HC 1048-III Health CommitteeWritten evidence from the Royal College of Paediatrics and Child Health (PH 92)

1. The RCPCH is pleased to submit written evidence to the Health Select Committee Inquiry into Public Health. As a professional body seeking to ensure the best outcomes for children, we want to highlight the particular implications for children and young people in the areas being specifically examined by the Committee. We will respond to each of the topics of enquiry in turn.

2. The Creation of Public Health England (PHE) and Abolition of the Health Protection Agency (HPA)

2.1 The creation of PHE is vital to the achievement of a joined-up, flexible and responsive public health service. However, we continue to request greater clarity on the role, structure and personnel of the new body. We also highlight the importance of the role that PHE should play in coordinating immunisation and vaccination programmes. A national service would achieve economies of scale and help to ensure safety.

2.2 RCPCH agrees with many commentators that the creation of PHE within the Department of Health has the potential to damage the independence and credibility of the organisation and by extension, the public health workforce. While we acknowledge that an entirely independent body may not be desirable in the light of the other reforms suggested by the White Paper, we believe the discrete role and relatively autonomous reputation of PHE should be preserved. To this end, we recommend that PHE should be required to comply with the Nolan principles of public life, have an established board with public meetings and publication of board papers.

2.3 The HPA is an internationally recognised body that provides high quality independent research and advice on health protection issues. Its dissolution and the integration of its functions and (presumably) workforce into the PHE will have to be carefully managed both in terms of health protection functions in the transition period, and the issues identified with independence and autonomy above.

3. The Role of Local Government in Public Health

3.1 RCPCH supports the transferral of public health functions to local authorities. This reform represents an opportunity to reduce silo working and increase collaboration between agencies, particularly with children’s care. Their role in addressing the social determinants of health, such as housing, education or transport, cannot be understated. The Health and Wellbeing Board (H&WB) will need to play a vital role in coordinating a coherent strategic approach, and the input of community paediatricians, educational authorities and public health professionals will be essential to achieving this.

3.2 Nonetheless it is important that H&WBs, in their broad remit, do not lose focus of children’s health and, in particular, child protection. It is important that Children’s Trust (CT) arrangements, where still in existence, or in whichever form they have taken following abolition of statutory requirements to have a CT structure, work closely with H&WBs and provide specific focus and expertise on matters affecting children and young people. We would recommend that CT arrangements remain in form and function (if not name), and that they remain separate from the H&WBs, yet still having a shared agenda on children’s matters.

3.3 It is vital that Local Safeguarding Children’s Board (LSCB) functions are not subsumed into H&WBs. It is crucial that LSCBs retain independence and can properly hold local authorities, and other agencies, to account.

3.4 Clinical consortia must be actively represented and engaged on H&WBs, and schools must also be included on the membership. This is especially important given the increasing amount of schools, particularly secondary schools, applying for academy status, as well as the increase in free schools. The increased autonomy from local authorities that these schools will have means that oversight via the H&WBs is required, as well as enabling schools to access expertise and be part of the multi-agency child protection process.

3.5 Finally, we would advocate that, despite H&WBs merging adult’s and children’s services issues, local authority directorates should stay separate. Merging would contradict Professor Eileen Munro’s review and be potentially damaging for children’s outcomes.

4. Public Health Involvement in the Commissioning of NHS Services

4.1 Public health expertise should be embedded at all levels of commissioning, from the NHS National Commissioning Board (NCB), clinical commissioning consortia, Public Health England and any supra-local or sub-national commissioning arrangements.

4.2 As outlined in the College’s response to the Public Health White Paper Healthy Lives, Healthy People, we believe that the role of the community paediatrician will also be essential in ensuring that the various commissioning agencies take into account the health interests of children and young people. Their membership on the Health and Wellbeing Board should be mandated to ensure that a holistic view of children’s services, and that links are made with Community Children’s Nurses and health visitors. They will also be able to oversee safeguarding, disability services, Joint Strategic Needs Assessment, helping to develop the joint health and wellbeing strategy and navigating the sometimes complex commissioning arrangements for children’s services.

5. Arrangements of Commissioning for Public Health Services

5.1 The commissioning arrangements outlined in Healthy Lives, Healthy People are sensible, but need some refinement. We agree with the commissioning of children’s public health under five years being directed by the National Commissioning Board, and five to 19 by Local Authorities, but caution that this separation should be based on peer group (ie September to August for the majority of children) rather than exact age. Commissioning arrangements needs to be carefully managed to ensure a natural and continuous transition into a largely school-based approach to health protection and promotion, and be consistent across boundaries between clinical consortia and local authorities.

5.2 We believe it is vital that local authorities commission school nursing. We would also make the case for some services to be commissioned nationally, for reasons of economies of scale. These might include vision services and child health mapping. There must be clear arrangements between local authorities and clinical consortia to agree contractual arrangements for healthcare for looked after children, particularly where they are placed out of area. Too often at present, children are placed without these agreements and specialist and general health support may be interrupted or inconsistent which can significantly affect wellbeing and safety of the young person and their carers. It should be clear who commissions and provides health assessments and plans for looked after children.

5.3 Some high-cost, low volume services, perhaps around health protection issues, will need to be commissioned by PHE, rather than clinical consortia. The RCPCH also supports the possibility, outlined in Healthy Lives, Healthy People, of sub-national or supra-local commissioning arrangements for certain specialist conditions. Many of these may be too financially risky for clinical consortia or other local agencies to commission, but arrangements may not be sensitive enough to local need if commissioned by the NCB.

5.4 RCPCH is also looking for clarity around commissioning for health service aspects of Sexual Assault Referral Centres (SARCs). We suggest that this is commissioned on a national basis, but we are happy to discuss this further with relevant partners.

6. The Future of the Public Health Observatories

6.1 We support the creation of the National Institute for Health Research (NIHR) and the School for Public Health Research. However, the College believe that the availability of and access to data should still be localised. However, it is vital that the knowledge and expertise amassed by Public Health Observatories, which is particularly useful in Joint Strategic Needs Assessments (JSNAs), is not lost in the new arrangements. We seek reassurance from the DH that the new system will continue to provide robust and credible local intelligence, and that the tools, data analysis and support currently provided by Child and Maternal Health Observatory (ChiMat) for maternal and child health will not be lost.

7. The Public Health Outcomes Framework

7.1 The RCPCH believes the Outcomes Framework as outlined provides a robust and flexible framework for determining meaningful indicators. It pays close attention to a life course based approach, but we share concerns with other commentators that the Outcomes Framework is not sufficiently aligned with the outcomes frameworks for the NHS and social care.

7.2 Specifically, on safeguarding, we agree with our colleagues at the NHS Confederation that this area shows a particular incoherence in its approach. The proposed Public Health Outcomes Framework has a child protection element aimed specifically at children under five years, while the Social Care Outcomes Framework contains adult safeguarding elements and the NHS Outcomes Framework contains no safeguarding elements. RCPCH suggests a consistent approach that ensures adequate child protection as a key outcome for all relevant agencies.

7.3 We are encouraged that there are a number of outcomes specifically for children and young people, but similarly, these need refining if the Outcomes Framework is to drive improvements in children’s health care effectively. RCPCH believes that aligning them with existing European datasets would make international comparisons easier, and avoid any duplication of effort in developing relevant indicators. The Child Health Indicators of Life and Development (CHILD) project provides an holistic set of 38 core desirable national indicators, ranging from infancy to adolescence. In terms of children’s health, this is the most comprehensive range of measures identified. These form the basis of the WHO Europe Strategy for Child and Adolescent Health across over 50 countries.

8. Funding of Public Health Services

8.1 We welcome the ring-fencing of the public health budget. In particular RCPCH highlights the importance of protecting the funding for vital health protection measures such as immunisation and vaccination, as well as full implementation of the Healthy Child programme.

8.2 We welcome the introduction of the health premium as a mechanism to address local health inequalities. However, it will need to be carefully calibrated to encourage activity that has been shown to reduce health inequalities. While it might appear sensible at first glance to simply reward achievement in reducing health inequalities, we know that the results of some interventions take many years to appear, especially in areas where such inequalities are deeply embedded. Furthermore, it may not be sensible to incentivise certain, short-term achievements in that this may encourage local authorities to focus on ‘easy wins’ rather than long term goals that will bring improvements in health for future generations. In short, the reward system needs to be calibrated carefully to reward tangible, measurable achievement, but in such a way that minimises the opportunity to ‘game’ the system and rewards a long-term and sustainable approach.

9. Government Response to the Marmot Review

9.1 The public health white paper Healthy Lives, Healthy People builds on the evidence presented by Sir Michael Marmot’s review of health inequalities. It takes a life course approach, and pays particular attention maternal, child and adolescent health, under the ‘Starting well’ and ‘Developing well’ strands. This approach dovetails with the independent reviews led by Rt Hon Frank Field MP and Graham Allen MP, on poverty and life chances and on early intervention, respectively.

9.2 However, the Marmot review also identified poverty as a key determinant of health. The government’s response to this particular aspect has been disappointing. The recently published Child Poverty Strategy marked a divergence from previous government efforts in this area, despite Johan Mackenbach’s assessment that it “was the first European [attempt] to pursue a systematic policy to reduce socio-economic inequalities in health”. The new Strategy rejects this approach as “exhausted” and “exacerbating the problem by weakening incentives to work”.

9.3 The Institute of Fiscal Studies (IFS) recently published a review of progress on child poverty over the last 10 years. This provided evidence that whilst progress has been made, the cumulative effect of the benefit reforms introduced by the government are likely to increase the number of children living in poverty from 2.6 million to 2.9 million by 2013–14.

9.4 The Marmot review’s recommendations appear to have found traction at the Department of Health, but have failed to make an impact on other government departments. The report’s recommendations covered a wide range of the social determinants of health, very many of which have a direct impact on children’s health and development, and upon which the Department of Health will have little influence upon. The author of a previous report on health inequalities, Sir Donald Acheson, famously defined public health as “the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society”. There is little evidence that this philosophy has taken root across government departments, and without such a joined-up approach, there is little possibility of child poverty, and by extension children’s health, improving.

June 2011

Prepared 28th November 2011