Communities and Local Government CommitteeWritten submission from the Royal College of Nursing

1.0 Introduction

1.1 With a membership of more than 410,000 registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world. RCN members work in a variety of hospital and community settings in the NHS and the independent sector. The RCN promotes patient and nursing interests on a wide range of issues by working closely with the UK Governments, the UK Parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations.

1.2 The RCN welcomes this opportunity to make a submission to the Communities and Local Government Select Committee inquiry into the role of local authorities in health issues.

2.0 Executive Summary

2.1 Nurses play a pivotal role at all levels of health care commissioning and provision. It is vital that their expertise is used by local authorities within the new system, both for service planning and delivery.

2.2 The RCN supports localised public health planning and supports local authorities to have the necessary autonomy to deliver on this.

2.3 During the transition period of responsibility for public health from the NHS to local authorities, skilled staff must be retained by local authorities. The RCN is concerned that many staff, and therefore their knowledge, are not being retained and are not moving to the new structures.

2.4 NHS staff have faced much uncertainty over their future, better efforts must be made to ensure good communication to keep staff on side.

2.5 The link between poverty and poor health outcomes must be acknowledged and taken into account by the public health funding allocations.

2.6 Without sufficient investment in preventative care and public health interventions the NHS will be left to deal with the huge cost of acute care and long term conditions.

2.7 The RCN supports a focus upon patient outcomes through a robust national outcomes framework that allows for local variations and relevant local decision making powers.

2.8 Health and wellbeing boards (HWBs) have the potential to play a very significant role in promoting integration of services and providing multidisciplinary oversight.

2.9 Directors of Public Health (DPHs) must be appointed with sufficient focus and autonomy to allow them to oversee effective services for their localities. To allow them sufficient authority they should report to the Chief Executive. However, the RCN is concerned that this is not happening.

2.10 Ring fenced public health budgets are to be welcomed. However, the RCN is concerned that in some situations public health budgets may be pooled with other budgets and then be subjected to cuts.

3.0 The introduction of a public health role for councils

3.1 Nursing staff carry out public health activities in nearly every context and at every level of health care provision, including public health services and health prevention. Nurses will, in fact, be carrying out the majority of the public health interventions that local authorities will be responsible for after April 2013.1

3.2 Nursing’s presence at almost every stage and setting of care means they are engaged across a whole spectrum of public health interventions. Nurses are able to view individuals’ needs and circumstances holistically to understand the full package of support and care required. Nurses reach deep into the heart of families and communities. They are confronted daily with the consequences of social conditions on the health and well-being of the communities they are caring for. The RCN believes that the unique perspective of nursing expertise should be fully utilised in the new Public Health system.

3.3 The RCN supports proposals for local authorities to have sufficient autonomy to develop public health services designed to meet local need. We also agree in principle with the new responsibilities assigned to local authorities for health improvement.

3.4 However, the RCN has concerns that during the period of transition staff working in public health have faced uncertainty about their future. Staff have faced restructuring, budgetary cut backs and uncertainty over transition arrangements. Every effort must be made to retain and develop the public health workforce and to clarify transition arrangements which are still outstanding to allow the public health community to move forwards within the new system. It is vital for the success of the transfer that staff are adequately engaged with and informed about the transition process.

3.5 The RCN believes that in order to successfully deliver for the future public health needs of the country the Government must recognise the links between poverty, incomes and poor physical and mental health. The RCN has serious concerns that the welfare reforms currently being introduced may be counterproductive for the health and wellbeing of some vulnerable sectors of the population.

3.6 In the RCN response to the Public Health White Paper for England, Healthy Lives, Healthy People, we called on the Government to recognise the links between low incomes (amongst both the employed and unemployed) and poor physical and mental health. Poverty and low living standards are powerful causes of poor health and health inequalities.2 The impact of the financial climate is having significant implications for the health status of the least well off in society. The RCN has concerns that the currently proposed funding allocations are not adequately weighted to address the health inequalities of the poorest the most expedient way.

3.7 Nurses recognise that until the root causes of illness and poor health behaviours are tackled, the NHS will constantly be required to deal with the long term health consequences. Strategies for reducing health inequalities will never be effective if they fail to address the endemic social and economic inequality in the UK.

4.0 The adequacy of preparations for the new arrangements

4.1 It is vital that the transfer of skills is prioritised and facilitated alongside the transfer of money and financial responsibility for the commissioning and delivery of public health services.

4.2 We are still waiting for some Primary Care Trusts (PCTs) and local authorities to share their plans for the transition of public health services locally with trade unions. The transfers of public health responsibilities to local authorities is happening alongside wider and more complex health reforms and it is unfortunately not always clear how these are being managed.

4.3 In order to bring some consistency and support to the process the RCN, alongside other relevant trade unions, has suggested setting up a Staff Commission. This Staff Commission would be an independent body established to provide a route to resolve disputes for former public health staff on issues relating to their transfer from PCTs into local authorities. Such a commission would take on cases that thus far have not been resolved through the authority’s internal grievance procedure.

4.4 The objective is that the majority of issues can be resolved locally and that the Staff Commission will not therefore be called upon too often. The purpose of the Commission is to consider appeals on issues arising as a direct consequence of the transfer of staff from the PCT into local authorities under the Health and Social Care Act 2012. The RCN believes the Commission would greatly help to facilitate what is a complex and sometimes difficult transition.

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

5.1 Outcomes framework

5.2 The success of the new arrangements should be measured by the improving health of individuals and the population as a whole. Therefore, the RCN supports the focus on patient outcomes within a national framework that allows for comparisons, bench-marking and for local responses. This approach should help to ensure that populations across England are not disadvantaged through poor commissioning, poor delivery or inappropriate allocation of resources.

5.3 The RCN supports a model of explicit overlap between the frameworks for all levels of health and social care. Integration of services is key to improving efficiency and providing better patient care and outcomes. We believe isolating segments of health provision will be a barrier to service ownership and will fragment services.

5.4 Outcomes frameworks, although useful and important, do not always tell the whole story of a patient’s care. It is important to recognise that outcomes are influenced by issues such as staffing and skill mix, internal processes such as team work, leadership, safety systems, supervision and the culture of the organisations in which people work.

5.5 The RCN believes that there would be value in including, within an outcome framework, measures that are linked to the health and wellbeing of the public health workforce. Such measures would include staff access to occupational health services, as these are now shown to have an impact on the quality of services and care delivered for patients.

5.6 Health premium

5.7 The RCN supports the work of the Advisory Committee on Resource Allocation’s (ACRA) expert group in considering the formula for health premium payments so that disadvantaged areas will see a greater incentive if they make progress. This recognises that they face the greatest challenge to attain an increase in outcomes. The RCN looks forward to the final recommendations of this expert group.

5.8 However, this greater incentive will be of little assistance to those areas that fail to make any progress as a result of the comparative greater disadvantage of their populace. This can only be remedied by including a weighting of the public health allocation to reflect the deprivation that an area experiences.

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

6.1 HWBs have a duty, established in the Health and Social Care Act, to encourage integrated working between all health and care providers and commissioners. This means, for example, encouraging the use of pooled budgets, lead commissioning and integrated provision. The RCN supports the boards’ purpose.

6.2 Whilst supporting the role of these boards the RCN has identified a number of key challenges, which if not addressed, may prevent Boards being able to effectively carry out this duty. Furthermore, the legislation governing the boards is not prescriptive and their form and roles are likely to be subjected to a large degree of local variation.

6.3 Nursing insight is particularly important in any efforts to integrate care pathways, both within health and across the care systems. Nurses understand the holistic needs of patients and they play a key role in anticipating service gaps. If the reforms are to succeed, meaningful engagement and involvement with frontline staff is vital. Along with other professionals, nursing staff will need to be looked to for leadership and representation at all levels of decision-making in the new system.

6.4 The RCN is concerned that funds have not been allocated to the Boards, leaving local authorities to provide resources. This could mean they will struggle to act independently of the local authority, or to work in meaningful partnership with representatives from other organisations.

6.5 Alongside the issue of funding is accountability. It is unclear to whom HWBs are accountable. Government states that they will be accountable to local people through having local councillors as members of the board who are accountable through election. The RCN does not believe this is adequate.

6.6 Local Strategic Partnerships (LSPs) will continue to exist in some places, potentially causing confusion. These bodies are, not dissimilar to HWBs, composed of a range of representatives from local authorities, the NHS, and the voluntary, community and private sectors aimed at encouraging integrated approaches and joint working. As a result there are overlapping membership and purpose for some HWBs and LSPs, which may cause confusion and duplication.

6.7 Whilst their statutory existence is an important first, the strategic role and powers at the disposal of HWBs are, in truth, similar to those of previous arrangements. Indeed, the powers and influence of health and wellbeing boards, Joint Strategic Needs Assessments (JSNA) and Joint Health and Wellbeing Strategies (JHWS) in relation to Clinical Commissioning Groups (CCGs) may not be sufficiently robust in legislation. It remains to be seen whether health and wellbeing boards will have any real power in challenging commissioning decisions, or how or what action the NHS Commissioning Board will take in local disputes.

6.8 Early implementers and shadow HWBs have demonstrated many different approaches to their role in view of local priorities. The undefined scope of their role presents challenges. For instance, some boards are unclear about their role in relation to acute service provision whilst others see a very clear role for themselves in influencing hospital commissioning and play an active role in doing so.

6.9 The RCN is also concerned that there are not uniform measures to evaluate the success and impact of HWBs. Previous partnership arrangements had clear targets and data sets to measure their success and impact by. HWBs will, by comparison, determine their own evaluation mechanisms. Some may be tangible, for example monitoring success against the NHS outcomes frameworks. Some may be less tangible, such as evaluating whether partnership arrangements are working well. Local variations will make it difficult to compare their achievements and apply learning across the country. This also increases the very real risk of increasing the postcode lottery in service provision.

7.0 How all local authorities can promote better public health and ensure better health prevention with the link to sport and fitness, well-being, social care, housing and education

7.1 The RCN is clear that whilst there are opportunities for improving services at a local level, services do not operate in a vacuum. Central government policy is the largest influence upon people’s economic and social circumstances. The links between low incomes, both amongst the employed and unemployed, and poor physical and mental health must be recognised in the development of any policy.

7.2 The RCN is concerned that the budget available for prevention work is relatively small. The desire to show progress against outcomes framework measures will divert resources from preventing ill health from occurring in the first place.

7.3 Local authorities will fund all prevention work out of their allocation of 42% of the Public Health Funding budget. However, our RCN Public Health Network understands that £2.2 billion, more than half of the Public Health money going to local authorities, has been identified as necessary spend for sexual health and substance misuse services, which are demand-led services. This presents real problems and significantly reduces the funding available to invest in prevention work on issues like obesity and smoking.

7.4 The Public Health White Paper for England, Healthy Lives, Healthy People, clearly outlined the prevention agenda of increasing spend on public health issues before they become an issue for a population. The RCN has concerns that this agenda is being undermined and risks being neglected altogether if the importance of public health prevention work is not adequately reflected in the prescribed functions for local authorities.3

8.0 Barriers to integration, including issues in multi-tier areas

8.1 HWBs will play a key role in facilitating integration and co-operation. However, if boards are too big, meaningful discussion and decision-making becomes difficult. If boards are too small, the views of appropriate representatives will not be heard and challenges will not be appropriately understood and acted on. Partnership working arrangements will, therefore, be tested more in larger local authority areas, with second tier district councils, urban and rural areas and potentially several CCGs to include.

9.0 The accountability of Directors of Public Health

9.1 Directors of Public Health (DPHs) will have a critical role in the leadership and management of public health services and initiatives. They must retain the authority and independence to advise and guide public health decisions. The RCN believes that Directors of Public Health should be appointed on an executive level and be accountable to the local authority Chief Executive. We are aware that unfortunately in some localities this is not the case.

9.2 DPHs are to have control over ring-fenced budgets within local authorities and are to act as strategic leads for all public health services. Annual accounting must demonstrate that directors of public health have the freedom to act and implement their public health plans. Structures within local government must not adversely influence strategic plans or divert funding.

9.3 The Secretary of State for Health must, by virtue of the Health and Social Care Act 2012, have due regard to health inequalities. This will form part of the conditions of the grant for the ring fenced public health budget. The annual report of the DPHs should be underpinned by this commitment.

9.4 DPHs have a professional responsibility to produce an honest and unbiased annual report. Correspondingly, they should have the professional independence to speak out on public health issues within their area. The DPHs should be supported and empowered by their employing local authority to carry out all public health duties necessary.

9.5 It is concerning that there remains a lack of clarity regarding the role of DPHs in relation to the medical role of responsible officer. This should be clarified as soon as possible whilst also underlining the principle that the role of DPHs is a role suitable for candidates who are not from a medical background, ie are not a doctor.

9.6 The RCN believes there must be parity of pay for professionals who undertake a particular role. DPHs should receive salary based on skills and experience rather than on their professional background.

9.7 The RCN looks forward to the publication of guidance clarifying that the Public Health England, on behalf of the Secretary of State, will not authorise job descriptions that do not include an appropriate span of responsibility for improving and protecting health.

10.0 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

10.1 The RCN welcomes the commitment to ring-fence public health spending. However, we also recognise that all public sector bodies currently have to make significant financial savings. To ensure the development of an effective public health service, it is imperative to have financial protection. The Public Health White Paper noted that “existing functions in local government that contribute to public health will continue to be funded through the local government grant”.4 The RCN is concerned that in reality this may not be honoured and this must be monitored.

10.2 The Secretary of State for Health has set the size of the budget available to the NHS Commissioning Board and Public Health England, as well as the size of the ring-fenced public health grants provided to Local Authorities.5

10.3 Healthy Lives, Healthy People: Update on Public Health Funding paragraph 3.6 makes reference to pooling the ring-fenced public health grant with local authority funds being used for a similar purpose. The RCN seeks assurances that financial reporting will examine these pooled funds closely and seeks further details of the safeguards that will be built into the financial reporting system to ensure that the ring-fenced public health grant is being used appropriately.

10.4 The RCN notes that in paragraph 3.8 of Healthy Lives, Healthy People: Update on Public Health Funding there is a commitment that the conditions for the public health grant will set out the reporting requirements that local authorities will need to adhere to, over and above the standard reporting requirements. We look forward to further details regarding the categories, the reporting arrangements and the final supporting guidance. We also seek a commitment that these reports will be public documents for full transparency within the public health system.

October 2012

1 Healthy Lives, Healthy People: Update on Public Health Funding Annex C

2 http://www.who.int/social_determinants/thecommission/finalreport/en/index.html

3 Healthy Lives, Healthy People: Update on Public Health Funding, Annex F

4 Healthy Lives, Healthy People: Our strategy for public health in England p. 58

5 Baseline spending estimates for the new NHS and Public Health Commissioning Architecture http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_132540.pdf

Prepared 26th March 2013