HC 1048-III Health CommitteeWritten evidence from Yorkshire and the Humber Public Health Specialty Registrars (PH 59)

1. Summary

1.1 Public Health Specialty Registrars in Yorkshire and Humber are committed to improving health and reducing health inequalities. We are submitting evidence on the potential impact of proposed national health policy on public health action in the region. This paper is supported by the Yorkshire and Humber Postgraduate School of Public Health.

2. Public Health England

2.1 Consultants in Public Health have responsibility for the health of the local population. As NHS employees they have been able to advocate for their population and develop strategies to address inequalities. As part of the NHS reforms, Directors of Public Health (DsPH) will be joint appointments between local authorities and Public Health England (PHE). Currently DsPH are afforded a degree of independence from central government by being NHS employees. However, placing PHE within the Department of Health will impact on DsPH as they will no longer be independent of central government. Therefore, they will face challenges in opposing central policy decisions that will increase inequalities and are likely to be constrained by the short-term goals of the government of the day rather than the long-term preventative goals to reduce inequalities and illness burden. There is a conflict between working within the aims and objectives of central government, and advocating for the local population as part of the localism agenda.

2.2 Strategic planning requires information to inform decisions, and whilst working within the NHS this information is relatively readily available, but information sharing agreements will need to be drafted and potentially lead to delays or information asymmetry. However, if PHE were to be developed as a Special Health Authority within the NHS, independence will be maintained and the above scenarios could be avoided.

3. The Health Protection Agency and the National Treatment Agency

3.1 What the National Treatment Agency (NTA) and the Health Protection Agency (HPA) share is a clear trusted brand identity that has taken some years to build up. Building brand recognition takes huge resource both financial and in terms of staff efforts. The benefit of a clearly identifiable agency is the increased utility for partnership work; other agencies know who you are, what you do and how you do it. These relationships are essential for partnerships to deliver change for the kind of intractable problems that both these agencies address.

3.2 Confidence from the public is also increased by a strong brand identity and in the case of the HPA, a number of marketable products have been developed by which the agency can generate revenue streams. The work still needs to be done. For these reasons we would recommend retaining the HPA and NTA as individual brands, even if they sit within PHE in the larger structure.

4. Role of the Secretary of State

4.1 There is a lack of congruence between the proposed dispersal of public health capacity and the well-established view of the three domains of public health (health protection, health improvement and health service improvement) working together as a public health system. It is of concern that the secretary of state envisages being personally responsible for the appointment of DsPH, and holding significant powers over them thereafter. There is a real danger is that those experts will no longer have an independent position from which to give their professional advice.

5. Local government in public health

5.1 Many services provided by local authorities impact on health, hence there is huge potential gain from co-operative working between public health and other directorates of a local authority. However there were reasons why public health initially moved from local authorities.

5.2 DPH roles are likely to be increasingly fragmented, and inconsistent between geographical areas – differing job descriptions, varied membership/structure of Health and Wellbeing Boards (HWBs), differing assignment of statutory and non-statutory roles and a lack of coterminous boundaries with GP commissioning groups will all make roles incomparable, making sharing of learning and best practice even more difficult.

5.3 DsPH risk political interference in the appointment process or in the production or dissemination of their reports. Actions requiring a public health response are often politically contentious, yet in the best interests of a society. Elected members wishing to silence their DPH (whose reports may be politically damaging) will have much greater ability to do so under the new arrangements. There is a high level of trust in the NHS which facilitates communication with the public. This may be compromised coming from local authorities who may have to implement spending cuts (eg closing swimming pools whilst promoting physical activity).

5.4 There is significant risk that we lose the focus on public health. Under current arrangements many DsPH are jointly appointed and have a role on councils executive boards, meaning public health messages get heard at the highest level available. Under current plans, many local authorities will not create a directorate of public health, but will instead place public health within existing directorates, effectively muting this voice.

5.5 Staffing public health directorates will present challenges, already implemented rounds of redundancies and potential loss of conditions as staff transfer from NHS to LA contracts mean existing posts will be vacated with little chance of recruiting equivalently able people. This is occurring currently, leading to the loss of experienced staff and organisational memory. Loss of experienced analytical staff and reduced data collection will devalue of reports like the Joint Strategic Needs Assessment (JSNA), which rely on up to date, comparable data.

5.6 Local Authorities may be required to undertake NHS functions for people in their population who are not registered with a General Practitioner. This is a major risk as it could create a two tier system whereby those who are not registered with a GP (out of choice or because they are refused by their GP Consortium) will be the responsibility of the local authority and therefore receive a different level of service. It is essential that GP commissioning consortia retain the responsibility for all people within a defined geographical boundary.

6. Commissioning NHS services

6.1 At present public health teams are central to the commissioning of NHS services. The new arrangements will make it considerably harder for public health to engage with commissioners of many services and conversely will make it harder for commissioners to engage public health support for their decision-making. The current proposals for GP consortia commissioning do not include public health input other than the implicit belief that consortia will work hand in hand with local authorities – a rose-tinted view of collaborative commissioning.

6.2 We propose all organisations with a commissioning function should take advice from specialist public health advice with the board of each organisation including a specialist public health representative, in line with the Faculty of Public Health’s (FPH) view. The General Practitioners Committee has recognised “public health doctors…may be appropriate leaders in certain roles” within consortia. GPs as commissioners and the staff they employ will not have the skill set to focus on all three domains of public health or to undertake the systematic reviews of evidence and cost-effectiveness that inform quality commissioning decisions at a local level.

6.3 One of the criticisms of PCT commissioning was that it was not always evidence based but rather evidence was found to support decisions once they were taken. Public health expertise offers rigour. The JSNA identifies local health needs and public health specialists can inform cost-effective decisions to support the implementation of clear commissioning and decommissioning intentions.

7. Commissioning public health

7.1 Splitting public health commissioning between different structures in the proposed new architecture results in a danger of commissioning that’s not joined up. Greater accountability between GP commissioning consortia (GPCC), NHS Commissioning Board (NHSCB) and HWBs locally will help to strengthen commissioning arrangements at a more localised level.

7.2 Commissioning of services by GPCC needs to take into account a population-wide and prevention perspective, and not just respond to the needs and wants of those individuals who already access services. Otherwise there’s the danger of developing services in response to those who make themselves heard, rather than in response to the systematic identification of population need. There is also a risk that GPCCs have too much of a secondary care focus (as that is their key commissioning role) and not enough focus on primary prevention. Incentives for primary prevention need to be strengthened.

7.3 Engagement of the NHS Commissioning Board NHSCB within this process is weak. Therefore there is a risk that the HWB boards yield little influence over broader commissioning activities. The position of the HWB board needs to be strengthened to ensure that the priorities highlighted in the JSNA are translated into actions by the appropriate commissioners – a firm duty to act on the JSNA must be applied to the NHSCB, as well as local authorities and GPCC.

7.4 GPCC will need the expertise of other professional groups in order to commission services fairly, according to identified need, and from a multi-disciplinary perspective. In order for them to be able to commission most effectively, the consortia would need to include community and hospital clinical colleagues and public health colleagues.

7.5 We agree that overall it is beneficial to have the commissioning of some services take place by one organisation for the country, (eg screening programmes and specialised services). But, there needs to be strong reach-down from the NHSCB into local areas to ensure that on-going commissioning maintains its safety and effectiveness by being informed by local delivery.

7.7 It is not clear who will be responsible for the Child Health Information System.

7.8 Currently in the region we are experiencing difficulties trying to commission care for marginalised groups, for example offender health. It is unclear how to establish new care pathways when everything is in transition and it is unclear where responsibility will ultimately lie. We are concerned that “Cinderella areas” will really suffer when PCTs are in fire-fighting mode and unable to be take risks on commissioning innovative work. We are also concerned about the loss of “partnership memory” and good work that has been evolving at a multi-agency level is in danger of disappearing.

8. Public Health Observatories

8.1 High quality health intelligence to support commissioning in Yorkshire and the Humber is provided by the Yorkshire and Humber Public Health Observatory (PHO) and both the Northern and Yorkshire Cancer Registry and Information Service and the Trent Cancer Registry. It will be essential to retain the local links to this specialist resource in the proposed new structures to support the National Commissioning Board, GP Commissioners and Local Authorities to deliver high quality health care and public health commissioning. Both PHOs and Cancer Registries run information request services for local NHS partners. It is important that such services continue to be available to commissioners locally and that the local knowledge involved in dealing with such requests is not underestimated.

8.2 PHOs and Cancer Registries have a dedicated pool of analytical staff whose training has been publicly funded by the NHS. Typical training for band five analytical staff will take two years and include a part or fully funded Masters in Public Health with a focus on epidemiology and statistics. Higher grade staff will have developed further specialism through their continued professional development. It is essential that this resource is retained within future commissioning structures. We would recommend that PHE would be an appropriate home for this specialist resource to ensure it can be accessed by commissioners to ensure high quality information is available for decision making. It is crucial the outputs, skills, and expertise listed above are not lost during transition.

8.3 The retention of the specialist skills and local knowledge of the PHOs and Cancer Registries to support NHS commissioning will be especially important if the proposals to move Public Health specialist staff to Local Authorities are implemented. It is Public Health directorates who lead on local needs assessment, data analysis and evidence appraisal within PCTs, and there is a real danger that the loss of these skills from NHS commissioning will be detrimental to population health.

9. Public Health Outcomes Framework

9.1 There is overlap among the five domains identified. The three domains of public health identified by the FPH might provide a clearer structure for the framework. Too much overlap and lack of clarity between the domains may lead to unnecessary data collection and confusion about who is accountable to which domain.

9.2 There appears to be a contradiction between the purposes of the outcomes as a way to set out the government’s goals, whilst also stating that they do not want them to become a performance management tool. Currently the outcomes and indicators within the framework are not worded as SMART goals or objectives, and to do so would presumably be seen as performance management. However, without these it is hard to see who will hold local authorities accountable for these goals.

9.3 It is often unclear who is accountable for the outcomes and what happens if progress is not achieved in these areas. Frequently local communities are identified as being able to hold local authorities accountable; however there is much evidence that those in deprived areas are much less likely to be actively engaged in these processes. Thus if accountability is left to local communities alone those in poorer areas are least likely to drive up progress in these indicator areas, further deepening health inequalities.

9.4 Data gathered through the public health outcomes must be a driving force for commissioning within the NHS as well as within local authorities. This point does not come out clearly within the purpose specified for the outcomes.

10. Funding public health services

10.1 We support the King’s Fund recommendation that the DH estimates the scale of the public health budget on a proper assessment of need and not solely on estimates of current spending.

10.2 There is a risk that wider changes to the economy, employment, education, and welfare will have a large impact on public health outcomes.

10.3 The consultation on Funding and Commissioning Routes for Public Health stressed the key principles of localism, devolved responsibilities, freedoms, funding. However large parts of the Public Health Budget are being allocated without any input from local areas eg the public health aspects of the Quality Outcomes Framework, all of screening, parts of the immunisation programme. It is understandable that some of these aspects are handled centrally, however there must be the structures to allow local areas to feed contextual intelligence into this central commissioning.

11. Public health workforce

11.1 The multi-disciplinary nature of the Public Health workforce is important for the delivery of the breadth of public health practice and should be maintained. In maintaining this workforce diversity is a need to ensure that public health specialists attain a core skill set to provide assurance and appropriate safeguards to the public.

11.2 We would strongly recommend the statutory registration of all public health specialists. Equity between the different routes to specialist registration and the registration requirements for practitioners from all backgrounds is needed. We would recommend that registration for Public Health specialists should require passing the FPH’s professional exams and meeting the competencies set out in the FPH curriculum.

11.3 To deliver public health outcomes for their populations, public health specialists will need to be able to maintain a level of independence, providing robust and unbiased evidence and delivering the necessary actions to improve health and reduce health inequalities. There is a potential that the proposed move of the public health workforce to local authorities could affect the independence of public health advice and action, subjecting it to the influence of local politics. Mechanisms to ensure the independent voice of public health must be put in place to retain the ability to present public health evidence in an impartial way to the public and local decision makers. Employment of public health specialists as well as the DPH by PHE could provide an effective mechanism to achieve this, with local teams supporting their local authority to achieve the public health outcomes for which they will be responsible.

12. Response to Marmot

12.1 The Marmot Review recommends that to tackle health inequalities action is needed across all the social determinants of health. The current Bill lacks a clear framework for the role and responsibilities of public health in the local authority to allow the actions recommended by the review to be enacted at a local level.

12.2 With the removal of the duty to provide comprehensive care under the proposed legislation, the more profitable health care activities will be pursued by independent sector treatment organisations instead of health promotion activities aimed at reducing inequalities.

12.3 Furthermore individuals will be free to choose their general practitioner without geographical restriction; this implies that general practitioners and hence consortia will also be able to choose which patients are registered with them. This entails a risk that consortia as independent financial bodies will select the healthiest individuals in a population at the expense of the individuals with the greatest health needs to reduce their financial risk, therefore widening existing health inequalities further.

12.4 There is significant risk that the proposed health premium will skew efforts to reduce health inequalities and will have the opposite effect to that intended (assuming the intention is improving the health of the least healthy fastest). Health inequalities within an area are relative – the most deprived areas will have the greatest gap. It is easier to reduce an already small gap by a significant percentage, meaning more affluent areas will appear successful on this measure and attract increased funding over deprived ones. Health inequalities are primarily the result of national economic and educational strategies which are not within the power of local authorities to alter. Shifting public health funding from poor to rich areas can only make this worse. We recommend the health premium should be piloted before general implementation, and should relate to changes in the Slope Index of Inequality for an area.

June 2011

Prepared 28th November 2011