The role of local authorities in health issues

Written submission from the Royal Town Planning Institute (HLTH 21)

Introduction

The Royal Town Planning Institute (RTPI) is pleased to respond to the call for written evidence to the Communities and Local Government Committee on the future role of English local authorities in health issues. The RTPI is the largest professional institute for planners in Europe, representing some 23,000 spatial planners. The Institute seeks to advance the science and art of spatial planning for the benefit of the public. As well as promoting spatial planning, the RTPI develops and shapes policy affecting the built environment, works to raise professional standards and supports members through continuous educati on, training and development.

The RTPI has been engaged in building links across the planning and health disciplines since 1991 when we held our first conference on the role of spatial planning in the delivery of public health objectives.

Executive Summary

· Health improvements will not be achieved by improvements in just one part of the system alone, and a whole-system approach to health issues must be adopted.

· A holistic approach to measuring improvements in health issues needs to be introduced across local and national government.

· Vital that strategies prepared by health and wellbeing boards are fully taken into account into the commissioning plans of clinical commissioning groups.

· Good planning for health services with community involvement can help improve mental health and wellbeing of members of that community, and help to promote community cohesion, which will in turn help to reduce crime rates.

· Health services, when planned into town and district centres, will act as a springboard for the wider economic regeneration of an area.

The introduction of a public health role for councils

1. The RTPI broadly supports the return of the public health role to local government, as it has a powerful influence on the drivers of health such as spatial planning and transport. It is vital that the opportunity for local authorities to develop new relationships with GPs, dentist and other primary care professionals be fully grasped in order for integrated working to flourish.

2. In order to maximise the benefits arising from the transfer of public health, there is a need to ensure that other departments involved in shaping the wider determinants of health, such as planning and transport authorities, are given training on how to build up an effective dialogue with health and wellbeing boards. Sandwell’s health and wellbeing board, which has been in place since June 2011, has structured its Joint Health and Wellbeing Strategy (JHWS) according to the six policy objectives of the Marmot Review [1] , including integrating public health, planning, transport, housing and environmental services. Sandwell’s approach is a positive step to addressing the Department of Health’s own concerns that ‘the ways that the NHS works with other services is often an issue that needs improvement to prevent hard-to-reach groups falling through the gaps. Partnership working with other public services should be seen as a core part of what the NHS does, not an optional extra.’ [2]

3. This is also an issue which is seen as one of the key recommendations in the UCL-Lancet Commission’s report ‘Shaping Cities for Health: complexity and the planning of urban environments in the 21st Century’ [3] , which states that progress in alleviating public health will need to be achieved through involving ‘practitioners and communities in active dialogue and mutual learning’.

4. There is also a need to ensure that public health professionals moving into local authorities are sensitive to the existing and ongoing work supportive of public health which many professions there such as environmental health and spatial planning are already doing. Local planning authorities are bound by the National Planning Policy Framework to ‘take account of and support local strategies to improve health, social and cultural wellbeing for all, and deliver sufficient community and cultural facilities and services to meet local needs’ when formulating their Local Plans.

5. Integrating healthcare services with planning for town and district centre areas can lead to the promotion of health and wellbeing for the whole community. This would echo the Marmot Review’s call to fully integrate healthcare policy with transport, housing and environmental policy. The review states further that ‘strategies that only rely on intervention in one part of the system will be insufficient to make the necessary difference.’ Public Health England has called for further integration within authorities, saying in the Outcomes Framework for 2013-16 that ‘Local authorities with their partners, including the police and criminal justice system, schools, employers, and the business and voluntary sectors, will all have a significant role to play in improving performance.’ [4]

6. It is important that future service delivery is located so as to take account of wider considerations for the local population in order for there to be wide utilisation of services, and The Healthy Urban Development Unit (HUDU), based in London has stated, the ‘provision and access to good public services… has a direct positive effect on human health.’ [5] Their review of health service location goes further to say that the most vulnerable will be the most adversely affected if services aren’t planned within reach of good transport links: ‘For those with mobility problems including the elderly localised access to public services is vitally important, public services located far away can cause significant problems not only in terms of accessing vital services but also preventing opportunities for daily social interaction which could contribute to isolation and depression.’ [6]

The adequacy of preparations for the new arrangements

7. The different versions of guidance from the Department of Health and Public Health England for the various new bodies that will be introduced from April 2013 is currently in various states of completion, and the Institute has been a little concerned that representations on drafts are having little impact on the final outcomes. There is a lack of recognition of the interlocking elements between the new bodies in the draft guidance, in particular how Clinical Commissioning Groups (CCGs) will work to deliver the JHWS prepared by the local authorities’ Health and Wellbeing Boards. The Draft Mandate for the NHS Commissioning Board does recognise that there is a statutory duty upon CCGs to take into account the strategies planned by health and wellbeing boards, but doesn’t prescribe any advice on how to do this successfully, or examples of good practice currently being undertaken involving the work of shadow health and wellbeing boards leading up to April 2013.

8. There is no mention in either versions of the draft guidance to Foundation Trust hospitals. This seems puzzling going forward as the Department of Health has stated that it hopes all NHS trusts will achieve foundation status by 2014 [7] , and it is necessary to include them into any guidance for future commissioning plans.

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

9. The RTPI believes that a holistic approach to measuring performance should be introduced, encompassing aspects of improvement across society, brought about through improvements in the provision of public health. Improvements in public health will lead to wider improvements in areas such as economic recovery for an area, increased employment, and reduced crime rates. The latter has been recognised by the Department of Health, who have noted that ‘good cooperation between health services, the criminal justice system, and policing organisations can help reduce the risk of crime and reoffending.’ [8] There is a recognition that the direct involvement of health services in improvements in these areas would be difficult to measure, however, and there would need to be more investigation into how this would work.

10. The two sets of draft guidance for the new national bodies involved in the delivery of Public Health in England, the NHS Outcomes Framework published by Public Health England [9] and the draft mandate of the NHS Commissioning Board [10] , are in many ways pulling in different directions. This confusion from higher level guidance will not help local authorities in the preparation of their own strategies, as they are on one hand bound to improving public health via the guidance prescribed from Public Health England, and in other respects they will be looking to meet the outcomes recommended in the draft mandate of the NHS Commissioning Board, in order to maintain a good relationship with CCGs.

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

11. It is vital that health and wellbeing boards are truly effective in shaping the wider determinants of health, and in promoting other services that impact on public health (e.g. land use planning, housing, green space and transport) and are not seen as a secondary body to CCGs who are commissioning services. In the draft guidance on Joint Strategic Needs Assessments (JSNAs) and JHWSs published in the summer for consultation by the Department of Health, it is prescribed that ‘it would be good practice for local authorities and the NHS Commissioning Board to also involve health and wellbeing boards when developing their plans for commissioning to make sure each plan is informed by the JHWS.’ However, as previously stated in this response the draft mandate of the national NHS Commissioning Board doesn’t prescribe any advice for CCGs on how to do this successfully, or examples of good practice currently being undertaken involving the work of shadow health and wellbeing boards leading up to April 2013.

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

12. We recommend that local regard to the provision of healthcare services needs to be viewed as shaping outcomes beyond what is seen to be traditional improvements in health.. The integration of public services into what have traditionally been seen as our retail centres would have overwhelmingly positive effects across different areas, as has been suggested throughout this response. The government has taken steps in the past year or so to support regeneration of town centres, most notably through the Portas Review [11] into the future of Britain’s high streets. However, this analysis was heavily based in the retail aspects of high streets, and neglected the role that sectors such as public services can play in the regeneration of our high streets. This is seen as a missed opportunity, as in some of our most deprived communities the public sector is the main investor in infrastructure – highlighting further the role that local councils’ could play in the wider regeneration of areas through healthcare services, as it is within the strategies and commissioning plans prepared by local government that healthcare services will be planned and prioritised. The review also neglects emerging good practice such as Bromsgrove-based social enterprise EPIC (Empowering People in Communities) which has already begun to revitalise a run-down shopping parade as a by-product of its work in public health.

13. Health services can act as a springboard for wider economic regeneration of an area. Encouraging health services to relocate to town and district centres within communities is a positive step as these areas are in most cases already served by good transport links. A user of health services would take the opportunity to spend money in the town centre, whilst in the area to visit the health services, helping to improve the local economy. For regeneration to flourish, experimentation will be required, and a willing on the part of local authorities to take risks – such as promoting a change in the hours which certain services will open from during the day to evening and weekends, in order to provide for a wider range of consumers who would otherwise not be able to access services, due to the hours of the working day.

14. There is wider evidence to suggest that good planning for public services with wider community involvement has positive effects on mental health and wellbeing of individuals, as well as promoting community cohesion. This will not be limited to primary healthcare services, noted by HUDU who have advised that ‘opportunities for the community to participate in the planning of such services [healthcare and other public services] has the potential not only for positive effects on mental health and wellbeing but also can lead to greater community cohesion.’ Whilst these are outcomes which are difficult to quantify, the Department for Communities and Local Government has stated that the most positive estimate for crime reduction in the UK due to increased community cohesion stands at £530 million [12] .

Barriers to integration, including issues in multi-tier areas

15. The public health function is being assigned to principal authorities (ie county councils and unitary authorities).  Whilst much guidance (eg the public health draft guidance released in May 2012 for consultation by the National Institute for Clinical Excellence on obesity [13] ) refers to the advantages that local authority involvement in public health will confer almost invariably NICE/DoH guidance fails to distinguish between country councils and district councils, and seems to presuppose that all local authorities are unitary.  This is a serious failing since in two tier areas it is district councils which provide some of the vital roles which are determinants of health such as spatial planning, environmental health and recreation, are fully brought into the public health process.  We are aware that this could potentially provide quite a challenge in a county with a large number of districts.  There are however parallel processes which can be used as well as membership of health and wellbeing boards.

16. Under the Localism Act, local planning authorities are required to cooperate on strategic planning matters with each other and a number of other bodies including "Primary Care Trusts (PCTs)."  We would assume that PCTs’ obligations here will be transferred to either HWBs or principal authorities, although we are not clear about this. Be that as it may, since cross boundary cooperation between district councils is expected to be occurring within county areas at least for planning purposes, it would make sense to use the same channels to foster cooperation for public health purposes, rather than reinventing the institutional wheel.  This would also ensure that the strong interconnections between public health and planning were properly addressed in two-tier areas.

17. A similar issue effectively arises in unitary council areas where the unitary councils are small and what is termed "underbounded".  These are councils where the council boundary is frequently crossed by people on the way to work or recreation and the council is really part of a wider functional area.  In this case we would recommend that adjoining HWBs may also need to be cooperating with each other, and using again existing channels to do this would be helpful.

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

No evidence submitted

The accountability of Directors of Public Health

No evidence submitted

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

No evidence submitted

Recommendations for Action

The Institute would like to make two recommendations for action, arising from the memorandum:

18. Guidance prescribed by the national bodies for health needs to successfully distinguish between the different authorities at a local level. At the moment, all guidance seems to presuppose that all local authorities are unitary, a failing in two tier areas when many vital services which impact upon the wider determinants of health, such as planning and environmental health are taken at the district level.

19. Guidance needs to be given to promote how CCGs and health and wellbeing boards will work together to effectively meet the challenges of public health in their areas. Whilst recognised that there is a statutory duty upon CCGs to take into account the strategies planned by health and wellbeing boards, no advice is prescribed from the Department of Health on how to do this successfully, or examples of good practice currently being undertaken involving the work of shadow health and wellbeing boards leading up to April 2013. The draft guidance on JSNAs and JHWSs states that the NHS Commissioning Board can ‘take action if the [commissioning] plan doesn’t take into account the JHWS’ [14] what action that can be taken is not laid out.

October 2012


[1] UCL Institute of Health Equity (2010) Fair Society Healthy Lives: A strategic review of health inequalities in England post-2010 UCL: London

[2] Department of Health (2012) A Draft Mandate to the NHS Commissioning Board (Online) Available at: http://www.dh.gov.uk/health/files/2012/07/A-draft-mandate-to-the-NHS-Commissioning-Board.pdf Department of Health: London

[3] UCL-Lancet Commission on Health Cities (2012) Shaping Cities for health: complexity and the planning of urban environments in the 21 st century UCL: London

[4] Department of Health (2011) The NHS Outcomes Framework 2012-13 (Online) Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131723.pdf Department of Health: London

[5] Healthy Urban Development Unit (2009) Watch out for Health: a checklist for assessing the health impact of planning proposals (Online) Available at: http://www.healthyurbandevelopment.nhs.uk/documents/integrating_health/HUDU_Watch_Out_For_Health.pdf The King’s Fund: London

[6] Ibid.

[7] http://www.publications.parliament.uk/pa/cm201012/cmselect/cmpubacc/1566/1566.pdf

[8] Department of Health (2012) A Draft Mandate to the NHS Commissioning Board

[9] Department of Health (2011) The NHS Outcomes Framework 2012-13 (Online) Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131723.pdf

[10] Department of Health (2012) Draft Mandate to the NHS Commissioning Board

[11] Department for Business, Innovation and Skills (2011) The Portas Review: An independent review into the future of our high streets BIS: London

[12] Department of Communities and Local Government (2009) The Economic Case for Cohesion DCLG: London

[13] National Institute for Clinical Excellence (2012) Public health draft guidance – Obesity: working with local communities (Online) Available at: http://www.nice.org.uk/nicemedia/live/12109/59116/59116.pdf NICE: London

[14] Department of Health (2012) Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies – draft guidance (Online) Available at: https://www.wp.dh.gov.uk/publications/files/2012/07/Joint-Strategic-Needs-Assessment-and-Joint-Health-and-Wellbeing-Strategy-draft-guidance-a-consultation.pdf Department of Health: London

Prepared 8th March 2013