HC 1048-III Health CommitteeWritten evidence from the Chartered Institute of Public Finance and Accountability (PH 24)

The Arrangement for Public Health Involvement in the Commissioning of NHS Services

1. CIPFA believes it is particularly important that Public Health input into the Commissioning of NHS services continues and that NHS investment decisions continue to be supported by robust Public Health evidence.

2. There is the risk that with significant organisational changes, the NHS becomes focused on providing a treatment only service as Public Health responsibilities are transferred to Public Health England (PHE) and Local Authorities (LA)

3. The major risks within the NHS at the moment are as below:

Budgetary constraints.

An ageing population.

Significant organisational change.

Significant reduction in management capacity.

Increasing prospect of competition and financial difficulties within current NHS providers, (particularly those with significant PFI commitments that cannot decommission services and reduce longer term fixed PFI costs).

The revenue cost of new drugs and new technology.

Increasing medical negligence costs.

Increasing costs as a result of lifestyle choices relating to obesity, alcohol, smoking, poor housing and environmental factors.

The case for investing more in preventative strategies to reduce the longer term burden on the NHS has never been so persuasive.

4. The development of Joint Strategic Needs Assessments (JSNA) and Joint Health and Wellbeing Strategies (JHWS) are key tools in the development of an integrated commissioning framework.

5. It is recommended that the duty of Partners to “have regard” to an agreed JSNA & JHWS when exercising their functions should be more clearly defined. We are concerned that the commissioning of complete care pathways for defined conditions may become more fragmented under these proposals.

6. CIPFA believes that Partners should demonstrate that recommendations in the JSNA and/or JHWS are given “due consideration” and that where material recommendations within these strategies are not or cannot be addressed the reasons for this are provided and recorded. A “comply or explain” principle should be applied here.

7. The need for a joined up approach to Commissioning, inclusive of Public Health input, is demonstrated in the example below.

The fragmentation of Commissioning is well illustrated within certain long term conditions where public health prevention, NHS care provided by GPs and specialists may all be commissioned by separate bodies. These arrangements will make service planning and commissioning around the patient more complex.

It must be recognised that there may be no single responsible Commissioner. An example for Diabetes is shown below.

(a)Prevention and detection of Type 2 Diabetes via healthy weight & diet strategies and NHS Health Checks will be commissioned by Local Authorities.

(b)(Local Authorities being responsible for health checks for Heart Disease, Stroke, Diabetes and Kidney Disease).

(c)Treatment of Type 2 diabetes will be mainly by GP Practices commissioned by the NHS Commissioning Board.

(d)Treatment of Type 1 Diabetes will be mainly by Specialists commissioned by Consortia.

(e)Highly Complex Diabetes & Islet Transplantation carried out within specialist national centres could be expected to be commissioned via the NHS CB.

The example highlights the risk that comprehensive whole service strategic planning, the commissioning of integrated services, and the accountability and responsibility for services become more fragmented requiring the development of robust governance arrangements.

8. CIPFA supports the overriding principle that significant changes to NHS services should be accompanied by both a Public Health Needs Assessment (PHNA) and a Public Health Impact Assessment (PHIA) that confirms the need to address service gaps and the optimum solution for change respectively.

9. A public health needs assessment (PHNA) will determine whether health needs are being met by current service models or would be better met under proposed new service models.

10. The results of PHNAs are similar to those of value for money (VfM) assessments. The results can be categorised as:

Needs are being met (consequence – move on to next assessment).

Needs are not being met because there is no service (consequence – put forward for reform proposal).

Needs are not being met because the current service cannot deliver its objectives.

The types of questions which need to be included in a PHNA are:

What are the required public health outcomes of the service area?

Is the target population clearly identified?

What are the different models for achieving the outcomes and which is most suited to the local population?

Does the management structure for the service facilitate the most suitable model?

What are the local health inequalities and access issues pertaining to the service and does the current/proposed service model facilitate resolving them?

What are the preventative measures available pertaining to the service and does the current /proposed service model facilitate achieving them?

The Public Health Impact Assessment (PHIA) is an integral part of the business case process and its purpose is to:

Identify the potential health consequences of a proposal on a given population.

Maximise the positive health benefits and minimise potential adverse effects on health and inequalities.

11. A Public Health Impact Assessment should be carried out during the planning process for early involvement activity. The main output is a set of evidence-based recommendations to inform the decision-making process for that proposal.

12. NHS organisations should consider undertaking a PHIA for most proposals affecting health services. Although there has been no statutory requirement to do this in the past, their preparation and publication make sure that professionals and service users can:

Understand why change is being proposed.

Understand how and to what extent proposed changes may impact on them.

Understand the estimated costs and benefits of proposed measures.

Identify potential unintended consequences.

13. A PHIA should include an examination of a proposal’s potential impact upon each of the equality strands – ethnicity, disability and gender. It is good practice to consider other dimensions such as age, sexual orientation and religion or belief.

14. It is also important that NHS policy-makers continue to acknowledge the three aspects of Public Health.

Health improvement.

Health prevention.

Quality and effectiveness of service provision.

15. It is equally important that the Public Health function can support both LAs and GP Commissioning Consortia (GPCC) without being critically fragmented.

16. PHE also have an important role to support this model with back-up information, intelligence and networking opportunities so that organisations having limited Public Health capacity and expertise can be supported.

17. Different Local Authorities may have different preferences for supporting or not supporting certain types of public health provision. Examples might include sexual health services, drug treatment services, HPV vaccination, children’s height and weight measurement. PHE should consider developing a consistent set of principles to enable LAs to provide a consistent and core offer to vulnerable groups.

18. Principles could include a duty to reducing health inequalities and to promote social inclusion, and a duty to provide interventions that are evidence-based.

19. Public Health England can address current gaps in public health evidence by:

Developing an information strategy to address information and evidence requirements.

Commissioning of research for new evidence.

Ensuring adequate resource for public health research and dissemination.

20. Partners nationally and locally can contribute to improving the use of evidence in public health by developing Community Health Profiles. Health and Wellbeing Boards (HWBs) should have resources for training and development in evidence-based decision making.

21. Nationally the NHS and PHE should make it clear that this evidence should be used.

22. Public HIA is also a useful tool for ensuring that evidence is used to underpin and delivery decisions.

Arrangements for Funding Public Health services, including the Health Premium

23. The ringfenced grant to Local Authorities for Public Health should initially be accompanied by:

A clear definition of Public Health activities and services.

A current schedule of NHS public health budgets.

NHS Public Health commitments.

Changes to NHS budgets to provide a transparent transfer from the NHS. These should include a baseline position of pay and non-pay budgets and staffing Whole time equivalents, together with efficiency savings that have been made prior to any transfer.

24. When introducing a health premium to incentivise reductions in inequalities there should be a regular re-assessment of requirements to ensure that health outcomes improve in practice.

25. In areas of higher deprivation that also face a significant reduction in Local Authority budgets account should be taken of the potential for public health outcomes to diminish as services to a number of vulnerable groups/charities are re-assessed.

26. It may be worth considering an allocation approach similar to the developed by the Accounting Advisory Committee for Resource Allocation (ACRA) for the NHS with appropriate pace of change policies to move departments to a fair share of resources.

27. It may also be useful to consider the introduction of some form of peer support similar to the schools “special measures” process. There is also a significant emphasis on improving children’s deprivation though an increasing number of Health Visitor posts and other initiatives. It is important to acknowledge that children’s deprivation may stem primarily from their parents’ deprivation (resulting from multiple and complex factors).

June 2011

Prepared 28th November 2011