HC 1048-III Health CommitteeWritten evidence from the National Heart Forum (PH 84)

About the National Heart Forum (NHF)

The NHF is a charitable alliance of 70 national organisations working to reduce the risk of avoidable chronic diseases including coronary heart disease, stroke, cancer and diabetes. Our members include medical professional organisations, charities concerned with health, welfare and social policy as well as many individuals distinguished in the fields of disease prevention and public health.

The following remarks draw on consensus-based responses submitted by the National Heart Forum to the Government’s consultation on the public health white paper—Healthy Lives, Healthy People.

Summary Points

The primary concern of the NHF is that the new arrangements proposed for public health should not lead to any weakening of the public health function, or any loss of expertise or momentum in tackling the major burdens of ill-health in the UK caused by largely avoidable risk factors of poor diet and poor living conditions, smoking, alcohol harm and sedentary behaviours.

NHF is, in principle, broadly supportive of the direction of change; shifting the locus of public health from the health services to local authorities, but we have significant, specific concerns about aspects of the process involved, including the scale and pace of change, and how it may impact on the independence, accountability and prioritisation of public health.

We welcome the Committee’s inquiry into public health. We believe that it will be a timely and helpful interrogation of the Government’s plans and an opportunity for the Government to respond to the contentious issues and clarify areas of uncertainty about the mechanisms of the new arrangements.

Recommendations that the NHF would like the Committee to Consider

1. Independence of public health advice

The role of the Chief Medical Officer (CMO) must be kept as an independent adviser to Government, across all departments, not just health. The CMO must have experience in public health and needs to be free to speak out about all public health issues. The position of CMO should be a full time commitment in view of the high demands of the role.

Directors of public health (DsPH) should have protected independence and be recognised as principal adviser on all health matters to their local authority, the NHS and their local Health and Wellbeing Board. To ensure this, we recommend that DsPH should be appointed as a second tier officer accountable to the CEO of the local authority and their statutory responsibilities should be defined in the Health and Social Care Act. This is not unprecedented within Local Authorities; the solicitor role has a similar independence under the section 151 legislation. These duties should include statutory consultation input in all major policy and planning matters across local authorities to take into account the protection and promotion of population health. We also recommend that DsPH should have a formal relationship with GP consortia to help ensure that consortia decision-making is underpinned by expert, professional public health advice. The objective is to ensure co-terminosity between the NHS and local authorities on public health matters and to safeguard the important role of the NHS in delivering public health.

2. Public accountability in the public health system

We recommend that a new Public Health Act or provision is introduced to enshrine the Government’s duties of state and capacity to protect the population’s health and to have reserve powers that would enable legislators to introduce health protection measures as and when necessary to reduce the risk of chronic diseases as well as communicable health threats. A broader perspective on health protection is needed as the boundaries with health improvement increasingly overlap.

Under the proposed new arrangements, the public health system will, in effect, sit within the political system. This raises significant concerns about a lack of independent scrutiny of public health across government. If this arrangement is to be enacted then in addition to protected roles for the CMO and DsPH, we would recommend the establishment of a new independent Office of Public Responsibility to act in a complementary role to the health service and social care remit of the Care Quality Commission.

We also propose that Public Health England becomes an arms length Executive Agency or non-departmental public body (NDPB) with an independent public interest governance structure to ensure public health science and policy analysis is properly independent of vested and ideological interests. This will separate scientific risk assessments and policy advice from political decision making on risk management and it will be transparent. Public Health England should be a “whole government” resource. Such considerations are normal in other areas of Government such as economic and fiscal advice, and have proven essential components of effective public health organisations in the UK end elsewhere in the world.

To protect the independence of DsPH and to ensure rights of access to both the health service and local authority we recommend that while jointly appointed by the local authority and Public Health England (PHE), DsPH should have their contractual arrangements with PHE if it becomes an executive agency or NDPB. Depending on the eventual status of PHE and its relationship with the NHS, it may be necessary to strengthen the links within the public health system – between PHE, the NHS and local authorities by giving DsPH and their specialist staff honorary contracts with the NHS. In theory and practice, dual accountability is not recommended.

The reliance on voluntary agreements with the commercial sector through the Responsibility Deal for public health raises issues of accountability which require clarification. The consideration of “attributable risk” is currently absent from Government thinking in regard to food, drink and associated marketing industries. Specifically, the role of the commercial sector must be clearly delineated and should not include any involvement in public health policy development. Independent monitoring of the pledges and robust evaluation of the public health outcomes of the Responsibility Deal should involve public interest organisations and the Government.

We support the principle of an outcomes-focused approach to public health. With the right indicators and with clear leadership from DsPH, DH Policy, Public Health England and NICE, we believe this approach has the potential to improve transparency and accountability and to support a common focus and prioritisation of public health resources, at both national and local level, on tackling the major causes and determinants of ill-health.

The prevention components of Quality, Innovation, Productivity and Prevention (QIPP) need to be considerably strengthened and the purpose of the exercise framed as contributing to long term reductions in health service burdens, not just short term efficiency savings.

We recommend that consortia commissioning plans should be formally signed off by Health and Wellbeing Boards.

There should be a mandatory requirement to produce independent annual reports on public health at both national and local levels by the CMO and DsPH respectively. The reports should include a declaration of the resources available to the public health department.

3. The role of central Government in public health

There is a significant risk that the shift of responsibility for aspects of public health to local authorities under the localism agenda will create gaps in the public health system and loss of expertise. The health care system also needs dedicated public health expertise, outcome targets and other incentives. Public health expertise is needed at the NHS commissioning executive and in DH policy and to strengthen cross-government arrangements and co-ordination. We are concerned about the loss of public health expertise and capacity in DH policy and in other Government Departments especially with respect to health improvement and the prevention of avoidable chronic conditions. As the main driver of health and social care costs, this should be a public health priority.

There must be leadership from central Government to develop and deliver robust national and international level public health strategies that tackle the major risk factors of poor diet, inactivity, smoking and alcohol harm. Local authorities cannot address the upstream policy challenges of tackling price and availability of tobacco and alcohol for example, controls on HFSS food marketing to children or the introduction of effective and consistent nutritional labelling on food products.

The role of central Government in setting minimum national standards (for school food and public procurement policies, for example) must be safeguarded. Evidence shows that the major population-wide public health gains are delivered by upstream policy actions (legislation for smoke-free public places, energy-efficient homes, seat-belts and a ban on tobacco advertising, for example). Evidence to support the effectiveness of “nudging” individuals as a means to improve population health and reduce health inequalities, on the other hand, is weak. Indeed the evidence base supports measures which stop or re-engineer potentially harmful modern marketing nudges. Upstream measures need public acceptance and this should be an important aspect of social marketing initiatives. Upstream measures also efficiently and proportionately reduce health inequalities.

We recommend that there must be a continuing role for the “centre” to support and resource ideas, research, evidence and information. Operational functions should be contracted out to expert providers. The way in which new arrangements will maintain the public health observatory function requires urgent clarification as well as confirmation that vital national surveys, data collection and surveillance mechanisms, and the analysis of the data into useful information, continue so that the evidence gathered is used to underpin effective public health practice. The UK is recognised to be a world leader in such public health systems and it is vital to maintain this position.

The centre has a key role to play in the development of effective public health practice and this should be identified as a function which is properly resourced within the new system.

The importance of the cross-Government role in public health is fundamental to the success of the new arrangements. The new public health arrangements need to be strengthened across government and public health should be a feature of all Government policy making. For example, to be sustainable, any national economic plan must include measures to tackle the unsustainable, demand side pressures on health and social care services caused by escalating burdens of chronic but mostly preventable conditions. The national cross-Government arrangements need to mirror and connect with what is expected at local level: local authority governance and the policy shift to a broader health and wellbeing agenda. Local Authorities and DsPH need defined mechanisms to be able collectively to inform Government about the support they need at local level from Government departments.

Increasingly there are many significant international determinants (eg EU directives or trade agreements) of health and disease and the Government needs to strengthen its capacity and capability to work on such issues with the EU, UN and Bretton Woods organisations.

Government should make health impact assessments (HIA), which include an equity focus, a statutory requirement in all policy processes at national and local levels as part of the integrated impact assessment process, applied both prospectively and as a three to five year follow up assessment.

4. Public health expertise and resources

We recommend that DsPH and consultant specialist appointments should be individuals who are trained, accredited and registered in specialist public health.

There are worrying signs that the changes to the new arrangements are already leading to public health professionals losing their jobs and services being reduced or lost such as National Support Teams, Public Health Observatories and regional offices. We recommend that local authorities should be obliged to transfer all specialist public health staff or that they be retained in the NHS under the new arrangements. Temporary transition funding should be made available to avoid redundancies.

We recommend that the scope of the ring-fenced public health budgets for public health is clearly defined and the size of the budget calculated from a realistic baseline that is taken before the implementation of efficiency savings. Traditional health protection measures for infectious and communicable disease and emergency preparedness will take up the lion’s share of the proposed £4bn allocation, so it will be essential that other budgets and local authority resources from transport, planning, education and environment are unlocked and accessible for public health purposes as part of a wider cross-government approach. There is a real danger that health improvement budgets will be squeezed at national and local levels. This is short- sighted as the main drivers of cost in the health and social care systems are now preventable chronic diseases. It is also essential that any public health funds are not utilised by local authorities to underpin existing services, such as leisure services, which in theory could be justified to have a public health function.

As resources inevitably become scarcer, policy makers, planners and commissioners need to understand what the current distributions of avoidable chronic diseases are, among whom, and how they are likely to develop in the future, particularly their impact on different population. It is essential that the centre—either Department of Health or Public Health England—makes sure that those involved in commissioning have the right tools available to them. An example is the public health micro-simulation the National Heart Forum developed for the Foresight Tackling Obesities enquiry and which is now able to provide valuable insights and potential information on future outcomes and cost effectiveness.

The new arrangements do not fully acknowledge the potential role and contributions of the voluntary and the academic sectors. We recommend that the Department of Health establishes statutory expert groups, drawn from the voluntary sector and academia, for key public health areas—particularly nutrition, tobacco, physical activity and alcohol harm—under the auspices of an independent Public Health England and DH Public Health Policy. The DH strategic partnership arrangements with the voluntary sector need strengthening and the role of the voluntary and community sector as both advocates and providers of public health services should be realised. We refer the Committee to the report of the Association of Chief Executives of Voluntary Organisations (ACEVO) for examples.

The portfolio of work on public health guidance produced by the National Institute for Health and Clinical Excellence (NICE) has been an invaluable resource in recent years. Many important NICE reviews—on obesity, inequalities and child health—were halted in late 2010 with damaging consequences. We recommend that these should be reactivated as a matter of urgency. We recommend that the functions of NICE should be enhanced and its focus broadened to include the review and evaluation of national and international public health measures as well as local level interventions.

There is a need for a public health repository, a digital knowledge management system, which provides public health resources at the point of need. Charities, community groups and the voluntary sector generate and publish valuable resources that need to be seen as valuable resources contributing to the evidence-based and deposited in the public health repository for knowledge sharing.

The framing of public health as “everybody’s business” needs to be practically supported. Public health should have an input into medical education and training. This would support the ambition for a public health-led NHS that is primarily focused on the cost-effective prevention of disease rather than treatment. Public Health England and NICE should be part of the new Health Education England arrangements.

The Government should give clearer encouragement for bodies to commission jointly on a larger geographical foot print where this provides better value for money.

Integration with children’s services could strengthen the potential to achieve the Government’s ambition to take a “life course” approach to public health. An example might be smoking prevention and cessation among the young.

5. Tackling health inequalities

We welcome the referencing of the Marmot Review in the public white paper but recommend that the interpretation of tackling inequalities must go beyond inequalities in access to health services and fully address inequalities in health outcomes.

The mechanisms for tackling inequalities such as the proposed Health Premium need to be more carefully thought through. Without care, for example, the Health Premium could have the perverse effect of penalising communities where need is growing fastest.

June 2011

Prepared 28th November 2011