HC 1048-III Health CommitteeWritten evidence from the Institute of Public Health (PH 187)

By Professor Carol Brayne and the Public Health Theme (CLAHRC Cambridgeshire and Peterborough), in consultation with colleagues at the Institute OF Public Health, University OF Cambridge and the wider service public health community.

There should be a single National Public Health Service for England as a special health authority within the NHS, encompassing all 3 domains of public health, or as an executive agency of the department of health.

Public health is at risk of becoming fragmented by reforms with damaging consequences for commissioning of quality services.

Health and Social Care Bill should be amended so that the Secretary of State remains accountable for the commissioning and delivery of a comprehensive health service free at the point of need, for the whole population.

DPHs must be a statutory member of the Health and Wellbeing Board and directly accountable to the local authority CEO.

GP consortia must cooperate with the DPH, so public health expertise into planning, commissioning and delivery of health services can be maintained.

Fragmentation of commissioning responsibilities, and eradication of GP practice boundaries increases the likelihood of people falling through the net.

The budget for public health should be ring-fenced and not subject to other pressures such as those of reduced local authority budgets

Healthcare (health services) Public Health has been overlooked in these reforms. Public health specialists in this area provide expertise to commission clinical and cost effective services for the local population based on need. Public Health professionals must be put at the heart of commissioning.

New arrangements should strengthen working relationships between academic public health and service public health, enabling public health research and practice communities to engage more effectively with each other.

The recruitment and training of public health professionals is in danger of being severely damaged as a consequence of the Health Bill. The profession must continue to recruit high calibre candidates.

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

1.1 We believe that there should be a single National Public Health Service for England set up as special health authority within the NHS encompassing all three domains of public health. Alternatively, it can be set up as an executive agency of the department of health. The specialist public health workforce currently employed in PCTs and SHAs should be employed on NHS terms and conditions by the National Public Health Service and seconded as required to sub-national and local teams, including commissioning consortia or any organisation requiring public health input. This would allow the Directors of Public Health, jointly appointed with the local authority, to be supported by the public health specialists. Support would be available nationally and locally, by all 3 domains of public health—health protection, health improvement and healthcare public health.

1.2 PHE should not come under the DH, as the public health workforce would lose the independence to challenge powerful interests whose actions risk the health of the population, and could no longer be a powerful advocate for the health of the public. This model would also allow for quality training programme for the future public health workforce, and robust mechanisms for maintaining professional competence would be easier to administer if the public health workforce were integrated.

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

2.1 Health protection incidents are always complex, and often require expert input at national, regional and local levels, involving multi professional collaboration. The current proposals lack clear lines of accountability and communication for protecting the health of local population. Local authorities have been given duties around protecting the health of the population, but if PHE (health protection) also has responsibility, there is a risk of duplication and confusion. This is of vital importance at all times, but particularly at times of emergency eg the flu pandemic, when there is no time to debate accountability.

2.2 With the duty of the protection of the health of the public moving to local authorities, it is not clear how the after hours health protection function will be delivered when PCTs are abolished. Public health consultants currently at the PCT, supported by Public Health Registrars in training, perform many health protection roles providing expert knowledge on infectious diseases eg infection control, sexual health (HIV and AIDS), TB contact tracing, as well as emergency planning. It is not clear where this function will be held in future, or how the accountability will work when there is a serious outbreak of disease such as E coli, flu pandemic or a meningitis outbreak.

2.3 If PHE were to be set up as a special health authority, this would also allow the HPA to continue research activities which are under threat if it becomes part of the DH as proposed in the Health Bill.

3. The Public Health Role of the Secretary of State

3.1 Splitting the role of the Secretary of State into two, (1. a duty to secure provision of public health services; 2. to act with a “view to” securing the provision of health services for the purpose of the NHS), relieves the SoS of his accountability for a comprehensive health service. This has directly resulted in the fragmentation of public health with little regard for the consequences on commissioning of quality services for populations.

3.2 In the past, costs and provision were balanced at population level by public health as honest brokers without specialism. There is no gain for patients in changing the current accountability of the secretary of state. We believe that the Bill should be amended to make it clear that the Secretary of State remains accountable for the commissioning and delivery of a comprehensive health service free at the point of need, for the whole population through a statutory “duty” to do so.

4. The Future Role of Local Government in Public Health

4.1 The Bill must require that the DPH be a health professional, the local representative of PHE, an independent advocate for health, who reports to the Chief Executive of the Local Authority so that the importance of the role is clear and reinforced. The DPH provides expert strategic leadership in public health, and so must be in the position where they can exert a major influence on decisions made by the local authority, yet still maintain independence to provide advice and speak publicly. The DPH also needs to be able to influence commissioning decisions, so there must be a duty for consortia to cooperate with the DPH. In this way, public health expertise into planning, commissioning and delivery of health services can be maintained.

4.2 If the DPH is jointly appointed by PHE and the LA, then the DPH will be accountable to the secretary of state for health, the CMO, the LA, and possibly the NHS commissioning board. This could lead to confusion.

4.3 The DPH will need a wide range of expert support from public health specialists and practitioners with skills and expertise in a wide range of areas including public health. DPHs need to be properly professionally qualified and so there needs to be statutory provision on appointment processes, and qualifications, as well as statutory registration for non-medical public health specialists.

4.4 The DPH must be a statutory member of the Health and Wellbeing Board and directly accountable to the local authority CEO, be responsible for managing the ring-fenced public health budget and public health staff, have direct access to the local authority’s cabinet and councillors, and not be removed from his/her position without the approval of both the local authority and the Secretary of State.

4.5 Local authorities should be accountable for protecting and improving the health of their populations at all times, including outbreak and emergency situations

5. Arrangements for Public Health Involvement in the Commissioning of NHS Services

5.1 There have been no arrangements laid out for public health involvement in the commissioning of NHS services. Public Health professionals must be put at the heart of commissioning, which is where the profession has been for over 30 years, providing the expertise for which its workforce are trained. The public health workforce is already disappearing and their skills will be more expensive to purchase from the private sector under a fragmented market. If this skill disappears altogether, the health care system will be distorted by expensive demand and the need for rationing, and poorly informed from a population and contextual angle. Commissioning decisions must be grounded in quality information systems, needs assessment, service model development, standards and specifications, and design which ensures a balance between cost effectiveness, quality improvement, impact on education and training, and the long term sustainability of the local health economy. This is the core business of public health as it has been practised in the UK, and will continue to be practised in Wales and Scotland.

5.2 GPs are not trained in population health, GPs are trained in individual health. The local population includes not only those on the GP practice register, but also those not on any register such as the vulnerable populations who are likely to be underrepresented. Consortia cannot selectively commission services, rather they must commission for the population based on a needs assessment carried out by population health experts. GPs must have a duty to collaborate with public health specialists at all stages of commissioning, including needs assessment. Commissioners must retain a responsibility for the provision of a comprehensive health care service to protect and promote the health of the population for which they are responsible.

5.3 Most pathways of care will span a range of interventions from prevention to rehabilitation, and include both generalist and more specialist areas. Collaboration with specialists outside the NHS is important for almost all these stages, and requires public health specialist advice. Across the whole range of health services, this task is immense and becomes highly specialised, requiring a general understanding of the particular health and service area (cardiovascular, maternal and child health etc.) as well as general skills, in order to commission in an integrated way.

5.4 One of the most contentious areas of commissioning is exceptional funding decision making. Public health specialists currently take the lead in decisions around funding treatments which are not within NHS guidelines. This role requires a population perspective on budgets and evaluating evidence, which will be competences of crucial importance for GP consortia. Whatever the arrangement for the future, decisions must be informed by public health expert opinion.

5.5 Related to this, we are concerned that the White Paper and related Bill, in it current state, makes no provision for a strong means of generating the evidence to underpin the advice (public health research). We believe that the commissioning process should mandate commissioners to:

regularly draw on research evidence to inform commissioning and to ensure that commissioning organisations have access to high quality, local, research partners (including Universities) which will inform the local and national commissioning process;

oblige providers to undertake and support high quality research; and

include a suite of appropriate research metrics (some of which may be used as proxy measures for clinical quality) to ensure that the obligations of providers to support research are being met.

6. Arrangements for Commissioning Public Health Services

6.1 Commissioning services such as immunisation, sexual health, mental health, safeguarding and public health services for children (including school nursing and health visiting), is often a complex, interdisciplinary and interagency process. Under the current proposal, services in these areas will be commissioned by multiple bodies. This is a waste of money and expertise. This fragmentation, together with the proposed eradication of GP practice boundaries increases the likelihood of individuals, even whole areas, falling through the gaps, and particularly leaves vulnerable children and adults at risk.

6.2 Provision for joint commissioning must be strengthened, and cost shunting between health, public health and social care avoided. Clarity is required to establish how each part of the system will work together to ensure effective and coordinated commissioning.

7. The Future of the Public Health Observatories

7.1 The public health system must have access to up-to-date, comprehensive public health intelligence on which to base decisions. Robust and accessible public health intelligence underpins all service commissioning, outcomes assessment, planning and redesign of services, and surveillance of infectious disease in the community. It is about collecting data, analysing and interpreting it. Only with this information can health needs be established, the modelling of future scenarios of future needs, and the assessment of the impact and effectiveness of interventions.

7.2 The cut in 30% of funding for PHOs is already resulting in the departure of skilled staff. Once these skills are lost they cannot be recovered, as future analysts will find another profession. There is a serious risk to provision of information if the future funding of public health observatories is not guaranteed. The Government is not acting to preserve the skills in the Public Health Observatories, whose existence is being prolonged only by a short term extension, with no clear strategy for the longer term. The public health observatory role should be protected, and clarification is required on how this, and access to health service data at population level, will be ensured. More generally, national and local public health intelligence efforts need to be joined up. If funding to the regional PHOs is not guaranteed, this will lead to gaps in surveillance and monitoring, in turn affecting ability to produce trend data in population health and health inequalities.

7.3 There also has to be an appreciation of the role of public health research at the core of the improvement of the health of the nation, and the role of healthcare observatories in analysing public health datasets to provide reports on the health of the nation. The removal of PCTs will also remove any guarantee that research plays a role in the provision of safe, and effective services, since Local Authorities and commissioning consortia are unlikely to commission research to the same, or any, extent, and equally may not welcome hosting research. The gap that this leaves will put the UK backwards in its international standing of its medical academic institutions, and affect the health and wellbeing of the population. It seems to us that the UK has fast changed from being one of the best places in the world to do true population based epidemiological research to near the worst.

7.4 We must also remind ourselves that public health intelligence functions include not only public health observatories, but also cancer registries and regional epidemiology units. The scarce local public health intelligence skills that currently lie within PCTs need to be protected.

8. The Structure and Purpose of the Public Health Outcomes Framework

8.1 Our stated position in respect to the Public health outcomes framework was submitted in response to the consultation document Transparency in Outcomes—Proposals for a public health outcomes framework. Briefly, we highlighted:

a need for clarity on the actual measures and methods to be used, as well as the purpose of measuring them;

Questionable measurability of several indicators;

data collection for poorly defined items; and

risks in reproducing another “target culture”, with arguably less of the benefits.

8.2 We suggested improvements could be made if indicators are: strengthened to guarantee measurability and validity; if indicators described as outcomes actually are outcomes; transparent and care is taken not to merge definitions that do not mean the same thing (eg wider determinants of health and wider determinants of health inequalities).

9. Arrangements for Funding Public Health Services (including the Health Premium)

9.1 We suggest looking at Australia’s example, where a proportion of the taxation income from alcohol and tobacco goes to fund national public health measures aimed at supporting changes to the environment which make healthy life easier. We could extend that here to other health damaging products, such as confectionary and sugary drinks. The funding of health protection and health service public health should be raised nationally, not locally if we want these services.

9.2 The budget for public health should be ring-fenced and not subject to other pressures such as those of reduced local authority budgets. The uses must be clearly defined, and the amount calculated from a realistic baseline. There is a danger that public health priorities will be downgraded or lost in the current financial climate, restricting the ability of public health specialists to deliver on the wider determinants of health and health inequalities.

9.3 There is a risk of unfair allocation of the health premium. Specifically, there is no guarantee that deprived areas will receive more funding as they did in the past, or that vulnerable groups will have access to services, because it will be more complex to evidence improvement in health status. There will be a need to review and evaluate any mechanism for allocating the health premium, to ensure a level playing field. The health premium could be incentivised, however, to ensure that it leads to reductions in health inequalities if there is corresponding support for data collection on reliable metrics to evidence:

a reduction in inequalities where activity is specifically targeted to do so;

milestones and progress towards improved health in the community as a whole; and

the geographical distribution of resources and relative performance in relation to changes in health status. (To monitor the balance between rewarding relatively “richer” areas, who might achieve clinical targets more easily, at the expense of those experiencing far greater socio-economic (and health) disadvantage).

10. The Future of the Public Health Workforce

10.1 The term “public health” in the White Paper and the Health bill is both confusing and used to denote a number of interconnected services relating to the health of the population and some of the public health professionals who are involved in these services . However, its use in this generic way does not do justice to the many different components of public health, nor to the highly skilled health professionals within these components. As a result, we believe that one very important domain of public health, has been overlooked: Healthcare Public Health.

10.2 There are three domains of public health: health improvement, health protection and health services or healthcare public health—which must all be covered by the public health system if the health of the public is to be fully protected and improved. This forgotten element relates to the planning, audit and evaluation of health services. Public health specialists in this area provide expertise to commission clinical and cost effective services for the local population based on need. There are about 200 public health experts practising this subspecialty, with the training to analyse extensive amounts of information and data, and to interpret the findings in order to meet population health needs. They work with colleagues in public health observatories, academic public health and health economics, and are also trained in management and leadership so that they can deliver service change, including decommissioning, where needed.

10.3 Commissioning has been handed to GPs who have no specialist training in health services planning nor the expert population or epidemiological skills required. The speciality of public health medicine emerged from the recognition of a need for systematic training. Until relatively recently, this was through recruitment of experienced medically qualified professionals (of any speciality) to the public health training programme. At this time of the NHS, public health physicians provided the honest broker population role. The future scenario as it stands is extremely worrying, as without expert input into the commissioning of health services, we run the risk of commissioning services that are not cost effective, not clinically effective and not integrated into patient care pathways.

10.4 Another area of public health with minimal mention in the White Paper is high quality public health teaching and research, which are nevertheless crucial. Links between service and academic staff have often been weak in the past. Local authorities do not generally have a strong research tradition. The new arrangements should be strengthening working relationships, enabling public health research and practice communities to engage more effectively with each other (such as in the CLAHRCs). Academic public health consultants currently have honorary contracts with the PCT, and have input into public health matters at local and regional level. So in the new structure, it is unclear where academic public health will link. As well as playing a key role with the three strands of public health, academic public health is of course integral to the education and training of public health undergraduates, postgraduates and the specialist training of public health doctors and trainees.

10.5 Consultants in Public Health are very concerned that, with one strand of public health moving to local authorities, and uncertainty surrounding healthcare public health, and around the future of the public health observatories, the public health workforce is becoming fragmented and it will be increasingly difficult to collaborate and share skills. It is increasingly likely that skilled staff will no longer see a future career in public health.

10.6 The training of public health professionals is in danger of being severely damaged as a consequence of the Health Bill and the consultation paper “Developing the Healthcare Workforce.” In order for public health training to maintain its high standards, it must continue to recruit high calibre candidates. If there is any doubt as to the quality of training or the career path, then the best candidates will choose another speciality. In order to keep the specialty attractive to doctors, the training must keep its place alongside other specialties, with similar routes of access, standard setting and quality assurance, and with registration with the GMC after completion of training. If it is to remain an attractive career option then it must have equity of pay with comparable careers.

10.7 Doctors and dentists working at this level must have statutory registration to demonstrate achievement and maintenance of satisfactory standards of competence and ethical behaviour, to safeguard the public and minimise the risk to them and their employers. This is not currently required for those from backgrounds other than medicine. It is therefore necessary for specialists in Public Health to have some registration eg with the Health Professions Council.

11. How the Government is Responding to the Marmot Review on Health Inequalities

11.1 Unfortunately, it looks as though the bigger picture changes are of an increasingly fragmented society, which with low employment and youth disengagement, is likely to lead to greater inequalities. The “Big Society” exists already in many more affluent areas, but is much rarer in disadvantaged communities alienated from mainstream society.

11.2 The Government clearly has a preference for voluntary approaches and responsibility deals over regulation in relation to health improvement and protection, and responsibility seems to rest largely with individuals to look after their own health and wellbeing. Legislation has a complementary role to play, and should be used where appropriate.

11.3 The role of social marketing has been increasingly adopted in the NHS as a mechanism to motivate consumers to choose “healthier” options , yet social marketing conducted in commercial style may lead to loss of trust between community and public health. Nevertheless, national-level campaigns can become launching pads for locally designed and administered public health interventions, creating context-specific local-level campaigns.

11.4 However, information-giving is generally a weak way of changing behaviour particularly if used in isolation. Most people value their health but engage in behaviours that are damaging even though they are aware of the damage they might do. “Nudging” can be used to improve our health, and is the dominant approach today , however, Marteau et al. note that few nudging interventions have been evaluated for their effectiveness, so evidence that nudging alone can improve population health is weak. It is critical that such health messages are grounded in solid evidence from appropriate research generated on relevant populations. Policy making must take into account the full range of interventions for which there is evidence of effectiveness, and ensure that monitoring and evaluation of initiatives takes place.

11.5 Evidence also shows that behaviour change campaigns only modestly increase knowledge and modify attitudes, with minimal effects on long term behaviour. Individual behaviour cannot happen in isolation of socio-environmental factors, and the most socially advantaged have more resources to adopt health promoting activities. The government needs to address barriers such as poor housing and unemployment that prevent people from making healthier choices. Poverty is the key risk factor for poor health, so structural economic polices are arguably more influential in this area of public health.

References

Marteau T M, Ogilvie D, Roland M, Suhrcke M, Kelly M P. Judging nudging: can nudging improve population health? BMJ 2011; 342:d228.

Grier S, Bryant CA. Social marketing in public health. Annu Rev Public Health 2005; 26:319-339.

June 2011

Prepared 28th November 2011