Communities and Local Government CommitteeWritten submission from the Chartered Institute of Environmental Health (CIEH)

1. Executive Summary

1.1 The period of transition from existing public health arrangements to new ones which are not yet completely clear, is fraught with danger, especially in respect of the uncertainty of the arrangements for health protection.

1.2 It is right for local authorities to be responsible for leading the local delivery of England’s new public health service. They have the democratic legitimacy and accountability and they are capable of the necessary strong leadership.

1.3 Environmental health practitioners, who are working in all sectors and in all communities, are well placed to help make key contributions to the successful implementation of the new public health arrangements.

1.4 In those parts of England with multi-tier arrangements for local government, it is essential that the efforts of all the councils are engaged in improving the health and wellbeing of their communities.

1.5 The proposed ring-fenced funding for local authorities for their new public health responsibilities is insufficient for the purpose and at risk of being unfairly distributed.

2. Recommendations

2.1 It is essential that four things should happen quickly:

2.1.1Local authorities must be assured that the funding being transferred from the NHS for commissioning additional public health services will be adequate to meet local need and that the move to the fair share allocation will be through an agreed and fair process.

2.1.2Public Health England must establish and publish its “standard offer” which must match, at the least, the current level of support provided to local authorities by the HPA and its health protection units.

2.1.3A mechanism such as a Service Level Agreement should be developed and put in place to ensure that Directors of Public Health have a binding commitment from NHS organisations to respond when called on for technical support and planning and emergency capacity.

2.1.4All local authorities should consider the nature of the current services they provide in the context of public health gain and how resources for the new public health service, deployed alongside existing services, will be allocated and managed.

2.2 In the absence of the above immediate actions, local authorities will not be able to plan for effective arrangements to keep the public safe from health threats, which by their nature are unpredictable and may be “unknowns”.

3. Health protection arrangements in England are crumbling, just when they need to be strong

3.1 The transition from well-established, effective safeguarding arrangements to something still unclear and denuded of resources is filled with risk. We only need to recall last year’s E.coli outbreak in Germany and this year’s Legionnaire’s Disease outbreak in Edinburgh, and more recently Staffordshire, to appreciate that the stakes are high.

3.2 The success of the current arrangements is built on a strong three-way partnership between:

Local authorities.

Health Protection Agency.

NHS organisations led by Directors of Public Health and their teams.

3.3 Directors of Public Health and their teams are moving to local authorities. It is unclear if they will be able to lead or engage the same NHS response, as previously available to them, when they are no longer employed within the NHS.

3.4 The Health Protection Agency (HPA) is being abolished, although its staff and other assets will form part of the new executive agency which will comprise Public Health England. The Department of Health has stated that the HPA’s premises (its four remaining laboratories and twenty five health protection units included) will be retained by Public Health England, although the latter’s organisational design sets out plans for four regional offices and 15 centres.

3.5 In addition, the HPA is managing substantial budget reductions and there is no clarity yet about the “offer” that Public Health England will make to local authorities.

3.6 Local authorities are therefore in the position of “last man standing” in the provision of an effective health protection service. It can be anticipated that with environmental health teams at its core, and reinforced by the arrival of Directors of Public Health and their teams, the service will hold. However, local authorities are also managing major budget reductions causing them to shed staff including those providing this service.

3.7 In addition, the CIEH doubts that the total pot of money, out of which the new ring-fenced grant will be paid to local authorities, will be adequate to maintain the service. This we believe will be a significant cause of tension between (1) the bedding down of the new arrangements and (2) the consideration of wider public health improvement strategies. Of course local authorities should be preparing to incorporate existing and new commissioned services into their forward planning.

4. The CIEH consistently supports the Government’s proposal for local authorities to lead England’s new public health service locally

4.1 The CIEH is convinced by the variety of evidence available that health inequalities are long-standing, are determined by a “social gradient” of health and can only be tackled effectively by addressing all the causes, including the social causes, in a holistic and co-ordinated way as well as the proportionate universalism advocated in the Marmot Review. This is in accordance with the Government’s own views expressed in the documents supporting the new arrangements for the organisation of public health management and delivery.

4.2 Similarly, it is right that local authorities should lead this new approach locally because of their democratic legitimacy, their public accountability and their knowledge of local conditions. These attributes make local authorities ideal leaders of a more determined population-wide effort to improve health and wellbeing and reduce health inequalities. Councillors will readily grasp the social injustice of differences in life expectancy and lives lived free of disability determined by wealth and where people live.

4.3 Environmental health services in local authorities today perform a wide range of public health-related activities which include: air pollution control; emergency preparedness, resilience and response; food safety and promotion of healthy eating; supporting health improvement programmes such as smokefree environments, sensible drinking and increasing physical activity; health protection; housing conditions (in the private rented sector in particular); occupational safety and health; pest control; waste management and water safety. They often also lead on activities to address issues of climate change (adaptation and mitigation) and sustainability.

4.4 More important than the individual services provided by environmental health teams in local authorities, is their ability to make things happen. They have exactly the right skills needed to achieve the stated aims of the new public health service: seeing the holistic solutions to population-wide problems; putting together appropriate partnerships and working collaboratively with them; engaging with relevant communities (including communities of SMEs); managing service delivery and monitoring and evaluating outcomes.

4.5 Despite the Department of Health’s stated commitment to the recommendations contained in the Marmot Report (2010), the Government does not appear to appreciate the scale of what is achievable by local authorities, their communities and their partner organisations in tackling the “causes of the causes” of ill-health, both the mental and physical aspects.

4.6 What the local authority lead makes possible is the industrial-scale application of “prevention” being better than “cure”. This requires a multi disciplinary approach, with health and well being boards taking account of not just the topical headline issues but integrating the existing health and environmental protection functions into cohesive programmes which will require longer term leads-in and planning with budget certainty over a period of time to enable the results of such programmes to be evaluated.

4.7 There is therefore an opportunity to create the synergy between new and existing programmes of work under a meaningful public health banner. Health and wellbeing boards must be forceful in establishing that the joint health and wellbeing strategies will determine the future of all relevant local services. This means local authorities, CCGs and the wider NHS integrating their own services, shaping the services provided by others and securing widespread public involvement in order to achieve the necessary higher gains with reduced resources.

5. Environmental health practitioners have a proven track record in directing population-based interventions

5.1 Environmental health practitioners (EHPs) have been involved in the design and delivery of interventions that address the wider determinants of health for centuries. They have done this by working holistically in partnership with others which is one of their strengths.

5.2 A modern-day example of this ability is their contribution to both developing the arrangements and securing compliance with the requirements for smokefree workplaces and enclosed public places. This measure has been described by a previous Chief Medical Officer as representing a “footprint in the history of public health” and is now being followed by other countries around the world. EHPs worked in partnership with many others to achieve not just the acceptance of this public health policy but also the incredibly successful implementation of these measures with virtually complete compliance in a very short space of time.

5.3 A current example of EHPs leading a large multi-agency public health programme is Liverpool’s Healthy Homes initiative. Liverpool’s award-winning programme is a very effective environmental health-led approach to improving health and wellbeing and reducing health inequalities in parts of the City of Liverpool where residents experience a range of disadvantages, including in relation to their housing conditions. Major activities of the programme include:

Access to medical practitioners (GPs and dentists).

Benefit maximisation and employment access advice.

Energy efficiency measures.

Housing condition improvements.

Specialist Advocates using a bespoke Single Assessment Process.

5.3 It is this central role within local authorities that led a former Chief Medical Officer in 2001 to describe EHPs as the only local government professional considered to be a full-time public health practitioner, evidenced in his description of the environmental health practitioner as: “Professionals who spend a major part, or all of their time, in public health practice”. It is a role that has not changed; indeed it has been enhanced by focussing on increased joined-up working between and within local authorities.

5.4 Hence in England’s local authorities EHPs provide a unique capacity to co-ordinate this “upstream” public health activity in every community. It is an ability demonstrated by the joint Memorandum of Understanding between the CIEH and the Health Protection Agency in respect of health protection arrangements for responding to incidents and outbreaks of communicable disease and harmful pollution.

5.5 EHPs are not only active in local authorities, they also work in many business settings where they bring the same science-based, problem-solving knowledge and skills to bear. This is particularly relevant for the key aspect of the Government’s approach to improving the nation’s health, namely the emphasis on behaviour change and acceptance that public health is everyone’s responsibility.

5.6 Nationally, the Government is pursuing this aspect in part through its engagement with businesses in the Public Health Responsibility Deal. There is every reason for the new Health and Wellbeing Boards to pursue a similar strategy with businesses locally, for example in workplace wellbeing, healthier food products and warmer, safer homes.

5.7 EHPs working for those businesses can contribute to the development, implementation, monitoring and evaluation of responsibility deal-type pledges. They already work in the key areas of occupational health and safety, food hygiene and nutrition and housing conditions in the private rented sector.

5.8 EHPs in the private and public sectors are well placed to harness these approaches through existing structures where businesses and local authorities work together, including community safety partnerships and local enterprise partnerships, for example.

5.9 Leicestershire’s “Better Business for All” is an excellent example of businesses and local authorities sharing local responsibility for achieving commonly agreed outcomes. That particular initiative has its roots in a shared desire to improve business compliance and the approach taken by regulatory services and there is good reason to expect that it can apply equally effectively in respect of public health.

6. A joined-up approach in multi-tier areas is essential

6.1 Leicestershire is an example of the one-third of England with two-tier county and district local government arrangements.

6.2 In two-tier local government areas of England, the CIEH believes that district councils should have representation on, or some equally effective means of influencing, their county’s health and wellbeing board. In keeping with the spirit of localism it is essential that the district councils are engaged in determining the best arrangement for their involvement. This is particularly relevant at a time when a county’s total resources for its public services, including its public health service, will be scarce and there is such a pressing need for synergistic service provision.

6.3 The Secretary of State has said that the challenge of co-ordinating public health services in two-tier local government areas will be through the health and wellbeing boards. This intent clearly does not take into account the wider opportunities for joining up public health strategies and interventions across all tiers of local government because the health and wellbeing boards will be, as we understand it, focussed on the management of commissioned services. While it will be open to county and district councils to agree for there to be a number of subsidiary health and wellbeing boards in the county—this should not be a reason for excluding the district councils from the county’s health and wellbeing board.

6.4 The CIEH’s evidence to date tells us that practical experience of co-operation at this local level is mixed. Some district councils have excellent joint working arrangements with their counties for public health service delivery, including representation on the health and wellbeing board and good channels of communication. Others have no direct involvement yet in their county councils’ shadow health and wellbeing boards. As a result, some elected members and officers in district councils express frustration that they do not know enough about the public health plans of their county councils.

6.5 The CIEH will actively support any work to devise the most effective ways for county and district councils to work together in order to deliver an effective public health service for all their citizens.

7. The funding is in danger of being too little and unfairly distributed

7.1 The proposed formula for determining and distributing the new public health grant allocations to local authorities has been advised upon by the Advisory Committee on Resource Allocation (ACRA) and informally consulted upon by the Department of Health.

7.2 It is well recognised that standardised mortality ratio statistics are not closely related to deprivation. Yet the Public Health Outcomes Framework says we are to improve the health of the poorest fastest. Resources must be targeted towards deprivation, while not losing sight of Marmot’s “proportionate universalism”.

7.3 The Department of Health has given assurances that no local authority’s ring-fenced grant will be lower than the current level of spending on public health services in their area (by primary care trusts). However, for a local authority with high levels of deprivation and poverty, a formula which does not explicitly distribute the grant funding by reference to such matters will see its ability to address health inequalities decline over time.

7.4 In the longer term we need a formula based directly on underlying drivers of need including measures of deprivation, population growth, population churn, numbers of older people and morbidity levels.

7.5 The CIEH believes that the forecast of £2.2 billion available for local authorities is insufficient by an order of magnitude of 50%. As councils establish and initiate the operation of their public health services they are in danger of being set up to fail.

8. Conclusion

8.1 The CIEH asserts that the work of environmental health as currently practiced in local government is a primary preventative public health improvement and health protection function, addressing food safety dangers, controlling the sources and tracing outbreaks of infectious disease, improving and enforcing safe working practices, preventing environmental pollution and protecting the vulnerable from the effects of poor housing condition.

8.2 Such essential functions must be maintained and taken into account when determining what resources a locality has available to it to address public health need. Our concern is that health and wellbeing boards as currently envisaged and without, in some cases, adequate representation from second tier authorities, will only focus on the commissioning of new services and fail to take account of these existing ones.

8.3 With further reductions to Council budgets to come, such existing services could become reduced to such a level that public health protection will suffer and with it the health of the population both short term and long term. By increasing representation on health and wellbeing boards, widening their scope and addressing the wider opportunities of tackling the causes of inequalities in health there is a real possibility that improvements to public health can be achieved. We fear however that the structures being created under the current arrangements will not be bold enough or wide enough in scope or representation to be able to succeed.

About the CIEH

As a Chartered professional body, we set standards and accredit courses and qualifications for the education of our professional members and other environmental health practitioners.

As a knowledge centre, we provide information, evidence and policy advice to local and national government, environmental and public health practitioners, industry and other stakeholders. We publish books and magazines, run educational events and commission research.

As an awarding body, we provide qualifications, events, and trainer and candidate support materials on topics relevant to health, wellbeing and safety to develop workplace skills and best practice in volunteers, employees, business managers and business owners.

As a campaigning organisation, we work to push environmental health further up the public agenda and to promote improvements in environmental and public health policy.

We are a registered charity with over 10,500 members across England, Wales and Northern Ireland.

August 2012

Prepared 26th March 2013