HC 1048-III Health CommitteeWritten evidence from the Wellcome Trust (PH 40)

Summary

1. Our key messages are:

research plays a vital role in informing the evidence base for public health interventions. It is essential that research, evaluation and the use of evidence are embedded in the public health system;

Public Health England (PHE) must be established in a form that enables it to provide independent advice to ministers, the Department of Health and the National Health Service (NHS). The proposed loss of independence of key functions currently undertaken by the Health Protection Agency (HPA) will seriously compromise the provision and use of scientific evidence for policy and practice;

the fragmentation of public health services across local authorities may make it more difficult to deliver evidence-based services. A coordinated national approach to public health is required;

reforms to the public health system need to be considered within the context of the proposed reforms in health and social care services, including the reorganisation of the NHS. The public health functions of the Department of Health, the NHS and the National Institute of Health Research need to be clarified and must be coordinated with PHE and local authorities; and

we support the proposal that PHE will act as a central repository for public health data in England. In order to maximise the use of this resource it will be important that this is supported by appropriate mechanisms to facilitate access to these data for research.

Introduction

2. Reform of the public health system in England provides an important opportunity to establish a new vision for public health, fit to respond to the challenges of the 21st century, including: an ageing population; the increasing burden of non-communicable diseases; and the threat posed by global infectious diseases. Realisation of this long-term vision for the provision of public health in England needs to be reflected in the structural reform of public health services.

3. Given the Trust’s remit, our comments focus primarily on research and the use of evidence in informing public health policy and practice. We are pleased to have the opportunity to submit evidence to the Health Committee’s inquiry and we welcome scrutiny of the Government’s proposals to reform public health service provision, as part of the wider reforms outlined in the Health and Social Care Bill. We look forward to the publication of the Government’s response to the consultation on the strategy for public health in England and note that this is likely to lead to significant changes to the Health and Social Care Bill.

4. The Wellcome Trust, the Medical Research Council and the Economic and Social Research Council held a joint workshop in March 2011 that brought together public health practitioners and researchers. The aims of the workshop were to discuss the implications of the White Paper “Healthy Lives, Healthy People” and to discuss how evidence can be effectively translated into policy and practice in the new system. The discussions at the workshop and the report summarising the day’s discussions have informed our response and is attached as Annex 1 to this paper. Our vision is that a reformed public health service for England must be able to:

commission, undertake and adopt the results of high quality research;

provide independent advice to Ministers;

take a nationally co-ordinated view, with clear lines of accountability;

draw on suitably trained professionals;

make effective use of data from surveillance, patient records and research; and

have the capacity to utilise a range of technologies.

Research and Evidence in Public Health

5. Although the White Paper “Healthy Lives, Healthy People” emphasised the importance of an evidence-based approach to public health policy and practice, both the White Paper and the Health and Social Care Bill fail to set out mechanisms to achieve this.

6. A public health research framework is needed to ensure that the full range of research that could inform public health policy is supported. This will include epidemiological research; natural experiments; social science research; health service research; bioethics research; and environmental health research. In turn, mechanisms must be in place to facilitate uptake of these findings into practice and to ensure that information is made available for all stakeholders in public health service provision to inform their policy and practice. Implementation of this approach can be promoted through improvements in education and training, and the development of incentives that reward adoption and ongoing evaluation of practice.

7. Robust methods to evaluate the success of public health interventions are required. The proposed Public Health Outcomes Framework and Health Premium, outlined in the White Paper, must be underpinned by the best available evidence and should be refined as evidence is gathered over time.

8. Research and evidence-based evaluation of public health policy and practice should be embedded in the new system for public health. One possible mechanism would be to create public health research networks, based on clinical research networks, that can coordinate research and act as the interface between researchers and health practitioners. A culture of research and the use of evidence must be fostered in all components of the public health system, notably PHE and the local authorities. This should be supported by legislative duties on these bodies to promote research and the use of evidence in public health services.

Independence of Public Health Functions

9. The HPA undertakes research and is responsible for providing independent advice on health protection issues. However, the Health and Social Care Bill would abolish the HPA and transfer its key functions to PHE within the Department of Health. This will undermine the actual or perceived independence of the advice provided. Public trust in Government advice was undermined during the BSE crisis due to a perception that Government scientists lacked independence, and this contributed to the establishment of an independent HPA in 2003.

10. Another potentially damaging consequence of moving the functions of the HPA to within the Department of Health is that it may compromise the ability to obtain external funding and carry out independent research, which is important in retaining expertise. The eligibility criteria of external funders, including the Wellcome Trust, will often not be met if the work is to be carried out within a Government department, and this would therefore limit the availability of resources to carry out research. The retention of expertise is fundamental to the role of providing advice; for example, the experts leading the UK response to the recent Fukushima nuclear accident were supported by external research funding.

11. It is essential that the public health system can provide Government with independent advice on health protection issues. We therefore propose that the functions of the HPA are retained at arm’s-length from the Department of Health, for example within a Special Health Authority or Executive Agency.

Coordination and National Oversight are Critical to Avoid Fragmentation

12. We are concerned that commissioning of public health services by local authorities will lead to fragmentation in public health service provision and increase social inequalities. Devolution to a local level is likely to make it more difficult to communicate and implement successful evidence-based initiatives consistently. Local authorities do not have experience of managing public health services or commissioning research at a local level and it is vital that some level of national oversight and coordination is maintained to ensure public health policy and practice can be refined over time. The White Paper proposes to abolish Public Health Observatories, removing a regional tier that could have provided advice to local authorities if they became responsible for public health commissioning.

13. Reform of public health must be considered alongside, and be compatible with, reform of the NHS and social care systems. The health reforms attempt to draw a distinction between prevention and treatment, as responsibilities of PHE and the NHS, respectively. However, this distinction is somewhat arbitrary. Prevention and treatment lie along a continuum with overlap between the two spheres; for example, public health practice spans health promotion, health protection and improvement of health services. The reforms should take a holistic view of public health within health and social care and the Government should outline how the responsibilities of the National Institute of Health Research, the Department of Health, the NHS, local authorities and PHE will be coordinated.

14. The commissioning arrangements outlined in the Health and Social Care Bill are confusing and lack detail. As outlined in paragraph 12, it will be necessary to coordinate public health services commissioned through the NHS, PHE and local authorities, as well as commissioning social care and research. We welcome the Health Committee’s proposals that local Directors of Public Health should be represented on the proposed commissioning consortia; and that co-terminosity of these consortia with social care structures should be encouraged to facilitate integration.

15. We believe that the local commissioning consortia, alongside local authorities and PHE, should support and foster public health research. We welcome the creation of the NIHR “School for Public Health Research” and the “Policy Research Unit of Behaviour and Health” to promote the role of research and its adoption into practice, as outlined in the White Paper. However, we would welcome further clarification on the roles of these organisations.

16. The Government should clarify the functions of organisations involved in public health research and the mechanisms for their coordination.

Embracing New Technology and the Use of Patient Data

17. It is essential that the public health system is responsive, and can adapt to emerging technologies, such as genomics and informatics, and it is therefore critical that research is embedded in the public health and healthcare systems. It is essential that the single repository for population health data, research and surveillance, as outlined in the White Paper, is created. This will require a specialist workforce for analysis and development of the web-based system, as well as training at a local level in public health and primary healthcare settings to maximise its potential. Concurrently, mechanisms must be developed to ensure that this valuable resource is available for public health research while safeguarding individuals’ data. These issues must be taken into account in the upcoming “Information Revolution” strategy.

The Wellcome Trust is a global charitable foundation dedicated to achieving extraordinary improvements in human and animal health. We support the brightest minds in biomedical research and the medical humanities. Our breadth of support includes public engagement, education and the application of research to improve health. We are independent of both political and commercial interests.

June 2011

Prepared 28th November 2011