HC 1048-III Health CommitteeWritten evidence from the Royal College of Physicians (PH 180)

1. About the Royal College of Physicians

1.1 The Royal College of Physicians (RCP) has been at the forefront of improving healthcare and public health since its formation in 1518. The RCP plays a leading role in the delivery of high quality patient care by setting standards of medical practice and promoting clinical excellence. As an independent body representing over 25,000 fellows and members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare.

1.2 The RCP continues to play a leadership and advocacy role in relation to public health. As well as delivering seminal reports on public health-related issues, such as tobacco, the RCP coordinates the Alcohol Health Alliance UK. The RCP is currently undertaking a range of public health-related activity, including on the social determinants of health, obesity, sexual health and alcohol.

2. Introduction

2.1 The future viability of the National Health Service (NHS) depends on an effective approach to public health, nationally and locally. Only through long-term strategies, investment and integrated action across all three domains of public health (health improvement, health protection and healthcare) can we reduce the burden of disease, disability and dependence caused by health inequalities, non-communicable diseases caused by smoking, obesity and alcohol misuse, and morbidity levels in an ageing population.

2.2 Health is everybody’s business. Tackling health inequalities, improving health and wellbeing, and protecting communities and individuals from harm rely on a coherent long-term vision and coordinated action across organisations, from central government and councils to hospitals and charities. This means adopting a joined up approach to health improvement, protection and healthcare, and to the planning and provision of primary, secondary and tertiary care and local authority functions, including social care, housing and planning.

2.3 Secondary care specialists and public health doctors are crucial, providing specialist knowledge and expertise on clinical issues and population health.

2.4 Individuals have a responsibility for their own health, supported by health and other professionals who can empower them to change unhealthy behaviours through targeted interventions. Education and health promotion targeted at individuals must be complemented by a broader population view and national leadership and action, including the introduction of legislation where appropriate.

2.5 The RCP welcomes this opportunity to submit evidence to the Health Select Committee on this important issue.

Summary of the RCP’s Written Evidence

All levers must be used to improve and protect health and reduce health inequalities

Government must seize the opportunity to reduce health inequalities and address the social determinants of health, and ensure the new health system reflects these goals.

The contribution of healthcare public health and the medical profession must be recognised and promoted when councils assume greater public health responsibility.

Government must use the full suite of public health interventions available, including regulation, and coordinate action across departments and partners.

Integration and collaboration must be embedded across the health service, local and national government, and in all commissioning and service planning arrangements

Secondary care specialists and public health doctors must be embedded at the highest level of decision-making throughout the system, ie in clinical commissioning groups, Health and Wellbeing Boards (HWBs), Public Health England (PHE) and the NHS Commissioning Board.

There must be an independent public health voice, nationally and locally

The RCP supports the establishment of Public Health England. PHE must be independent and authoritative, and capable of holding government to account. We welcome government’s commitment to establish PHE as an executive agency of the Department of Health.

Locally, Directors of Public Health (DPH) must be independent, expert and influential, acting as a voice of challenge and representing their communities, including vulnerable people and children.

The DPH’s independent annual report on the health of their population should include and analysis of health needs, together with an analysis of whether these are being met or not.

There must be sufficient funding to provide effective and sustainable public health services

The ring-fenced budget of circa £4 billion underestimates the resources required to achieve the government’s wide-ranging vision for public health and should be recalculated.

Health Premiums should be introduced only when a complex formula that does not act as a perverse incentive has been developed.

There must be solid evidence and research to support public health knowledge, policy and practice

Evidence and data analysis capacity must be retained, with the Public Health Observatories working closely with PHE to provide comprehensive information on needs and performance.

Our reputation for epidemiological research should not be threatened by a fragmented system, and our ‘practice’ research capacity should be developed.

The development of the public health profession must be supported

Public health specialists, including the DPH, should be trained and registered to specialist level in public health.

Public health training should continue to be organised and provided alongside other medical specialities with similar arrangements for recruitment, standard setting and quality assurance.

3. Approach to Public Health

All levers must be used to improve and protect health and reduce health inequalities

3.1 Health inequalities

3.1.1 The RCP welcomes the focus on the social determinants of health in the Healthy lives, healthy people, its emphasis on the importance of adopting a life-course approach, and the explicit references to reducing in health inequalities in the Health and Social Care Bill (including the duty placed on the Secretary of State). This commitment should be backed up in all structures and financial arrangements.

3.1.2 The Marmot report, Fair society, health lives (2010), proposes major economic, educational and environmental interventions to address the wider social determinants of health. The RCP is disappointed that the current strategy and proposals for public health do not present a clearer, pan-departmental vision for addressing some of these issues, particularly when pitched against a backdrop of economic austerity and public sector spending cuts.

3.1.3 We must ensure that our record on equity of access to health services is protected. This must not be affected by the removal of practice boundaries or potential loss of public health expertise during the transition from Primary Care Trusts (PCTs) to councils.

3.2 Healthcare Public Health

3.2.1 Ensuring the health and wellbeing of people, protecting their health, and reducing health inequalities is dependent on an effective and robust public health system that integrates each of the three domains of public health: health improvement, health protection and healthcare. There is currently little reference to healthcare public health, or the contribution of the medical profession, in the public health white paper.

3.2.2 There is a risk, particularly with greater public health responsibility being given to local government, that there will be a dislocation of “medical” and “public” health. To avoid this, it is vital that the knowledge and ability of hospital clinicians and others to influence good public health and to improve public health planning is not lost in this reorganisation.

3.2.3 Hospital doctors have the expertise in their own specialties to work with GPs and other colleagues to promote:

Quality, integrated care for patients, including those with rarer/complex conditions and co-morbidities.

Effective use of service, clinical and research data to identify need, clinical effectiveness, capacity and potential efficiencies.

3.2.4 Public health expertise is needed to assess risks to health and trends in ill health—for example, assessing the risks of alcohol to young people, trends in common cancers and addiction, and recognising the benefits of new drugs. Public health expertise has devised new risk stratification for the treatment of heart disease and identification of people at highest risk from diabetes, alcohol problems or frequent admission to hospital.

3.3 Individual responsibility and national action

3.3.1 To improve the nation’s health, we must use all available tools and take action at all levels. Devolving to local level the responsibility for improving people’s health and wellbeing and reducing inequalities does not replace the need for action and leadership from the centre. Although there should be flexibility to tailor programmes to suit the needs of local populations, there is still a need for national programmes, service frameworks and coordination, eg for alcohol consumption and smoking.

3.3.2 Central government must assume responsibility for taking a population approach to public health interventions and programmes, and use the full suite of interventions available, including regulation. At present, many of the public policy measures that have been announced rely on personal enablement and individual responsibility for healthy choices. We welcome the recognition of the importance of these factors, but regulation and legislation also have an important role and can be key to ensuring that change happens quickly—from legislation on clean air and smoke-free spaces, to seat belts and drink driving.

3.3.3 With any public health plan as many levers as possible must be pulled simultaneously, as, for example, with smoking prevention (see extract from UK Centre for Tobacco Control Studies submission for illustration). The uptake of local services by individuals, and their success, is dependent on their motivation to quit, which is driven by both national and local policies.

3.3.4 Central government also has a responsibility to maintain and develop health protection services at national and local level. Protecting the public from infectious diseases and major chemical and biological incidents must be paramount.

3.3.5 Action must be coordinated across government departments. Options for ensuring this happens should be explored, such as mandating that each government department has a senior public health advisor.

3.4 Responsibility deal

3.4.1 The RCP agrees that all sectors – including government, health, industry and the voluntary sector— have an important role to play in improving the nation’s health. However, public health policy must be independently set and measured. Any involvement of industry in public health action must be open and transparent, and accompanied by independent monitoring and evaluation (of both compliance with voluntary measures and their impact on public health outcomes) and by a spectrum of other public actions, including the introduction of regulatory measures.

3.4.2 At present, the RCP is not a signatory of the public health Responsibility Deal due to concerns that the criteria outlined in paragraph 3.4.1 are not currently being met, particularly for alcohol. We wish to see a clear presentation of the steps that will be taken if the voluntary objectives set for the alcohol industry are not met (see: RCP’s position on the Responsibility Deal for more information).

4. Integration and Co-ordination

Integration and collaboration must be embedded across the health service, local and national government, and in all commissioning and service planning arrangements.

4.1 To ensure an integrated approach to the public’s health, secondary care specialists and public health doctors must be integral to commissioning and service planning arrangements at a national and local level. Locally, specialist doctors will bring their experience and knowledge of secondary care and the hospital environment to the table, working with GPs to challenge existing practice where it does not deliver good outcomes for patients, and to promote innovation and high quality joined up services across primary and secondary care.

4.1.1 Clinical commissioning groupsSecondary care specialists should have a place at the highest governance level of local commissioning groups, with access to wider networks of clinical expertise. The RCP is pleased government recognised this in their announcement of 14 June 2011. Public health specialists should also be involved at the highest level.

4.1.2 Health and Wellbeing BoardsHospital clinicians (as well as the Director of Public Health) should have a mandatory role on HWBs, with other specialists called upon to advise as appropriate (eg via clinical senates and networks). Specialists should be involved in:

analysing and interpreting data;

preparing Joint Strategic Needs Assessments;

setting local priorities via the Health and Wellbeing Strategy; and

assessing if commissioning groups reflect local priorities in commissioning plans.

4.1.3 Public Health EnglandClinicians of all types should be advisors to Public Health England.

4.1.4 NHS Commissioning BoardPrimary care and services for rare conditions will be commissioned by the Board. Specialist doctors and public health specialists must be integral to national commissioning decisions. Specialist services must be part of a total integrated pathway of care and not allowed to operate in isolation.

4.1.5 Foundation and NHS TrustsThe RCP also recommends that there are cross-representation appointments within providers, with GPs on trust boards and public health consultants across the system.

4.1.6 The RCP welcomes the government’s move (announced 14 June) to promote the co-terminosity of commissioning group and local authority boundaries.

4.1.7 Proper consideration should be given to the commissioning arrangements for “uncommon conditions”. Access, and equity of access, to such services are a core component of an effective public health service. Facilities such as a trauma centres, and conditions such as immunodeficiency, require a critical mass to be cost effective and should be commissioned on a sub-national basis.

5. Independent, Expert and Authoritative Public Health Voice

There must be an independent public health voice, nationally and locally.

5.1 Public Health England

5.1.1 The RCP supports the proposal to establish a national body, Public Health England (PHE), focused on coordinating and supporting public health. PHE must be accountable for its own performance and an independent and authoritative body capable of providing expert advice and holding government to account across departments. It should also act as a network for Directors of Public Health, supporting them to challenge local performance and utilising their knowledge of the local situation to identify where action is needed at a national level (such as by introducing new national initiatives, legislation, etc), and challenge central government when this does not happen.

5.1.2 We welcome the government’s new commitment to establish PHE as an executive agency of the Department of Health (DH). Creating PHE as an executive agency at arm’s-length from DH will help to establish it as an independent, authoritative source of public health expertise, whilst still providing the Secretary of State with a clear line-of-sight.

5.1.3 PHE should make use of the existing public health specialist workforce currently working in Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs) so that valuable expertise is not lost. Expert PHE staff could be seconded to local authorities and clinical commissioning groups.

5.2 Local responsibility and accountability

5.2.1 Councils will often be best placed to design services and deliver programmes that best meet the needs of communities. However, steps must be taken to ensure that localism and the devolution of health budgets does not lead to unnecessary costs and bureaucracy, unjustifiable variation, piecemeal and fragmented service provision, an absence of quality evaluation metrics, and a lack of information sharing and best practice. We believe an expert, influential and independent Director of Public Health - supported by robust data analysis and outcome monitoring systems—is essential.

5.2.2 Responsibility for public protection, including health protection, must be clear across the system. Councils should be given responsibility for - and be accountable for—all aspects of public protection at a local level.

5.3 Directors of Public Health

5.3.1 The independent public health voice should be replicated at a local level through the Directors of Public Health (DPH). The DPH must be expert and influential, and be able to act as the “voice” of the local community, including disadvantaged groups and children. The DPH must have influence across all aspects of local authority work and throughout the local health economy. To achieve this, the DPH must have direct access to the council’s cabinet, councillors, chief executive and directors, and manage the ring-fenced public health budget.

5.3.2 The DPH must be seen as the strategic leader for public health in their area providing, through their annual report, independent analysis of local needs and performance. The Health and Social Care Bill’s requirement that the DPH produces an annual report on the health of their population should be expanded to require the DPH to describe health needs, with an independent analysis of whether needs are being met.

5.3.3 The DPH must have the skills and experience needed for this expert and specialised job. The DPH should be recruited through a statutory appointments process. To ensure the Secretary of State as a “direct line-of-sight” to specialist public health expertise at the local level, the DPH should be jointly appointed by PHE and the LA.

5.3.4 The movement into local authorities must not result in the DPH losing access to valuable data and resources (eg NHS data systems). Likewise, links with local health service structures and the workforce must be retained or, indeed, strengthened. The DPH will need to ensure robust arrangements for seeking input and advice from colleagues working in primary, secondary and tertiary care.

6. Funding

There must be sufficient funding to provide effective and sustainable public health services.

6.1 Ring-fenced budget

6.1.1 Government has allocated 4% of the total NHS budget to public health, which it estimates at approximately £4 billion. It is important in these times of austerity that public health initiatives and interventions that will save money in the longer-term receive proper investment now. We therefore welcome the protection afforded to the public health budget.

6.1.2 However, the RCP believes the £4 billion figure underestimates the resources needed to achieve the government’s wide-ranging vision for public health, and represents a significant cut to funding. The figure does not take into account a range of costs (eg overheads, on costs, etc) and money will be deducted for various activities (eg Health Protection Agency, public health and GP screening) before the it reaches councils.

6.1.3 There must be clarification of exactly what services are intended to be funded from the ring-fenced budget, and how funding will be split between the various public health functions, including PHE, the NHS and councils. These functions must be clearly defined to enable a robust assessment of the ring-fenced budget, calculated from a realistic baseline that considers activities across all three domains of public health. There must be sufficient funds to support the transition of public health teams and DPHs to councils, and projects that have not yet been rolled out, such as health checks.

6.1.4 It is vital that the ring-fenced budget is not seen as the only budget for public health. It must be clear that the ring-fenced money is intended only as a core budget intended to protect a clearly defined set of core services.

6.2 Health premium

6.2.1 The RCP appreciates the desire to incentivise public health action and reward good performance. However, to be effective and not a perverse incentive, a complex formula will need to be developed. The health premium should not be introduced until a formula is developed that: does not penalise those areas with the greater incidence of entrenched disadvantage, resulting in a cycle of increasing health inequalities; does not encourage “easier” public health wins over more difficult long-term gains; takes account of the impact of broader factors, such as funding cuts, the economic downturn and the impact of population change; and does not increase inequalities between already disadvantaged groups through the incentivisation of a limited range of specific indicators

6.2.2 This will take time and investment.

7. Data, Evidence and Rresearch

There must be solid evidence and research to support public health knowledge, policy and practice.

7.1 The new system must ensure that there is access to timely, reliable, appropriate and relevant public health information and intelligence to inform decision-making and service planning. Understanding the health and wellbeing needs of local communities requires in-depth analysis and assessment.

7.2 Public Health Observatories (PHOs) are vital in providing this important function. A reduction to the capacity of PHOs will have serious implications for the collation, assessment, analysis and provision of essential public health intelligence. Public health observatories should be retained and, working closely with PHE, could play a crucial role in:

Gathering reliable information essential to the understanding of health needs.

Undertaking modelling of future scenarios and assessment of impact and efficacy.

Evaluating the effectiveness of local initiatives with different delivery methods.

Gathering and disseminating examples of good practice.

Providing a comprehensive and detailed understanding of their local population, across all three domains of public health.

Coordinating longitudinal studies.

7.3 High quality public health teaching and research, addressing all three public health domains, are crucial to the success of public health. Our reputation for epidemiological research should not be threatened by a fragmented system (councils, in particular, do not have a strong research tradition), and our “practice” research capacity should be developed. Appropriate funding will be required to ensure that the evaluation of evidence and research in public health is not sidelined during the current financial climate.

8. Public Health Profession

The development of the public health profession must be supported.

8.1 It is essential that public health specialists, including each DPH, are trained and registered to specialist level in public health. This should be a requirement in the Health and Social Care Bill.

8.2 Robust mechanisms must be in place for ensuring that public health competence is obtained and maintained by staff in all areas, including universities and research. There is concern, for example, that councils do not have the training structures or workforce plans in place to support development of public health competencies.

8.3 To ensure public and profession confidence, public health training should continue to be organised and provided alongside that for other medical specialities with similar arrangements for recruitment, standard setting and quality assurance. This should be considered in the government’s planned restructuring of the way the healthcare workforce are trained and educated set out in Developing the healthcare workforce (see: RCP’s response to the workforce consultation for further information).

8.4 It is important that public health continues as a specialty that is attractive to doctors. It is also vital that in the new system specialty registrars undertaking public health training have access to the full breadth of experience and settings (such as local health protection units, provider trusts, local authorities) in order fully to develop their specialist public health competencies.

June 2011

Prepared 28th November 2011