HC 1048-III Health CommitteeWritten evidence from the Stockport Shadow Health and Well Being Board (PH 61)

Summary

1. This submission provides a broad focus on behalf of Stockport, taking into account contributions from and discussions with a range of interested parties including the Health Scrutiny Committee. Public health professionals working in NHS Stockport are submitting separately a more specialised response.

2. One of the major purposes of the HWB is to protect and promote the health of the population in Stockport, which is heavily polarised in terms of inequalities. We believe that a core function for the Local Authority is to support health improvement interventions in our communities. Commissioning services require considerable attention to be given to population health. We welcome the leadership role for the LA in public health and future local authority arrangements require the systematic integration of public health specialists.

The creation of Public Health England within the Department of Health

3. We consider that the independence of the public health function from the management of the NHS would be damaged should Public Health England become part of the civil service machinery of the Department of Health. As the Department is responsible for delivery of services, there are conflicting interests. However in order to achieve the desired integration by the Secretary of State Public Health could be an NHS body chaired by a Minister .

The abolition of the Health Protection Agency(HPA) and the National Treatment Agency for Substance Misuse (NTA)

4. We are unclear as to the arguments and benefits for the abolition of these agencies The NTA for substance abuse brings together a range of interdepartmental interests, which will continue to exist and need to participate in decision making. Whilst the NTA has at times seemed to struggle because of “competing” interests it should be made to work.

5. In Health Protection, as well as routine activity, Stockport undertook considerable work to prepare for a pandemic – not if but when –of “Bird” Flu. This proved invaluable for the swine flu outbreak. However the local work needs to be within necessary (sub)regional and national co-ordination .

The public health role of the Secretary of State

6. The need for an independent public health voice remains. Whilst public health is a key contributor it is one of many cross cutting contributors to address the wider determinants of health and health improvement. Policy formulation must draw on all.

The future role of local government in public health (including arrangements for the appointment of Directors of Public Health; and the role of Health and Wellbeing Boards, Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies)

7. In Stockport the Director of Public Health’s annual report is now integrated with the Joint Strategic Needs Assessment (JSNA). So recognising the vital contribution of public health to the wider role of local government, would a organisational place other than the local authority be more appropriate? Between 1948 and 1974 the NHS was based on a tripartite structure of which local (health) authorities were one part. We believe that there is no place other than the local authority to which the Public Health function should be transferred. However this has to be done properly, which will include time for considerable organisational preparation and development. Prior to the major 1974 re-organisation a full two years was allowed for this. Reducing tensions and reconciling the varying agenda and viewpoints of professionals and elected members will be a challenge.

8. We support the further development of Greater Manchester Health Commission which provides a sub- regional dimension to health improvement and related public health work. However there always appears to be organisational clutter with some degree of confusion and duplication. The creation of PCT clusters certainly in the short term will add to this.

Arrangements for public health involvement in the commissioning of NHS services

9. We believe there is vital need for Public Health involvement to ensure that the priorities within the JSNA are captured within commissioning priorities and plans. Health and Wellbeing Boards need to have real powers to influence commissioning to ensure these local evidence based priorities were being actioned. We await Secretary Lansley’s decisions following the listening exercise and pause. We hope he will accept the consequences for commissioning to be aligned with the health and well being strategy. However there are concerns about the powers of the HWB to object to the business plans of NHS providers when these appear in conflict with the strategy.

Arrangements for commissioning public health services

10. Health and Wellbeing Boards should have a clear remit and powers to sign off commissioning decisions. Until clarification is provided we have concerns about the proposed divisions between local and regional/ national commissioning. Transition problems will arise from any separation of responsibilities for under and over fives. In supporting a greater emphasis on preventative services, linked to local priorities and through integrated arrangements, greater understanding of the concept of prevention is needed. Some professionals use terminology such as low level in a disparaging and off putting way. Both Black (1980) and Marmot (2010) put an emphasis on simple physical activity such as walking.

The future of the Public Health Observatories

11. We value the excellent information and evidence bases provided by them. In addition to major use in relation to for example JSNAs , we use their health profiles in all our children publications and stress the need for their retention. We do not have the specialist knowledge to comment in detail on the organisation of the observatories. However workforce skills need to be developed locally as well.

The structure and purpose of the Public Health Outcomes Framework

12. The Department of Health and its predecessor Ministry of Health has had performance management arrangements for over 50 years following the Guillebaud report (1956). Measures of progress on key health issues are essential but have to take account that in Public Health they may take many years to achieve. In our opinion some short term measures have not always been credible. Greater dissemination of the underlying practice that gives rise to improved outcomes is required – what works. A focus on quartile, quintile or decile positions alone is meaningless.

Arrangements for funding public health services (including the Health Premium)

13. Legislation must ensure adequate funding for public health services, in particular those local services commissioned through local authorities. This is an area where the devil will be in the detail, so that cost shunting and opacity is avoided. There is a need to prevent conflict between Public Health England and local authorities over the allocation limited resources. Highly polarised districts such as Stockport could suffer unfairly if the health premium is paid on the basis of district-level indicators rather small area (super output) area indicators. Our focus is on improving health and reducing inequalities for Priority People wherever they live in the district. For instance within a ward one super output area with high deprivation can contribute to a reduction of two years lower expectation of life for the ward as a whole.

The future of the public health workforce (including the regulation of public health professionals)

14. Existing arrangements provide a diverse team with a range of skills and professional training. They are part of a wider workforce which contribute to addressing the wide determinants of health (see Black and Marmot below). There is a need for robust arrangements to be in place to ensure future roles are fit for purpose. The holistic nature of public health requires thought out workforce development and a realistic recognition of career paths.

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

15. Stockport Council first discussed inequalities in September 1980, following the publication of the Black report. The agenda is little changed, with the challenge still how to harness complex and multiple determinants of health. The importance of linkages between local agencies and partners to deliver effective services to reduce inequalities cannot be over emphasised. We are also concerned that introducing more competition into the NHS would limit opportunities for the integration between primary, secondary and local authority service delivery. Similarly GP consortia would not be able to effectively commission preventative services without the wider, and meaningful, input of local authorities, health and social care professionals and the community. Within the past month Stockport Partnership has devoted a full meeting to exploring these issues. However robust partnership mechanisms will be needed that give stakeholders powers to decide and hold to account.

June 2011

Prepared 28th November 2011