HC 1048-III Health CommitteeWritten evidence from the Greater Manchester Directors of Public Health Group (PH 106)

The 10 Directors of Public Health work as part of the Greater Manchester (GM) PCTs Cluster and the Greater Manchester Public Health Network. However the Directors of Public Health also have a professional responsibility to work independently to hold to account statutory agencies for their contribution to public health gain. This submission is written on behalf of the 10 Directors of Public Health in Greater Manchester working as independent advocates for public health. This submission does not necessarily reflect the views of the GM PCTs Cluster or the Greater Manchester Public Health Network.

1. Background to the GM DPHs Group

1.1 The 10 DPHs in GM work together, complementing local action, as independent advocates for Public Health in the conurbation and part of the GMPCTs Cluster.

1.2 We co-ordinate the GM Public Health Network – a programme exploiting collaborative advantage in addressing GM’s health inequalities. We oversee leading edge programmes of work, operate and support robust GM wide partnerships, and deliver improving health outcomes for GM’s people.

1.3 We also provide professional leadership and guidance to the GM Health Commission – one of several Commissions established by the Association of Greater Manchester Authorities to drive the new GM Combined Authority and Local Enterprise Partnership. These bodies recognise GM as a highly-coherent functional economic area, a conclusion supported independently by the Manchester Independent Economic Review (MIER).

2. Summary

2.1 On each area referred to we comment as follows:

the creation of Public Health England (PHE) within the Department of Health (DH);We believe PHE should be an NHS body;

the abolition of the Health Protection Agency and the National Treatment Agency for Substance Misuse;We fear loss of local links and relationships with Directors of Public Health;

the public health role of the Secretary of State;We think the role should be to represent the health of the people across Government on key issues like the alcohol epidemic, active travel’s role in preventing obesity, the strength of civil society and the role of poverty and income inequality. Legislation on such issues should be included in Health Acts. Litigation to protect public health is an issue;

the future role of local government in public health (including arrangements for the appointment of DPHs; and the role of Health and Wellbeing Boards, JSNAs and Joint Health and Wellbeing Strategies);DPHs as health professionals treat a population. They have a multiagency challenge role, should be properly professionally qualified, managerially accountable to the Chief Executive with right of access to elected members and freedom to put their views into the public domain. The Health & Well Being Board as the democratic strategic voice in the NHS should have powers to require compliance with the health and well being strategy by commissioners, providers and those influencing the determinants of health. Public health staff should be employed by an NHS body (PHE if it has that status) and placed in local authority areas;

arrangements for public health involvement in the commissioning of NHS services;Health care public health should be population-based across local authorities and commissioning consortia, working at local level but achieving critical mass and epidemiological stability by cooperating at a larger population level with which NHS Commissioning Board outposts should align;

arrangements for commissioning public health services;The child health programme should not be divided at age five. The public health contribution of primary care should be accounted for;

the future of the Public Health Observatories;These important bodies have already lost critical capacity whilst Government thinks about them;

the structure and purpose of the Public Health Outcomes Framework;We emphasise inequality and the relation between different frameworks;

arrangements for funding public health services (including the Health Premium);We describe potential dangers in the current approach;

the future of the public health workforce (including the regulation of public health professionals); Workforce development and planning is needed. Capacity building is needed in frontline NHS and local authority staff as well as specialists. There should be statutory registration of non-medical specialists; and

how the Government is responding to the Marmot Review on health inequalitiesWider determinants are being neglected. We advocate a reporting framework for all Marmot recommendations to support cross governmental action on social determinants of health.

3. Our Response to the White Paper

3.1 We welcomed the core principles, recognised the local authority contribution to the wider determinants of health and health inequalities, and seek to work across the whole local authority and other partners for best population heath and reduced inequalities. We welcomed the focus on the DPH as an authoritative, independent and influential leader, shaping local services and delivering a public health vision. 

3.2 The white paper reflects and partially advances the Marmot Review. Health inequalities are a challenge within GM and between GM and the rest of England. We welcomed the life course approach and commitment to “improving the health of the poorest fastest”. We supported a new, integrated, national public health service, PHE, to drive health improvements.

3.3 We will exploit opportunities for stronger Local Authority leadership on population health and health inequalities. However we fear potential fragmented public health expertise, absence of HR arrangements for transfer, and confused responsibility between PHE, the National Commissioning Board, and Local Authorities. Discussions with the LGA and others suggest value in local public health staff being formally part of PHE allocated to local authorities’ local teams, strengthening public health leadership and professionalism, providing resilience and reducing potential for overlapping responsibility.

4. Reponses to the Committee’s Areas of Interest

4.1 The creation of PHE within DH

4.1.1 PHE’s roles, responsibilities and nature need clarifying

4.1.2 PHE as part of DH will be a civil service body unless it is recognised that normal models of civil service organisation are inappropriate for some of its functions and alternative provisions explicitly made for areas such as

occasions requiring separate policy functions and programme delivery;

areas where PHE directly provides services needing a system of management more akin to an NHS body;

areas where PHE or its agent directly commissions services needing to be more interventionist than for policy and regulatory roles;

areas where PHE or DH have duties to the public and the political process rather than solely to Government, including areas where the independence of the CMO is to be promoted;

negotiation of responsibility deals, whether done by PHE or DH needs an underpinning power of regulation to be taken seriously;

research - academic contracts should be used and academic freedom, scientific integrity and the right to publish recognised;

workforce development; and

external consultancy.

4.2 The abolition of the HPA and NTASM

4.2.1 PHE could provide a strategic framework and context for isolated parts of the national system. However these arrangements could lose their relationship to local working. The GM Public Health system has an excellent working relationship with the local Health Protection Unit, with mutual respect, and recognition of the roles of the lead DPH and the professional expertise of HPA staff. We plan to co-locate the health protection agency with the GM Public Health Network unifying public health leadership in the conurbation. PHE need not obstruct this but unbalancing of the local partnership would constitute a step backwards.

4.3 The public health role of the Secretary of State

4.3.1 The duty to promote equality should relate to equality of outcomes not just of access

4.3.2 Legislation to improve health should be included in Health Acts, starting with the current Bill. There are many possible broader policy areas which would not previously have been included such as the following;

Transport and health.

Spatial planning.

Pricing of energy for heating.

4.3.3 On the issue of legal action (such as judicial review or applications for injunctions) in the interests of public health we have nothing to add to the evidence of the Transport & Health Study Group.

4.4 The future role of local government in public health (including arrangements for the appointment of DPHs the role of Health and Wellbeing Boards, JSNAs and Health and Wellbeing Strategies)

4.4.1 DPHs will manage the services transferred from PCTs but also have a multiagency challenge function. The Bill currently recognises only the first of these. DPHs should not only be local authority officers but also health professionals treating a population, local representative of PHE and independent advocates for health. In the last of these roles they operate across the whole of the public, commercial, voluntary and community sectors.

4.4.2 Public health specialists are change agents for improving the health of the people. Corporate authority and independent advocacy are mechanisms to be used in balance.

4.4.3 The following roles require more than corporate authority.

Preparing an independent professional report on the health of the population every year.

It is the duty of the DPH to act as the advocate of public health within all areas of the local authority and to keep health at the forefront of many areas of local authority decision making eg the provision of walking and cycling infrastructure.

Undertaking health impact assessments of local authority policies, programmes, and services.

Professional public health advice (rather than corporate advice) to other public and private bodies active within the area.

A centrepiece of public health practice is the promotion of a big society which will address the cultural determinants of health in local communities. People do not alter their norms of behaviour in response to bureaucratic messages and the DPH must be close to their communities showing an open and hones professional commitment to their well being.

Public health plays a part in local professional leadership. The profession would be concerned if this were lost or if it became merely a bureaucratic role. The Chair of the Health & Well Being Board needs the protection of being supported by somebody who will be valued as a professional colleague by health care professionals including doctors. The local authority needs the influence that comes from that person’s participation in local professional leadership.

The DPH should be a statutory consultee in local planning, transport and environmental issues and should participate in such processes in accordance with professional judgment.

When DPHs conduct, or comment on, health impact assessment it should only be their professional public health opinion which influences their judgment.

4.4.4 Prioritisation of tackling health inequalities would be strengthened by nationally requiring the DPH to be accountable directly to the Local Authority Chief Executive (in addition to the Secretary of State) with a right of access to elected members.

4.5 Public health involvement in commissioning NHS services

4.5.1 The subspecialty of health care public health is concerned with optimising the contribution the health care system makes to the health of the people. It is concerned with:

the contribution the provision of healthcare makes to the health of the people;

the optimisation of resources;

the application of population perspectives to the use of evidence; and

the application of evidence to the organisation of health services and the assessment and prioritisation of population needs for healthcare.

4.5.2 There are about 200 public health specialists practising this subspecialty. Ideally there should be a health care public health specialist in each health and well being board area. It is also important that GP consortia have a direct public health input. The only way that both of these criteria can be achieved is if joint appointments are made either through joint employment, through secondments or through honorary contracts.

4.5.3 Health care public health needs a critical mass of analytical and intellectual capacity. It also requires epidemiological stability of need – a population large enough (at least a million) that predicted needs will not vary randomly to a destabilising degree. To achieve this, specialists, working locally should cooperate over a larger population in a team which has critical mass (at least four). To get to this point, workforce planning and workforce development is needed.

4.5.4 The NHS Commissioning Board should have a footprint at the same spatial level as the Greater Manchester Combined Authority, to align decision making overseen by a Greater Manchester Health and Well Being Board.

4.6 Commissioning public health services

4.6.1 The division between local programmes and the role of the national commissioning board for under5s undermines the crucial whole family concept. Different commissioning arrangements for young children will complicate co-ordinated activity, contrary to the Marmot’s whole life course approach.

4.6.2 Commissioning of primary care services has the potential to be remote from core public health interventions. In some areas improvements in primary care are preconditions of tackling inequality.

4.7 The Public Health Observatories

4.7.1 We are concerned about the current position and future role of the Public Health Observatories. Excellent and independent public health intelligence is a cornerstone of public health practice. The current uncertainty around the future of observatories is of great concern. Government is not taking the steps necessary to preserve the skills in the Observatories, whose existence is being prolonged only by a short term extension with no clear strategy. Capacity and direction has already been lost, just when intelligence led public health and health system practice requires it most –supporting identification of interventions of best practice and value. Loss of expertise reduces the likelihood of QIPP delivery and makes the service more reliant on expensive and often less valuable intelligence.

4.8 The Public Health Outcomes Framework

4.8.1 We proposed amendments to the range of indicators.

4.8.2 Inequality is key in developing the indicator set - data collection and reporting must address health inequality (for example using postcode or ethnicity).

4.8.3 A separate outcomes framework for public health could cause other associated frameworks, including the adult social care framework and the NHS outcomes framework not fully to reflect the priority afforded to public health. All 3 outcome frameworks need to consider population health and reducing inequalities.

4.8.4 We seek assurance that actions associated with the indicator set are fully embedded in related cross government programmes eg the commitment to addressing fuel poverty must be aggressively pursued with energy retailers.

4.9 Arrangements for funding public health services

4.9.1 Concerns with the proposed funding arrangements include:

additional responsibilities loaded into local public health services;

reduction of local public health budget to support the creation of Public Health England, by “top-slicing” to support arrangements at the national level, potentially creating a net reduction in public health spend locally;

unless ACRA’s allocation formula corrects the historic underfunding of NHS activity in Greater Manchester, health inequalities will continue;

inequalities must be weighted appropriately in allocation formula. The weighting for inequalities in the PCT allocation formulae for 2011/12 has been reduced from 15%, to 10%. This shifts target and actual allocations from poor health PCTs to good health PCTs. Other changes and the very slow pace of change partially obscure the effect but there is still a general shift of resources from deprived to prosperous areas; and

basing overall funding of PHE on 2009-10 sums institutionalises recent cuts in public health funding instead of reversing them.

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

4.10.1 General Public Health Workforce development.

Workplace development needs in public health arise from transition to new employers and existing shortages.

The whole Public health workforce, not just Public Health Specialists, should work as change agents.

Public health capacity building is needed with frontline staff in the local authority. NHS provider organisations including primary care using competency based frameworks in planning and growing the workforce.

Government views workforce development as a local problem but shortage of specialists will undermine an arms length approach with seriously disruptive short term effects. In particular retirements due to dissatisfaction with the new proposals coupled with loss of new entrants due to disruption of training could worsen the shortage of specialists. Loss of trainees at the end of training due to reorganisation-induced vacancy freezes is particularly wasteful.

Diversity of employers may lead to professional isolation with variable support.

Some areas may not attract needed specialists.

Training should remain within the medical professional training system, with continued arrangements for non-medical entrants alongside medical ones but with a broader range of training placements.

Workforce development is needed to support public health specialists who focus on health care; PHE, the NHS Commissioning Board and Monitor need to work together.

Information analysis is another important area of shortfall.

PHE should take on workforce development with reserve powers to ration scarce resources and apply training levies.

4.10.2 We referred previously to the importance of non-medical specialists in public health. As they are often appointed to roles identical to those occupied by public health specialists from a medical background, including DPHs, public protection requires that they should have a similar system of statutory registration commanding public confidence and conferring a status equal to that of medical specialist registration.

4.11 How the Government is responding to the Marmot Review

4.11.1 We recognise the White Paper’s response to the Marmot Review with a strong focus on health inequalities and the Life Course approach. However Marmot challenged all to recognise health as a measure of well being, and well-being as a more important societal goal than simply more economic growth. We would wish to see the presentation of all aspects of government policy in the context of health inequalities. There are for example specific recommendations in the Marmot Review on:

paid parental leave;

the take up of early years educations from families in areas of greatest deprivation;

increased availability of non vocational life long learning opportunities;

the provision of support and advice on training and employment opportunities;

encouraging, incentivising and enforcing measures to improve the quality of jobs;

developing greater security and flexibility in employment;

developing and implementing standards for minimum income for healthy living;

improving active travel across the social gradient; and

a national target that progressively increases the proportion of households that have an income, after tax and benefits, that is sufficient for healthy living.

4.11.2 We would wish to see a reporting framework for all recommendations from the Marmot review to allow and support cross governmental action on tackling the social determinants of ill health.

June 2011

Prepared 28th November 2011