HC 1048-III Health CommitteeWritten evidence from Barbara James (PH 74)

I am making a brief submission to highlight concerns about:

the importance of an ongoing focus on health inequalities;

placement of the public health function and the need for statutory accountability mechanisms; and

the benefits of and need for strong regulatory arrangements in relation to public health.

1. My Background

I have been freelance for the past 11 years, working internationally on a range of strategic national initiatives as well as with UK government departments (Office of the Deputy Prime Minster/ Communities and Local Government, Department for Education and Skills/Department for Children, Schools and Families, Department of Health) as well as in the Healthcare Commission and Care Quality Commission (CQC, where I was head of public health). Before that I worked in east London in the NHS.

2. Health Inequalities

2.1 Under previous Conservative governments, while there were helpful and progressive national policies to address key health issues, there was not a strong strategic approach to reduce health inequalities. Indeed, health authorities were required speak of “variations” rather than inequalities. The Labour government focused on reducing health inequalities both between and within local areas.

2.2 Health inequalities are a stark reminder of how much work is needed before the UK can consider itself a fair society. A life expectancy gap of close to 30 years between the richest and poorest neighbourhoods in the UK, postcode lottery access to services and poor performance by the UK compared to similar countries must be tackled.

2.3 One of the Healthcare Commission reviews I worked on was Are we choosing health? (Healthcare Commission 2008), a consideration of the previous 10 years of policy and its impact on public health. It found that targets on their own often had mixed results, including “gaming” and inappropriately focused resources. However, when part of a programmed approach targets could make a significant difference. This approach includes needs-based planning, focused resources including knowledgeable staff, use of evidence-based approaches, broad-based partnership and engagement with relevant communities, measures to address wider determinants and strong performance management.

2.4 I believe that the programmatic approach to teenage pregnancy and tobacco control—while not fully achieving all targets—had considerable impact, let alone the fact that it is unlikely that teenage pregnancy (a cause and result of inequalities) would have been tackled at all without a target. However, obesity (a target under the previous Conservative government, but dropped for several years by Labour) and alcohol had had no such framework to support the targets, and much less progress was made over the period.

2.5 While national inequalities targets were not all achieved, there was tremendous progress in a large number of critical public health/health inequalities areas. It will be important to maintain a means of focusing on both national and local priorities, as well as maintaining means of comparing and measuring the differences. In addition to the now widely discredited targets, a great range of expertise was built up—for example, in the National Support Teams for a range of key health inequalities issues.

2.6 Many initiatives to tackle health inequalities have now been abolished, reduced (eg targets) or dispersed (teams of expertise in DH, PCTs, government offices, regional health authorities). It will be important to ensure the evidence-based tools, expertise and resources developed over the past 15–20 years are not lost, that “the baby is not thrown out with the bathwater”. When re-establishing programmes and initiatives for public health improvement and tackling health inequalities, it will be helpful to identify useful resources and mechanisms and to make effective use of these.

2.7 CQC’s report—Closing the Gapon health inequalities and cardiovascular disease and smoking found that GPs in deprived areas are less likely to refer smokers to stop-smoking services or to prescribe nicotine replacement products and do not manage the cholesterol levels of their patients well.

2.8 Without technical support for lesson learning and disseminating good practice on reducing health inequalities to GP commissioners and local authorities, it will be difficult to make significant progress. Evidence of effectiveness on health improvement from, for example public health observatories and NICE, as well as the guidance on good practice by NSTs, needs more than simply being available on a website for it to be used in the field. An institution providing technical support located centrally or regionally will be essential for cost effective and effective lesson learning and delivery.

3. Placement and Accountability and Regulation

3.1 Placement and accountability

The placement of public health in local authorities has the potential to bring a health inequalities/health improvement approach together with the wider determinants that can have the most significant impact on these issues. However, local authorities will be challenged to cover their remit in a difficult financial climate. When located in PCTs, a focus on public health has had to be balanced with the need to address urgent treatment and care issues. In local authorities, public health will need to establish its place alongside crime, housing, education and a range of other urgent local issues.

3.2 Without a clear understanding of how (and the need) to take health into account when addressing these wider issues (for example through meaningful use of health impact assessments along with specific targeted public health interventions), many of the benefits of the placement of public health within local authorities will not be realised.

3.3 Evidence shows that GPs—with their main responsibility dealing with the ill health of individuals—are not always focused on health improvement or on reducing health inequalities (see 2.7, above).

3.4 It will be important to ensure strong, statutory accountability mechanisms between GP Commissioning Consortia and local authorities to ensure commissioning is based on and responsive to local need and that it is contributing to health improvement and reducing health inequalities.

4. Regulation

The Healthcare Commission assessed all healthcare providers in relation to the public health elements of the Standards for Better Health, the quality standards for the NHS. The Healthcare Commission did research to assess the impact of this regulation and found that both in PCTs and in other trusts—acute, mental health/learning disabilities, ambulance—all respondents felt “strongly” that the inclusion of public health in the regulatory framework had resulted in significant developments in public health in all sectors.

4.1 For example, in many acute settings, no previous effort had been made to take advantage of the health promotion and disease prevention opportunities when people have experienced ill health or injury. Making public health part of the regulatory framework meant that acute trusts were beginning to take these issues into account.

4.2 A reduced focus on public health in CQC (eg there is no longer a public health function in CQC), combined with lack of specific training on public health issues and understaffing have meant that public health has not been a priority for CQC in the past year. It will be important to ensure an effective regulatory function is in place that focuses on public health. Ideally, that would be within CQC to ensure an integrated approach across health and social care.

4.3 The regulation of public health should consider the joint role of GP commissioning and local authorities in improving the health of local communities and reducing health inequalities between and within local areas.

June 2011

Prepared 28th November 2011