HC 1048-III Health CommitteeWritten evidence from University College London’s Division of Population Health (PH 70)

Summary

Our response focuses on five of the committee’s areas of inquiry:

1.The future role of local government in public health.

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

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

4.The future of the Public Health Observatories.

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

1. The future role of local government in public health

Consultants and Directors of Public Health need to be vested with the necessary independence and authority to advise public authorities and implement evidence-based policies in health promotion, disease prevention and health services provision. A mechanism to achieve this is to transfer the NHS based public health workforce to an NHS Special Health Authority or an Executive Agency called Public Health England. This body should retain control of the public health budget to ensure investment in Public Health is retained.

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

Commissioning consortia should be required to fully involve and be effectively supported by public health consultants in the commissioning and evaluation of services. These are both key areas of Public Health expertise.

GP commissioning consortia must ensure that robust responsibility—monitoring—accountability frameworks are in place to improve population health across the social gradient.

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

The basis on which the health premium is awarded is crucial. The current proposal may widen health inequalities. A UCL research team was recently funded by the Advisory Committee on Resource Allocation (ACRA) to review and suggest improvements for the health inequalities element of the NHS weighted capitation formula. Their recommendations should be considered with respect to both the allocation of commissioning funds to GP consortia and to ring fenced public health budgets to local authorities.

4. The future of the Public Health Observatories

To achieve effective surveillance and health intelligence at population level, including that provided by the Health Observatories, these functions must continue to operate at regional levels.

Further investments in data linkage would significantly improve the value of routinely available data. The regulatory frameworks for sharing patient information across organisational boundaries should be reviewed.

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

To achieve its stated commitment to aims of the Marmot Review, we urge the Government in committing to evidence based policy making, to include regulation, legislation, taxation and subsidy, where voluntary responsibility deals fail within a reasonable and agreed timescale.

Improving the implementation and dissemination of evidence based public health requires an embedded public health research culture within public health systems. Joint appointments and a stronger research training component between and within academic and service units can facilitate this.

1. The future role of local government in public health

1.1 The challenges associated with implementing the proposed reforms in the context of efficiency savings and major restructuring of the NHS has been widely discussed. However, with respect to public health practitioners’ ability to deliver on improving health and reducing health inequalities through the new structures proposed, we predict that the anticipated lag in implementation will be compounded by the 28% budget reduction to local government. Of particular significance are any proposed cuts in services that invest in children’s and young people’s development. Furthermore there is a danger that public health priorities will be downgraded and that the public health budgets will be “re-designated” in ways that were never contemplated.

1.2 Consultants and Directors of Public Health need to be vested with the necessary independence and authority to implement evidence-based public health policies both within and outside the NHS. A mechanism to achieve this is to transfer the existing NHS based public health workforce to a new body which could be still called Public Health England. This body would ideally be an NHS Special Health Authority or an Executive Agency. This idea was published in a recent Lancet article and has received widespread support from the public health community. In addition to independence, this model would allow Directors of Public Health to retain control over the public health budget ensuring that sound investment in a professional Public Health service is retained; supported by a critical mass of public health expertise. It will be crucial for Directors of Public Health to be accorded the necessary standing within Local Authorities to promote and safeguard the health of the population and to have the capacity to influence wider local authority budgets, for example in housing.

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

2.1 The third domain of public health expertise, that of efficient, equitable and effective health services, is largely overlooked in the Public Health White Paper.

2.2 We urge the Government to ensure that commissioning consortia are required to involve public health consultants (and clinicians) in the commissioning and evaluation of health services. This is crucial given the Government’s policy of maximising competition and the number of providers and the revisions to the Health and Social Care Bill, which removes the duty of the Secretary of State to provide comprehensive care.

2.3 These arrangements may impact on population health and widen inequalities through:

Introducing inequalities between areas: The Bill requires each commissioning consortia to provide only “such services or facilities as it considers appropriate.” Individual consortia may construct different definitions and criteria for the “services it considers appropriate” to provide. Given the abolition of restrictions on GP practice registration, it is likely that it will be the more affluent populations who have the resources to allow them to “shop around” for their care.

Reducing entitlement to services for unregistered populations: the Bill states that consortia “may” have responsibility for “persons who have a prescribed connection with the consortium’s area”. However, without clear requirements for consortia to have responsibility for providing and commissioning care, unregistered residents—often vulnerable groups such as the homeless or asylum seekers—may lose access to essential healthcare.

A shifting balance between services that address “wants” (offered as a result of market choice) versus “needs”.

Multiple new entrants into the market for complex services (eg cancer). Here quality and outcomes have improved by focusing care within centres of excellence. This was achieved by reducing the number of providers and patient choice.

Reductions in provision or quality in some services. In particular, in situations where there are no providers, the Bill makes provision for local authorities to provide health services. Local authority provision would occur in the context of extensive local authority budget cuts; without necessary expertise and with none of the Government’s proposed levers designed to drive quality or efficiency in the healthcare sector. This scenario may disproportionately affect complex chronic disease services eg services for the elderly , mental health.

2.4 For GPs to play a key role in public health, they will need to work in partnership with Directors of Public Health on Health and Wellbeing Boards. The expertise that public health consultants have in the commissioning and evaluation of services should not be overlooked. Public health consultants should be fully involved and effectively support by GP commissioners in this role.

2.5 GPs will need to adopt a public health perspective and understanding of epidemiological principles of relevance to commissioning decisions in partnership with local Public Health professionals. This can be achieved by inclusion in undergraduate training and GP postgraduate curricula. Of particular relevance for commissioning to improve public health are the population needs assessment, the annual report (on health improvement, protection and health services) and recognition that public health requires change both within and outside the NHS.

2.6 We also recommend that responsibility- monitoring- accountability frameworks are strengthened to enable GPs to reduce health inequalities (as recommended by the Public Accounts Committee). This will require:

commissioning requirements for routine data on service access and uptake to be collected by socio-demographic group (age, sex, socioeconomic circumstances, and ideally ethnic group) at each significant point in the patient pathway;

performance standards by socio-demographic group to promote strategies to provide appropriate services solely on the basis of clinical need;

mechanisms to be put in place to hold providers to account over whether they apply evidence based interventions to improve population health and that have been agreed during the commissioning process. The NHS Commissioning Board should identify and implement the action needed to stimulate the wider adoption of these interventions so that health care providers in all areas comply with accepted good practice; and

strong leadership from the NHS Commissioning Board to achieve these changes.

2.7 We also recommend that:

collection of cancer incidence data becomes a mandatory commissioning requirement;

the Government reconsider proposals that fragment commissioning arrangements for different components of public health services particularly those for sexual health, child health and vaccinations. With respect to sexual health, for example, under the current proposed arrangements, HIV falls under the NHS commissioning board, STIs are the responsibility of local authorities, and GPs will provide or commission contraception. Such an arrangement will undermine attempts to provide an integrated sexual health service; and

appropriate mechanisms are in place to ensure the continuation of integrated collection of surveillance data on infectious diseases.

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

3.1 The basis on which the health premium is awarded is crucial. The premium may not reduce health inequities if it is paid retrospectively to reward areas that have made progress in health improvement. This is because some areas may have insufficient funding to start making progress in the first place. This approach may widen health inequalities if progress is more likely to be made in more affluent areas. In addition, the total budget for the premium must be at least as big as the health inequality adjustments in council and Department of Health resource allocation formulae, otherwise inequalities may widen.

3.2 The White Paper states that the Department of Health will ask the Advisory Committee on Resource Allocation (ACRA) to support the development of its approach to allocating resources to local authorities. We suggest that DH refer to the recent review of the health inequalities elements of the NHS weighted capitation formula undertaken by a team of researchers led by Professor Steve Morris from UCL and commissioned by ACRA. On the basis of their findings, we suggest that the underlying principles of the proposed health premium are clearly delineated and that the methods used to calculate it are justified.

3.3 The UCL report included proposals for improving the current health inequalities adjustment. One option could be an area-based adjustment to reduce health inequalities based on the relationship between funding and health outcomes. We suggest that these proposals are considered with respect to both the allocation of commissioning funds to GP consortia and to ring fenced public health budgets to local authorities.

4. The future of the Public Health Observatories

4.1 We consider the future of Public Health Observatories as part of a wider issue concerned with the availability and validity of information necessary for surveillance, monitoring of population health and planning healthcare.

4.2 Maximising the value of public health information depends upon the existence of a critical mass of skills and expertise. However the proposed removal of Regional public health intelligence and surveillance functions are likely to lead to fragmentation of public health skills. The workforce in each local authority will be too small to undertake all the required functions; they will cover a geographical area which is often too small to produce meaningful data for decision making for rare serious outcomes; there will be duplication of tasks in neighbouring local authorities and loss of the ability to disseminate learning or to develop specialist knowledge, which will have a deleterious impact at both organisational and individual levels.

4.3 Moreover, the combination of actual and threatened job cuts and structural changes to surveillance and monitoring functions (eg abolition of the HPA) may lead to loss of capacity. There is therefore a genuine risk to the existing availability of information. This may lead to gaps in surveillance and monitoring and directly affect our ability to produce robust data to inform public health policy and in particular to reduce health inequalities.

4.4 We therefore urge the Government to ensure that public health intelligence and surveillance functions continue to operate at regional levels within Public Health England. During this current state of uncertainty we advise that interim surveillance and monitoring systems are established to prevent loss of data collections. We also recommend that current robust systems of surveillance and monitoring are enshrined in commissioning requirements.

4.5 The utility of public health information and intelligence could also be significantly enhanced by linking individual patient data on social determinants, behaviours and outcomes. This is possible and currently used to powerful effect in Scotland. However, in England, systems have moved backwards in this area. To enable faster and more extensive data linkage, we recommend that investment is made in data linkage systems and that the regulatory frameworks for sharing patient information across organisational boundaries are reviewed and simplified. Adequate funding of the UK Data Archive’s proposed secure data function will address many problems.

4.6 With an increase in private healthcare providers, there is a significant risk of losing comprehensive datasets on the pretext of commercial confidentiality. There is evidence that an increase in private provision has already had this effect, seriously compromising the capacity of regulators to monitor the quality of patient care. In addition, the Government’s consultation paper, An Information Revolution, proposes to increase the range of information providers. In contrast to current central data collections, which provide NHS data analysts with full access to data and have transparent methods for their analysis, there is a risk that commercial sensitivity may present barriers to sharing data, including sources and methods of analysis. We recommend that it is mandatory for all providers of NHS health care and information on healthcare to collect, provide and make available data on the same basis and to the same standards as the NHS.

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

5.1 The Government states that the White Paper responds to Professor Sir Michael Marmot’s Fair Society, Healthy Lives and that its strategy for public health is evidence driven. With this is mind, we draw the Government’s attention to the research evidence which, if acted upon, is likely to produce the greatest public health impact.

5.2 Tobacco control: We welcome the Government’s announcement on the removal of tobacco displays in shops and their commitment to look further at tobacco packaging. Research evidence on the effects of plain packaging consistently shows that package brand imagery reduces the impact of health warnings. The Australian government is well advanced with this intervention. We urge to Government to implement this policy and independently evaluate it without delay.

5.3 Voluntary “responsibility deals” have been agreed with industry to remove artificial trans fats, to reduce salt content in manufactured food and to display nutritional informational in restaurants and takeaway outlets. However, long established voluntary codes have yielded consistently disappointing results. We therefore urge the Government to commit to the implementation of regulation if these voluntary measures fail within a reasonable and agreed timescale. In addition we urge the Government to accept widespread expert advice to implement an effective minimum price for a unit of alcohol (ie £0.50 a unit minimum).

5.4 Insights from behavioural science clearly demonstrate that behaviour change campaigns only modestly increase knowledge and modify attitudes and have minimal effects on long term behaviour changes (Appendix). Moreover, there is comprehensive, long standing evidence demonstrating that individual level factors influencing behaviour change do not act in isolation from the social, environmental, structural and regulatory context within which people live and by which they are constrained. Finally, strategies which rely on individual behaviour change generally widen health inequalities because the most socially advantaged people are more likely to have the material or psychological resources to promote risk avoidance and to adopt protective strategies.

5.5 In sum, we believe that there is compelling evidence in a number of areas of a greater impact of regulatory policies at the population level in comparison to individual approaches alone, for improving health and reducing health inequalities.

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

6.1 We support Dr Gabriel Scally’s recommendations for statutory regulation of non-medical public health consultants. Consultants in public health and public health medicine are eligible for the same professional roles and increasingly have undergone the same specialist training. Therefore, it is a logical and necessary progression to make both subject to statutory regulation.

Members of the Division of Population Health, UCL, who Contributed to this Response

Professor Rosalind Raine, UCL Partners Programme Director for Population Health, Honorary Consultant in Public Health &Professor Graham Hart, Head of Division of Population HealthDr Eric Brunner, Reader in Epidemiology and Public HealthProfessor Peter Goldblatt, Senior Research FellowProfessor Anne Johnson, Co-director UCL Institute for Global Health/Honorary Consultant in Public HealthProfessor Michael King, Professor of Primary Care PsychiatryProfessor Sir Michael Marmot, Professor of Epidemiology and Public Health/Honorary Consultant in Public HealthProfessor Mark McCarthy, Professor of Public Health/Honorary Consultant in Public HealthDr Jennifer Mindell, Clinical senior lecturer/Honorary Consultant in Public HealthProfessor Steve Morris, Professor of Health EconomicsProfessor Aubrey Sheiham, Emeritus Professor of Dental Public HealthMs Jessica Sheringham, MRC Research FellowDr Pam Sonnenberg, Senior Lecturer/ Honorary ConsultantProfessor Richard Watt, Professor / Honorary Consultant in Dental Public Health

June 2011

APPENDIX

DIETARY INTERVENTION VERSUS NO INTERVENTION AMONG HEALTHY PEOPLE. SYSTEMATIC REVIEW OF RANDOMISED CONTROLLED TRIALS

The Cochrane review examined the effects of one-to-one or group dietary advice with or without printed materials in healthy people. The findings using objective as opposed to self-report outcomes show that advice is, at best, a weak intervention. It will not generate the health gain and financial saving to the public purse the Government is looking for if systematic change in UK food culture and obesogenic environment is not pursued.

Outcome

N studies

N participants

Net change (85%CI)

Systolic BP (mm Hg)

8

6,223

−2.1 (−3.2 to −1.0)

Diastolic BP (mmHg)

8

6,223

−1.2 (−1.9 to −0.5)

Serum cholesterol (mmol/l)

17

2,124

−0.2 (−0.3 to −0.1)

Median follow-up =10 months, range 3-48 months.

Source: Brunner et al. Dietary advice for reducing cardiovascular risk. Cochrane Database of Systematic Reviews 2007 (CD002128)

Prepared 28th November 2011