HC 1048-III Health CommitteeWritten evidence from Anna Lynch (PH 94)

1. Introduction

This submission is provided by Anna Lynch, Director of Public Health (DPH) for County Durham and is written from a personal perspective. I believe my evidence is valid, based on my experience as Director of Public Health for County Durham, jointly appointed in 2006 by County Durham PCT and Durham County Council and my former experience as Director of Public Health for Easington, County Durham, from 2002 to 2006.

2. Summary

In drafting this submission I have followed the order of key points the Inquiry will consider as detailed on the Parliament website. The main concerns raised in my submission are summarised as below:

Public Health England requires a sub-national infrastructure as close to the local level as possible.

Great care must be taken to ensure emergency preparedness and resilience at the local level during and after transition to the new public health system with minimum disruption or change to the local health protection units which already have very effective arrangements with local systems.

The role of DPH in local authorities needs to be able to influence across the organisation irrespective of positioning and reporting arrangements.

Health and wellbeing boards should be authorised to sign-off commissioning plans.

The JSNA should be monitored to ensure that it influences commissioning investments.

All commissioners should have access to public health specialist expertise to inform decision making and prioritisation.

The complex commissioning of public health programmes across pathways and whole systems requires oversight by the DPH to ensure quality and patient safety.

The proposed ring-fenced public health budget is an area of immense concern and may lead to disinvestment in health improvement activity.

The proposed health premium has the potential to perpetuate the north-south divide and widen health inequalities.

Mandatory regulation of the public health profession is essential to safeguard the public and ensure fitness to practice.

Government policies should be subjected to a Marmot version of health impact assessment.

Further detail is captured in the full narrative below.

3. The Creation of Public Health England (PHE) within the Department of Health

3.1 There is an interesting debate between public health professionals about whether PHE should be an executive arm of the DH or a special health authority. I have no strong views on this and believe that the terms of reference/constitution for PHE and its relationship as an advisory body to the DH should be spelt out clearly to afford the independence required. The relationship between PHE and the local PH system is more important and there is inadequate clarity in the proposals detailed in the PH White Paper. By subsuming the functions of the Public Health Observatories (PHO) support could be offered to the DPH and commissioners at a local level in relation to the evidence on cost effectiveness, benchmarking services, dissemination of good practice, support for joint strategic assessments and other needs assessments, use of intelligence, analysis, support in developing local indicators and outcomes, performance support etc.. There must be clarity about the role of PHE and the local interface and what can be expected as soon as possible to ensure that the transition to the new system takes this into account.

3.2 The second point relates to the sub-national infrastructure for PHE. I believe that there is a need for this to be as close to the local level as possible to enable adequate support and relationships to develop. This will be crucial if the new PH system is to work as a whole system and not be disjointed. Whilst understanding that the old strategic health authority and government offices’ boundaries are unlikely to be replicated, an infrastructure echoing the four resilience hubs will not be sufficiently local enough to enable the PH system to work effectively. I understand that consideration must be given to population size when determining infrastructure but I also believe that geographical size and rurality are significant factors that should be taken into account.

4. Abolition of the Health Protection Agency (HPA) and the National Treatment Agency (NTA)

4.1 I understand that the functions of both these organisations will be subsumed into PHE during 2011–12.The local Health Protection Units (HPU) should remain and there should not be a reduction in their numbers in the North of England. The HPU covering the 12 local authority/PCT areas in the north-east has very well-established and highly effective working relationships with both local DsPH and heads of environmental health services in local authorities. This arrangement and level of support has served our population well in relation to the protection of their health. I would not want to see any dilution of this level of proactive support. The risks in relation to emergency preparedness and resilience are too great to justify reducing this support to the local multi-agency system. If the role of the HPUs is extended to enable them to become the local PHE presence, this is likely to result in confusion in the local system, particularly if the NTA functions operate from the HPU together with intelligence and epidemiological support.

If this is the case then great care must be taken to ensure the local system partners understand the working arrangements and that there remains enough qualified staff to provide on the ground advice and support to enable the discharge of robust statutory health protection functions by the DPH, GP commissioning consortia and the local authority.

4.2 I understand that the functions of the NTA as it moves into PHE are likely to incorporate a performance approach to alcohol treatment services as well as drug treatment services. I would like to see equivalent robust support from PHE in relation to all health improvement services that incorporate treatment options, eg smoking cessation services, sexual health services (including Chlamydia Screening and GUM) cervical screening services, bowel cancer screening services etc. All impact on the health of the population to a greater or lesser degree but have not been offered the same level of support from the centre.

5. The Public Health Role of the Secretary of State (SoS)

The authority and leadership of the SoS to impact across all government departments offers real opportunities to impact on health inequalities and the health of the population. Cross-government working to tackle the root causes of poor health have not always been successful, particularly in relation to the wider determinants of health which are predominantly outside the influence of the NHS. However, the current challenge of austerity and budget constraints is likely to have a massive impact on this, both at a local and national level given the correlation between poverty and poor health status and outcomes.

6. The Future Role of Local Government in Public Health

6.1 Appointment of Directors of Public Health: the proposals are for the DPH to be jointly appointed by the local authority and PHE and for the DPH to be jointly accountable to the chief executive and the Secretary of State for Health. I believe that if the role of DPH as an officer of the council is to be fully accountable to communities through elected members then the appointment process needs to be reconsidered. Localism as a concept does not involve or require central control and influence and in this context could create potential conflicts of interests for the post-holder. If the post is to be jointly appointed and have dual accountability as proposed then the parameters of this arrangement must be made absolutely clear regarding the circumstances preceding central intervention and accountability.

6.1.2 I agree that the DPH post should be a statutory requirement for upper tier local authorities and that smaller local authorities should be able to share a post where it fits local arrangements.

6.1.3 There is an interesting debate focused around the positioning of the DPH post in local authorities and whether it needs to be accountable to the chief executive.

My view is that irrespective of whether the post-holder is accountable to the chief executive or a corporate director, as long as the DPH has direct access to elected members and is not restricted to working and influencing only this one directorate but is enabled and expected to work across the organisation then the role can be effectively delivered. Realistically, in the current period of austerity and budget cuts many councils are exploring reducing their corporate management teams, not increasing their size. Localism firmly places this decision with individual councils unless legislation dictates otherwise.

6.1.4 The DPH role must have oversight and responsibility for all aspects of the health of the population thereby incorporating the three domains of health protection, health improvement and health service quality and effectiveness.

Health service quality—It is essential to ensure that GP commissioning consortia are able to make commissioning decisions based on the following with support from the DPH and public health team:

Identified health needs utilising the joint strategic needs assessment (JSNA) and the health and wellbeing strategy.

Robust local intelligence.

Best practice and evidence-based interventions.

Address and reduce health inequalities.

Take account of health equity.

Understanding hidden and hard to reach vulnerable patients as well as a population approach.

Cost effectiveness and prioritisation of resource allocation.

Health outcome measures as determined by the three national outcomes frameworks and locally agreed outcomes through the health and wellbeing board.

In the proposals for the new public health system the exclusion of this crucial domain of public health poses a risk to effective commissioning and best use of scarce resources. The DPH will in effect no longer be in the NHS and therefore there is a risk that local authorities may not consider the role should include health service quality. The role of the DPH in supporting GP commissioning consortia must be explicit in the legislation and job description so that local authorities as employers have clarity on the scope and breadth of the role and duties of the post-holder.

Health protection—the role of the DPH needs to be explicit in relation to the protection of the health of the population. The relationship and accountability arrangements with PHE and the health protection function needs to be spelt out with great clarity in the legislation and the job description for the DPH and in the constitution of PHE. The DPH must have responsibility at a local level to work with PHE on a day to day basis in the event of healthcare acquired infections, infection control issues, communicable disease control, local outbreaks such as food poisoning, immunisation and vaccination incidents, emergency planning, major incidents, environmental hazards to health, TB and Pandemic Influenza.

Health improvement—the role of the DPH encompasses this domain and as it is very pertinent to the work of local authorities it is therefore the domain they understand the most comprehensively. It is important that health improvement programmes encompass a population health perspective, some personal health level interventions and a community health perspective. The third perspective, community health, is particularly relevant in the context of localism and democratic legitimacy for health and creates opportunities for elected members to engage and work with the DPH on local issues. Existing community development programmes led by local authorities offer great opportunities to progress health improvement in communities and reduce health inequalities. In County Durham, the existing health and wellbeing partnership is supporting and facilitating the development of community health networks, coterminous with the five .shadow GP commissioning consortia, thus offering inroads to improve health at a community level.

6.2 The role of health and wellbeing boards: it is important that health and wellbeing boards have the authority to sign-off GP commissioning consortia and local authority commissioning plans to ensure that they take account of the JSNA and the local joint health and wellbeing strategy. The opportunities for improving health and reducing health inequalities are increased by the creation of these boards as long as they are given the mandate and authority to lead this agenda. Democratic leadership for health is encompassed in this approach but needs to be backed up with the appropriate authority and accountability arrangements. Further clarity is required on dispute resolution. There is potential for the role of the health and wellbeing board to include place- shaping and incorporate broader planning issues which impact on health and wellbeing in communities.

6.3 Joint strategic needs assessment: the JSNA needs to be enhanced and commissioners need to track and demonstrate how resource allocation and service developments have been shaped by the identified priorities. This has been a weakness to date. Additional support for local areas in developing and monitoring the impact of their JSNA should be provided by PHE and the intelligence functions that move from the PHOs.

6.4 Joint health and wellbeing strategy: it would be useful to have minimum guidance on the local health and wellbeing strategy but it should be flexible enough to allow for local interpretation based on population needs. The Government has decided that sustainable community strategies (SCS) are no longer required but that locally partners may determine how to develop a strategic approach to place-shaping. Currently, most health and wellbeing strategies and delivery plans will sit underneath the SCS and this has provided the accountability and mandate for partners. The accountability for the development and delivery of the joint health and wellbeing strategy will sit with the health and wellbeing board in future and the board must have the mandate to hold partners and commissioners to account for delivery and achievement of outcomes. Scarce resources will hopefully encourage cross-authority collaboration to address issues common to a number of communities.

7. Arrangements for the Involvement of Public Health in the Commissioning of Health Services

Commissioning of all health services, whether at a national, sub-national or local level should take account of public health specialist advice. It will be necessary to ensure that appropriate public health specialist expertise is made available preferably through board level membership. This is an area of public health i.e. domain three, which is absent in the current proposals but has the most potential for short term improvement in health outcomes.

8. Arrangements for Commissioning Public Health Services

8.1 This is a complex issue reflected well in the consultation paper on commissioning and funding routes for public health. Many health improvement programmes are commissioned across whole patient pathways and include primary prevention, early interventions, secondary prevention and treatment options. Examples of this include sexual health programmes, cervical screening, obesity and weight management programmes and services for children under five. These programmes are delivered by a range of providers in primary and secondary care and the voluntary and community sector and span patient pathways. The DPH and specialist public health staff have oversight and understanding of these complex arrangements and are able to trouble-shoot and intervene across the whole system if quality or patient safety issues arise. The proposed arrangements split the commissioning of some of these complex pathways between PHE, the NHS commissioning Board, the respective local authority and potentially GP commissioning consortia. This puts unnecessary fragmentation and risk into the system as it is difficult to see who will have complete oversight of arrangements.

8.2 I have major concerns that the ring-fenced budget for public health that will be allocated to local authorities by PHE will not be equivalent to the investment already made at a local level by PCTs and councils. If this is the case, then current commissioned public health improvement activity is likely to be unsustainable. This would be a real backward step for the population in the north east which suffers from poorer health than the rest of England and the outcome would be an increase in health inequalities for the most deprived communities. For example, in Easington, County Durham there has been great investment in upstream prevention work based on a socio-economic model of health involving a range of partners including the shadow GP commissioning consortia (formerly Easington practice Based Commissioning Group). The allocation needs to be sufficient to enable the transfer of existing public health specialist staff to the new public health system, whether in PHE or the local authority and to maintain the level of investment in commissioned health improvement programmes. This does not mean that local authorities will not do things differently and indeed they should but the level of investment needs to be maintained or increased in real terms if improvements in health in the most deprived communities are to be the outcome of this whole system change programme.

The on-going benchmarking and public health budget data capturing exercises undertaken by the DH over the last year have been difficult to work with due to lack of guidance or adequate definitions of activity and I have major concerns that the results will culminate in a financial envelope for public health that is considerably smaller than the actual investment locally. This is a concern echoed by DsPH across England and therefore merits some focused attention to ensure it is progressed in a satisfactory way.

9. The Future of Public Health Observatories

The proposals are to shift the functions of the PHOs to PHE. Public health intelligence and analytical skills are a specialist area and always in demand. The current capacity in PHOs must be retained in the transition and future model in PHE to ensure this resource is available to support all levels of commissioning, JSNAs and additional specialist work. PHOs have already been subjected to a 30% budget cut and this puts the resource at real risk for the future public health system.

10. The Structure and Purpose of the Public Health Outcomes Framework

A move away from centrally driven targets is welcome and the breadth of domain two in the framework offers good opportunities to impact across a range of wider determinants of health. Indicators must relate to the actual activity that is being undertaken as well as focused on overall health outcomes. Some of the proposed indicators are process and output indicators which aim to measure progress towards an outcome which is acceptable as they can demonstrate movement in the right direction. The outcomes framework must be flexible and allow for an element of local input to reflect local priorities.

11. Arrangements for Funding Public Health Services (including the Health Premium)

My views on the ring-fenced budget for public health have been captured in section 8.2 of this response and the focus in this section is the health premium. There is still no clarity on how this will be allocated, how much the total funding pot will be and what the criteria for allocation will be based upon. The health premium has massive potential to worsen the north-south divide and increase health inequalities if it is focused solely on health outcomes without factoring baseline positions, distance to travel and most importantly, deprivation and poverty.

12. The Future of the Public Health Workforce (including the Regulation of Public Health Professionals)

The current requirements for public health specialists to be registered with the UKPHR should continue together with registration for those in defined groups. Registration is the safest way to ensure the public is protected by a workforce that is fit to practice. Major consideration needs to be given to the ongoing public health specialty training programme during and after the transition to the new system to ensure continuity.

13. How the Government is Responding to the Marmot Review

I am not assured that there has been a robust and considered approach to the Marmot Review and its six policy recommendations. Indeed, some of the changes instigated nationally only serve to undermine these recommendations and are a retrograde step. If Government is serious about reducing health inequalities and improving health outcomes across the social spectrum then due and proper regard must be given to these six recommendations and national policy change should be subject to a Marmot version of health impact assessment.

June 2011