Home Affairs Committee - Drugs: Breaking the CycleWritten evidence submitted by Association of Directors of Public Health ( UK ) (DP105)

ADPH is the representative body for Directors of Public Health (DPH) in the UK. It seeks to improve and protect the health of the population through DPH development, sharing good practice, and policy and advocacy programmes.

ADPH has a strong track record of collaboration with other stakeholders in public health, including those working within the NHS, local authorities and other sectors.

ADPH President Dr Frank Atherton is a member of the NHS Future Forum.

ADPH has provided extensive information in response to consultations and inquiries relating to the proposed reforms to Public Health,1 and has continued to highlight continuing concerns that the proposals could endanger the effective delivery of public health, undermine existing collaborative work and fragment the specialist public health workforce—already at risk due to management cuts in the NHS.

We welcome the Home Affairs Committee inquiry into drugs policy, particularly in light of the fact that the local and national context for addressing the problems associated with illicit drugs is changing. The government is committed to putting recovery at the heart of drug treatment, widening the coverage to cover more drug types, moving to outcome-focused delivery, and piloting payment-by-results for drug services.

At a national level, the National Treatment Agency is moving into Public Health England. At the local level, responsibility for public health, which will include the commissioning of substance misuse treatment, is moving back to local authorities under the leadership of Directors of Public Health. In some areas drugs treatment will be a new responsibility for public health, in other areas it will not be.

As part of these changes, the budget for public health interventions, including the currently ring-fenced pooled treatment budget (PTB) for drug treatment, will also pass to local authorities with the new Health and Wellbeing Boards overseeing the spend. The local public health allocations will be ring-fenced for spending on public health interventions but there will be no ring-fencing of money within the overall public health pot.

Spending on services for people with dual diagnosis will be the responsibility of Clinical Commissioning Groups, while spending on provision of drug treatment in prisons will come down from the NHS Commissioning Board; whilst the situation concerning GP-prescribing is currently unclear.

In light of the above, ADPH and the UK Drug Policy Commission (UKDPC) recently held a round table event involving Directors of Public Health and national government officials, to consider the impact of decreasing expenditure and policy reform on efforts to tackle drug problems at the local level.

1. Specific Issues/Concerns

Given the strong focus on the role of Directors of Public Health in both crime/disorder and in drug/alcohol services, ADPH has identified a number of issues and concerns which we summarise below, followed by wider but linked contextual issues with the PH reforms in section 2.

Whilst the government is committed to moving to outcome-focused delivery, within the draft Public Health Outcomes Framework there is only one proposed outcome relating to drugs, which relates to successful completions of treatment, and one on alcohol concerning a reduction in hospital admissions. While we welcome the proposed focus of a performance indicator on drug treatment outcomes this should include long term maintenance treatment as well as recovery. 

We are also concerned that, whilst some PH services have been made mandatory in the latest guidance (eg health checks; NCMP; access to sexual health services), drug and alcohol services have not been made mandatory. This will undoubtedly make it more difficult at a local level when it comes to prioritising. 

Drug interventions encompass a range of activities by a wide variety of organisations and inter-agency partnership working has been seen as essential to effective delivery. Within the current re-organisation of service delivery in England, drug interventions will be affected by multiple changes to structures for management and delivery. Each of these will require the establishment of new relationships with an area’s Health and Wellbeing Board and local Clinical Commissioning Groups.

Public health leadership will facilitate a greater focus on early intervention and prevention, and location within a local authority gives an opportunity to integrate approaches to alcohol and drugs and link with other services such as housing, employment and education. However, the transition to public health and the way in which responsibility for commissioning and delivering drug interventions will work is unclear in many areas, with local decisions around structures and processes having to be developed without key pieces of information being known (eg size of budgets, specific responsibilities)—resulting in a wide variety of different models being established across the country. Whilst public health allocations are currently undefined, the Pooled Treatment Budget allocations are likely to remain at a similar level to 2011–12 which raises the risk of PTB funding being used to meet the efficiency savings required by local authorities. Different local authority structures pose complications in making the links with different services, with district and county councils delivering different responsibilities.

At the same time, overall public expenditure is decreasing and the budgets for most service areas are being reduced. We are concerned that there is therefore a risk that Local Authorities might choose to disinvest from drug/alcohol services as they are not mandatory.

Public Health professionals are used to working in partnership, managing complexity and working across different organisations. In the current climate of shrinking resources it is even more important to invest time and energy on this.

The introduction of Police and Crime Commissioners (PCCs), intended to shift power and accountability for policing to the local level, will also have an impact on drug interventions. An area’s PCC will have an important role to play in relation to the Health and Wellbeing Board (or Boards) in their jurisdiction. PCCs and Community Safety Boards will have to input to commissioning decisions on drug and alcohol services, so Health & Wellbeing Boards and Community Safety Boards will crucially need to link together in order to maintain a common approach.

Guidance and/or best practice is needed on DAATs transfer to Local Authority ownership as part of the PH transfer, to ensure that the commissioning and technical expertise is retained. Health & Wellbeing Boards must bring together the right partners and involve key strategic and senior local authority partners.

There will be a need to ensure the new arrangements enable an appropriate balance between both long term maintenance treatment and recovery.

Fragmentation of service responsibility carries risks for the delivery of an integrated and good quality service. Overall responsibility for prison drug treatment now lies with the National Commissioning Board and will be devolved down to local areas, and mental health services will be commissioned by Clinical Commissioning Groups with implications for people who have dual diagnoses or co-morbidity between substance misuse and mental health.

There is real variety in the quality of GP leadership and Clinical Commissioning Groups (which are still evolving). Reluctance amongst some GPs to engage with substance misuse or in specific drug treatment services will be a significant barrier to successful delivery and result in inequalities of provision between different areas.

The aspirations of the national Drug Strategy rests on partnership. Good quality leadership, communication and advocacy by public health professionals and local Health and Wellbeing Boards are key to the promotion of this agenda. Joint Strategic Needs Assessment should be an important vehicle in the delivery of this.

In view of the increasing impact of alcohol harm on public health, wellbeing and the wider society, we welcome the fact that the Committee has included alcohol within the remit of its inquiry. In a survey conducted by ADPH in December 2009, 83% of Directors of Public Health said that lobbying for a minimum price of 50p per unit of alcohol was one of their top priorities. We believe a reduction in alcohol consumption at population level is needed, and have called for a 50p minimum price per unit of alcohol, which has been shown to deter heavy drinkers and could result in saving over 3,000 deaths per year.

UK government strategies to reduce alcohol-related harm need to be applied much more robustly, backed up with legislation and regulation where voluntary codes are failing. National policies need to support local strategies which will develop and implement a multi-sector approach to both preventing alcohol misuse and dealing with its consequences.

2. Overview—The Public Health System

We recognise that the proposed reforms raise opportunities for public health and welcome the increased formal role of Local Authorities (LAs) in the health agenda and integration of local DsPH into LAs. England needs an integrated system for delivery of public health outcomes, and we are concerned that the reforms should not have adverse effects on fragmentation:

of the public health workforce across a number of organisations;

of commissioning and finance responsibility for public health programmes; and

loss of clarity on accountability (particularly in the area of health protection).

2.1 Public Health England

Public Health England (PHE) can only effectively operate as a national public health service if it encompasses all three domains of public health:

Health protection (infectious diseases, environmental hazards and emergency planning);

Health improvement (lifestyles, inequalities and the wider social, economic and environmental influences on health); and

Health services (service planning, commissioning, audit, efficiency and evaluation).

PHE should operate as a supporting organisation which can:

provide independent scientific evidence-based advice to national and local government, the NHS and the public on all matters relating to the maintenance, improvement and protection of health;

offer expertise to the National Commissioning Board (NCB) in support of its role in providing national leadership in commissioning for quality improvement, commissioning national and regional specialised services, and allocating NHS resources;

provide effective, expert and adequately-resourced specialist PH capacity to support the work of local DsPH and their teams;

provide independent scientific evidence-based advice and guidance to the devolved nations where they are unable to access this locally; and

generate revenue from external consultancy and academic research funding.

Specialist public health capacity (including specialists working across the domains of health improvement, health protection, healthcare public health, and public health intelligence/analysis) should be consolidated into PHE. The specialist capacity can then be deployed to provide public health input to all parts of the health and social care system; CCGs, LAs, NCB, and NHS-funded provider organisations.

2.2 The future role of local government in public health

DsPH are the frontline leaders of public health working across the three domains of health improvement, health protection, and health care service planning and commissioning. DsPH must be enabled—through primary legislation—to provide oversight and influence across all these determinants of health within local authorities, the NHS and primary care, and other appropriate sectors and agencies in order to secure the improving health of their population.

DsPH should be jointly appointed by LAs and PHE and should have a contractual relationship with both.

DsPH will need clearly defined responsibilities and powers and the professional status and enablement to express an independent view in order to provide advocacy for the health of the population.

DsPH will require a well-resourced, professional and co-located Public Health team providing the skills and experience to input to local service planning and commissioning, and to deliver Public Health programmes and advice across the health economy, supported by access to high quality local and national data and scientific evidence base.

There is an immediate and transitional risk of loss of PH professional staff and expertise through uncertainty and staff concerns over the implications of potential transfer out of NHS employment.

Clarification of the resources that will support the DPH role in local authorities is urgently needed.

Health & Wellbeing Boards/JSNAs

Health & Wellbeing Boards must have the power to sign-off local commissioning plans, ensuring that they are aligned with the joint strategic needs assessment (JSNA) and address the identified needs of the population.

The DPH should act as a principal advisor to the Health & Wellbeing Board and as such, a DPH should not relate to more than one Board. However, we recognise that where local arrangements lead to a shared Board, then it may be appropriate for one DPH to work to this Board.

In two tier authorities existing health and well-being partnerships should continue to work together. District Authorities should have specific roles and duties for the improvement and protection of health and the reduction of health inequalities.

The JSNA must:

be asset-based, wide-ranging and thorough and include qualitative “citizen” views (not just service-user or patient views);

include preventative and health protection issues; and

be the basis for all local commissioning.

2.3 Commissioning

Public Health oversight of and input to commissioning will be essential to achieve real improvements in health outcomes and the reduction of health inequalities.

Locally, the DPH should provide oversight and the Public Health team input to CCG commissioning, supported by additional resources and expertise held within PHE. CCGs should be required to work through and with DsPH to ensure their decision-making is underpinned by expert, professional public health advice. DsPH should have a formal relationship with CCGs, and local commissioning plans should be signed-off by the Health & Wellbeing Board.

Specialists working in health services public health possess skills that are highly specialised. The essential role of this group in the commissioning of health services by CCGs (and NHS Commissioning Board) is crucial.

The requirement for commissioners to take advice should be extended to ensure that all organisations undertaking commissioning functions (at national or local level) should be required to consult and take cognisance of specialist public health advice in formulating their commissioning proposals. The board of each such organisation must include a specialist in public health as a full member.

The NHS Commissioning Board should be required to appoint a Director of Public Health with a national remit and to be a full member of its Board.

Decisions as to whether services are commissioned and delivered nationally, regionally or locally should be based on evidence of effectiveness.

Commissioners should be required to demonstrate the use of a strategy covering high quality, universal services, targeted services for communities of interest at greater risk especially deprived communities and tailored services for people with multiple and complex needs. This should be underpinned by evidence base, public health intelligence and needs assessments.

There must be clear lines of accountability, communication and access between PHE, CCGs, NHS and DsPH working within local authorities.

2.4 PH information and intelligence

The new system must ensure that all those working in public health have access to timely, comprehensive and appropriate data and analysis to inform their decisions and advice.

Reliable data and information are essential to the understanding of health needs, modelling of future scenarios and assessment of impact and efficacy. This is relevant both for service planning and design and for the recognition of and response to hazards and outbreaks.

The reforms could result in disruption of existing flows of data and the loss of analytical expertise. Arrangements for maintenance of the public health observatory function and for ensuring access to health service data at local and national levels need urgent clarification.

January 2012

1 www.adph.org.uk

Prepared 8th December 2012