HC 1048-III Health CommitteeWritten submission from Lancashire Public Health Network and Cheshire and Merseyside Public Health Network (PH 21)

1. We welcome the opportunity to respond to the Select Committee new public health inquiry. We are committed to protecting and improving people’s health and wellbeing and reducing health inequalities. Whilst we recognise that the Government’s call for a public health system that can deliver world-class outcomes raises huge opportunities for public health, with such changes there are also risks and unfavourable unintended consequences. In light of these major changes proposed by the Government the following issues need to be considered by the Committee in order to effectively deliver public health to all in the new public health system.

2. The variety of commissioning routes may lead to fragmented commissioning for a number of public health functions and priorities which will threaten the meeting of local needs as well as compromising quality service provision and accountability. Public health expertise and input needs to be provided to all the different commissioning routes for the identified public health priorities/functions and the delivery of health care. Public health expertise in evidence based decision making and prioritisation is key to ensuring services are efficient and commissioned according to need. For many services a whole pathway approach to commissioning is vital to ensuring that efficiency savings are met eg tackling increasing alcohol admissions needs to be addressed through interventions along the entire pathway from prevention to treatment.

3. The commissioning of children’s services is particularly fragmented. It is currently proposed that Children five to 19 is to be commissioned by local authorities while under five services is to be commissioned by the National Commissioning Board (NCB) and at some time transferred to local authorities. There is a strong evidence base to suggest that the healthy child programme will improve health and wellbeing. Local authorities should commission the complete healthy child programme from 0 to 19. This would also encourage a whole life-course approach, with potential impacts on positive outcomes and would enable local authorities to integrate commissioning for children’s public health with their other responsibilities for early years, school and young people’s services.

4. The division of the public health function between Public Health England (PHE) within the Department of Health and locally in local government creates a fragmented rather than a unified workforce; different people employed by different organisations on different terms and conditions (civil servants, NHS, local government) creating inequities in the PH workforce. Currently the proposals to position the functions and staff of the Health protection Agency and the Public Health Observatories within the Department of Health as Public Health England may rise to the following, additional issues of conflict:

it compromises the independence of public health workforce to act as advocates of health;

leads to a fragmented rather than a unified workforce. If all resources, capacity and capability are held at a national level PHE will not be able support local delivery and be responsive to local differences; and

lack of influence from the local level on national policy.

By establishing PHE as a special Health Authority or Executive Agency of Department of Health its credibility and independence will be increased. 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.

5. Clear lines of accountability for GPs, GP Consortia and Health and Wellbeing Boards (HWBs) need to be nationally agreed – with clear levers for influencing commissioning by GP Consortia and the National Commissioning Board. HWBs need to be more than advisory bodies, they need to be given more power and influence for the implementation and delivery of the Health and Wellbeing Strategy by different partners.

6. The Director of Public Health (DPH) is the only defined role at local authority level when the NHS public health function moves to the local authority and the local authority becomes responsible for population health improvement. The DPH needs to be responsible for and in control locally of the three key domains for delivery of the public health function – health improvement, health protection, and health services. Currently the relationship of the Director of public health with Public Health England is unclear. The DPH needs to be able to give independent, professional advice and have a strong and pivotal role on Health and Wellbeing Boards for NHS and Local Authority influence.

7. The role of the DPH therefore should be defined as:

Public health adviser to the LA Health and Wellbeing Board.

Responsible for developing, implementing, performance managing and reporting on the population health of the area.

The integration of health, care and wellbeing delivery through the Joint Strategic Needs Assessment, the Joint Health and Wellbeing Strategy and the Public Health Annual Report on behalf of the Board.

Provision of advice and leadership for area population health and wellbeing.

It is proposed that to reflect these roles:

statutory powers should be invested in the role to ensure control of resources and accountability to and from other public functions;

the DPH must retain the independence of the public health function, able to speak at all times on behalf of the health and wellbeing of the local population rather than from a political or administrative position; and

the DPH must be positioned at Executive Director level in the local authority, directly accountable to the Chief Executive and with strategic overview of all local authority functions rather than restriction to health and social care. Lines of accountability need to be nationally agreed.

8. There are issues around the proposed arrangements for funding public health services:

ring-fencing risks encouraging silo working by dividing public health activity from non-public health activity;

that local authorities may not receive sufficient funding to commission and deliver health improvement services because the national formula for public health resource allocation will not be sensitive enough to identify current variation in PCT investment;

the substantial financial restrictions that both LAs and PCTs are experiencing may put public health spend at risk; and

the PH budget will come with commissioning commitments attached which then reduces flexibility to respond to local public health priorities.

9. Since a local budgeting approach to the health of the public has been shown to promote innovative, joined-up and whole-systems approaches to improving health, where appropriate the public health budget needs to be aligned and/or pooled with other budgets to maximise overall public health impact in local areas. Current investment in health prevention should be acknowledged in the pace of change adjustment (alongside health premium allocations) so as not to penalise those areas that have invested in public health spend. An audit of prevention spend in LAs (similar to the NW 2009-10 prevention spend audit in PCTs) would help to strengthen the baseline on PH spend across key partners. It is acceptable that there should be some broad conditions/agreements on the use of the ring-fenced budget in the early transition periods. But in the longer term local areas must be free to identify their own public health priorities and given the power to address them through a democratic and accountable structure.

June 2011

Prepared 28th November 2011