HC 1048-III Health CommitteeWritten evidence from Spearheads (PH 189)

A. Author

Submitted by Dr Ruth Wallis on behalf of the London NHS (former) Spearheads Health Inequalities Network (Network Chair).

The London Health Inequalities Group draws together Directors of public health and health inequalities leads from the 11 most deprived areas in London (Barking & Dagenham, City & Hackney, Greenwich, Hammersmith & Fulham, Haringey, Islington, Lambeth, Lewisham, Newham, Southwark and Tower Hamlet); formerly known as ‘Spearhead areas’ and aims to reduce health inequalities in London through effective public health practice.

B. Written Evidence

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

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

3. Public health role of the Secretary of State

3.1 Need for sustained leadership to address inequalities in health and maintain investment in health improvement.

3.2 Need for oversight of impact of changes in financial climate and policy change on health.

3.3 Association of Public Health Observatories (APHO) key to developing a national picture, informed by local work.

4. Future role of local government in public health (including arrangements for the appointment of Directors of Public Health; and the role of Health and Well-being Boards, Joint Strategic Needs Assessments and Joint Health and Well-being Strategies)

4.1 Local Authorities have a major historical role in Public Health, most powerful when they enforced Public Health legislation and had resources to invest in housing and environmental improvement, and provided health and core services to those in need, in the absence of a universal service (pre NHS Care) They remain an important influence on the health of their residents, through advocacy, prioritisation (investment, service allocation), effective partnership, and service commissioning. The DPH within a local authority needs to have the highest possible influence across council directorates to influence health determinants (strategic development, safety, planning, public realm, housing, as well as children’s service and adult services). This means that the DPH needs to be a council director, accountable to the Chief Executive, or jointly across the local NHS Commissioning Board and the Council, to maintain influence.

4.1 Public health must become a core activity for the local authority rather than seen as a specialist “add-on”. For this to happen, local authorities need to influence NHS commissioning. This could be by giving the local DPH with local elected members the power to sign off or reject GP commissioners’ plans if they are not directed at improving health and well-being of the population (eg put financial balance as a higher priority to improving health outcomes rather than equal priority. It could be by establishing common goals and collaboration supported by Public Health across organisations.) Local authorities will need training and development to take on this role and a system of “delegation” needs to be agreed to ensure that Local authorities are supported to deliver on a full range of their responsibilities.

4.2 Public Health influence x NHS.

4.2 Much discussion of the DPH is written as if he/she works alone. No DPH will have much impact without a highly trained, well-functioning team working with them. Advocacy can be powerful but is unlikely to be influential in a challenging financial environment. Any moves to centralise PH resources into PH England need to ensure continuity of local knowledge and relationships.

4.3 Public Health will be a major new responsibility for the local authority, partly relative to the reduction in local authorities other responsibilities eg education, and also because of the substantial income likely to be attached to the broad definition of public health. Both the services commissioned and the mechanisms of commissioning differ between councils and the NHS, and there is a need to ensure that commissioning across NHS and local authority is coherent, although the mechanisms for doing this are unclear (partnership, holding to account etc).

The financial environment is likely to make protecting investment in health improvement challenging (not ring fenced). Much of the financial benefit from investment in health improvement will be in the NHS, and arrangements need to ensure that investment can continue even when benefits are achieved in other organisations.

4.4 An effective specialist public health function requires a critical mass, as with most clinical specialities. This means that individuals should not work in isolation, and that elements of public health practice should be part of a coherent function. In general, specialist services are less effective in generalist environments, and may move towards less expert tasks. The Acheson Report, Public health in England clearly set out the risks of a divided public function, and this still applies.

Information and understanding of local populations health needs is fundamental to public health; and is supported by clear definitions of boundaries, preferably consistent with local authorities. The inclusion of unregistered populations within local populations is welcomed.

The health and well-being board as currently constituted muddles two roles: i) a strategic role coordinating local efforts to improve health and well-being; and ii) maintaining financial balance with an operational coordination role which involves joint commissioning. The relationship with Clinical Commissioning needs to be clarified, and the accountability of the local authority for decisions.

4.5 Local health strategy should be informed by JSNA, which is dependant on both local information which can be shared (same boundaries/geographical definition), and public health intelligence. This will be critical in the development of JSNA, and enabling commissioners to address local issues, including inequalities.

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

5.1 Approximately, 50% of reductions in mortality will arise from health service intervention and 50% from primary prevention and work on determinants of health. it is essential that Public Health continues to work with NHS commissioners to commission evidence based services and inform prioritisation. Public Health influence is critical to this.

5.2 At a local level, best use needs to be made of public health expertise to improve health and reduce health inequalities. This would encourage a collaborative approach across agencies, informed by local need (JSNA), to agree common priorities. Public health would provide consistent advice to organisations, based on population priorities.

6. Arrangements for commissioning public health services

6.1 There is a real danger that there will be multiple providers doing a bit of health promotion to various parts of people, eg one provider for smoking, another for physical activity, another for diet, etc. There need to be safe guards to ensure that public health services are coordinated locally and that commissioning is aimed at reducing and that health inequalities, as well as improving health.

Potentially the new arrangements will be more complex, and yet services provided will need to be simple to use, to join up and to be used by those whose needs aren’t met by mainstream provision. The potential for local innovation involving communities (eg estate based) would need resourcing initially

6.2 Epidemiology is a core skill of public health and part of the core team. Expert additional work can be commissioned but local intelligence is essential to local priority setting, local surveillance and change management.

7. Future of the Public Health Observatories

7.1 The current system of leads for each PHO with local work supporting local Public Health departments works well and future arrangements need to support this model informed by local needs.

8. Structure and purpose of the Public Health Outcomes Framework

8.1 The NHS needs to retain responsibility for meeting Public Health outcomes—improving public health is central to its business. Public Health outcomes should matrix with NHS and social care outcomes.

8.2 Some process measures are required for PH actions that take 5–10 years to show financial dividends as well as health outcomes, eg stop smoking quit numbers.

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

9.1 The Health Premium needs to be used to pump prime Total Place pilots that promote joint working to improve health outcomes and reduce health inequalities, including schemes that will take more than one year to deliver.

9.2 Funding of public health services needs to stay with the main NHS commissioning budget.

9.3 The recent exercises to identify the Public Health budget need to be repeated within the local authority to establish a baseline and prevent cost shifting if current local authority expenditure is transferred on to the Public Health budget.

9.4 Areas such as East London have historically had their population undercounted (i.e. the census), so impacts of changes in resource allocation formula need to bear this in mind.

There have already been reductions to the budgets available for public health, via transfer of resources to providers (health promotion), loss of health improvement staff (eg immunisation co-ordinators), management cost savings and taking on responsibility for other NHS functions within existing public health resources.

10. Future of the public health workforce (including the regulation of public health professionals) Public Health is a specialist Profession with expert skills and knowledge.

10.1 Maintaining an integrated training programme across the three domains of public health (i.e. health improvement, health protection and health services) is essential. The inclusion of one workforce which provides expertise to improving health needs to be more widely extended to make health improvement part of all Clinical practice, and in those providing services.

10.2 We need to retain a route for senior people to come into public health from different routes, whilst encouraging younger people to enter via the training schemes as the depth of knowledge and skills brought by people with different backgrounds strengthens public health.

12. How the Government is responding to the Marmot Review on health inequalities

The Marmot review sets out specific evidence based recommendations to reduce health inequalities. These focus on action at national level, across the range of local authority commissioned services, including schools and employment, the NHS and voluntary sector. The emphasise investment in prevention, making sure services reach those in need and the importance of coherent service provision.

It is fundamental to their effective implementation that the DPH has influence across local authorities business, and can enable services to provide a coherent care pathway across the NHS and local authority. Joint appointments would support this.

June 2011

Prepared 28th November 2011