The role of local authorities in health issues - Communities and Local Government Committee Contents


5  The national perspective

Introduction

109.  The introduction of new bodies such as Health and Wellbeing Boards (HWBs) and Clinical Commissioning Groups (CCGs) will directly affect the architecture, provision and delivery of public health and health services in local areas, but the introduction of the two national bodies, Public Health England (PHE) and the NHS Commissioning Board (NHSCB), to which we have referred in previous chapters, will have a significant effect on local communities as well. We have dealt with the role of both bodies in evidence gathering, guidance and commissioning locally, but the two also have direct responsibilities for one significant area of public health: front-line health protection, dealing with infectious diseases, co-ordinating outbreak management programmes and responding to health emergencies such as flu pandemics. The arrangements for front-line health protection are another example of the complexity of the system from April 2013, which will include, for example, 39 Local Resilience Forums and 15 local PHE centres. In this chapter we consider how front-line health protection duties have been allocated and organised, the preparations locally and nationally for them and, in relation to the NHSCB, its central role in providing children's public health services and, in particular, screening and immunisation.

Front-line health protection

THE ROLE OF PUBLIC HEALTH ENGLAND

110.  On the creation of PHE, the Government said that the rationale for a national public health agency was "to bring together for the first time the full range of public health expertise," adding, "PHE will incorporate the functions of the Health Protection Agency (HPA), and thus will be responsible for front line health protection via its local centres which will support their local authorities."[258] In its evidence to us the Government described the preparatory work which had been undertaken. It drew attention to the "factsheets" and a "resource pack" that it had issued on the Emergency Preparedness, Response and Resilience (EPRR) roles of local government, and said that work was underway to ensure everyone knew their role:

The new structures and organisations will work through partnerships of the 39 Local Resilience Forums (LRF), each with a lead DPH […]. Initial responses will be led by the [Directors of Public Health], with PHE, in close collaboration with the NHS lead.[259]

111.  Several witnesses expressed reservations about the preparations for, and effectiveness of, the new arrangements. The Chartered Institute of Environmental Health described a "transition from well established, effective safeguarding arrangements to something still unclear and denuded of resources".[260] The Association of Directors of Public Health (ADPH) warned:

There remains a risk that emergencies, outbreaks and epidemic situations, will not be properly managed or responded to, may quickly escalate, and the public will come to serious harm.[261]

The ADPH pointed out that numerous agencies that might be involved in a health protection incident and called for:

clear delineation of responsibilities for health protection at local, sub-national and national levels, including the [local authority], the [Director of Public Health], the NHS and the 15 centres of PHE.[262]

The arrangements for a co-ordinated response to a health emergency locally were also a concern for the Faculty of Public Health, which described the situation as "fragmented", with responsibility spread across the local authority, the NHS and PHE.[263] Duncan Selbie, Chief Executive-designate of PHE, told us, however, that "the practical experience of outbreaks […] is that 90% of these incidents are handled locally, and always will be."[264] He added that, if a situation escalated, PHE would be responsible for ensuring that resources were in place, "so it is all about people and relationships at local level."[265] He also said, "I will do everything I possibly can to make sure that people know whom to talk to from day one and we simply do not have that risk emerging".[266]

112.  Other witnesses described an inconsistent picture across the country. Some were more content than others with the new arrangements, and with their understanding of them. Dr Nick Hicks, Director of Public Health in Milton Keynes, told us he did not share the "anxiety" of other witnesses about local arrangements.[267] In contrast, Cllr Nick Forbes, Leader of Newcastle City Council, told us that:

the fundamental point I make is we do not know whom to talk to, because Public Health England does not exist yet, apart from in shadow form. So it is not just what conversation do we have, but who do we have it with? I do not know.[268]

Cllr Mary Lea, Sheffield City Council Cabinet Member for Health, Care and Independent Living, had three concerns:

  • her council had just been informed of its responsibility for community infection control, and she told us that it "all happens in a few months, and we have only just found this out;"
  • the treatment and management of TB, which had been under the control of the Primary Care Trust, was being split between the local CCG and PHE; and
  • Sheffield's Director of Public Health "should know to whom to go to get some of the answers that we need to clarify these issues," but it was "proving very difficult for him to get the answers that he needs in order to advise us as a council".[269]

Cllr Steve Bedser of Birmingham City Council told us that he had been encouraging the NHS and local government to focus on relationship building and partnership, but

in this particular regard […] we need unambiguous wiring diagrams […] a clear line of sight from top to bottom of who is in charge, who is calling the shots, who is accountable, and we need to be satisfied as a health and wellbeing board that we properly understand that in our local context.[270]

Further witnesses told us they still had concerns about the co-ordination of a regional or national response to a health protection incident. Professor Gabriel Scally, from the University of the West of England, was:

not convinced that if we have a problem across a substantial part of the country, Public Health England would be able to provide enough staff to lead in every local area. I believe it should be the local director of public health and the local authority that leads that function, but that is not clear to me at all.[271]

Dr Peter Carter, chief executive of the RCN, wanted contingency plans made clear, and he wanted answers to the questions: "Who is responsible? When you press the hot button, who is the person on the spot that is going to be taking control?" Dr Carter concluded, "That is not clear at this stage, and that is not good".[272]

113.  When we put these concerns to Tim Baxter, deputy director of the Public Health Development Unit at the Department of Health, he said that after a recent local government self-assessment process, "the general message was that people felt they were moving forward and they understood the new arrangements". He explained:

Four contingency exercises are being planned. I am not sure whether any of them have taken place yet, but they are planned to take place before the system goes live […] I think people are clear about the general architecture. The point is more about nailing down exactly all the people in the local resilience architecture.[273]

114.  In previous chapters, we have remarked on the need for local authorities to develop sound working arrangements with health partners based on trusted relationships, leadership, persuasion and influence, but, when it comes to protecting the population in the event of a health emergency, those involved need to know unambiguously what their role is, understand who is in charge and have in place clear lines of accountability. Despite the assurances of Public Health England and of the Department of Health, we heard from witnesses who were still unclear about the details of this vital new responsibility, including who would be in charge locally in the event of a regional or national outbreak. This is a worrying state of affairs so late in the transition process. We therefore recommend that the Government sets out clearly and unambiguously the lines of responsibility, from Public Health England down to public health staff in local authorities, and confirms that Public Health England will have sufficient staff throughout the country to assist in the local and regional, as well as national, responses, in the event of a health emergency. We note that four contingency exercises have been planned before April 2013 but, to ensure that local authorities throughout the country are not only aware of, but practised in, the new procedures, we call on the Government to work with them to organise a continuing programme of such exercises.

THE ROLE OF THE NHS COMMISSIONING BOARD

115.  While PHE would be responsible for "emergency preparedness including pandemic influenza preparedness (supported by local authorities)", the NHSCB would be "mobilising the NHS in the event of an emergency".[274] Professor Scally told us that "the good thing about the NHS system as it has operated in the past is it has been possible to mobilise staff very rapidly, and I fear the loss of that."[275] Dr Penny Toff of the BMA was concerned that the new health protection

structures are very complex and not at all transparent to most people, and my main concern at the moment is what we are seeing as a result of that is huge variation [...] There is now a responsibility that will be placed on the NHS Commissioning Board's local centres, which was not there before, to make sure that there is that capacity on the NHS side to respond to these emergencies […] we will need to test out to see whether it works.[276]

Tim Baxter, from the Department of Health, told us that the task of ensuring people knew who the relevant people were in the NHSCB area teams and at the national level was "being dealt with".[277]

116.  The inclusion of the NHS Commissioning Board and its 27 local area teams in the health protection system, with its role in mobilising the NHS in the event of an emergency, and combined with the 39 Local Resilience Forums and 15 local Public Health England centres, adds a further layer of complexity and introduces potential variation to the new arrangements, with all the attendant risks. Local authorities will need to be completely clear about whom they speak to in the NHS locally in the event of an emergency, so we reiterate our recommendation that the Government and the NHS Commissioning Board ensure that these relationships are made unequivocally clear to public health staff in local government.

THE ROLE OF DIRECTORS OF PUBLIC HEALTH

117.  The Director of Public Health will have a pivotal role in the event of any health protection incident locally. Dr Penny Toff of the BMA emphasised the significance of their position, telling us, "it will be extremely important that they are given the resources and freedom to exercise that role in bringing the whole thing together locally, probably jointly with the local Commissioning Board".[278] As we noted, Professor Scally was concerned about a perceived lack of clarity regarding the Director of Public Health's role locally in the event of a regional outbreak that crossed local authority boundaries, but Ministers were keen to emphasise the responsibility of the Director of Public Health in specifically local emergencies. The Under-Secretary of State for Health, Anna Soubry MP, told us local politicians needed to ensure Directors of Public Health had the "power, respect and status within the local authority that they should have, given the job we want them to do," and the Under-Secretary of State for Communities and Local Government, Baroness Hanham, told us that in the event of an outbreak of norovirus or of TB, for example, it was "important that the local authority, local government and the public health director are together".[279]

Revised responsibilities

118.  In response to the Health Select Committee's 2011 report, Public Health, the Department of Health stated:

Local authority Directors of Public Health, supported by Public Health England, will be responsible for ensuring that plans are in place to protect the health of their geographical population.[280]

Under guidance issued in August 2012, the Department of Health expected local authorities "to ensure that partners have effective [health protection] plans in place".[281] The Faculty of Public Health told us, "There should be local responsibility with the Director of Public Health, beyond ensuring that plans are in place,"[282] but regulations introduced in February 2013 further clarified this DPH responsibility, providing only that each local authority "shall provide information and advice" to local partners "with a view to promoting" the preparation of appropriate local health protection arrangements.[283] The Faculty of Public Health told us these new regulations appeared to translate the Director of Public Health's function "into a purely advisory role, with no requirement for organisations to accept or act on the advice provided," and the Faculty added that "escalation to Public Health England (the body to which a DPH would take any concerns) risks unnecessary delays in responding to emergencies and puts the public at risk".[284]

119.  Tim Baxter, from the Department of Health, told us that giving local authorities a similar duty to that of the Secretary of State—to protect the health of the population—"would not have worked",[285] and when we asked him whether this meant the Health and Social Care Act 2012 was not quite as localist as we thought it might have been, he said there were a lot of situations in which it was "central Government's responsibility to ensure that the population's health is protected."[286] Cllr Mary Lea, Cabinet Member on Sheffield City Council, told us it would "prove very difficult" for Directors of Public Health to ensure the safety of people in the city "when other people have the authority and resources for commissioning these services",[287] but Mr Baxter emphasised that if any local body ignored the advice of the Director of Public Health, "they had better be pretty clear that they are doing it on the right basis".[288]

120.  We acknowledge the legal issues, raised by the Department of Health, which might arise from giving local Directors of Public Health a similar duty to the Secretary of State to protect the health of the population, but our main concern is with the practicalities. Given the importance that the Government has attached to the role of the Director of Public Health, it must make sense to include them as fully as possible in ensuring, rather than simply advising on and promoting, adequate preparation for local health protection arrangements. The Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) Regulations 2012 risk diminishing the authority of the Director of Public Health and creating delays while concerns about local preparedness are taken to Public Health England. We therefore recommend that the Government review these regulations, in order to enhance with identifiable authority the power, respect and status that the Government suggest should be accorded to Directors of Public Health.

Screening, immunisation and the NHS Commissioning Board

121.  Strategic Health Authorities and Primary Care Trusts have been responsible for commissioning screening and immunisation programmes from secondary care providers, general practices and others. PHE does not formally take on its responsibilities until April 2013, but it is expected that some of its staff will be seconded to NHSCB local area teams, which will be responsible for "system leadership" and "co-ordination functions" and will commission screening and immunisation services.[289] Day-to-day management of these public health staff will be through the NHSCB local area team, but as holders of key public health posts the staff will be professionally accountable to and have their professional development needs met through PHE.[290]

122.  Dr John Middleton, Sandwell PCT's director of public health, had:

very little confidence in what I have heard described in relation to screening, immunisation and emergency planning around the NHS Commissioning Board.

He added:

The staff we have trained and developed in Sandwell who are involved in screening and immunisation on a daily basis are destined for Public Health England and to be seconded to the National Health Service Commissioning Board and managed by heads of public health commissioning with no qualification in public health necessarily. You would not invent that system if it was not for the extraordinary difficulties that the health reforms put us in.[291]

Professor Scally said that, initially at least, the "clear but informal view" was that the NHSCB did not want any public health staff and would deliver the services itself, and he said he found the "whole way in which this (the transfer of screening and immunisation services) has been pursued unsatisfactory in terms of its delay and its fragmentation".[292] Responding to Dr Middleton's points, Duncan Selbie, Chief Executive-designate of PHE, accepted that there was

an issue about screening and immunisation. I agree that we would not have invented this, but it is my job with others to make sure that we have a safe transit.[293]

Tim Baxter, from the Department of Health, acknowledged that "we did not redesign the whole health system with screening and immunisation in mind," but he cited the introduction of a single national commissioner, evidence-based commissioning and the secondment of PHE staff to the NHSCB as representing "an improvement on the current arrangements".[294]

123.  Several witnesses expressed concern that the new arrangements, based on a national approach, would fail to take account of local diversity. Westminster City Council told us it wanted "to ensure that local diversity is fully considered in national immunisation and screening programmes,"[295] adding that with 30% or 40% population churn a year in some wards a person could be on one list, not receive their screening, move and not appear on the list in their new area.[296] Cllr Nick Forbes, Leader of Newcastle City Council, cited Sure Start as an example of the "reach that local government has to communities in very different ways from the Health Service", and he concluded that making screening and immunisation a responsibility of the NHSCB, rather than one of the local authority's arrangements, missed "the local flavour" of what was needed in order to ensure consistency across the board.[297]

124.  We noted above the division of TB treatment and management between local CCGs and PHE; TB screening and immunisation will be delivered by a third body, the NHSCB. The Health Minister, Anna Soubry MP, stressed the benefits of locating these services with the NHSCB's 27 local area teams. She explained that local councillors and GPs would be able, through their HWBs, to "make their representations to the local NHS commissioning board […] in a much better way because it is far more locally focused," and that in this way public health delivery locally "could be hugely beneficial, drilling right down to communities and sometimes within wards".[298] Sheffield City Council pointed out that while:

the DPH will have to be assured that screening programmes are working well locally [...] they will be commissioned by another organisation (PHE), working in a second one (NHS CB LAT) and from a variety of other organisations (local Foundation Trust, GPs etc.)[299]

Describing the situation in the north-west, Liam Hughes, independent Chair of Oldham's shadow HWB, said that the 2012 measles outbreak on Merseyside showed just how serious the situation was and why people needed to take it seriously, and he added: "I do not think I am reassured. Although I know people are working as well as they can locally, personally I am not yet reassured".[300]

125.  We heard serious concerns about the new arrangements for screening and immunisation, particularly the fragmentation of staff and organisations responsible for these services. We accept that local authorities will be able to work with the 27 NHS Commissioning Board Local Area Teams, but as we have already noted¯there are concerns about the ability of local government to influence the Board's decisions. In addition, when it comes to screening and immunisation there are additional concerns about the number of bodies the Director of Public Health will have to work with, and the Board's ability to reflect local diversity and to reach into local populations as effectively as local authorities can. We urge the Government and the NHS Commissioning Board to listen to local authorities, to respond to their calls for reassurance and we recommend that the Government reviews the arrangements with a view to devolving these services to public health staff within local government.

CHILDHOOD SERVICES

126.  When we visited Sweden as part of our inquiry, we were taken to a project called the Familjens hus (Family house), part of a joint county council and municipality-run health and social care programme in the town of Norrtlje, north-east of Stockholm. The Familjens hus was an integrated health and social care centre providing services for families and children from nine months to 23 years old, including an open pre-school centre for children up to six years old, a young person's clinic and a meeting point for school nurses. The staff there also worked in and with schools on children's health programmes, including vaccinations.

127.  In contrast in England, when the new arrangements start on 1 April, the "directors of public health will be the first public health officials in local government ever, or medical officers of health, who have had no responsibility [...] for childhood immunisation".[301] As we noted, the division of responsibilities under the new arrangements for children's public health in England has been a cause for concern. Children's public health services for those aged 0 to five years will be commissioned by the NHSCB. Cllr David Rogers told the Health Committee's 2011 inquiry into public health, "it doesn't make sense for school nursing to be in one place and health visiting to be in another".[302] Kent County Council also referred to that arrangement, when it told us:

From a children's services perspective a number of concerns have been raised, and in particular there will be challenges around interfaces and areas which require synergy e.g. Health Visiting and School Nursing.[303]

Health visiting, as part of the Healthy Child programme, will be commissioned by the NHSCB, while school nursing will be with local authorities. Cllr Forbes from Newcastle, when he raised the public health aspects of Sure Start, said that it provided "a great way" of reaching parents and people "who are most likely to slip through the traditional Health Service net—the people who might get one of the MMR vaccines, but not all three".[304] The Government have stated, however, that these arrangements are "a time-limited approach" until 2015 "to ensure that the necessary steps are taken to meet the Government's commitment to increased health visitor numbers".[305]

128.  Given the importance of early years interventions, and the reach that local authorities have into their communities, the Government should work with councils on devolving further responsibilities for children's public health, such as the Healthy Child programme, to local government—and guarantee at least that responsibility for health visiting will be transferred to local authorities in 2015, or when the target for increasing health visitors has been met, whichever is earlier. The Government should, as part of a general move to locate children's public health services in local government, also agree to a timescale for placing childhood immunisation services under the control of Directors of Public Health, in acknowledgement of their previous responsibility for this area and of the pivotal position that they now occupy in local public health provision.


258   Ev 166 Back

259   As above Back

260   Ev 79, para 3.1 Back

261   Ev w36 Back

262   As above Back

263   Ev 86 Back

264   Q 20 Back

265   As above Back

266   As above Back

267   Q 22 Back

268   Q 212 Back

269   Q 212 Back

270   Q 105 Back

271   Q 104 Back

272   Q 108 Back

273   Q 300 Back

274   NHS Commissioning Board Factsheet, www.commissioningboard.nhs.uk/files/2012/07/fs-ccg-respon.pdf Back

275   Q 104 Back

276   Qq 109, 110; according to an NHS factsheet on commissioning responsibilities, NHSCB local area teams will have a responsibility to co-operate with PHE and local authorities on outbreak control and to mobilise the NHS in the event of an emergency, NHS Commissioning Board Fact sheet for clinical commissioning groups, July 2012, www.commissioningboard.nhs.uk/files/2012/07/fs-ccg-respon.pdf, p 8. Back

277   Q 300 Back

278   Q 109 Back

279   Q 300 [Anna Soubry MP]; Q 303 [Baroness Hanham] Back

280   Government response to the House of Commons Health Committee's Twelfth Report of Session 2010-12, Public Health, CM 8290, para 67 Back

281   Department of Health, guidance, "Health protection in local government", www.dh.gov.uk/health/files/2012/08/9739908HP_in_LG_factsheet_v4_29_August.pdf p 7. "Partners" include an NHS body, a Chief Constable, a fire and rescue authority, a district council, Public Health England, schools, social care services, voluntary bodies and businesses. Back

282   Ev 86 Back

283   The Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) Regulations 2013, 2013/351 Back

284   Ev 89 Back

285   Q 336 Back

286   Q 337 Back

287   Q 209 Back

288   Q 335 Back

289   Department of Health, Letter to health organisation chief executives, 23 August 2012, https://www.wp.dh.gov.uk/publications/files/2012/08/2900372_ImmScreening_PostApril2013_acc.pdf Back

290   Department of Health, Letter to health organisation chief executives, 23 August 2012, https://www.wp.dh.gov.uk/publications/files/2012/08/2900372_ImmScreening_PostApril2013_acc.pdf Back

291   Q 23 Back

292   Q 117. Under the £5 billion draft interim budget, £2.2 billion would have gone to local authorities and £2.2 billion to the NHSCB. The remainder would have gone to Public Health England. Back

293   Q 24 Back

294   Q 296 Back

295   Ev 121, para 32 Back

296   Q 205 [Cllr Anthony Devenish] Back

297   Q 208 Back

298   Q 298 Back

299   Ev 131, para 28 Back

300   Q 208 Back

301   Q 51 [Professor Scally] Back

302   Health Committee, Public Health, para 234 Back

303   Ev 145, para 8.5. Health Visiting will be commissioned by the NHSCB; school nursing by local authorities. Back

304   Q 208 Back

305   Government response to Health Committee, para 62; the measure is time-limited until 2015. Back


 
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Prepared 27 March 2013