HC 1048-III Health CommitteeWritten evidence from Nuffield Trust (PH 31)

1. Nuffield Trust is an authoritative and independent source of evidence-based health service research and policy analysis. Our aims include promoting informed debate on UK healthcare policy. We are also a national training centre for public health specialists and four members of our senior staff, including our Director and our Head of Research, practise public health at consultant level.

2. We have concentrated on three specific topics in this memorandum: the future role of local government in public health; arrangements for public health involvement in the commissioning of NHS services; and arrangements for commissioning public health services.

Executive Summary

3. The future role of local government in public health—The NHS and local government both have important roles to play in public health. But to ensure that health services meet the needs of local populations, the Department of Health should consider strengthening the accountability of commissioning consortia to their local populations.

Arrangements for public health involvement in the commissioning of NHS services—Public Health skills are required for high quality commissioning. Under the current proposals there is a danger that the specialist public health workforce will be lost from the NHS. The Department of Health needs to consider making public health capacity part of the authorisation process for commissioning consortia. It should also clarify how public health skills will be secured by commissioning consortia and the NHS Commissioning Board.

Arrangements for commissioning public health services—Under the current proposals, public health services will be commissioned by a wide range of commissioning organisations. In order to prevent fragmentation, strategic oversight should be clarified and efforts should be made to devolve commissioning to the local level where appropriate. Overall, we believe it is vital that public health services be commissioned and provided for defined geographical populations. This is to ensure the health needs of vulnerable populations are met, especially for people who are not registered with a GP practice.

The future role of local government in public health

4. The Public Health White Paper states that local government will have a significant role in public health, with roles including health improvement, commissioning services jointly with GP consortia, and tackling health inequalities (Department of Health, 2010a). The Health and Social Care Bill gives all upper-tier local authorities a statutory duty to establish Health and Wellbeing Boards (HWBs) and to encourage integrated work between the NHS commissioners, public health specialists, and social care. HWBs will be required to produce Joint Strategic Needs Assessments (JSNAs) and joint health and wellbeing strategies with each of their partner commissioning consortia (Department of Health, 2011). As local authorities take on this new role, they will require public health capacity with sufficient authority and expertise to assure the quality of these commissioning plans.

5. The Nuffield Trust recognises that the proposal to create HWBs provides an opportunity to create a representative local body that helps shape local decisions about which services to commission and decommission (Nuffield Trust, 2010)]. However, we believe there are several weaknesses in the planned arrangements for local accountability. If left unchanged, these weaknesses may result in a failure to secure local legitimacy for health care and public health commissioning decisions—despite the government’s stated intentions. HWBs need to be given additional powers to scrutinise and guide commissioning decisions made by GP consortia. This could be achieved by placing a stronger requirement on commissioners to take into account the JSNA and by requiring consortia’s commissioning plans to be approved by their local HWBs.

6. In order to avoid major disputes between HWBs and commissioners it will be important to ensure there is clarity about roles and responsibilities at a local level. Where irresolvable disagreements arise between a HWB and a consortium, the White Paper proposes that a letter be written to the NHS Commissioning Board (NHSCB) which, in turn, will have extensive powers to direct consortia. However, it is difficult to see how this process will work in practice. We suggest that the Department of Health should consider the use of alternative resolution mechanisms that promote more cooperation at a local level. These could include simple measures such as ensuring that there are formal terms of reference in place together with clear governance arrangements and procedures for managing conflict. Another way to avoid escalating conflict may be to devolve the performance management for contracts held by the NHSCB and Public Health England (PHE) to a more local level.

7. The Department of Health is proposing to allocate ring-fenced budgets directly to upper-tier and unitary local authorities (Department of Health, 2010a). In order to ensure that this funding is used wisely, we suggest that appropriate governance arrangements are put in place. For example, all contracts for services funded from public health budgets should require the signature of the local director of public health.

Arrangements for public health involvement in the commissioning of NHS services

8. The 2010 Health Select Committee report on commissioning concluded that a lack of skills was one of the key reasons for weak commissioning by Primary Care Trusts (PCTs) (House of Commons Health Select Committee, 2010). The commissioning of health care is complex and requires a high level of technical and managerial skills (Ham, 2008). Public health expertise is required for many commissioning functions, including: understanding local population needs, strategic service planning, evaluating the evidence for the quality and cost-effectiveness of care, and holding providers to account (The Information Centre, 2011). Yet, the Public Health White Paper does not acknowledge sufficiently the importance of these public health skills to the commissioning process.

9. The abolition of PCTs and Strategic Health Authorities (SHAs) will result in the loss of vast majority of the public health workforce from the NHS. In particular, those public health professionals who specialise in health services (including public health experts with a clinical background), will diminish relative to the other two areas of public health (health improvement specialists will move to local authorities; and health protection specialists will move to PHE). Such experts are a crucial resource for the NHS, especially when challenging the quality and cost-effectiveness of clinical care in providers. Previous research into GP fund-holding and primary care led commissioning concluded that primary care-led commissioners typically pay insufficient attention to the role of public health in commissioning (Smith and Goodwin, 2006). This proposed change in workforce would run counter to the strategy set out by Sir Donald Acheson in his landmark report Public Health in England, which has guided the development of public health and training in the UK since 1991 (Acheson, 1988).

10. Options for securing public health support for commissioners include:

bringing public health specialists into consortia. This would help embed public health specialists into the commissioning cycle but it may lead to public health specialists’ being isolated in small organizations;

concentrating public health expertise (in health services) at the “PCT cluster” or NHSCB “outpost” level; and

alternatively, the Department of Health could encourage the development of a market for public health advice comprised of a variety of providers (akin to commissioning support agencies). This might include local authorities, consultancies or independent specialists. The evidence suggests that if done well, external support can improve commissioning (Naylor and Goodwin, 2010). However, commissioners’ ability and proclivity to purchase such support will depend on the budgets they are allocated, and on their recognition of the public health skills they need.

11. The NHSCB will need to collect evidence that consortia have taken and acted upon appropriate public health advice. This should include evidence that commissioning decisions have been: aligned to population needs; influenced by consideration of health care inequalities; informed by the best evidence; based on health service and treatment priorities; and that the quality and cost effectiveness of commissioned care has been adequately assessed. This collection of evidence could form part of the authorisation process for consortia and assessed annually by the local HWBs. Clear sanctions should be in place for consortia that fail to demonstrate that they have obtained and acted upon public health advice—including, as a last resort, the revocation of their authorised status.

12. Clearly, the NHSCB will have a pivotal role in the proposed new NHS structure, and the Public Health White Paper states that officials at PHE will be expected to work closely with the national leadership of the NHSCB. However, clauses 1–5 of the Health and Social Care Bill are silent on the roles, routes and accountabilities for the public health input into national commissioning decisions (Department of Health, 2011). We believe it would be important to clarify how these functions will work together, and what expertise in PHE will be available at which level for commissioners. Moreover, if “PCT clusters” are to remain, then it would seem prudent to align PHE staff with the clusters in order to ensure that public health skills are available and streamlined at this level.

Arrangements for commissioning public health services

13. The Department of Health is proposing multiple commissioning routes for public health services. Under the proposals, local authorities, NHSCB and PHE will all be commissioning public health services from ring-fenced public health funds (Department of Health, 2010a, Department of Health, 2010b). This complexity will have implications for commissioning across care pathways and could have a negative impact on the integration of public health and health care services. For example, cancer screening will be commissioned by the NHSCB through the GP contract, but it will be quality-assured and monitored by PHE; whilst cancer treatment services will be commissioned and monitored by GP consortia (Department of Health, 2010b). Given these complex arrangements, it will be difficult to ensure that services are tailored to local needs.

14. Public health commissioning decisions and performance management should be devolved to the most local level appropriate. Such devolution should help ensure that services are kept responsive to local needs and priorities. Devolution should apply both to services commissioned by PHE through the NHSCB, and to those elements of the GP contract pertaining to public health. In addition, there should be some flexibility at a local level for tailoring contracts to ensure that services address specific concerns and populations. At times, a system manager may need to be appointed at local or regional level to provide strategic oversight, for example to integrate or reconfigure services. This could be a local authority, PCT cluster, NHSCB outpost or GP consortium.

15. The proposed changes are likely to result in a loss of co-terminosity between NHS commissioners and local authorities in some parts of England. This has potential negative implications both for the collection and analysis of information and for the joint commissioning of public health services. It is vital, therefore, that robust arrangements be put in place for commissioning public health services for particularly vulnerable populations. Such vulnerable groups include homeless people, temporary residents, people who are not registered with a GP and people who live between geographical boundaries. We believe that consortia should be obliged to consider joint commissioning arrangements where appropriate to ensure that public health services are commissioned for the entire population.

June 2011

References

Acheson D (1988) Public Health in England: the report of the Committee of Inquiry into the Future Development of the Public Health Function. London: HMSO.

Department of Health (2010a) Healthy Lives, Healthy People.

Department of Health (2010b) Healthy Lives, Healthy People: Consultation on the funding and commissioning routes for public health.

Department of Health (2011) Health and Social Care Bill.

Ham C. (2008) Health Care Commissioning in the International Context: Lessons from Experience and Evidence. Birmingham: Health Services Management Centre.

House of Commons Health Committee (2010) Commissioning. Fourth Report of Session 2009–10.www.publications.parliament.uk/pa/cm200910/cmselect/cmhealth/268/268i.pdf

Naylor C, Goodwin N. (2010) Building high quality commissioning. What role can external organisations play? The Kings Fund.http://www.kingsfund.org.uk/publications/building.html (Accessed 26 March 2011).

Nuffield Trust (2010) Response to the White Paper Equity and Excellence: Liberating the NHS and the 2010 Spending Review.

Nuffield Trust (2011a) The Health and Social Care Bill: Where next?

Nuffield Trust (2011b) Response to the Public Health White Paper: Healthy Lives, Healthy People.

Smith J, Goodwin N. (2006) Towards managed primary care. 2006. Aldershot: Ashgate.

Smith J, Charlesworth A. (2011) NHS reforms in England: Managing the transition. The Nuffield Trust.

The Information Centre. (2011) Supporting world class commissioninghttp://www.ic.nhs.uk/commissioning (Accessed 27 May 2011).

Prepared 28th November 2011