HC 1048-III Health CommitteeWritten evidence from Heart of Mersey (PH 77)

About Heart of Mersey

Heart of Mersey (HoM) is a cardiovascular health charity covering Cheshire and Merseyside. HoM aims to co-ordinate a strategic approach to preventing the high rates of cardiovascular disease (CVD) and associated inequalities in our region. We are jointly commissioned by the primary care trusts and local authorities in our area to deliver a population-based approach to heart disease and stroke prevention. Merseyside and Western Cheshire, in comparison with the rest of England, have long suffered disproportionately from CVD. CVD is the biggest contributor to health inequalities in our region.

Although our principal activity is to work with local organisations to achieve improved access to healthy food and a reduction in exposure to smoking, we believe that local action alone is not enough to improve the health of our population. We therefore work in partnership with national and international organisations where appropriate to advocate for healthier policy in tobacco control (such as the recent ban on point of sale tobacco advertising) and food and agricultural production (including advocating for a European Common Agricultural Policy which supports healthier nutrition).

Summary

HoM welcomes the opportunity to comment on the Government’s proposals for the establishment of a new public health system. It is important that public health is considered carefully along with other concerns about the future of the National Health Service.

HoM broadly welcomes the responsibility for public health being shifted to local authorities and the possibilities thereby provided to integrate with services such as children’s and adult services. However this transfer should not be at the expense of any lack of independence for public health and should be a transparent process with clear accountability at all times.

HoM has concerns about the pace of change and any possible reduction in public health capacity which should be resisted.

As a CVD prevention charity, HoM would like to emphasise that the key risk factors for CVD and other noncommunicable diseases such as type 2 diabetes and many cancers, are a poor diet, smoking, alcohol harm and physical inactivity. The new arrangements for public health should therefore maintain a focus on making it easier for people to lead healthier lifestyles through appropriate policies and regulation at regional and national level.

We would welcome encouragement from the Government for commissioning at a supra local level where this is appropriate and provides better value. There are many examples where work on a larger geographical footprint has been very effective such as in tobacco control (around illicit tobacco for example) and in promoting healthier eating (such as in pres-school nutrition policy).

General Comments

1. HoM welcomes the opportunity to respond to the Inquiry on Public Health. We recognise that much of the recent discussions and listening exercise about the Government’s Health and Social Care Bill have focused on debates around GP commissioning, competition ruling and suchlike. However it is essential in addition that there is full scrutiny of the Government’s proposals for the establishment of a new public health system and it is important that this is considered carefully along with the other concerns about the future of the National Health Service.

2. HoM supports the transfer of responsibility of public health from the NHS to local authorities in England. There are clear advantages in providing opportunities with integration with children’s and adult services. The Marmot Review1 said “Give every child the best start in life” in its policy objectives to address health inequalities. By placing public health in local authorities there is a clear opportunity for example to focus on smoking prevention and cessation among the young and a healthier diet in pre-school settings. However, in a time of cutbacks in public sector spending, local authorities must give appropriate priority and resources to public health and its independence must be fiercely protected.

3. As we wrote in our response to the Government’s consultation Healthy Lives, Healthy People, HoM supports the Government’s focus on public health and preventative medicine, tackling health inequalities, and the establishment of a national Public Health Service with a ring-fenced budget to lead a cross-government, life-course approach to public health. We support the clear commitment to “improving the health of the poorest fastest”, focusing on outcomes, evidence, fairness, and localism. However, whilst HoM agrees that empowering local communities to tackle health inequalities and improve outcomes is essential, we believe that national oversight and monitoring by Public Health England will be vital to maximise public health improvements.

4. We also believe that although local leadership is critical, there is still an important role for supra-local commissioning to address important prevention issues such as illicit tobacco and that there remains a need for national regulation around for example food labelling, reduction in dietary salt, saturated fats and sugars, and the elimination of industrial transfats.

5. HoM welcomes the recognition of the important role of Directors of Public Health as strategic leaders in local public health, health inequalities and health partnerships. We recommend that Directors of Public Health must have the authority and independence to advise on policy areas that have a bearing on smoking cessation, physical activity, healthy eating and all aspects of population health and health inequalities. They should ensure that the National Institute for Health and Clinical Effectiveness (NICE) public health guidance is implemented including guidance on the prevention of cardiovascular disease, overweight and obesity, physical activity and the environment, and on reduction in smoking.2–8 They must also have their independence to comment on any problems and deficiencies and to know that when in the right, they will have the backing of Public Health England. The public health role of NICE should be enhanced and the reviews halted in 2010 should be reactivated.

6. HoM believes that transparency and accountability are essential components in public health delivery. We therefore have some concerns around perceived reliance on voluntary agreements with the commercial sector through the Responsibility Deal. The role of the commercial sector must be clearly identified and should not include any involvement in public health policy development.

7. HoM is concerned about the speed and scale of reorganisation and change and the impact this is likely to have on public health capacity.

8. We believe that third sector organisations make an important commitment to public health9 in demonstrating and sharing good public health practice, in providing independent scrutiny, in a key advocacy role, in engaging local communities and helping to provide an evidence basis to support public health policy. The role of the third sector should be explicitly laid out wherever possible in the new public health system and be seen as key and active partners in shaping the proposed new structures given the sector’s expertise in public health. Further, the role of the academic sector should be recognised particularly in the development and dissemination of data and evidence to support decision-making.

9. As a heart health charity, we are concerned principally about how the two key risk factors of tobacco and poor nutrition are addressed.

10. The Committee has said it will consider specific issues in its Inquiry:

Responses to Specific Issues

The creation of Public Health England within the Department of Health

The abolition of the Health Protection Agency and the National Treatment Agency for Substance Misuse

11. We have concern around both the abolition of the Health Protection Agency and its absorption within Public Health England, which itself will be established within the Department of Health. The independence of Public Health England is very important to ensure it has the authority to carry forward evidence-based policy. An independent and transparent scrutiny facility is also necessary. For these reasons we would support the establishment of Public Health England at “arm’s length” from the Department of Health as a Special Health Authority for example.

The public health role of the Secretary of State

12. Public health and preventative health should remain a key focus of the Secretary of State. It should also be recognised however that better public health should be a challenge for all Government’s departments; improved health leads to increased wealth and should be a key component of any economic regeneration strategy. National cross-Government arrangements should mirror what is expected at local level including a move towards a broader health and wellbeing agenda.

13. The role of the Chief Medical Officer should be maintained and kept independent.

14. As previously noted, there remains a need for national regulation around for example food labelling, reduction in dietary salt, saturated fats and sugars, and the elimination of industrial transfats. Similarly, there must be a continued focus on smoking which is the largest cause of preventable death in England.10 HoM supports the Government’s commitment to protecting health policy from the vested interests of the tobacco industry. The forthcoming consultation on tobacco packaging must be transparent and ensure that it is not subverted by tobacco industry interests operating through “front groups” as identified by Action on Smoking and Health. The European Union has an important role in legislation and the Government should be aware how key policies such as the Common Agriculture Policy impact not only on the food we eat but our public health.

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)

15. HoM would suggest that the remit of health and wellbeing boards includes public health improvement, health protection and healthcare service commissioning, with the Director of Public Health performing a statutory role of principal advisor.

16. We would support that health and wellbeing boards should assess the needs of the local population, taking into account the key role of the Director of Public Health, and lead joint strategic needs assessment. Tools need to be developed to enhance the local commissioning process to measure future avoidable chronic disease outcomes and cost effectiveness. Governance arrangements for local agencies with lead responsibilities for public health should be required to include representatives with population health experience as well as representatives able to engage civil society and the voluntary sector, to feed into strategic decision making.

17. The boards should be responsible for scrutinising and signing off local commissioning plans. There are existing arrangements to work across local authority areas – such as in Liverpool City Region—which should be supported. This is particularly important when considering upstream population based approaches to address obesity, cardiovascular disease etc. Local Transport Plans are excellent examples of working together to offer a collective strategy. The health and wellbeing boards should include representatives from the local authority (including directors of adult social services, children’s services, environmental health, planning etc) in addition to voluntary sector representatives, GPs and service providers. Existing services in local authorities such as environmental health and trading standards have had important roles in the effective implementation of tobacco policies at local level such as in enforcing age of sale restrictions and similarly in healthier food policies around hot food takeaways for example. Their work should be supported as part of the public health function but not at the expense of the public health workforce currently placed within primary care trusts. Sufficient funds should be allocated to the ring-fenced public health budget to enable it to deliver effective services.

Arrangements for commissioning public health services

18. It is important that the localism agenda does not ignore the potential benefits of commissioning at supra-local level. There are strong advantages in supra-local co-ordination as a means of avoiding duplication of activity and resourcing. Thus upstream prevention interventions may be best addressed across local authorities and at a population level. Changes at population level with reference to cardiovascular disease has been addressed in NICE guidance 2 which focused on how national or regional policy and legislation can be powerful levers for behaviour change. Paid advertising is an area where national campaigns generally deliver better value for money, while unpaid media can be gained effectively at a supra local level. Examples of obtaining greater value for money include the delivery of a comprehensive cardiovascular disease (CVD) prevention programme across Cheshire and Merseyside (Heart of Mersey). This has included supra-local programmes on tobacco control (including smokefree mental health, underage tobacco sales, illicit tobacco), and food (including takeaway food and pre-school nutrition). It is often the case that communities straddle (or move across) local government boundaries and are better served by interventions delivered at the scale of the functional urban region.

19. HoM is further concerned that public health procurement practices follow the DH Procurement Guide.11 It is important that potential providers are involved in the development of service opportunities at an early stage to ensure best value and improved services. Those commissioning public health services will need support particularly where providers may be from within the voluntary and community sector.

The future of the Public Health Observatories

20. Having good public health intelligence is critical to informing both national and local work. The observatories need independence and a protected budget to continue their essential activities. Similarly, it is essential for annual surveys for the Health Survey for England to be maintained. With a focus on outcomes, we need to ensure we are in a position to effectively measure public health programmes and delivery at both national and local levels.

The structure and purpose of the Public Health Outcomes Framework

21. HoM supports the commitment to an Outcomes Framework and believes that open access to data and shared priorities will enable a common focus on health and wellbeing priorities. Effective tobacco control and improving diets are essential to reducing health inequalities and should be pivotal in data availability and focus. Cardiovascular disease is the biggest contributor to health inequalities in Cheshire and Merseyside and we welcome the commitment to health inequality reduction and advancing equality.

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

22. Focusing the health premium on health gain in a recession may have the unfortunate effect of penalising the most needy in society and communities. It is often the poorest whose health suffers fastest in a recession. HoM believes that reduction in smoking prevalence, maternal smoking and smoking in mental health should be key factors in allocating the health premium.

23. We have some concern that the health premium could potentially widen inequalities between areas that do and do not receive the payment and are therefore interested in how the formula will be devised. The health premium should be based on a percentage improvement rather than a relative level as different local authorities will have different starting points. Percentage improvements will not disadvantage lower performing local authorities further as these will most likely be those with populations experiencing multiple levels of deprivation.

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

24. All specialist public health staff should either be transferred into local authorities or retained in the NHS under the new arrangements; this is not a time to reduce public health capacity.

25. It is essential that the role of Director of Public Health (DPH) is positioned at a senior level within local authorities—ideally directly responsible to the CEO—with the professional freedom and independence to ensure effective public health delivery. The DPH’s statutory responsibilities should be defined in the Health and Social Care Act. Duties should include input into major policy and planning matters; health impact assessment being an important tool. Whilst DsPH will be jointly appointed by Public Health England (PHE) and the local authority, it would be preferred that contractual arrangements should be with PHE (assuming its own independence as previously recommended) to prevent problems of dual accountability. Ring-fenced public health budgets will need to be robustly defended by DsPH and PHE. Independent annual public health reports should be produced at both local and national levels.

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

26. We agree with organisations such as the National Heart Forum that it is important that the Marmot Review is referenced in Healthy Lives, Healthy People. The interpretation of tackling inequalities must go beyond inequalities in access to health services and fully address inequalities in health outcomes.

June 2011

References

1 The Marmot Review (2010). Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England Post-2010.

2 NICE (2010). Prevention of cardiovascular disease at population level, London: NICE.

3 NICE (2006). Obesity. Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children, London: NICE.

4 NICE (2008). Maternal and Child Nutrition, London: NICE.

5 NICE (2008). Promoting and creating built or natural environments that encourage and support physical activity, London: NICE.

6 NICE (2006). Brief interventions and referral for smoking cessation, London: NICE.

7 NICE (2007). Workplace interventions to promote smoking cessation, London: NICE.

8 NICE (2008). Preventing uptake of smoking by children and young people, London: NICE.

9 ACEVO (2010). The Organised Efforts of Society. The role of the voluntary sector in improving the health of the population, London: ACEVO.

10 DH (2011). Healthy Lives, Healthy People: A tobacco control plan for England, London: DH.

11 DH (2010). Procurement guide for commissioners of NHS-funded services, London: DH.

Prepared 28th November 2011