HC 1048-III Health CommitteeWritten evidence from Durham County Council (PH 73)

About County Durham

1. Durham County Council is a large unitary authority comprising a mix of urban and rural settlements with a population of 498 706. The area is characterised by high levels of deprivation together with smaller pockets of wealth in the university city of Durham and market towns of Barnard Castle and Middleton Teesdale. County Durham has high levels of unemployment, incapacity claimants and subsequent health inequalities with male and female life expectancy in County Durham being significantly lower in County Durham than England.

Introduction

2. Durham County Council is pleased to provide evidence to the Health Select Committee’s inquiry into public expenditure and public health.

3. We have focused on those areas which are of most relevance to the County Council:

Key Points

(i)Durham County Council wholly supports the conclusion made by the Marmot Review which confirmed the role of local government as pivotal in tackling health inequalities; Local councils hold the power to secure the economic and environmental health and well-being of their population.

(ii)The County Council therefore welcomes the proposal for local authorities to assume responsibility for public health with Directors of Public Health working within local authorities. The proposal creates the potential for greater synergy between public health interventions and the services delivered by local authorities to jointly tackle the wider determinants of health.

(iii)The Council supports the proposal for Health and Wellbeing Boards and suggests that these could be developed along the lines of Community Safety Partnerships with similar freedoms to respond to local need.

(iv)It is recognised that strong collaboration between Commissioning Consortia and local authorities is needed to develop a robust and evidenced based Joint Strategic Needs Assessment (JSNA). This is essential to informing the agreement of a Health and Wellbeing Strategy which articulates a shared view of commissioning priorities against which relevant agencies will be required to deliver.

The Future Role of Local Government in Public Health

4. Durham County Council welcomes the proposal that local authorities should have a lead and strengthened role in Public Health. The Council believes that any action on health improvement and inequalities must address the wider determinants of health. The contribution of local authorities to these through housing, regeneration, leisure, social care, employment (direct and indirect via business support and promotion) education and children’s services, is enormous.

5. A Public Health Service within Local Government can ensure that public accountability and transparency is strengthened with public health services being held to account by locally elected Councillors who have been given a mandate by their constituents and who know the public health needs of their communities.

6. Similarly there is potential for Councillors’ role as community leaders to be more readily utilised to generate support to tackle the health problems in their communities, particularly those which are most deprived.

7. The severe reduction in Local Government funding arising from the Government’s Comprehensive Spending Review has placed unprecedented pressures on Councils’ ability to maintain service delivery. This also jeopardises Councils’ ability to maintain core services that deliver against health inequalities, which could in turn result in a widening of the “health divide”.

8. The resources transferred to local authorities in future should reflect the need in their area and should be no less than the historic level of funding for the relevant functions from the NHS locally. This is key to ensuring that local authority funding pressures are not augmented by cuts in Public Health services.

9. In the context of Public Health services, it would be helpful to clarify what will be the strategic ground rules for Public Health set nationally and what scope will local authorities and Directors of Public Health have for local interpretation and service design?

Arrangements for the Appointment of Directors of Public Health

10. The Council welcomes the proposal for the Director of Public Health to be an officer of the Council and the public accountability that this will bring. This will create enhanced opportunities for democratic public debate on local health issues, for example as a result of the scrutiny process, the accountability of the Director of Public Health (DPH) to elected members and their communities.

11. There are concerns at the potential conflict of interest if the DPH is accountable to both the Local Authority and the Secretary of State for Health. This needs to be clarified and explicit in any legislation. For example it would be helpful to determine the parameters for local freedoms to act in response to local circumstances, and those situations which may require a degree of prescription from the Secretary of State for Health.

12. Whilst the Council would support the creation of a statutory DPH post in each local authority it should be for local authorities to determine the reporting arrangements for the DPH, consistent with the principles of localism. It will be essential that Directors of Public Health have the freedom and authority to work across the whole council and its partnerships, in order to realise their influence upon all council services which constitute wider determinants of health as well as to fulfil their statutory role effectively.

13. A local authority DPH will ensure closer engagement and involvement of public health services in reviewing core priorities of the Sustainable Community Strategy and Council Plan as well as reflecting any legislative developments in the field of Public Health.

14. A “core” Public Health service hosted by the local authority will be able to integrate its Public Health services with other core local authority services.

Health and Wellbeing Boards

15. Durham County Council notes the requirement for local authorities to establish Health and Wellbeing Boards (HWB) and supports the proposed functions for HWBs set out in the Bill. However, the County Council believes only limited prescription of the functions of the HWB from Government is required. This is because a similar approach to that taken to successfully developing Community Safety Partnerships, could be adopted; this arrangement requires local authorities to establish the Partnership and publish a plan, and makes requirements of certain other bodies to participate in the Partnership. Furthermore, there is some prescription of the issues that Community Safety Partnerships must address (for example Anti-Social Behaviour, Reducing Re-offending,) although how these are addressed is for local partners to determine.

16. The Health and Well being Board will be pivotal in ensuring that local commissioning intent reflects public health priorities, and that it is joined up and consistent across the local authority area. This is essential to avoiding inequalities in service access and outcomes arising within and across larger geographical local authority areas.

17. Durham County Council suggests there are additional functions that the HWB should perform locally, including:

(i)The approval of Joint Commissioning Strategies and intentions.

(ii)Receiving Scrutiny reports relating to health and wellbeing.

(iii)Commissioning arrangements for Local HealthWatch.

Joint Strategic Needs Assessments

18. A Director of Public Health based within the local authority will be able to further embed and support collaboration between the local authority and Partner Commissioning Consortia covering both current and future needs around wider health determinants.

19. We consider that with the DPH role sitting within the Local Authority there are opportunities for the preparation of JSNA with Commissioning Consortia and subsequently the monitoring of progress against the JSNA will be more robust.

20. Access to locally sensitive data will be crucial to developing the JSNA and this will be an issue for consideration in relation to the Public Health Observatories.

21. The issue of co-terminosity between Commissioning Consortia and local authorities is relevant here. There are possible difficulties in co-ordinating and managing the data flows that will inform the JSNA and the Health and Wellbeing Boards, particularly where organisations are not party to existing information sharing agreements.

Joint Health and Wellbeing Strategies

22. A collaborative approach with Partner Commissioning Consortia to developing the Joint Strategic Needs Assessment creates a strong foundation for a robust and evidence based Joint Health and Wellbeing Strategy against which all relevant agencies can deliver.

23. We welcome the commitment to integrating performance frameworks for public health, NHS and adult social care outcomes since this will support a cohesive Health and Wellbeing Strategy.

Arrangements for Public Health Involvement in the Commissioning of NHS Services

24. To achieve the benefits equated with local authorities and wider determinants of health the Public Health service should be a service wholly based/located within local councils and not split to have a “Public Health Commissioning Arm” within the Commissioning Consortia.

25. The transfer of Public Health services to local government should not be seen as an invitation for the NHS to step back from its crucial role in Public Health through providing NHS Services that promote the reduction in avoidable illness, and tackle secondary and tertiary prevention.

26. It can be foreseen that commissioning could result in a postcode lottery, resulting in an unacceptable variation in service access nationally.

27. DCC support the view that it is important to evaluate all health improvement measures to ascertain what works and is value for money in order to inform commissioning intentions.

28. DCC considers that Public Health expertise could greatly assist Commissioning Consortia to develop a population based approach to preventative health care.

29. To ensure that local authority activity can maximise its potential benefits upon health inequalities we would propose that health impact assessments should be undertaken to determine how proposed projects/programmes will impact in health and wellbeing in the local authority area. This will obviously create a need for staff to interpret findings and may necessitate protocols for sharing information and accessing data.

Arrangements for Commissioning Public Health Services

30. Clearly all commissioning must be based upon need. The JSNA is an important commissioning tool that will assist the Council and its partners to commission services and develop interventions to improve health and address health inequalities. The Marmot review on health inequalities should provide the basis for commissioning intent in delivery of a public health agenda and action to reduce health inequalities.

31. Commissioning Consortia should reflect public health priorities and action to reduce health inequalities in their commissioning strategies drawing on all of the above. They should also be encouraged to invest further in local Public Health services where appropriate in the context of the Health and Wellbeing Strategy.

Arrangements for Funding Public Health Services (including the Health Premium)

32. The proposal to ring fence the public health budget at a local level needs to be in conjunction with freedoms to utilise the budgets flexibly to ensure Councils are not prevented from spending their budgets in smarter more collaborative ways. For example in 2009, NHS County Durham Primary Care Trust agreed to provide additional funding of £1 million to Durham County Council towards an enhanced winter service provision with a view to increased health benefits and outcomes, particularly in relation to reducing the numbers of slips, trips, falls and accidents during the winter period. This contribution was referred to in the Chief Medical Officer’s Report 2009 under the Section “Winter Kills”. The County Council considers it is essential that the new public health arrangements bring with them sufficient ring fenced resources that allow for effective whole system interventions.

33. A new health premium to reward Councils for progress made against elements of the proposed public health outcomes framework, taking into account health inequalities is to be welcomed. However such a system must be fair, robust and transparent with safeguards to ensure that other key health priorities are not excluded. Such a system must also reflect the respective baseline starting points for local authorities’ who may have experienced deep-seated health inequalities.

34. The links between poverty, social disadvantage and health inequalities are well known. There is concern that developing a health premium which measures health gain may have the unintended consequence of further depriving communities of resources where there is greatest need. This is particularly an issue in areas of high unemployment at a time of economic recession.

35. Additionally in areas where demographic projections demonstrate that the working age and economically active population will decline, with a corresponding increase in older and less advantaged groups, it would be helpful to understand how the health premium will avoid widening the health gap and augmenting possible under-funding.

36. For this reason the criteria for allocating the new Health Premium needs to be robust and transparent. The Government should also explain who will undertake the assessment of whether Councils have delivered successfully, and how this will be undertaken against a backdrop of Government reduced Performance Target setting and reporting.

37. The Council suggests that the health premium should be designed in such a way that it can also reward sustained action by local authorities as improvements in public health can take many years to achieve. The health premium should also take account of the fact that greater efforts are needed to improve entrenched health inequalities which feature in deprived communities.

38. In terms of utilising resources local authorities should be free to determine how to commission or provide public health services without prescription from the Government. Guidance however would be welcomed.

39. The Council considers that there are public health services which are better commissioned on a larger scale either nationally or regionally; paid advertising is an example where greater efficiencies can be achieved through collaboration. Unpaid and third sector media however can be more effective when commissioned at very local levels.

40. There needs to be in place robust and measurable public health outcomes. These could reflect the six Marmot policy objectives.

How the Government is Responding to the Marmot Review on Health Inequalities

41. The Marmot Review of Health Inequalities “Fair Society; Healthy Living” stated that reducing Health Inequalities would require delivering against the following six policy Objectives, namely:

(i)Give every child the best start in life.

(ii)Enable all children young people and adults to maximise their capabilities and have control over their lives.

(iii)Create fair employment and good work for all.

(iv)Ensure healthy standard of living for all.

(v)Create and develop healthy and sustainable places and communities.

(vi)Strengthen the role and impact of ill health prevention.

42. The Marmot Review identified the role of local government as pivotal with a crucial role to play in renewal of local democracy and giving citizen’s voice in developing the prospects for their local area. Local councils hold the power to secure the economic, environmental health and well-being of their population. This calls for the effective exercise of community leadership in drawing together citizens, communities and key partners to build health, well-being and resilience through transformational leadership of sustainable community strategies and health and well-being boards. These roles become even more important as understanding of the social determinants of health has developed. If inequalities in early child development and education, housing, employment and working conditions, place and the built environment, and sustainability are driven by the same causes, it requires a concerted effort across the whole system. A number of policy strands are being developed as part of the transition process for public health moving into local government. This can only strengthen what the Marmot review concludes.

43. The Director of Public Health and Local Authorities generally again are best placed to help deliver against these policy objectives, shaping their services accordingly to reduce health inequalities within their communities. These six policy objectives should form the basis of the Council’s JSNA, Health and Wellbeing Strategy and Sustainable Communities Strategy.

44. The County Council welcomes future Government guidance to clarify the points about which it has raised concern.

June 2011

Prepared 28th November 2011