HC 1048-III Health CommitteeWritten evidence from NHS Sefton’s Public Health Directorate and Sefton Council (PH 76)

This is NHS Sefton’s Public Health Directorate and Sefton Council’s joint submission to the Health Committee inquiry into Public Health.

NHS Sefton’s Public Health Directorate and Sefton Council have previously responded to the White Paper consultation related to the proposed Public Health reforms and this forms the basis of this submission. In addition this submission has been informed by the Association of Directors of Public Health (ADPH) evidence to the Inquiry.

Overview—Concerns for the Public Health System

We recognise that the proposed reforms raise opportunities for public health and welcome the increased formal role of Local Authorities (LAs) in the health agenda and integration of local DsPH into LAs.

However, England needs an integrated system for delivery of public health outcomes, and we are concerned that there is a significant risk that the proposals could have adverse effects on fragmentation:

of the public health workforce across a number of organisations;

of commissioning and finance responsibility for public health programmes; and

and loss of clarity on accountability, particularly in the area of health protection.

LAs should be accountable for improving and protecting the health of their population at all times (with support from Public Health England). However, in order to ensure a coherent system-wide approach to public health, the Health & Social Care Bill should place a statutory duty on all health and social care bodies (including NHS funded providers) to cooperate in efforts to improve and protect heath and in responding to public health incidents and emergencies.

There must be clear lines of accountability, communication and access between PHE, GP consortia, NHS and DsPH working within local authorities.

Response to Specific Issues to be Considered by the Health Committee

1. The creation of Public Health England within the DH; the abolition of the HPA and the NTA for Substance Misuse

Public Health England (PHE) can only effectively operate as a national public health service if it encompasses all three domains of public health:

health protection (infectious diseases, environmental hazards and emergency planning);

health improvement (lifestyles, inequalities and the wider social, economic and environmental influences on health); and

health services (service planning, commissioning, audit, efficiency and evaluation).

PHE should operate as a supporting organisation which can:

provide independent scientific evidence-based advice to national and local government, the NHS and the public on all matters relating to the maintenance, improvement and protection of health;

offer expertise to the National Commissioning Board (NCB) in support of its role in providing national leadership in commissioning for quality improvement, commissioning national and regional specialised services, and allocating NHS resources; and

provide effective, expert and adequately-resourced specialist PH capacity to support the work of local DsPH and their teams.

It is unlikely that these aims can be achieved if PHE becomes a fully-integrated part of the Department of Health. It should be established as an NHS body which would:

facilitate the employment of public health staff by PHE;

enable pooling of scarce and specialist public health capacity;

enable the continuance of external income streams that currently support national health protection activity; and

facilitate the separation of science from policy and therefore re-enforce the independence of DsPH and health protection for the populations’ health and protection.

Health Protection

Capacity for emergency preparedness and response must be maintained within the new structures—and robust interim arrangements to ensure a stable transition.

Clarity is vital over which part of the system will lead responses to incidents at local and sub-national/supra local or regional levels.

There needs to be clear agreement on the roles and responsibilities for DsPH and local health protection units, including assurance that health protection work carried out in second tier local authorities is connected with coordination and planning mechanisms organised at the top tier of local government.

2.2 The public health role of the Secretary of State

We welcome proposed new duties on the Secretary of State to have regard to the need to reduce health inequalities. However these duties are narrowly drawn, only applying to the role of the NHS in providing services to patients. The duties should reflect the broader role of the NHS in promoting public health as a provider, commissioner and major employer.

2.3 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)

DsPH are the frontline leaders of public health working across the three domains of health improvement, health protection, and health care service planning and commissioning. DsPH must be enabled - through primary legislation - to provide oversight and influence across all these determinants of health within local authorities, the NHS and primary care, and other appropriate sectors and agencies in order to secure the improving health of their population.

A DPH should be an individual trained, accredited, and registered in specialist public health.

DsPH should be jointly appointed by LAs and PHE and should have a contractual relationship with both. However the supporting HR framework and clarification of terms/conditions and accountabilities are urgently needed. There is an immediate and transitional risk of loss of PH professional staff and expertise through uncertainty and staff concerns over the implications of potential transfer out of NHS employment.

DsPH will need clearly defined responsibilities and powers and the professional status and enablement to express an independent view in order to provide advocacy for the health of the population.

DsPH will require a well-resourced, professional and co-located Public Health team providing the skills and experience to input to local service planning and commissioning, and to deliver Public Health programmes and advice across the health economy, supported by access to high quality local and national data and scientific evidence base.

There should be a statutory requirement for top tier Local Authorities to appoint a DPH with the appropriate professional training and accreditation; The DPH should work at corporate/strategic director (top team) level as a full executive member of the corporate leadership team with direct access to the local authority Cabinet and councillors—influencing and working alongside other Local Authority Executive Directors and normally reporting or accountable to the CEO or equivalent.

The DPH should be recognised as the principal adviser on all health matters to the local authority, its elected members and officers, and its Health & Well Being Board, on the full range of local authority functions and their impact on the health of the local population as stated in Annex A of the PH White Paper.

The professional status of the DPH and ability to express an independent view in order to advocate for health improvement and reducing health inequalities within their local population and act for the protection of the local population - and the independent DPH annual report—must be protected.

Clarification of the resources that will support the DPH role in local authorities is urgently needed. Funding for DPH and PH team development will be crucial to support effective transformational change.

Health & Well Being Boards/JSNAs

There is a lack of clarity regarding the statutory role of Health and Wellbeing Boards. The powers granted to Health and Well Being Boards are weak and there is a risk that health and social care integration may be more difficult to achieve.

The Boards have not been granted sufficient powers to meet the expectation that they will join up commissioning between the NHS and local authorities. The interface between GP consortia and local authorities will be critical in ensuring that services meet the full range of local population health needs. However, while Consortia must consult Boards in drawing up their commissioning plans, there is no requirement for Consortia to have regard to the views of the Board.

Health and Wellbeing boards must have the power to sign-off local commissioning plans, ensuring that they are aligned with the joint strategic needs assessment and address the identified needs of the population.

The DPH should act as a principal advisor to the Health and Well Being Boards.

The JSNA must:

be asset-based, wide-ranging and thorough and include qualitative “citizen” views (not just service-user or patient views);

include preventative and health protection issues; and

be the basis for all local commissioning.

2.4 Arrangements for public health involvement in the commissioning of NHS services; arrangements for commissioning public health services

Public Health oversight of and input to commissioning will be essential to achieve real improvements in health outcomes and the reduction of health inequalities.

The proposed reforms:

lack clarity over who will be responsible for providing “local system leadership” and planning services across GP consortia boundaries following the abolition of SHAs/PCTs;

include few requirements on the governance of consortia;

do not require GP consortia to promote integration between health and social care—an omission that will be exacerbated by lack of co-terminosity between consortia and local authorities;

do not appear to place a duty on GP consortia to promote and protect the health of their local health population; and

will lead to fragmented commissioning for a number of public health priorities eg screening, sexual health which will threaten the meeting of local needs, compromise service quality and reduce accountability.

Locally, the DPH should provide oversight and the Public Health team input to GP consortia commissioning, supported by additional resources and expertise held within PHE. GP consortia should be required to work through and with DsPH to ensure consortia decision-making is underpinned by expert, professional public health advice. DsPH should have a formal relationship with GP consortia, and local commissioning plans should be signed-off by the Health and Well-being Board.

GP Consortia (and NCB) should be responsible for improving inequalities of health outcome rather than just inequalities of access to health services. Clarity is required over where responsibility lies for ensuring GP consortia meet their responsibility for improving outcomes and how consortia are to be held to account for PH outcomes.

The population size of GP consortia should be based on evidence of effectiveness, as should decisions as to whether services are commissioned and delivered nationally, regionally or locally. Consortia should develop structures for stable joint commissioning where these would best serve their population. It must be recognised that for many services a whole pathway approach to commissioning is vital to ensure efficiency savings are met e.g. tackling increasing alcohol admissions needs to be addressed through interventions along the entire pathway from prevention to treatment.

2.5 The future of the Public Health Observatories

The new system must ensure that all those working in public health have access to timely, comprehensive and appropriate data and analysis to inform their decisions and advice.

Reliable data and information are essential to the understanding of health needs, modelling of future scenarios and assessment of impact and efficacy. This is relevant both for service planning and design and for the recognition of and response to hazards and outbreaks.

The reforms could result in disruption of existing flows of data and the loss of analytical expertise. Arrangements for maintenance of the public health observatory function and for ensuring access to health service data at local and national levels need urgent clarification.

2.6 The structure and purpose of the Public Health Outcomes Framework

The use of outcomes as opposed to targets is a positive development. However:

there are no socio-economic outcomes, despite the acknowledgment of health inequalities and the acceptance that good health is only 30% attributable to health services. The outcomes also fail to reflect the life course approach set out in the Public Health White Paper Healthy Lives, Healthy People and the Marmot review Fair Society, Healthy Lives;

greater emphasis should be put on ensuring that the Public Health framework is relevant to all sectors – with greater emphasis on linkage across the NHS, Social Care and Public Health outcomes frameworks;

public health analytical capacity is essential to delivery of public health outcomes and current capacity must be preserved and enhanced; and

investment will be needed in national surveys relating to health and wellbeing to ensure LA data can be assembled.

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

The ring fenced budget

The scope of the ring-fenced budget must be defined clearly and the funds available in the ring-fenced budget must be sufficient to meet the needs for which that budget is intended.

PHE will require adequate resources to immediately and effectively fulfil its wide remit—and vitally to invest in the continuing development of public health expertise and the public health workforce.

In relation to the local ring-fenced public health budget:

it should be explicit what will fall within this budget, and equally explicit that excluded activities with a bearing on public health will continue to be resourced from other / existing Local Authority and GP commissioning consortia budgets;

within the LA these budgets should be deployed with flexibility for DsPH to direct resources to best meet the needs of the local population based on the JSNA and Health & Well Being strategy; and

it should be clarified as to how baseline budgets will be set. Public health resources have already and will continue to be lost through the impact of local financial savings—any baseline must not be based on reduced resources.

Resources will also be required to support transition—including funding for DPH and PH team development to support effective transformational change, plus funding an awareness programme to ensure that politicians (national and local) fully understand the DPH role and all key PH functions.

Health premium

The health premium should:

target need;

reward relative improvement; and

identify and reward “value added” activity/outcomes.

We are concerned over potential unintended consequences and that the health premium may create greater health inequalities.

The extent of the health premium is unclear but may not provide significant additional resources. Learning and evidence from existing programmes (such as the Spearhead approach) may provide useful evidence/outcomes to inform development of the health premium. We recommend that a full assessment of Spearhead experience should inform the further development of the health premium concept.

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

We support the recommendations within Dr Scally’s Report on the Review of the Regulation of Public Health Professionals.

The Faculty of Public Health is the standard setter for all public health practice in the UK.

The title “Specialist in Public Health” should be a protected title, required by statute to be registered.

The training of public health specialists should be planned and delivered through Health Education England and should be consistent with arrangements for training other health professionals It is vitally important that Public Health specialist Registrars continue to be trained at a high level in all three domains of public health supervised by accredited trainers.

The independent PHE should act as the employing body for public health specialists, seconding them to other organisations as necessary, to ensure their primary responsibility is to the public. The use of honorary contracts can facilitate this model.

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

The current reorganisation of the NHS and of Public Health significantly underestimates the role of the NHS in addressing health inequalities.

We welcome new duties on the Secretary of State, NHS Commissioning Board and GP consortia to have regard to the need to reduce health inequalities. However these are narrowly drawn and do not reflect the broader role of the NHS in promoting public health as a provider, commissioner and major employer. There are also no equivalent duties on the Secretary of State or local authorities in respect of their roles in promoting public health.

The duties are unlikely to be sufficient to ensure that tackling health inequalities is prioritised in the health system. We strongly recommend that the NHS commissioning bodies should be held to account for reducing inequalities in health outcomes.

The proposed new system risks service fragmentation with detrimental impacts on the very areas the reforms seek to improve: quality of services, education and training, patient choice, efficiency and equity, and has the potential to exacerbate any existing postcode lottery in health services.

The “Nuffield Intervention Ladder” should be applied to the Responsibility Deal approach. Robust, time-limited monitoring and evaluation after 12 months will be crucial to assess the effectiveness of voluntary commitments.

There is concern that responsibility for health falls to heavily on the individual at a time of increasing economic pressure and a real reduction in the wider social and economic support networks.

3. Additional Issues

Provider and Regulatory organisations

Protecting, maintaining and improving the public’s health require services to cooperate, take a population approach to identifying and addressing shared priorities to meet health needs, and making best use of all available resources. A requirement to promote competition will discourage integration and collaboration across the sectors, and should be removed from the draft Health & Social Care Bill. A duty of cooperation should be placed upon service providers and commissioners.

Public health influence within provider organisations sh be extended, eg:

a public health lead working within Foundation Trusts and community service organisations;

provider trusts should work with LAs in improving the health of the population; and

above a capped level of reserves, an annual proportion of Foundation Trust reserves to be spent on initiatives agreed locally as providing health gain for the population.

June 2011

Prepared 28th November 2011