HC 1048-III Health CommitteeWritten evidence from Centre for Mental Health (PH 32)

Centre for Mental Health is an independent charity working to improve the life chances of people with mental health problems in the UK. We are pleased to have the opportunity to submit evidence to the Health Committee Inquiry into Public Health. Our submission focuses on areas where we have specific knowledge and expertise based on our research and development work.

Summary

We welcome the focus and priority to be given to improving public health under the new arrangements for health, public health and social care.

The creation of Public Health England (PHE) could provide the opportunity to ensure that mental ill health is a priority for the new public health system. The public health White Paper, taken together with the cross-government mental health strategy No health without mental health, symbolise a clear commitment to improving the nation’s mental health and improving the life chances of people with mental health problems.

Transferring public health responsibilities largely to local authorities could provide important opportunities for taking a life course and integrated approach to addressing the needs of individuals and families. PHE must support local communities to deliver strong local leadership and joint working, and ensure that good quality evidence is available to inform commissioning decisions.

We support the creation of health and wellbeing boards, which have great potential to improve the health and wellbeing of people in local communities. This is particularly so for those who are the most vulnerable and disadvantaged, who often require support across a range of services.

The Health and Social Care Bill should be amended to ensure broad representation on health and wellbeing boards not just across health, public health and social care, but also other relevant agencies such as housing services and the police, and including all local GP consortia. It should also be obligatory for local authorities to consider the role of services other than health and social care services when planning Joint Health and Wellbeing Strategies so that all the main factors which influence health and wellbeing are brought into local strategies from the outset.

It is crucial that Joint Strategic Needs Assessments (JSNAs) accurately capture the needs in their locality, across all groups in their local population, and that delivering on them is a requirement of both local authorities and GP consortia. This will require proper support and advice in areas where expertise may be limited.

Reducing crime should be a priority for the new public health system. We would welcome clear guidance on the commissioning routes for prison public health and drug and alcohol treatment in order to improve the coordination of support across the community and the criminal justice system.

The transfer of the responsibilities of the National Treatment Agency for Substance Misuse (NTA) to PHE could provide the opportunity to address the current lack of equivalence between alcohol and drug service commissioning. But without specific ring-fenced budgeting for these services there is a risk of disinvestment in alcohol and drug interventions. We therefore think that there should be a mandatory responsibility for local authorities to commission specialist alcohol and drug services.

It is crucial that the public health outcomes framework provides clear lines of accountability for achieving progress between relevant local and national bodies. Wherever possible, the outcomes framework should create joint outcomes across health, public health and social care, and ensure that where appropriate there are equivalent outcomes for mental health as for physical health.

1. Public Health England

1.1 We welcome the creation of PHE which could allow for a new focus on prevention and early intervention. This provides an important opportunity to tackle the range of factors that influence wellbeing, and to develop integrated and holistic services.

1.2 PHE should put mental health and wellbeing at the heart of the new public health system. At least one in four people will experience a mental health problem at some point in their life, and half of those with lifetime mental health problems first experience symptoms by the age of 14. Our estimates show that the aggregate cost of mental health problems in England is now some £105.6 billion.

1.3 PHE must support local communities to deliver strong local leadership and joint working, and ensure that good quality evidence is available to inform commissioning decisions. There must be concerted action to raise awareness of mental health among all public services and Directors of Public Health (DsPH) must be given adequate support to understand the importance of mental health to achieving public health improvements.

1.4 PHE must also ensure that high priority is given to addressing the needs of children with early starting behavioural difficulties, in a way that minimises stigma to their families and engages them in seeking support. Behavioural difficulties that start early are the most common mental health problem in childhood, affecting 6% of children at a level of severity sufficient to merit a clinical diagnosis of conduct disorder. Children who develop behavioural difficulties early have some of the poorest long-term outcomes, including not only continuing mental health difficulties but also poor educational and labour market performance, disrupted personal relationships, criminality, substance misuse and increased risk of suicide and premature death.

1.5 We welcome the commitments to increase the number of health visitors and the number of families reached through the Family Nurse Partnership Programme. Such early interventions with vulnerable families have shown to be effective in promoting resilience and protective factors in children, and have been successful in engaging those most in need with evidence based support promoting multiple improved outcomes for children. However, there are a number of significant challenges which impede the effective delivery of parenting programmes for those with early starting behavioural difficulties. One of the greatest challenges to providing effective support has been the difficulty in ensuring that what is available both reaches those most in need and avoids stigmatising or labelling children and families. PHE must work towards ensuring that evidence-based programmes are well coordinated and are targeted at those who need them the most.

1.6 Reducing crime should also be a key priority for public health. Offending, poverty and poor mental health often have the same causes and DsPH will be well placed to reduce the risks of each within their communities, taking positive action to improve mental health within families to reduce the risk of future reoffending, as well as supporting ex-offenders to get their lives back on track.

1.7 Much more needs to be done to address the lack of equivalence between alcohol and drug service commissioning. Alcohol misuse is a major public health issue across England, costing around £23 billion a year, more than half of this in the costs of crime. Yet support for offenders who misuse alcohol is very limited: both PCTs and the NTA have restricted the range of services available to this group at all levels, from basic screening and advice to specialist treatment and support. Transferring the responsibilities of the NTA to PHE could provide an opportunity to tackle this lack of support. There needs to be adequate support available across the community and the criminal justice system to address a wide range of alcohol problems including alcohol dependency and binge drinking.

1.8 The transfer of responsibility for public health to PHE and local authorities could facilitate innovative local approaches, allow for a focus on prevention and early intervention, and lead to a better integration of alcohol and drug service commissioning. However, this will depend on whether DsPH are able to work with a range of health and other local services such as housing, employment and the police.

2. The role of local government

2.1 Partnership and joint working will be crucial to the success of PHE. A partnership approach is particularly important for people with complex needs where support on a number of health and other related issues is needed. Transferring public health responsibilities largely to local authorities has the potential to facilitate joint working and the development of an integrated, holistic and life course approach to addressing the needs of individuals and families. Local authorities are in a good position to improve the coordination and integration of services that have a role to play in improving health, and to promote a coherent approach to different stages of life and key transitions.

2.2 However, for this to be achieved there need to be clear mechanisms in place to secure commitment from local agencies and services to joint working. Health and wellbeing boards may provide a means to achieve this.

2.3 Health and wellbeing boards will only be effective, however, if working together is seen as a “must-do” for all. This would be supported by shared outcomes across relevant agencies as well as incentives on all agencies to work together and pool resources. The scope for promoting integration and partnership exists well beyond the NHS, public health and social care, and we would recommend that this is emphasised clearly in the creation of the new boards.

2.4 We would therefore encourage broad membership for these boards. For example, the Health and Social Care Bill as originally drafted proposed that as a minimum boards should include representatives from, among others, children’s and adults’ social services and GP consortia. We would urge that housing services and the police should also be a minimum requirement for membership of the boards. Housing and law enforcement have a significant impact on health and wellbeing, and including representatives from these services will help to bring them together with health and social services to identify areas for cooperation.

2.5 Health and wellbeing boards should also help to ensure that GPs can play a key role in areas for which PHE will take responsibility. The requirement for GP consortia to work with local authorities in relation to health and wellbeing supports this involvement, but consortia should also be encouraged to work with a range of other local bodies such as criminal justice agencies, welfare and employment services, as well as voluntary and community organisations, to ensure that GPs still play an active role in advancing the wellbeing of their local communities. Further, all GP consortia should be required to participate in health and wellbeing boards. We do not think that one person should be allowed to represent more than one commissioning consortium on a health and wellbeing board. Each commissioning consortium in a local authority area should contribute fully to promoting health and wellbeing. Having a presence at the health and wellbeing board is one way of securing the commitment required to do this.

2.6 JSNAs could also help to facilitate local partnerships. However, the NHS Commissioning Board must publish guidance for commissioning consortia on ensuring that JSNAs capture the current and future needs of consortia populations in their entirety. Sufficient expertise must also be available to consortia to ensure that JSNAs are to a high standard. It should be a duty of both local authorities and GP consortia to deliver on the core goals of the JSNA and to account locally for what has been achieved.

2.7 Joint Health and Wellbeing Strategies will also be crucial in delivering an integrated and holistic approach to improving public health. The Health and Social Care Bill enables local authorities to consider the role of services other than health and social care in drawing up these strategies. We believe that this provision should be strengthened so as to make it obligatory. This would help to ensure that all the main factors which can influence health and wellbeing are brought into local strategies from the outset. Without this requirement, key opportunities to engage services outside health and social care will be missed.

3. Commissioning and funding

3.1 It is important that good quality advice is available to inform commissioning decisions. This is particularly important in relation to mental health, an area in which commissioning bodies, such as GP consortia, may currently lack expertise. Where PHE transfers commissioning responsibility for public health services to the NHS Commissioning Board and the Board then transfers this to GP consortia, it is crucial that consortia have sufficient access to public health expertise.

3.2 Joint commissioning routes and clear lines of accountability for achieving progress on outcome measures will be crucial in bringing together a wide range of agencies to improve the health and wellbeing of local communities. Different outcomes frameworks and payment by results systems are emerging in a range of public services and these need to be brought together as far as possible to ensure that a range of services all work together towards common goals. Joint commissioning routes could be encouraged through the use of community or place-based budgets, and there must be sufficient encouragement, guidance and expertise available to support this.

3.3 Commissioning structures must also be able to provide for stable and secure funding for voluntary organisations so that they can support health improvement plans. For example, funding should be available for periods of longer than a year at a time. In addition, voluntary organisations, service users and carers and organisations representing them, should be involved from the outset in local and national decision-making forums.

3.4 The new health premium could provide a mechanism for diverting additional funding to more disadvantaged areas and incentivise action to reduce inequalities. This premium could be an opportunity to focus on what the Marmot Review identified as the social determinants of health, which is crucial for tackling health inequalities. The premium could relate to measures of these social and economic risk factors for later ill health, including risk factors for poor mental health and wellbeing. It could also be targeted at actual rates of mental and physical ill health. Whatever measurements are used, there needs to be parity of esteem between mental and physical health.

3.5 We would welcome clear guidance on the role of GP consortia in alcohol and drug commissioning. According to the White Paper, public health will be responsible for the funding of drug and alcohol misuse services, prevention and treatment. We believe that it should be mandatory for local authorities to commission a full range of drug and alcohol services to meet local needs.

3.6 While we welcome a new ring-fenced budget for public health, we are concerned that the absence of a specific ring-fenced fund for specialist alcohol and drug services could result in disinvestment in these services, particularly at a time when public funding is under pressure. To counteract this, there needs to be strong local leadership to ensure that decision-makers are aware of the benefits of investing in alcohol and drug services in terms of meeting their public health objectives. It is crucial that the public health outcomes framework reflects the responsibility of PHE and DsPH to commission specialist alcohol and drug services, and that there are clear lines of accountability for achieving good outcomes.

3.7 It is also vital to ensure that the new commissioning and funding arrangements do not result in unintended gaps in services for people with complex needs, such as those with a dual diagnosis of mental health and substance misuse problems. Although the new arrangements could provide the opportunity to improve integration between mental health and substance misuse services, greater consideration needs to be given to how NHS commissioning for mental health services but public health commissioning for alcohol and drug misuse will affect people with dual diagnosis, for whom integrated treatment is essential yet seldom delivered in practice.

3.8 We would also welcome clear guidance on the commissioning routes for prison alcohol and drug services. If the NHS Commissioning Board is to take overall responsibility for prison health care, as is currently proposed, we assume that this will include alcohol and drug treatment and interventions. This could hinder joint working and coordinated support across the community and criminal justice system. There is a strong case for health, public health, criminal justice and other agencies working collaboratively to commission a range of support as well as prevention and early intervention. Aligning funding streams on drug and alcohol treatment services across the community and in criminal justice settings could improve continuity of treatment for offenders and those leaving prison.

4. Outcomes

4.1 It is vital that outcome measures are shared jointly across public services and that services are encouraged to work with others to achieve key shared goals. This will not just bring about improvements in care and support but should secure good value for public money. We welcome the integration of the public health outcomes framework with the outcomes frameworks for the NHS and for adult social care. This will need to be developed further over time, however, to create genuine parity between physical and mental health in all domains and to extend to the full range of services for children and young people.

4.2 It is crucial that the outcomes framework provides clear lines of accountability for achieving progress between relevant local and national bodies. Wherever possible, the outcomes framework should create joint outcomes across health, public health and social care, and ensure that where appropriate there are equivalent outcomes for mental health as for physical health. Overlaps between health, public health and social care outcomes must be clearly set out and accountability for achieving progress on those measures must be shared between the relevant bodies locally.

4.3 We support the overall framework and domains but believe that it is vital that outcome measures for mental health are fully captured within these domains, where necessary by translating some of the ideas to the specific needs of mental health service users and people with common mental health problems. We believe that there should be a duty on health and wellbeing boards to ensure that outcome measures for public mental health are given equal weight to those for physical health.

June 2011

Prepared 28th November 2011