HC 1048-III Health CommitteeWritten evidence from Department of Health Equality, NHS Nottingham City (PH 170)

1. The creation of Public Health England within the Department of Health

1.1 We would suggest that creation of Public Health England as a part of a separate system to deliver “public health” carries some significant risks. To implement population level approaches, coordinated activity between many different organisations and agencies is required and cannot be delivered by a single agency. Creating a public health agency risks other agencies demurring from their important roles in delivering public health. As proposed there would be a considerable weakening of the relationship with the NHS which makes significant contributions to health improvement and reducing inequalities in health in the short and medium term.

1.2 However, assuming it is intended that the public health function be transferred to Local Authorities and some degree of sub-national level of organisation, it will be absolutely necessary to hold these functions in an organisation such as Public Health England. This will need to be an NHS body independent of the DH. Reasons for this include:

Securing of independent highly skilled specialist workforce.

Within an NHS contract framework, avoiding the significant contractual problems in transfer of staff.

Reducing the inherent risk of transition to Local Authorities that have yet to grasp the importance of Public Health and without the capacity and governance arrangements to support it.

Reduce the risk of erosion of influence of public health and the public health budget as it comes under pressure from other financial cuts.

Enable continued close working with the NHS.

To support health care commissioning.

To support important functions not directly related to patient care such as mobilising resources to support the health protection function.

To contribute important expertise to sub-national organisation of services such as health protection, screening programmes, regional networks, specialist centres (where planning is necessary to ensure access, efficiency and good outcomes).

1.3 Assuming that those working in public health (including those currently working at a local level in primary care trusts) are realigned into a national public health service, we would also see a number of roles for such a service at national level. Nationally it would:

provide centralised independent evidence-based advice to the National and Local Government and the NHS;

support the National Commissioning Board in commissioning for quality improvement and specialised services; and

provide and umbrella for governance and training in public health.

1.4 To accomplish this it will be necessary for PHE to be an NHS body that:

facilitates the employment and deployment of NHS public health staff (Specialists working across all three domains of health improvement, health protection, and healthcare public health, as well as public health intelligence/analysis) should be consolidated into PHE);

enables pooling of scarce and specialist public health capacity (the specialist capacity could then be deployed to provide public health input to all parts of the health and social care system including Commissioning Consortia, Local Authorities, National Commissioning Board, and NHS-funded provider organisations);

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

facilitates the separation of science from government policy and therefore reinforces the independence of DsPH and health protection staff for the population’s health and protection.

1.5 In a marketised system PHE could generate income from provision of services to other agencies – such as training, analysis and consultancy. However, marketisation may not be technically efficient where there are important statutory implications of the work involved (such as health protection) and where the majority of the work is for internal agencies.

2. The abolition of the Health Protection Agency and the National Treatment Agency for Substance Misuse

2.1 Delivery of Health Protection depends on a variety of organisations beyond the Health Protection Agency. Hithertofore, PCTs and other agencies have been key in mobilising support, services and response to local emergencies and outbreaks of communicable disease (as well as implementing important health protection measures such as immunisation). It should therefore be recognised that these important linkages are vital to the safety of the public in transition. We would agree that capacity for emergency preparedness and response must be maintained within the new structures – and robust interim arrangements to ensure a stable transition. We would also agree that clarity is vital over which part of the system will lead responses to incidents at local and sub-national/supra local or regional levels. Transition from regional to sub-national governance creates considerable risk to delivery of the health protection emergency response.

2.2 There needs to be clarity of where responsibilities lie in relation to the health protection of the local population between the Directors of Public Health and Public Health England. We would point out that present responsibilities are set out in the legal framework for PCTs and the HPA but are not clear in the future arrangements, creating a risk of fragmentation of emergency planning and response.

2.3 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. The public health role of the Secretary of State

3.1 We 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.

4. The future role of local government in public health

4.1 Arrangements for appointment of Directors of Public Health

4.1.1 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.

4.1.2 DsPH should be jointly appointed by Local Authorities and Public Health England and should have a contractual relationship with both. To retain staff and promote continuity within the public health profession DsPH contracts should remain with the NHS. The supporting HR framework and clarification of terms/conditions and accountabilities are urgently needed to retain highly skilled staff in the current uncertain climate. It will also help DsPH retain credibility within the NHS which will be important to effective functioning.

4.1.3 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.

4.1.4 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.

4.1.5 We would agree with the Association of Directors of Public Health 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:

be appointed jointly by the local authority and PHE, through a statutory appointments process which mirrors the existing Advisory Appointments Committee process for DsPH and Consultants/Specialists in Public Health – and accredited by the Faculty of Public Health (as is currently the case);

have a formal contractual relationship and role – which could be honorary – with PHE; and

have 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.

4.2 The role of Health and Well Being Boards, Joint Strategic Needs Assessments, and Joint Health and Well Being Strategies

4.2.1 The proposed powers granted to Health and Well Being Boards are weak. 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. This will pose a serious challenge to Board’s ability to hold partners to account. The aim of democratic accountability may be better achieved by making GP consortia boards democratically accountable.

4.2.2 As currently proposed there is a considerable risk that health and social care integration will be difficult to achieve. This may be compounded in times of relative austerity by contention over the middle ground where funding for services can come from health or social care depending on view point. There is also a gulf in organisational ethos between NHS commissioning organisations and Local Authorities that are predominantly providers. We think that the government could consider integrating commissioning of health and social care within NHS commissioning as an alternative arrangement.

4.2.3 Health and Well Being Boards need to serve the needs of the whole population and this is the Public Health perspective. We therefore believe that The DPH should act as a principal advisor to the Health and Well Being Board and appropriate authority to ensure plans are justified on population health grounds.

4.2.4 Under the current proposals it would appear that some DsPH will potentially relate to more than one Health and Well Being Board. This situation should be resolved so that no DPH relates to more than one board.

4.2.5 We welcome the central role of the Joint Strategic Needs Assessment and the delegation of responsibility for its production to the Local Authority and the GP Consortium. However, we would support strengthening of the requirements for these agencies to engage with public health to ensure the quality of such a document achieve its commissioning and population health aims.

5. Arrangements for public health involvement in the commissioning of NHS services

5.1 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 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”.

5.2 Specialists working in health services public health possess skills that are highly specialised:

5.3 Public health specialists are trained to analyse a wide range of information in assessing population health needs, to critically appraise evidence to ensure health services are based on evidence of effectiveness and are cost effective, and in evaluating health services. These specialist skills are critical for “world class commissioning”. Although GPs have a good understanding of individual patient health issues and are experts in diagnosis and treatment, they trained in the skills required for commissioning.

5.4 Public health specialists bring a population perspective that values the relative benefits of prevention alongside treatment, a key area better use of NHS resources and for control of NHS expenditure.

5.5 Public health specialists can provide a neutral unbiased perspective based on evidence and not subject to conflicted interests of service providers.

5.6 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 health and prevent disease nor to protect the health of their local health population.

5.7 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.

5.8 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.

6. Arrangements for the commissioning of public health services

6.1 There should be clarity about what is meant by public health services, as much of mainstream provision could be seen as public health services.

6.2 For Local Authority led commissioning, there needs to be a clear remit for a public health role where services have a clinical element (for example sexual health services).

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

7. The future of the Public Health Observatories

7.1 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 are likely to 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.

8. The structure and purpose of the Public Health Outcomes Framework

8.1 We agree with a 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.

8.2 However:

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.

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

9.1 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.

9.2 Resources will also be required to support transition of public health into Local Authorities. This would include support to transition commissioning arrangements around tendering, procurement, contract and performance monitoring and an awareness programme to ensure that politicians and councillors fully understand the role of public health and the DPH.

9.3 In relation to the local ring-fenced public health budget:

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.

9.4 The health premium should:

target need;

reward relative improvement; and

identify and reward “value added” activity/outcomes.

We are concerned over potential unintended consequences and that the health premium may create greater health inequalities.

9.5 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.

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

10.1 We would agree with 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.

10.2 The title “Specialist in Public Health” should be a protected title, required by statute to be registered.

10.3 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.

10.4 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.

11. How the government is responding to the Marmot review on health inequalities

11.1 We believe that the current reorganisation of the NHS and of Public Health significantly underestimates the role of the NHS in addressing health inequalities.

11.2 We 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.

11.3 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.

June 2011

Prepared 28th November 2011