Communities and Local Government CommitteeWritten submission from the UK Faculty of Public Health

About the UK Faculty of Public Health

The Faculty of Public Health (FPH) is the standard setting body for specialists in public health in the UK. FPH is the professional home for more than 3,000 professionals working in public health. Our members come from a range of professional backgrounds (including clinical, academic and policy) and are employed in a variety of settings, usually working at a strategic or specialist level.

FPH is a joint faculty of the three Royal Colleges of Public Health Physicians of the United Kingdom (London, Edinburgh and Glasgow). In addition, FPH advocates on key public health issues and provides practical information and guidance for public health professionals, aiming to advance the health of the population through three key areas of work: health promotion, health protection and healthcare improvement.

The introduction of a public health role for councils

The Government’s policy of “empowerment of local communities” offers great potential for health improvement through embedding public health expertise in local authorities, opportunities to work across the full range of Council and local authority issues and determinants of health such as housing, education and planning; and increase the focus on population health. It is critical that this new public health role addresses the following key challenges:

Ensuring clear lines of accountability and communication for protecting and improving the health of the local population—and that statutory guidance is followed.

Enabling the public health workforce to challenge powerful interests whose actions risk the health of the population.

Providing clarity as to how professional standards will be maintained for staff who will undertake the public health functions that are moving out of the NHS system.

Fully recognising the health service domain of public health and creating explicit mechanisms for public health input and advice to the commissioning and provision of healthcare services.

Addressing the fragmentation of the public health workforce, limiting opportunities to share scarce skills, maintain and develop capacity and assure competence.

Ensuring that the HPA is not inhibited in its trading activities, resulting in a loss of funding for key members of staff, ultimately affecting its ability to the deliver high quality services.

Ensuring that ring-fencing of the public health budget does not result in its redistribution for activities other than fulfilling Public Health outcomes, and that the funding formula reduces inequalities.

Ensuring safe, equitable and appropriate health and health services at a time when the traditional levers for strategic oversight are being removed.

Ensuring that the potential loss of public health staff during the transition period is mitigated.

Ensuring that the terms and conditions of public health teams in local authorities reflect their health background—and maintain an equivalence to NHS T&Cs.

FPH continues to believe that Public Health England is an SHA within the NHS—Executive agencies, whilst being semi-independent are constitutionally part of their parent body.

SHAs however are independent bodies with greater assurance of freedom from political interference.

PHE as an SHA enables further development of academic collaboration with service public health for teaching and research.

This will also encourage local authorities as strong venues for public health specialists and practitioners.

The adequacy of preparations for the new arrangements

The order of these reforms has left the public health workforce in limbo for over two years.

The organisations that currently employ public health specialists (Strategic Health Authorities, Primary Care Trusts, the Health Protection Agency, Public Health Observatories) have had their budgets cut prior to their being disbanded.

Many of those working in public health are still uncertain as to where they will be employed in April 2013—or even, indeed, whether they will be employed at all.

The position is variable. In some areas, county councils seem well prepared, whereas in others—especially metropolitan councils and across London, there are still substantial problems.

These include problems with regard to staff transferring contracts or contracts being terminated by primary care trusts; information governance, practical considerations including accommodation and IT; and due diligence.

The objectives of the new arrangements and how their impact can be measured

In the short term, it will be important to demonstrate that safe systems are in place. In the medium term, evidence of local authority health policies in practice will be required, and in the longer term it will be important to be able to measure achievements and outcomes.

It is important that local areas are given autonomy to allocate their resources according to local priorities, whilst recognising the tension between the localism agenda and the need for national priorities to be resourced and addressed.

We would support the idea of there being both core indicators and locally decided indicators which would be selected from a national basket.

As described, the outcomes framework suggests that there will be national collation of data and evidence to support reporting against these indicators and measure local authority performance.

Experience from previous approaches has illustrated that performance reporting places a significant burden on local areas in the collection and extraction of data.

It is essential, therefore, that the local Director of Public Health has adequate public health specialist support at a local level to support this delivery.

If the outcomes framework is to be deliverable, the DPH must be able to hold commissioning bodies to account independently for their performance in relation to a particular population in order to ensure delivery.

The Director of Public Health annual report is an provides an important means to measure the impact of the new arrangements against their objectives.

The intended role of Health and Wellbeing Boards in coordinating the NHS, social care and public health at the local level

The Health and Wellbeing Board—General Principles

HWBB should not become “talking shops”, but be able to robustly hold to account stakeholders and enable the NHS and local government to make real improvements to health and wellbeing.

Potential political tensions between their overseeing commissioning and promoting integration across public health, local government, local NHS and the third sector need consideration.

Potential political tensions between their overseeing commissioning and promoting integration across public health, local government, local NHS and the third sector need consideration.

National policy imperatives must balance with local priorities, via co-production and dialogue.

National policy Imperatives must be in accordance with agreed findings from the JSNA.

Roles, responsibilities and membership need clear definition to ensure the Board is robust.

Stronger national framework for integrated care with a single outcomes framework needed across health, social care and public health.

Lessons and best practice from shadow Boards, supporting local determination of arrangements to best meet the requirements of local conditions must be considered.

Must deliver strong, credible and shared leadership across local organisational boundaries.

Where services are not meeting needs the Board should be able to challenge and hold to account, and take a broad and holistic view of determinants of health.

Essential that duties underpinning JSNAs/JHWSs undertaken by CCGs and local authorities via HWBBs are robust.

It is important to give HWBBs maximum freedom to determine the context of JSNA and JHWS.

Health and Wellbeing Boards, JSNA and JHWS—Addressing Health Inequalities

The JSNA and JHWS will need a strong focus on inequalities across the social gradient (proportionate universalism) in addition to the needs of disadvantaged and vulnerable groups.

JSNA are the key to addressing inequalities.

Health and wellbeing boards will need to consider their organisation’s Equality Duties.

JSNAs can address the health needs of specific disadvantaged groups with protected characteristics if this is the agreed priority of the HWBB.

Each agency has a statutory responsibility to address these needs, and Local HWBBs should be able to determine the HWBB priorities they need to address.

The major inequalities in health faced by HWBBs are economic and social rather than inequalities solely related to the protected characteristics.

The HWBBs responsibility to take an overview of the social as well as health care needs of the local community living in the board area must not be overlooked.

The JSNA/JHWS guidance must make consistent reference to health inequalities.

The recommendations from Fair Society Healthy Lives need to be embedded in the JHW.

Equal weight should be give to physical and mental health and wellbeing—parity of esteem between mental and physical health is vital.

It will be important for boards to have mechanisms to monitor their own outcomes and measure the effectiveness and impact of JHWSs (see the HWB self assessment tool).

Health and Wellbeing Boards, JSNA and JHWS—Integration, Autonomy and Leadership

The DPHs independent annual report should be emphasised strongly—this key resource for identifying local priorities should underpin the JSNA.

Successful HWBB members will behave supportively and collaboratively, and have capacity to challenge one other where they find that one or other partners is not committing its resources towards agreed joint priorities, programmes and care pathways.

Strong HWBBs will also be vocal and successful lobbyists of central government.

Public health will benefit from DsPH as leaders within the HWBB and within local authorities.

Whilst CCGs and LAs have joint and equal responsibility for the development and delivery of the JSNA and JHWB strategy, the DPH is best placed to lead on the JSNA and JHWS on behalf of the HWBB.

This follows from their role delivering public health advice to the local authority on needs and policy and in delivering the core offer of PH advice to the CCG.

JSNAs should result in a shared understanding locally between all partners not just local authorities and the NHS; but also other public sector bodies, voluntary and private sectors.

They will set out communities’ needs but also community assets, and where there are inequalities in outcomes and access to services, as well as identify the causes of inequalities.

JSNAs/JHWSs should be owned jointly by all members of health and wellbeing boards.

They should involve ongoing dialogue with communities, to ensure their needs, assets and experiences are understood, and that priorities reflect what matters most to them.

Barriers to integration, including issues in multi-tier areas

Health and Wellbeing Boards—A Mechanism for Integration

Health and Wellbeing Boards provide a useful mechanism for integration.

CCGs, the NHSCB and local authorities’ commissioning plans must be informed by JSNAs/JHWSs.

Where plans are not in line with JSNAs and JHWSs, CCGs, the NHSCB and local authorities must be able to explain why.

Agreeing a JHWS must involve a two-way dialogue that allows for challenge by local commissioners where they feel the JSNA and JHWS have been ill thought through.

Local authorities should be held to account for the public health funding that will be disbursed to them by PHE and made explicitly accountable for the delivery of an agenda through commissioning, policy and management that addresses the social determinants of health.

Health and wellbeing boards will need to engage partners, stakeholder and communities in different ways than in the past, and communities themselves will need to proactively take part.

Engagement should be continuous, recognising that JSNAs/JHWSs go beyond health and care.

Evidence from multiple sources will be needed, including input and views from the community.

HWBB members need to provide collective leadership, with members working together to jointly agree upon needs and priorities, as well as translating the priorities into action.

Individual board members will need to influence their own organisations, as well as others across the health and care economy and wider existing partnership arena.

Upper Tier and District Councils

The JSNA/JHWS are the equal and joint duty of LAs and CCGs, through the HWBB.

LAs in this context are top tier, but much of the local government spend which is equally or more relevant to population health, is by district councils in two tier authorities.

There is no statutory requirement for them to be involved or even have a place on the HWBB.

There must be explicit requirements for their active engagement, as they will have a crucial role in promoting public health.

The NHS Commissioning Board and Integration

The NHSCB commands a considerable expenditure in local areas and is required to have a place on the HWBB—this is essential.

The NHS Commissioning Board is the major public health budget holder and needs to be held to account as any other Health and Wellbeing Board partner.

The NHSCB, as Commissioner of pharmacists, GPs, opticians, dentists has major front line role.

The NHSCB’s responsibilities complement but do not duplicate those of CCGs and it is unreasonable to expect CCGs to have a comprehensive understanding of the specialised services that the NHSCB commissions and which all local populations need.

The NHSCB commissions primary care and might reasonably be expected to offer an informed view on the quality of that care delivered locally and the appropriate response to unmet need.

It follows that the NHSCB should be party to every single JHWS in England, to agree to them, and to be held to account by them.

The Outcomes Frameworks and Integration

The draft JSNA/JHWS guidance, which states that the three Outcomes Frameworks should help form priorities, but shouldn’t overshadow local evidence.

They may prove problematic in practice, given that, for example, health services will be required to take account of the NHSCB mandate, likely to draw heavily upon the NHS Framework, and the funding available to local authorities is likely to be determined to an extent by their response to the PH outcomes framework.

Other Sectors

Drug and alcohol services and “homeless” charities are surprising omissions from the list of organisations Health and Wellbeing Boards need to work closely with.

Early years providers and parenting coordinators should also be mentioned since these have a key role in life course health promotion.

The potential role of universities should be acknowledged in JSNA/JHWS guidance.

How the transfer to local authorities of the front-line health protection role and the creation of Public Health England will affect resilience arrangements at the local level

There must be clarity over who, within the various local agencies involved, has lead responsibility for ensuring the response to an emergency/outbreak is effective and appropriate.

There should be local responsibility with the DPH, beyond ensuring that plans are in place.

The picture at local level for this response is fragmented, with responsibility across it, the NHS and PHE—This fragmentation places public safety at great risk.

It is imperative there is a clear delineation of responsibilities for health protection at the local, sub-national and national levels, including those of the LA, DPH, NHS and PHE local outposts.

The Act does not articulate lines of responsibility or accountabilities for co-ordinated action.

This lack of clarity at local level on who is operationally responsible for ensuring that an effective response is put in place at the local level will result in delay and confusion.

Grave risk that emergencies, outbreaks and epidemic situations, will not be properly managed or responded to, may escalate, and the public—and economies—will be come to serious harm.

Under the Act, local government takes on a substantial share of the responsibility for public health, alongside PHE, across the three pillars of public health.

It follows that a primary leadership role and central port for emergency preparedness and for ensuring effective management of the local response should rest with the local authority.

PHE needs a clear leadership and coordination role when emergencies cross local boundaries.

The relationship between local hubs of PHE and the DsPH needs clarification.

FPH is concerned that the current proposals do not address the need to establish and maintain an effective health protection workforce at the front line (ie local authority level).

FPH is concerned that the other functions of PHE will be overlooked and poorly resourced as PHE becomes in all but name the national functions of the Health Protection Agency (HPA).

The accountability of Directors of Public Health

To provide effective strategic leadership for public health, the DPH must be able to influence all aspects of the work of the local authority and the local health economy. The public must also be confident that the DPH is able to provide informed, independent professional advice.

The DPH must be the local strategic leader and Chief Officer for health and wellbeing within the local authority, trained and registered with broad range of PH expertise.

This ensures that those responsible for providing vital advice of a technical nature are appropriately qualified to do so and that the public can be assured of that competence.

The DPH must be a Chief Officer of the LA.

The DPH must have direct access to the Council, Cabinet, elected members and Board, and direct accountability to the head of the organisation (CEO, Mayor or equivalent).

The DPH must have day to day responsibly for management of the ring-fenced PH grant; be a statutory member of the HWBB; and have lead responsibility for planning and leading the local response to outbreak and emergency situations

The DPH must be subject to statutory guidance on their responsibilities, in line with that for Directors of Children’s Services and Directors of Adult Services.

The DPH must be able to produce a robust and truly independent annual report on the current health and future health needs of their population (and how well they are being met).

The DPH (and all consultant level posts) must be jointly appointed by the LA and PHE through a statutory appointments process (or equivalent consistent with FPH standards).

The Secretary of State should have a veto over the termination of employment of the DPH.

Forthcoming statutory guidance must reflect good practice.

Must be able to promote opportunities for action across the whole “life course”, working together with local authority colleagues such as the Director of Children’s Services and the Director of Adult Social Services, and with NHS colleagues.

FPH is concerned by reports some local authorities wish to have their DPH report to, for example, the Director of Adult Social Services, not giving the DPH the required status to be effective.

FPH is concerned to hear of examples where the AAC process is not being followed correctly.

The DPH must have the ability to work with all executive members across all functions of the council—considering the wider determinants of health including “place” as well as “people”.

The financial arrangements underpinning local authorities’ responsibilities, including the ring-fencing of budgets and how the new regime can link with the operation of Community Budgets

The Proposed Public Health Funding Formula

FPH is concerned by the way the proposed public health funding formula redistributes funding from areas whose residents have the worst health to areas where residents have better health.

The formula uses as an indicator the standardised mortality ratio for those aged under 75.

This allows the existing allocation to remain in areas where it is now higher than this minimum.

This minimum allocation will have the effect of levelling up those areas giving too little priority to public health, rather than rewarding those areas taking action to reduce health inequalities.

If the proposed formula is used to redistribute the existing pot it will reward the lower spending less deprived and increase inequalities.

It is a core public health value that inequalities in health should be reduced.

For a detailed overview of FPH’s analysis of the proposed public health funding Formula, please refer to FPH’s response to the engagement process on @Healthy Lives, Healthy People: Update on Public Health Funding@, which you can find at the following link:

The ring-fenced budget

The “ring-fence” needs to be protected at a local level as well as at a national level.

It is important there exists robust and external monitoring of the ring-fenced budget, in particular for those situations where the Director of Public Health should be able to give an independent view (but this may not be possible).

Additionally, Public Health England and the relevant CCG should have a role in monitoring the integrity of the ring-fence.

Clarity is needed over what services will be funded from the public health budget and how these monies will be routed from the DH to service providers.

Clarity is also needed about how decisions need to be made to redistribute the ring-fenced budget—who needs to be involved?

This is vital in assessing the adequacy of the budget in relation to the infrastructure it is required to support and the services it is intended to deliver.

The DPH should have final control over these monies and be accountable for their use and have a right of veto over a cabinet decision.

For future consideration

FPH believes that as the formula is refined, weighting should consider reflecting those aspects of public health spend which reflect younger people.

This could include child poverty, preparation for school age and adolescent years.

FPH underscores the relevance of a marker for mental health and wellbeing need/provision.

The Health Premium

Payment of the premium will be based on historical activity so it is difficult to see how it will support innovation and development in public health approaches.

To be effective, it must be directed not at simply supporting good health status in areas where health is already good, but at a true reduction in health inequalities.

It must reflect the number of people whose health has been improved, as well as the extent of the improvement.

It is hard to envisage how it might account for population migration since emigrants are often replaced by a poorer and unhealthier population it could be that a local authority consistently doing excellent work goes unrewarded, while an already affluent neighbour reaps the financial benefits.

Prepared 26th March 2013