HC 1048-III Health CommitteeWritten evidence from Dr Sue Gordon, Executive Director of Public Health, NHS North of Tyne (PH82)

1. Introduction

1.1 NHS North of Tyne is a PCT cluster which has been in place since 2007–08. The cluster has an integrated public health team working across three PCOs and in partnership with three local authorities covering Newcastle, North Tyneside and Northumberland. This allows public health skills and expertise to be applied to: health improvement programmes; activities intended to reduce health inequalities; health protection and emergency preparedness; and commissioning for quality and equity of healthcare services.

1.2 Major strengths of these arrangements have been the ability to develop links between public health, planning, commissioning and performance management and the ability to influence commissioning along whole pathways of care. My comments are made based on my experience of leading a team working across all three domains of public health from a single team covering multiple PCOs.

2. Executive Summary

2.1 There is a significant lack of detail in the public health policy. This, coupled with imprecise use of language, has led to confusion and omission of a whole domain of public health activity from the policy. The dislocation of public health policy and reform from NHS policy and reform means that the role of public health within the new NHS commissioning landscape is not adequately addressed in either.

2.2 All three domains of public health need to be addressed in policy and legislation if the public’s health and wellbeing are to be effectively protected and improved.

2.3 Healthcare public health—which is not limited to preventive interventions, but covers the whole range of healthcare services—focuses on the commissioning of healthcare services to meet local population needs. The importance of healthcare public health is its contribution to more effective and efficient commissioning and improved health equity.

2.4 The public health workforce is large and diverse, and should be led by suitably trained and qualified public health specialists. Uncertainty about future roles and employment prospects for specialist staff risks fragmentation and loss of capacity during the transition.

2.5 The role of Director of Public Health needs to be clarified in relation to its seniority and scope, particularly in championing the wider determinants of health across the breadth of local authority functions as recommended by Marmot.1 Only suitably qualified public health specialists should be able to be appointed as Directors of Public Health.

2.6 Access to the profession should be through the specialty training scheme as the single route of entry. Regulation of all public health specialists should be placed on a statutory footing to ensure consistent approaches irrespective of professional background.

3. Information

3.1 Imprecise language and dislocation between public health and NHS policy and reform

3.1.1 Within Healthy Lives, Healthy People2 and its accompanying consultation documents the term “public health” is used variously to mean: the health of the public, the specialty of public health, staff employed in public health teams, the director of public health, health improvement, or prevention activity.

3.1.2 Within Healthy Lives, Healthy People and Liberating the NHS3 and their accompanying consultation documents the term “inequalities” is used variously to mean: any unfair differences, differences in health status arising from lifestyle factors and the wider social determinants of health, differences in ability to access healthcare services, or differences in the outcomes arising from healthcare services. I would recommend making the distinction between:

“health inequalities”—used for differences in health status arising from lifestyle factors and the wider social determinants of health—ie, the Marmot agenda1; and

“health equity”—used for the drive to remove or minimise differences in access to and outcomes arising from healthcare services—ie, part of the healthcare public health agenda.

3.1.3 The significant lack of detail in the presented policy coupled with this imprecise use of language, means that the omission of a whole domain of public health activity was not immediately apparent. The dislocation of public health policy and reform from NHS policy and reform has further compounded the problem.

3.1.4 As a result, the role of public health in improving health service quality and supporting healthcare commissioning is largely absent from both Liberating the NHS and Healthy Lives, Healthy People. The consequence of this absence is a lack of any detail about where qualified public health specialist staff will be located in the system to adequately support these functions and how the NHS Commissioning Board and GP Consortia will access public health advice. The resulting uncertainty creates a real risk that specialist workforce will be lost during the transition.4

3.2 Three domains of public health

3.2.1 There are three domains of public health:

health improvement—including people’s lifestyles and inequalities in the wider social determinants of health;

health protection—including infectious diseases, environmental hazards and emergency preparedness; and

healthcare public health—including service planning, efficiency, audit, evaluation and equity of access to and outcomes from health services.

3.2.2. Healthy Lives, Healthy People proposes that, subject to the passage of the Health and Social Care Bill,5 responsibility for health improvement functions and health inequalities will transfer to local government from April 2013 and Directors of Public Health will be employed by upper tier local authorities to act as the strategic leaders for public health and health inequalities in local communities. The main justification for this, given in the impact assessments,6 is that the Government has already announced that PCTs will be abolished and their commissioning functions therefore need to move elsewhere. The impact assessments are clear that there is “limited evidence” that transferring these responsibilities to local government will serve to improve the health and wellbeing of the population. The possibility of making these improvements is described as “plausible” at best. Improvements in health outcomes will only be realised where the Director of Public Health is in a position to take control of levers relevant to the wider social determinants of health;6 this is likely to pose a significant challenge for areas where local government is arranged in two tiers and many of the critical functions that link to the social determinants of health are delivered at lower tier. The Improvement and Development Agency has recently highlighted areas of local government activity that have the potential to impact on the social determinants of health.7

3.2.3 Within Healthy Lives, Healthy People, Public Health England is described as having a mission across the whole of public health. Despite this apparently broad remit, it is clear that the key driver for the establishment of Public Health England is the perceived need to strengthen the national response on emergency preparedness and health protection.2, 6 There is some detail about how Public Health England will, subject to the passage of the Health and Social Care Bill, take on functions currently provided by the Health Protection Agency. There is little reference to Public Health England’s role in relation to health improvement, health inequalities, improvement of health service quality or public health support to healthcare commissioning.

3.2.4 Healthy Lives, Healthy People makes a case for GPs and their practices to play a more active “public health” role through primary and secondary prevention, and referral to targeted services. In relation to tackling health inequalities, the Marmot Review1 sets out specific roles for GPs and their practices as providers of care and for GP Consortia as commissioners of care. The Royal College Of Physicians’ policy statement8 goes further and outlines specific roles for all doctors, but recognises that a significant cultural shift would be required to refocus beyond the immediate needs of individual patients and towards a population health perspective.

3.2.5 Healthy Lives, Healthy People suggests that GP Consortia will access public health expertise from the Director of Public Health (employed by the local authority) via the health and wellbeing board; however, this is unlikely to provide the necessary level of support for GP Consortia or allow them to play a full, equal and active part in their new duties for Joint Strategic Needs Assessment and production of Joint Health and Wellbeing Strategies.9 At local level, GP consortia will need public health advice on a range of issues, such as:

Profiling the local practice and resident population and identifying those at greatest risk.

Technical input into some areas of commissioning.

Prioritisation and areas for disinvestment.

Using evidence on cost and clinical effectiveness to challenge secondary care clinicians.

Advising on the evidence base for patient pathways.

Evaluation of services.

3.2.6 I believe that having qualified public health specialist support directly available to GP Consortia is likely to be more effective in supporting these new duties and in mitigating the risk that public health skills and evidence will not be an intrinsic part of commissioning appropriate healthcare interventions.6 There is recognition by GPs that they need the expert input of their public health colleagues to support commissioning of health services10 and there is a strong view from the public health profession that expert public health input must be “embedded in the fabric of GP and NHS Commissioning Board commissioning”. 11 At least some of this advice will be highly specialist and therefore an expensive and relatively scarce resource which will need to be concentrated and shared across a number of consortia.

3.2.7 Healthy Lives, Healthy People recognises that public health functions need to be included in the NHS Commissioning Board’s mandate. The following NHS Commissioning Board functions are likely to require expertise from qualified public health specialists:

Leading the achievement of health outcomes.

Allocation of NHS resources.

Leading on quality improvement.

Translating NICE quality standards into commissioning guidance.

Promoting equity in access to and outcomes of healthcare.

Implementation, management and quality assurance of screening programmes.

3.2.8 I believe that, unless professional specialist public health support is directly available to the NHS Commissioning Board, there is a risk that public health skills and evidence will not be an intrinsic part of commissioning appropriate healthcare interventions.6

3.2.9 Despite recognition that there is a need for public health support for NHS commissioning both nationally and locally, the role of public health within the new commissioning landscape is not adequately addressed in Healthy Lives, Healthy People. Additionally, there is no detail about where qualified public health specialist staff will be located in the system to adequately support these functions.

3.3 The importance of healthcare public health

3.3.1 Healthcare public health focuses on the effective commissioning (or decommissioning, where appropriate) and delivery of healthcare services to meet local population needs, secure equitable access to healthcare services, and deliver better fairer outcomes from those services. Qualified public health specialists working in this field provide critical expertise, skills and knowledge in:

interpreting large volumes of information and data received on their local population, their health needs, and the various services provided for them;

understanding the geography of health needs in order to direct the planning and commissioning of services to meet those needs;

applying evidence of cost and clinical effectiveness to transform services; and

leading and delivering change in systems and organisations.

3.3.2 The importance of healthcare public health and its contribution to more effective commissioning is outlined in the Right Care programme12 which aims to improve outcomes of healthcare services, increase the use of higher value interventions, and reduce unwarranted variations.

3.3.3 Analyses by both the Department of Health13 and the former Health Inequalities National Support Team14 have shown that, whilst tackling health inequalities successfully and sustainably requires partnership working to address the wider social determinants of health over the longer term, the biggest improvements over the short term will be derived from preventing the early deaths of people who already have disease or are at high risk of developing disease.

3.3.4 The effective management of chronic diseases in primary care using a population based approach will therefore be critical in reducing health inequalities and improving health equity.

3.4. The need for a suitably trained and qualified specialist workforce

3.4.1 The public health workforce is large and diverse made up of specialists and a wide range of professional practitioner groups. To ensure that expert support is available for all those concerned with protecting and improving the public’s health, specialist public health should be maintained and developed as a respected, resilient, multidisciplinary profession working across all three domains of public health.11 Appointment to senior public health roles should only be available to suitably qualified specialist public health staff (i.e., those on a specialist register of the General Medical Council, General Dental Council or the UK Public Health Register). The titles “Consultant in Public Health” and “Public Health Specialist” should be protected for such individuals.

3.4.2 Other than for Directors of Public Health—who are to be employed by the local authority—there is little detail about where qualified public health specialist staff will be located in the system. The uncertainty that this creates about future roles and employment leads to a risk of losing specialist workforce during the transition. Coupled with the significant cost savings to be achieved by both NHS employers and local authorities, there is a risk that qualified staff will be replaced by cheaper unqualified staff.

3.4.3 Systems for workforce development, education, training and regulation of qualified public health specialist and public health professional practitioner groups are still unclear. A workforce strategy for public health has been promised for autumn 2011. 2, 15

3.5. The role and status of Directors of Public Health

3.5.1 The Director of Public Health is the only public health role for which there is clarity about future employment. As has already been stated the “plausible” improvements in health outcomes will only be realised where the Director of Public Health is appointed in a sufficiently senior position and with sufficient authority within the local authority to deliver against the expectation of their new role.

3.5.2 In addition, appointment to Director of Public Health roles should only be available to suitably qualified specialist public health staff (ie, those on a specialist register). As currently drafted, Healthy Lives, Healthy People2 and the Health and Social Care Bill5 would allow someone without the relevant training or qualification to be appointed as a Director of Public Health. The title “Director of Public Health” should be protected for such individuals; if this is not possible, then an alternative mechanism should be enacted to ensure that only individuals on the specialist register could occupy such posts.

3.5.3 The vision for the Director of Public Health role as set out in Annex A of Healthy Lives, Healthy People2 is too broad and is likely unachievable. I would agree with the oral evidence given to the Committee by Professor David Hunter16 that the role of Directors of Public Health should focus on health protection, health improvement and tackling health inequalities in the local authority setting, whilst healthcare public health would be better placed with qualified public health specialists embedded within the new NHS commissioning landscape.

3.6. Implications for regulation of the public health profession

3.6.1 Regulation of public health professionals is focused on assuring consistent quality and safety of practice of qualified specialist public health staff (ie, those on a specialist register). At the present time, there are concerns about:

inconsistency in the regulation of different groups of specialist staff, with a mixture of statutory and voluntary approaches; and

the large and growing number of routes to specialty registration.

3.6.2 The Review of the Regulation of Public Health Professionals17 makes a compelling case for placing regulation of all public health specialists on a statutory footing. I agree with the recommendations and particularly:

“Defined Specialists” should not be considered as being equivalent to “General Specialists”, since they have not been able to demonstrate competence across the full range of public health professional standards.

There should be a single route of entry into the profession through a single training pathway. The Faculty of Public Health should carry out the central role in relation to education and standard setting.

Approaches to professional development and revalidation should be consistent for all public health specialists on the specialist registers. The Faculty of Public Health should have a central role in producing common revalidation frameworks.

4. Recommendations for Action

4.1 Significantly more detail is required within the policy on public health. Additional detail should be more precise in its use of language to improve clarity and support implementation. This will help to reduce variation in interpretation by different stakeholders.

4.2 All three domains of public health need to be addressed in the policy and legislation.

4.3 The importance and scope of healthcare public health needs to be recognised within the policy. How specialist public health input is positioned within the new NHS commissioning landscape needs to be addressed. It would be useful to reconnect public health policy and reform with NHS policy and reform and to reconsider whether PCT cluster type arrangements should be retained as a viable option for linking healthcare public health functions and commissioning support at an appropriate population size.

4.4 There is an urgent need to clarify systems for workforce development, education, and training for the public health workforce. Clarity is needed about future roles and employment prospects for specialist public health staff other than Directors of Public Health.

4.5 The role of Director of Public Health needs to be clarified in relation to its scope and its seniority. Only suitably qualified public health specialists should be able to be appointed as Director of Public Health. The Director of Public Health may not be best placed to provide leadership for healthcare public health.

4.6 Regulation of all public health specialists should be placed on a statutory footing with consistent approaches irrespective of professional background. Access to the profession should be through a single route of entry.

5. References

1 Strategic Review of Health Inequalities In England Post-2010. Fair Society, Healthy Lives. The Marmot Review. February 2010.

2 HM Government. Healthy Lives, Healthy People: Our Strategy for public health in England. Cm7985. November 2010.

3 Department of Health. Equity and Excellence: Liberating the NHS. Cm7881. July 2010.

4 Association of Directors of Public Health (UK). Response to consultation on White Paper Healthy Lives, Healthy People: strategy for public health in England. October 2010.

5 Bill 177 2010-11. Health and Social Care Bill [as amended in Public Bill Committee]. April 2011.

6 Department of Health. Healthy Lives, Healthy People: Impact Assessments. November 2010.

7 Improvement and Development Agency. The social determinants of health and the role of local government. March 2010.

8 Royal College of Physicians. How Doctors can close the Gap: Tackling the Social Determinants of Health through Culture Change, Advocacy and Education. RCP Policy Statement 2010. June 2010.

9 Department of Health. Liberating the NHS: Legislative framework and next steps. Cm7993. December 2010.

10 NHS Alliance & Solutions for Public Health. A shared agenda in the new world: the role of GP consortia and public health in improving health and wellbeing and delivering effective healthcare. Final report of a national colloquium.

11 UK Faculty of Public Health. Response to Healthy Lives, Healthy People: consultation on the funding and commissioning routes for public health. March 2011.

12 QIPP Right Care. Public Health Professionals and Commissioning for Better Value: Report of the first Right Care colloquium.

13 Department of Health. Tackling Health Inequalities: 2006–08 Data and Policy Update for the 2010 National Target. December 2009.

14 Health Inequalities National Support Team. Systematically Addressing Health Inequalities. June 2008.

15 Department of Health. Liberating the NHS: developing the Healthcare Workforce. December 2010.

16 House of Commons Health Committee. Q 2 oral evidence, 17 May 2011.

17 Scally, G. Review of the Regulation of Public Health Professionals. November 2010.

June 2011

Prepared 28th November 2011