HC 1048-III Health CommitteeWritten evidence from NHS Ashton, Leigh and Wigan (PH 44)

1. Creation of Public Health England within the DH

With major public health challenges such as demographic change, climate change, sustainability, impact of globalization, socio-economic determinants of health, health inequalities and lifestyle factors, there is huge potential for strengthening the role and influence of public health, and establishing a strong coordinated national (and international) evidence base to underpin and address the major challenges of today. The preferred model would be for Public Health England to be an organization within the NHS rather than a department within the DH. Public Health England would be the umbrella organization for employing the core Public Health Workforce in its entirety, at national, sub national and local level, across all three domains of public health. This would avoid fragmentation and loss of knowledge and skills within the workforce and public health agendas, as well as ensuring that ring-fencing of the budget was maintained. DPH’s would be responsible for the local Public Health budget and accountabilities for certain functions. Local partnership arrangements, joint accountabilities, pooling of resources and “hosting” of Public Health within the Local Authority would strengthen the response to the Marmot Review. This approach would also maintain a level of autonomy and professional independence for Public Health. The role of the CMO would be key at a national level, and DPH’s could be accountable to the CMO.

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

(a)The Health Protection Agency currently has a level of independence and autonomy that would not exist if Public Health England is part of the DH.

(b)The current model for the Health Protection Agency is resource intensive, but lacks accountability and does not cover all the functions eg immunisation. Local functions and accountability are still required.

(c)Local knowledge and networks are key to managing health protection and responding to emergencies. Local emergency planning and local relationships are key to successful operations. There are a variety of local models nationally.

(d)Consideration should be given to sub-national coordination once the SHA no longer exists.

(e)It is important that the local health protection function is able to provide expertise and advice as well as operational functions and local capacity to respond in emergencies and disease outbreaks.

(f)The benefit of Public Health England and extended powers of direction of the Secretary of State to command NHS organisations in national emergencies is key, however this needs to be extended to include service providers as currently there is no legal responsibility for individual practitioners eg GPs to respond as they are not bound by the Civil Contingencies Act. GP Consortia would however have statutory obligations in the future. NHS contracts with providers could possibly include arrangements for emergency situations.

(g)Lessons learnt from the pandemic flu emergency should be incorporated within new structures to ensure accountabilities and operations in emergency situations are robust and effective.

(h)Public Health England would need to be designated as a Category 1 responder. There is a need to be clear about the responsibilities of Public Health England and Local Authorities in emergency situations.

3. Public health role of the Secretary of State

(a)It is welcome that public health is being given greater importance within government.

(b)In order to balance government political agendas and the autonomy and independence of public health priorities, it is important that the Secretary of State is supported with a strong network of public health professional leaders, along with the CMO, to support and advise on the public health functions and influence policy.

(c)Cross departmental approaches to address the wider determinants of health and health improvement are key at national level as well as local level. Public Health can provide a key coordinating function and a means by which Health Impact Assessments and social policy analysis (eg accumulated impacts of a range of policy changes on health inequalities) can be conducted during the process of decision making.

(d)New powers proposed for the Secretary of State during emergency situations is an important development. These powers should be extended to include provider organisations for the NHS/LA.

4. Future role of local government in public health (including arrangements for DPH, role of Health & Wellbeing Boards, JSNA’s and Joint Health & Wellbeing Strategies

(a)Stronger partnership working arrangements between the Local Authority and Public Health is key to the agenda, however there may be tensions with professional independence, clinical governance and accountability (to elected members) with the current proposals.

(b)Joint clear accountabilities, and the “hosting” (but not “employing”) of an NHS Public Health organisation within the Local Authority may be a model that could overcome this. It would also ensure appropriate ring-fencing of the budget at a time of Local Authority cuts, so the budget is not seen as a substitute to meet service demand, as was the case in the NHS when the budget was not previously ring-fenced.

(c)The budget should bring additionality and new ways of working to address the wider determinants of health, including the pooling of resources.

(d)Maintaining a Public Health “core” workforce as a substantial body is important to ensure that public health functions do not become fragmented and weakened. There should be a whole system approach (national, sub-national and local) to ensure strong coherence, coordination and quality in advisory capacities and delivery.

(e)Setting up organisational structures that embed public health strongly within both the NHS and Local Authorities is key to tackling the major public health challenges of today. (The position and authority of the DPH needs to be much clearer and stronger than “advisory”)

(f)The JSNA and joint Health and Well-being Strategies are an important overview of health need in the borough, but these also need to be underpinned by more in depth knowledge and understanding of specific areas that individual public health employees have as specialist areas of knowledge. A strong evidence base and community engagement to understand issues on the ground are key.

(g)Maintaining a community engagement function within the public health workforce is key to the success of partnerships both with local authorities and GP Commissioners. Current public health directorates have staff skilled in community engagement which is gathered through a number of means and workstreams. The intelligence gained through this means is absolutely essential to ensuring that the strategies, policies, JSNA’s and themed needs & asset assessments, along with other key documents, are reflective of the needs of the population they serve, include public health outcomes wherever possible and are appropriate in terms of planning and reviewing service delivery.

(h)Joint Intelligence functions between LA and NHS can play a key coordinating role for intelligence, research and data sharing, and ensure intelligence led commissioning decisions.

(i)Health and Well-being Boards should have a clear remit and powers and be able to scrutinize and powers to “sign off” commissioning decisions. (Who will regulate processes, and conflict of interest eg robustness of commissioning decisions based on population needs and assets assessments such as JSNA; private business interests of GP Commissioners who are both commissioners and providers?).

It is essential to note that the DPH is not a lone expert but requires dedicated experienced support day to day from Public Health Consultants and Specialist, Public Health practitioners in health improvement, Public health intelligence staff, public health programme managers and administration staff currently employed by PCTs – for the most part, unless a DPH is fortunate to already have a dedicated resource in a Local Authority, these roles cannot be covered by existing Local Authority staff as they are specialist practitioner roles requiring appropriate training and qualifications. The current proposals for Public Health at a local authority level does not appear to recognize this vital local Public Health workforce currently employed by PCTs despite their critical role in the production of JSNAs, public health programme commissioning, public health advice and support to GPCC, health protection surveillance (local outbreaks), planning and response. Recently there were two meningococcal disease outbreaks in separate nurseries in the Borough each requiring prompt action to give antibiotic prophylaxis to 100 children and advise anxious parents. The local HPU provided expert advice but the actual delivery of the public health response was done through PCT Public Health staff.

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

(a)It is important that Public Health is a key player within the commissioning of NHS services. The specialist skills within public health can support data and intelligence gathering, community engagement, analysis and evidence to underpin understanding of population health and service development.

(b)Strong partnership arrangements with the LA and Third Sector can support integrated joint commissioning models for health & social care, and pooling of resources.

(c)Commissioning for population health requires specialist knowledge and upstream approaches for primary prevention as well as secondary prevention and self care, primary, secondary and tertiary care.

(d) Commissioning should be for the whole population, encompassing the diversity of the population and demographic change. Equity Audits, Equality Analysis and Impact Assessments and data collection across all equality strands can strengthen knowledge and understanding of the local population.

(e)Cost benefit analysis and Social Return on Investment models can support investment decisions.

(f)Issues surrounding coterminosity of GP Consortia and Local Authority boundaries could be problematic. Understanding population health requires support and development opportunities for GP Commissioners, however the current pace of reform does not enable this to take place adequately.

6. Arrangements for commissioning public health services

(a)There needs to be clarity regarding what “public health services” encompass. For example does this include Health Visiting and School Nursing, or will these universal services be commissioned from the main NHS budget rather than the public health budget. Public Health incorporates a wider role such as that it can play in policy, planning, sustainability etc. which is wider than traditional health remits.

(b)The ring-fenced budget needs to be clarified and adequately resourced if it is to be effective (4% may be inadequate).

(c)Details of what percentage of the public health budget will be spent at national level, GP Commissioning and Public Health/LA need to be calculated.

(d)It is important to maintain flexibility with commissioning to enable effective and innovative ways of working (eg in Wigan Looked After Children Service, Homeless & Vulnerable Persons Service, Public Health Capacity Building Programmes and Health Improvement Initiatives).

7. Future of Public Health Observatories

(a)Public Health Observatories provide a valuable regional focus, but local analysis is still very important, especially sub LA geographical analysis eg neighbourhood level, or by social identity eg older people, ethnicity etc. at local level. Support and development for local analysts who specialize in public health is also important, as well as the benefits afforded by PHO’s.

(b)With a skills shortage, workforce development should consider ways to enhance and develop these skills and knowledge. Analysis requires knowledge and understanding of the public health issues as well as technical data management.

(c)Nationally PHO’s have experienced a reduction in funding, but consideration should be given to finding means to utilise expertise to better support workforce development at a local level, as well as better coordinating the valuable work undertaken by PHO’s nationally, rather than risk losing valuable expert knowledge.

(d)Skills for the core public health workforce should be enhanced to be able to interpret and appraise public health data and intelligence.

(e)Sub national coordination of all public health functions that lie within the remit of Public Health England would enable the valuable work of PHO’s to continue, whilst maintaining a coordinated evidence base nationally.

(f)Evidence should also be coordinated with NICE.

8. Structure and purpose of the Public Health Outcomes Framework

(a)Outcomes focused Public Health is a welcome approach, and the Outcomes Framework covers key domains within public health, and provides potential for joint accountabilities with the LA.

(b)Statutory accountability would need to be established for Public Health England NHS and the Local Authority (if this model is adopted).

(c) However there is a need to consider the range of budgets that these are accountabilities for, as the measures go beyond the immediate ring-fenced public health budget (in particular domain 2). Again the ring fenced budget purpose and amount has not yet been clarified, but the Outcomes Framework clearly represents a range of NHS and LA budgets.

(d)Outcomes in Public Health can take many years to achieve and may not be measurable immediately in the short term. Progress measures may need to be considered. Outcome measures should also be linked to Quality Standards with joint accountability for Public Health England and Local Authorities.

9. Arrangements for funding public health services

(a)Clarity is needed over the amount and use of the budget, based on more robust assessments.

(b)There is potential for the health premium to disadvantage some areas with chronic complex issues and high levels of population churn and potentially exacerbate health inequalities.

(c)There is currently no clarity about what constitutes Public Health Services.

10. Future of the public health workforce (including regulation of public health professionals)

(a)It is important to maintain a coherent workforce, and not just consider “specialists” as the core public health workforce. The public health workforce is diverse and covers a range of skills, knowledge and expertise at different levels, as well as incorporating functions such as business administration and IT. Advisory roles and analysis are important, but a skilled operational/practitioner workforce is also important.

(b)The public health workforce should remain as employees of NHS Public Health England and “hosted” within the LA to avoid fragmentation and maintain a level of professional independence. Clinical governance issues for medical and clinical staff (eg health protection functions in particular) would also be addressed.

(c) Establishing a core public health workforce at a range of levels and from a range of disciplines is important in order to avoid a “medical model” and to address the wider determinants of health. Properly assessing the wide range of skills and knowledge required and constructing a Public Health career framework will enable strengthening and development of a core workforce to support the “wider public health workforce”.

(d)The functions of public health cannot be easily divided, and holistic approaches are needed to improve and protect health.

(e)A robust means of regulation for senior Public Health Consultants/Specialists/DPH’s is important to ensure quality, safety and robust practice that reflect the level of responsibility for the public’s health, well-being and protection and financial investment.

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

(a)The Public Health White paper adopts a life course approach, however, there is a need to emphasize socio-economic/wider determinants interventions more, in line with Marmot.

(b)There have been a wide range of major socio-economic policy reforms eg welfare reform, housing etc and an economic downturn. It is recommended that Health Impact Assessments be undertaken before decisions on reform are made in future. The cumulative impact of a wide range of reforms on the most vulnerable in society has yet to be realized, and has the potential to increase health inequalities and add to the burden of ill health.

(c)The Nuffield Ladder of Intervention highlights a range of intervention levels. It is important that public health policy and practice works across all these levels according to what is most effective, based on a robust evidence base.

Dr Kate ArdernExecutive Director of Public Health, Borough of Wigan

June 2011

Prepared 28th November 2011