HC 1048-III Health CommitteeWritten evidence from Alyson Learmonth (PH 55)

I am submitting this evidence in a personal capacity.

1. Summary

1.1 This evidence is presented from the perspective of a current jointly appointed Director of Public Health working across Gateshead PCT and Gateshead Council. It takes as a starting point, that the excitement generated by the idea of Public Health leadership transferring to the Local Authority, as an indication that the idea is a good one. Given enough power, Health and Wellbeing Boards could provide an opportunity to re-locate leadership in relation to the creation of health where it belongs, in relation to place shaping and the Determinants of Health. My evidence should be given weight because it is rooted in eight years of experience as a Director of Public Health, four of them leading Public Health in a co-terminous Borough and PCT, where the issue has been given a high priority, and the health of the population is disproportionately poor, when compared to the degree of deprivation.

1.2 My commentary below relates to the key headings set out in the terms of reference for the Select Committee, from the perspective stated above. Crucially, the argument presented is that the terms set out so far miss out on one major opportunity arising from the proposed transfer of leadership in relation to Health and Wellbeing. It is that the nature of Public Health “the science and art of preventing disease, promoting health and prolonging life through the organised efforts of society” is essentially political. By recognising this and addressing more clearly the potential for locally elected representatives to lead on public health, aligned with the community and health development function, there is the potential to multiply the potential influence of this transfer both on the health agenda, and on the democratic renewal process. Such an approach would also be consistent with the “community leadership” role of local authorities.

1.3 Secondly, the proposals implicitly recognise, through domain two of the proposed Outcome Framework, the breadth and potential of place shaping to create health enabling environments. This is a key part of the Local Authority role through spatial planning, the regulatory function, etc. However, this should be explicit and clear as part of the role definition which is currently focussed on only one aspect of the agenda: joint commissioning agenda between health and social care.

1.4 Because my evidence is presented from a local perspective, I will start with the functions closest to the ground and work up through the Public Health System. As a system it is the integrity of the whole that is vital, so this is not to imply importance. A second crucial issue which will emerge throughout the commentary is that of resources. At this time of budgetary restraint, can the existing Public Health resource be successfully picked up and rearranged, deliver the savings expected from those parts currently designated as quangos, and continue to stay safe?

1.5 The re-organisation of the small but crucial Public Health resource needs to be supported by sufficient investment. My experience suggests that hosting Public Health within an organisation does in time support further development within that organisation. But can we afford to wait? And what is our change management strategy to safeguard the health of the population in the meantime? Investment in work to improve the health of the population is the only way in the medium to long term, that the we will be able to afford the NHS, as modelled in the Wanless review.

1.6 In classic management models of change there is an “unfreezing stage” where everyone gets ready for change, followed by an adjustment and realignment stage as the system is re-engineered towards the desired end state. Currently, the “unfreezing” is well under way with the desired end state brought into question. It is vital to clarify the direction of travel urgently. Experience shows that massive structural change will slow and possibly halt actual delivery.

2. Arrangements at a Local Level

2.1 Future role of Local Government in Public Health

2.1.1 Appointments of DsPH My experience as a Jointly Appointed DPH has been positive. Certainly my current post, which is also jointly funded, has given me significant access to Local Authority strategically and practically. However, the nature of the Joint Appointment proposed with Public Health England (or, worse employment by Public Health England and secondment to the Local Authority) is counter to the Local Authority paradigm of leadership directly from the Elected Members, by superimposing central accountability onto the post. Alternatively accountability to Local Authority Chief Executives will require a powerful set of criteria ensuring the post of DPH is, like the former Chief Medical Officer, at a very senior level and with professional autonomy built into the role. Improving public health outcomes over a period of years, is as important as balancing the books, and this needs to be seen as part of Corporate responsibility at the highest level. Conceptually, this requires a recognition of the vast benefit in terms of democratic renewal, if the role of elected Members is adequately supported and developed, so that it becomes a strength in the cultural changes and place-shaping decisions required to create health. The independent voice of the DPH needs to be recognised as “grist to the mill” in terms of reaching well informed and transparent decisions. Currently, Healthwatch is the only identified part of this agenda (albeit an important one). The larger challenge of engaging and working with and through communities in the way demanded for large scale change is invisible. It is essential that the role of DPH embraces the overall perspective of the population’s health in relation to all three domains of public health: health improvement, health protection and health service improvement. Without this breadth of accountability and responsibility, it is possible that GP Commissioners (still at a very early stage in developing a population perspective) may not pick up the benefits in terms of cost-effectiveness and quality measurement resulting from the health service improvement domain. Also, in the health protection sphere, expertise provided through Public Health England will not enable an authoritative response to issues of public safety without local understanding, leadership and authority. The current criteria to enable one person to take on this breadth of role, is Registration with the UKPHR, the GMC or GDC. The removal of this aspect of public protection during a period of radical change is potentially dangerous. The location of my current post in Gateshead reporting to the Group Director of Community Based Services has not restricted my work across the Local Authority, for example around Health Strategy, Health Impact Assessment, Emotional Health and Wellbeing, and Capacity Building to Improve Health. However, in the more tightly managed environment we are moving into, the importance of “position power” (alongside professional expertise and personal influencing), should not be under-estimated. At a national level the Secretary of State responsibility for Public Health through a Cabinet Sub Committee is an excellent step towards working across functions. At a local level it is important to mirror the whole system approach, and not subsume the Director of Public Health within a single function such as adult social care or children’s services. This should be made clear nationally rather than left to local decision-making.

2.1.2 Role of HWB Boards The potential role of Health and Wellbeing Boards is an exciting recognition of the nature of determinants of health, and the power of democratic leadership for health. However, in the current legislation this potential is limited in two ways. The first is lack of authority, or at least clarity about authority and accountability. The HWB provides a strong opportunity in terms of drawing together key players and Members in relation to a strategic approach to the issues around improving health, which should be maintained regardless of the final arrangements for GP Commissioning. The nature of the relationship between GP commissioners/Commissioning Authorities needs to be clarified. For example, what would be the dispute resolution mechanism? The second is lack of clarity about their role. The core role described could simply narrow down to the joint commissioning of NHS and Local Authority services. The proposed domain two of the Outcomes Framework broadens this out with indicators such as children in poverty, overcrowding, first time entrants to the youth justice system, and the proportion of people in long term unemployment. However, the holistic nature of the challenge this sets needs to recognised in creating an appropriate leadership and membership of the HWB. This outline of the purpose of the HWB needs to include place-shaping roles of the Local Authority, for example through spatial planning and culture.

2.1.3 JSNA

Our experience in Gateshead over the last four years has been that with the skills of a public health analyst as well as access to both local authority information and community networks, it is possible to build up a strong JSNA that includes a wide range of information, and a transparent priority setting process (www.gateshead.gov/jsna). Work is still under way to demonstrate its impact on “Moving Resources Upstream”, which has tracked for three years now the distribution of resources along the care pathway choosing Circulatory Disease, Mental Health and Musculo-skeletal conditions as the first three case studies. The shift has been hard to demonstrate despite a strategic direction that set this out as an explicit goal, with the possible exception of mental health. This is an area where national work through Public Health England would help strengthen the methodology, as well as the use of national levers through the Secretary of State to improve the way in which the allocation of resources is recorded and can be audited. However, the principle of maintaining and strengthening the JSNA is very welcome. Work is underway in Gateshead to develop an overarching “Gateshead Assessment” in order to bring together intelligence from a range of assessment tools, adding value to the JSNA and ultimately helping to inform the commissioning of services.

2.1.4 Joint Health and Wellbeing Strategy Gateshead has developed a prototype Health and Wellbeing Strategy “The Big Shift”. This has been a useful exercise, drawing on the JSNA in relation to needs, recommendations from an OSC review of inequalities, and the Sustainable Community Strategy (Vision 2030), for long term milestones up to 2030. It is currently based on the LA role, but will expand to take on added value from partner agencies where this can be clearly demonstrated, over the next six months. This exercise has been undertaken with the expectation that the HWB would then be able to work with a draft Health Strategy. Stakeholders have already been involved at a variety of stages and support the work to clarify and join up our approaches. Establishing strong links between health development, community engagement and democratic leadership would greatly enhance the overall impact on neighbourhoods and communities in Gateshead. This is an important aspect to re-shaping in the light of the significantly reduced resources allocated to the Local Authority over the next three years. One way in which the strategy in Gateshead is being implemented to ensure that the place-shaping role is fully developed, is through the systematic use of health impact assessment as a tool to ensure that all decisions consider potential effects on health and wellbeing, including distributed impact on different groups within the population. There is a vital link between this work and the sustainability agenda, which is essential in recognising climate change and environmental degradation as one of our key long term public health challenges. Making the most efficient use of resources will require that mechanisms across the 12 LAs in the North East are allowed or encouraged to address common issues and challenges. The London model, for instance, involves a London Health Improvement Board, with a 3% top slice of Local Authority funding to fund public health activity where pan-London work is seen to add value. The London Council Leaders Committee has the power, however, to overturn the proposals.

2.1.5 Arrangements for Public Health involvement in Commissioning NHS Services

This is essential to ensure that commissioning NHS services is based on needs assessment, effectiveness, and quality. The health service improvement domain of public health is virtually invisible in the current description of the Public Health System. Yet, this is the area where public health skills can make the biggest short term impact through correctly targeted services, based on evidence of effectiveness, and using population based thinking. Local experience has demonstrated the difficulty that even enthusiastic GPs have in moving from a one-to-one case orientated approach to a population approach.

2.1.6 Arrangements for commissioning public health services Scoping work on the commissioning arrangements indicated in the “Healthy Lives Healthy People” consultation on the funding and commissioning routes for public health shows the complexity of the agenda, given the different locations of current commissioning for things like oral health, sexual health, services for children under five etc. One immediate issue arising from current policy implementation is the national commissioning of health visiting services. While the development of the relationship with the national model has been important, if new posts and the retraining programme for current staff is to achieve its potential, then a bridge from national work to local work needs to take place at the first opportunity. However, it illustrates the problems of different timescales for implementation in relation to different parts of the system, and the potential for an inefficient dis-connect of activity with the National Commissioning Board. A second issue, is the division of tiered services for health improvement (sexual health, obesity, weight management, tobacco) where broadly speaking the low key community based tiers will be commissioned through the local authorities, and the more costly treatment services through GPs. It is easy to see that this will exacerbate the difficulties traditionally experienced in securing an adequate balance of investment across the tiers and, from a user perspective, a smooth flow across the tiers. One potential solution could lie in strengthening the authority of the HWB to ensure that pathways are appropriate and use resources effectively at all tiers. A third issue is that investment in health improvement services has been enhanced across the three PCT clusters of NHS SOTW over the last three years. There are currently multiple “stocktaking” exercises going on, with poor definitions leading to fears of “double counting” of scarce resources. There is real concern that instead of consolidating and targeting health improvement services which have been set up for the first time during the last three years and have barely had time to demonstrate their value, we may be faced with major disinvestment to facilitate a nationally established “ring fenced pool”. Where health of the population is as poor as it is here in the North East, this should recognised in determining ring fenced allocations. There should also be some aspect of the ring fenced budget that allows for current investment to be maintained for a realistic amount of time.

2.1.7 Relationships with GPs

In Gateshead on a personal level, relationships with GP commissioners are excellent. The Pathfinder GP Commissioning Consortium works well into the LA. Currently, a joint exercise using lean methodology to engineer short term progress in relation to the Long Term Conditions agenda is being planned for the autumn. However, the question raised earlier in relation to how would a dispute be resolved remains an important one which would help both parties understand their role boundaries. It may be that when Scrutiny functions were first associated with the HWB (as part of the government’s initial proposals), it was also referring to authority to resolve disputes. This is no longer clear.

2. The Infrastructure

2.2 The future of Public Health Observatories

Public health analytical skills are essential and always in short supply. This applies to both the intelligence function underpinning the creation of a JSNA, and the evidence-based function supported by NICE. A significant body of analytical expertise resided in the Public Health Observatories. It would be a serious example of collateral damage if this important resource were to be lost in the transition because of mismatched timescales and contracts. The function needs to be strengthened in PHE, the LA teams and in GP Commissioning Support Units. It is vital to retain the current arrangement in the interim and this needs to be addressed as a matter of urgency.

2.3 The future of Public Health Outcomes Framework

2.3.1 The proposed set of indicators is welcome in principle. However there is more work to be done. This is partly technical. While they are called “Outcomes”, in fact they are mixed up with measures of process and outputs. Developing robust indicators that consistently enable people to performance manage using indicators that realistically relate to their actual intervention, is important. At the same time, we need to maintain an evidence-based eye on outcomes, or alternatively a plausible and well evaluated process.

2.3.2 There is also more work to be done to ensure that the indicators are reflective of the important public health issues. For example there is no indicator related to transport, apart from cycling activity. Yet transport is a crucial issue in terms of access to health care, as well as to education, and employment. Active transport strategies are a key element of a systemic approach to tackling obesity.

2.3.3 In Gateshead, we are using Outcomes Based Accountability to enhance the action planning aspect of our Health Strategy; and we are working with NICE to develop a model for evidence-based commissioning. Some of this work could well be done nationally if the right terms of reference for PHE are created.

2.3.4 Domain 2 of the proposed Outcomes Framework is welcome for its breadth, and has been mentioned positively elsewhere in this response, subject to the further development work described above. However, the question arises about how does this fit with the direction of travel for other aspects of the LA role, and the reduction of performance management infrastructure?

2.4 Arrangements for funding public health services including the Health Premium

2.4.1 I have serious concern that a simplistic outcomes based Health Premium will simply exacerbate the North South divide, and damage social cohesion. If the government wish to take Sir Michael Marmot seriously, then it is crucial to recognise that the Health Premium needs to reward long term investment in early years, life long education, a living wage, and a sustainable environment. It is crucial that the work demonstrating that national wellbeing and social cohesiveness depends on not widening the gap is adequately recognised, and incorporated into government policy.

2.4.2 It takes many years to change health status. These timescales make it difficult to “reward” the most high impact medium to long term interventions. It is important that the work of the National Health Inequalities Support Teams is built upon, in relation to the previous PSA target around life expectancy. Health related behaviour and treatment of long term conditions will yield improvements in life expectancy, and may, if targeted, narrow the gap. However “the devil is in the detail” and constructing measures that are sensitive to change in a short timescale, meaningful in terms of responding to interventions, and evidence-based in terms of longer term impact on disability free life years, will present major technical challenges. Smoking prevalence would be a logical choice because it is still the major cause of inequalities in life expectancy. Yet to demonstrate an achievement of say a 1% change in prevalence would require massive data gathering (25,000 sample survey). The issues of practicality around tracking lifestyle need careful consideration.

2.5 Future of the public health workforce including the regulation of public health professionals

2.5.1 The Regulation of Public Health Specialists should be maintained by the UKPHR, and more recent changes to extend its regulatory role to both defined groups of specialists and practitioners should be maintained. Anything else will be a reversal at a time when we need to build capacity. Ultimately, employers will determine the value of the regulatory process.

2.5.2 My experience both in Gateshead and as Head of the School of Public Health (www.sphne.org.uk) is that a key element often overlooked is leadership to improve health and wellbeing, across agencies, and at all levels. It is vital that any new Public Health Workforce Plan addresses this issue. Lesson could be learnt from the Common Purpose programme as a model for aligning the commercial, voluntary and public sectors (www.commonpurpose.org.uk).

2.5.3 A further gap is a lack of attention paid to expanding the academic sector, and addressing issues of quality and effectiveness among health educators.

3. National Roles

3.1 The creation of Public Health England

3.1.1 One major question about the role of PHE is whether it would be better as a Special HA. I do not have a strong view on this structurally. What is crucial is that evidence-based recommendations from Public Health England are made to impact on government policy. This does not necessarily result from being a Special HA, as has been experienced by NICE. I think that the CMO’s links with the SoS are crucial.

3.1.2 I think that access to PHE for timely and locally relevant advice will require a structure below the national level. This should relate to common needs in the population, and existing organisational boundaries.

3.1.3 I am concerned that the resources for PHE will be “top sliced” to leave inadequate local support for DsPH and LAs.

3.1.4 The role of social marketing is not apparently included in the PHE terms of reference but cost efficiencies could be made by conducting some social marketing at a national or sub-national level. Given the links with the “nudge” approach, missing out this element is an oversight. Recent evaluation of community based initiatives in five areas of Gateshead is included in my Director of Public Health’s Annual Report (www.cehi.org.uk) and includes fresh evidence of the impact that well researched national campaigns can have in raising awareness levels.

3.2 Abolition of Health Protection Agency and National Treatment Agency

There are particularly high risks associated with the abolition of the HPA. Change management plans need to recognise the cuts already implemented in this organisation. They also need to recognise that the HPA may look like the nearest infrastructure for the new PHE. However, because its focus has been on only one of the three domains of Public Health activity, it is not fit for purpose without radical re-shaping for its new generic role, incorporating some of the PHO functions alongside social marketing and aspects of the RDPH role.

3.3 Response to the Marmot Review on health inequalities

So far only lip service has been paid to the Marmot Review’s six key policy areas. In Gateshead we have used Marmot to inform our work on narrowing the gap in relation to Children’s Services, focussing on applying the principle of progressive universalism, prioritising early years and recognising the importance of life long learning. However, changes in the rules for example to do with educational maintenance allowance, and which qualifications are recognised as equivalent to GCSEs at A-C, contradict these efforts. This re-engineering of the very systems that create health for the future undermines attempts to offset inequality and increase social cohesion.

3.4 Public Health Role of the SoS

Enhancing the Public Health role of the Secretary of State is an excellent move, especially if the infrastructure to create a joined up approach across government departments is brought into being in a way that is truly effective. As discussed above, one powerful example of the way this role could be valuable is to assess and prevent the harmful health impacts arising, in this case from the changes to benefits and accreditation related to education and skills development. Educational attainment is known to be one of the best predictors of life expectancy, and to impact on many aspects of health and wellbeing along the way.

June 2011

Prepared 28th November 2011