensure consortia decision-making is underpinned by expert, professional public health advice. DsPH should have a formal relationship with GP consortia, and local commissioning plans should be signed-off by the Health and Well-being Board.

Specialists working in health services public health possess skills that are highly specialised. The essential role of this group in the commissioning of health services by commissioning consortia (and NCB) has not been grasped in the draft Health & Social Care Bill. The current position is that the Bill requires commissioners to take advice only from those with “professional expertise relating to the physical or mental health of individuals”.

The requirement for commissioners to take advice should be extended to ensure that all organisations undertaking commissioning functions (at national or local level) should be required to consult and take cognisance of specialist public health advice in formulating their commissioning proposals. The board of each such organisation must include a specialist in public health as a full member.

GP Consortia (and NCB) should be responsible for improving inequalities of health outcome rather than just inequalities of access to health services. Clarity is required over where responsibility lies for ensuring GP consortia meet their responsibility for improving outcomes and how consortia are to be held to account for PH outcomes.

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 develop structures for stable joint commissioning where these would best serve their population.

GP consortium must be responsible for a defined geographical population which is coterminous with local authority boundaries.

In order to promote coherent response to emergencies, GP Consortia should assume similar responsibilities as category one responders under the Civil Contingency Act (that have previously applied to Primary Care Trusts) and be required to have a responsible officer for emergency response.

Commissioners should be required to demonstrate the use of a strategy covering high quality, universal services, targeted services for communities of interest at greater risk especially deprived communities and tailored services for people with multiple and complex needs. This should be underpinned by evidence base, public health intelligence and needs assessments.

There must be clear lines of accountability, communication and access between PHE, GP consortia, NHS and DsPH working within local authorities.

3.6 The future of the Public Health Observatories

The C&M DsPH think that 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.

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 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.

3.6.1 Public Health Intelligence

The C&M DsPH agree that public health intelligence is needed at national, regional and local levels to specify what data is collected, and in what way, to analyse it and interpret it in context. Public health intelligence is the driver for evidence based commissioning for population health. Public health provides some of the strongest tools for assessment, such as asset based approaches, impact assessment and participatory research. Public health also takes a population view of consultation, engagement and involvement, recognising that health, care and wellbeing are whole population issues, rather than just the population accessing services.

3.7 The structure and purpose of the Public Health Outcomes Framework

The C&M DsPH welcomes this focus on outcomes, and whilst recognising that many of the proposed indicators are process rather than outcome measures, we feel that this mix of process and outcome measures is appropriate given the long time frames which may involved.

However the C&M DsPH feel there needs to be:

greater emphasis should be put on ensuring that the Public Health framework is relevant to all sectors – with greater emphasis on linkage across the NHS, Social Care and Public Health outcomes frameworks;

public health analytical capacity is essential to delivery of public health outcomes and current capacity must be preserved and enhanced; and

investment will be needed in national surveys relating to health and wellbeing to ensure LA data can be assembled.

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

3.8.1 The ring fenced budget

The C&M DsPH thinks that the scope of the ring-fenced budget must be defined clearly and the funds available in the ring-fenced budget must be sufficient to meet the needs for which that budget is intended.

PHE will require adequate resources to immediately and effectively fulfil its wide remit – and vitally to invest in the continuing development of public health expertise and the public health workforce.

In relation to the local ring-fenced public health budget the C&M DsPH agrees that:

it should be explicit what will fall within this budget, and equally explicit that excluded activities with a bearing on public health will continue to be resourced from other / existing Local Authority and GP commissioning consortia budgets;

within the LA these budgets should be deployed with flexibility for DsPH to direct resources to best meet the needs of the local population based on the JSNA and Health & Well Being strategy;

it should be clarified as to how baseline budgets will be set. We are concerned that public health resources have already and will continue to be lost through the impact of local financial savings – any baseline must not be based on reduced resources.

Resources will also be required to support transition – including funding for DPH and PH team development to support effective transformational change, plus funding an awareness programme to ensure that politicians (national and local) fully understand the DPH role and all key PH functions.

3.8.2 Health Premium

The C&M DsPH feel that the health premium should:

target need;

reward relative improvement; and

identify and reward “value added” activity/outcomes.

The C&M DsPH are concerned over potential unintended consequences and that the health premium may create greater health inequalities. The C&M DsPH feel that public health funding proposals offer perverse incentives, literally in the case of the health premium. Premiums should be attracted to populations with the worst health and wellbeing without performance conditions. Evidence of collaborative use of premiums directed through the HWBs would be more appropriate.

The extent of the health premium is unclear but may not provide significant additional resources. Learning and evidence from existing programmes (such as the Spearhead approach) may provide useful evidence/outcomes to inform development of the health premium. We recommend that a full assessment of Spearhead experience should inform the further development of the health premium concept.

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

The C&M DsPH support the recommendations within Dr Scally’s Report on the Review of the Regulation of Public Health Professionals. The Faculty of Public Health is the standard setter for all public health practice in the UK. The C&M DsPH agree that the title “Specialist in Public Health” should be a protected title, required by statute to be registered.

The C&M DsPH believe that the statutory regulation of public health specialists is the best mechanism for providing effective protection of the public. The current requirement for statutory registration for public health specialists who are doctors or dentists should therefore be extended to cover those from all other backgrounds. All specialist public health staff (including DsPH) should be appropriately qualified, should be appointed through a statutory Appointments Advisory Committee and should have access to recognised continuing professional development. The training of public health specialists should be planned and delivered through Health Education England and should be consistent with arrangements for training other health professionals.

The independent PHE should act as the employing body for public health specialists, seconding them to other organisations as necessary, to ensure their primary responsibility is to the public. The use of honorary contracts can facilitate this model.

3.9.1 Public Health Training

The C&M DsPH feel that PHE having the role of public health staff employer would mitigate against fragmentation of the public health workforce and enable the continuance of the public health specialist training scheme to build necessary capacity. Public health training should be equivalent to that for other health professionals and delivered through Health Education England via the existing Deanery network. The C&M DsPH also feel that current arrangements for recruitment and training of public health consultant staff (mirroring the NHS consultant recruitment process) should be maintained as, otherwise, we will not be able to maintain the diversity of workforce and skills in the future.

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

The C&M DsPH feel that the current reorganisation of the NHS and Public Health significantly underestimate the role of the NHS in addressing health inequalities.

Marmot advocates “proportionate universalism” – ie that health will continue to be a universal service but be tailored to the level of need within communities so the more needy will get more, should be more widely promoted as it will help with targeting resources in a more structured way.

The C&M DsPH welcome new duties on the Secretary of State, NHS Commissioning Board and GP consortia to have regard to the need to reduce health inequalities. However these are narrowly drawn and do not reflect the broader role of the NHS in promoting public health as a provider, commissioner and major employer. There are also no equivalent duties on the Secretary of State or local authorities in respect of their roles in promoting public health.

The duties are unlikely to be sufficient to ensure that tackling health inequalities is prioritised in the health system. We strongly recommend that the NHS commissioning bodies should be held to account for reducing inequalities in health outcomes.

The proposed new system risks service fragmentation with detrimental impacts on the very areas the reforms seek to improve: quality of services, education and training, patient choice, efficiency and equity, and has the potential to exacerbate any existing postcode lottery in health services.

The “Nuffield Intervention Ladder” should be applied to the Responsibility Deal approach. Robust, time-limited monitoring and evaluation after 12 months will be crucial to assess the effectiveness of voluntary commitments.

4.0 Additional Issues

4.1 Provider and Regulatory organisations

The C&M DsPH agree that protecting, maintaining and improving the public’s health require services to cooperate, addressing shared priorities to meet health needs, and making best use of all available resources. A requirement to promote competition will discourage integration and collaboration across the sectors, and should be removed from the draft Health & Social Care Bill. A duty of cooperation should be placed upon service providers and commissioners.

The C&M DsPH agree that public health influence within provider organisations should be extended to:

a public health lead working within Trusts;

provider trusts should work with LAs in improving the health of the population; and

above a capped level of reserves, an annual proportion of Foundation Trust reserves to be spent on initiatives agreed locally as providing health gain for the population.

The C&M DsPH support the conclusions of a 2010 ADPH survey on Transforming Community Services that are:

in any re-organisation the impact on public health services should be assessed - particularly true for emergency planning and response;

where possible there should be a named public health lead in community services; and

public health expertise should be readily available to provider services where no public health lead is in place.

The C&M DsPH agree that there should be clear lines of public health input into CQC and Monitor:

public health expertise and input at a high level within the CQC to ensure a strong population perspective in quality regulation; and

public health expertise and input into Monitor to ensure effective use of resources in support of the prevention agenda health improvement and a reduction in health inequalities.

4.2 Partnership working

The C&M DsPH highlight that considerable efforts have been made by health and wellbeing partnerships to maximise the impact of health inequalities funding such as Neighbourhood Renewal Fund and single budgets such as Area Based Grant on population health and wellbeing through public health delivery programmes. The 2010-11 in year savings requirements and abolition of Area Based Grant caused the loss of exactly those partnerships and integrated programmes that the Public Health White Paper exhorted public health to develop on its publication three months later. It is concerning that the government appeared unable to recognise the impact withdrawal of Area Based Grant would have for health and wellbeing commissioners across the health economy

The Cheshire and Merseyside Directors of Public Health welcome this opportunity to respond to the Health Select Committee inquiry into Public Health.

Authors

Janet Atherton – DPH NHS Sefton (w.e.f. May 2011)

Hannah Chellaswamy – Acting DPH NHS Sefton

Sue Drew – DPH NHS Knowsley

Dympna Edwards – Acting DPH NHS Halton and St Helens

Heather Grimbaldeston – DPH NHS Central and Eastern Cheshire

Paula Grey – DPH NHS Liverpool

Fiona Johnstone – DPH NHS Wirral

Rita Robertson – DPH NHS Warrington

Julie Webster – Acting DPH NHS Chester and Cheshire West

Dawn Leicester – ChaMPs Network Director

Paul Cordy – ChaMPs Deputy Network Director

June 2011

Prepared 28th November 2011