2 Maximising impact through working
with local authorities
13. There are significant health inequalities across
England, for example, healthy life expectancy for men ranges between
52.5 and 70 years in different areas and the North of England
has poorer public health outcomes than the South. There are therefore
different concerns and priorities for local authorities in different
parts of the country. PHE told us that local authorities are best
placed to co-ordinate public health activities in their areas
so they can respond to specific local needs, and that they have
their own priorities set out in their local strategy documents.[17]
14. While local authorities should obviously be free
to choose their own priorities, we were concerned that for some
issues such as smoking prevention, some local authorities have
relatively poorer outcomes and were spending relatively less.
Further, there are some local authorities where spending in some
areas, such as alcohol misuse, is not targeted to where outcomes
are worsening. The Department responded that it is only just starting
to understand the impact of local government commissioning public
health, as initially most contracts were transferred across from
the NHS. PHE accepted that that there should be a relationship
between outcomes and local authority spending, and that it should
act to help local authorities if these are not well matched. PHE
has developed a tool that compares health spending and outcomes
but it has not yet used the tool to inform and prioritise its
approach to helping local authorities.[18]
15. PHE has set out five priorities for public health
improvement, which it told us are based on evidence about what
is making people ill and miserable and killing them early.[19]
The Department and PHE can influence local authorities, by prescribing
particular services, imposing specific grant conditions, making
incentive payments, and reporting on public health outcomes. PHE
told us it believes it has the levers it requires to help get
the right outcomes. But we were concerned about whether these
mechanisms are effective and whether the agency had real 'teeth'
to bring about the necessary changes at a local level.[20]
16. The Department has stipulated that local authorities
must provide six prescribed public health functions.[21]
PHE told us that these prescribed functions were chosen by government.
The Department and PHE told us that they were chosen to ensure
a consistent approach across the country, for example, to measuring
children's weight.[22]
The Department added that some functions were prescribed because
their implementation was critical, for example providing public
health advice to clinical commissioning groups or for commissioning
NHS Health Checks. The six prescribed functions do not cover most
of PHE's priorities for public health such as obesity, smoking,
and harmful alcohol.[23]
17. The Department can also attach conditions to
its grant. It told us that there is now a new grant condition
that asks local authorities to demonstrate that they are getting
year-on-year improvements in take-up of, and outcomes from, their
drug and alcohol misuse treatment services.[24]
PHE noted that the recovery rates for both alcohol and drugs have
improved in 2013-14, although it said that local variation had
led to the grant condition.[25]
We asked whether it would apply more grant conditions if it had
concern in another area of public health. The Department responded
that there is a grant condition for reducing inequality which
is already wide-ranging, but that it could choose to impose grant
conditions if there was a particular concern.[26]
18. From 2015-16 the Department will introduce a
new health premium which will be awarded to local authorities
showing good progress. The premium is intended to be an additional
incentive for local authorities to improve public health outcomes,
and awards are assessed through two specific indicators. The first
indicator is on completion of drugs treatment, and second is chosen
by local authorities from an approved list. But the health premium
is small, at only £5 million for the whole country in 2015-16,
and it does not cover all of PHE's priorities. The Department
said that this was the first year of the scheme and that it is
piloting its approach. It told us that the spending review will
decide when or by how much the premium will be increased in future
years.[27]
19. Local authorities are also required to think
about the Public Health Outcomes Framework when deciding how to
spend their grant. The Public Health Outcomes Framework, created
by the Department in 2012, brings together many disparate datasets
to enable local authorities to assess their needs and monitor
their progress by comparing performance between authorities, which
increases accountability. The outcomes framework includes a wide
range of indicators from social factors such as employment to
health protection, health improvement and healthcare. It is still
developing, as some measures do not have any data and some others
take a long time to collect. The majority (83%) of directors of
public health use the framework frequently, but PHE told us it
would like even more to use it.[28]
20. Part of PHE's role as an expert body is to provide
support to local authorities in their efforts to seek better local
outcomes. PHE has produced national tools and reports for local
authorities to use, such as the Longer Lives tool, which provides
data on premature mortality for every local authority. Another
tool compares public health spending and outcomes, helping local
authorities to prioritise their spending. PHE acknowledged that
it needs to be more relevant and practical; supporting local authorities
at a local level in how to use the tools it has produced. The
NAO also found a number of areas where more support for local
public health staff would be valuable, and made recommendations
to PHE, including: to improve its responsiveness to local authority
requests for support; to improve advice to local authorities on
their support to clinical commissioning groups; and to help local
authority teams understand the evidence base and cost implications
of different public health interventions, including sharing best
practice.[29]
21. The Association of Directors of Public Health
spoke of good access to information on what works through PHE
and the National Institute of Clinical Excellence (NICE). But
directors of public health would value more assistance on economic
modelling and better advice on return on investment tools to forecast
the financial impact of particular interventions. This means they
need evidence about which types of intervention are most effective
to reduce future costs, for example whether group or individual
sessions on smoking cessation are more effective. PHE acknowledged
the need to provide evidence on effectiveness, using the example
of tobacco. It stated that half of the inequality in life expectancy
across the country is accounted for by tobacco but tackling smoking
can involve anything from tackling counterfeiting to national
smoking cessation campaigns.[30]
22. PHE's remit includes supporting and developing
a skilled public health workforce, but there have been difficulties
in recruiting permanent directors of public health to local authorities.
The Association of Directors of Public Health told us that since
April 2013 the number of vacancies has dropped from about 35 to
26. But there are still vacancies for about 20% of directors of
public health posts. Although interim staff are in place, substantive
post holders are far more likely to be able to influence the management
team in the council.[31]
23. The Association of Directors of Public Health
said that the programme for aspiring directors of public health,
funded by PHE, has been quite successful in building the pipeline
of people for director of public health posts. PHE added that
20 of those who have completed the programme are now in substantive
posts. But there is likely to be more turnover in the next few
years given the age profile of directors of public health. Problems
with recruitment include a lack of parity of pay and conditions
for those staff moving from the NHS to local government. The Association
of Directors of Public Health told us that further work was needed
to tackle issues with continuity of service and terms and conditions
for staff moving through their careers from local government into
PHE, the NHS and back again.[32]
17 Qq 1, 19-20, 39, 89, 102; C&AG's Report, para 2.8 Back
18
Qq 11-14; C&AG's Report, paras 2.11-2.12 and 4.5, 4.9- 4.10 Back
19
Qq 14, 27 Back
20
Qq, 1, 28-29, 123; C&AG's Report, para 3.7 Back
21
C&AG's Report, para 1.6 & Figure 3 Back
22
Qq 33, 134 Back
23
Qq 134, 137-138 Back
24
Qq 29-31 Back
25
Qq 34-37 Back
26
Qq 38-39 Back
27
Qq 97-98; C&AG's Report, paras 3.11-3.12 & Figure 11 Back
28
Qq 1, 20, 24-25, 27; C&AG's Report, paras 12, 13, 3.8 & 3.9 Back
29
Qq 12, 20, 91; C&AG's Report, paras 20a, 1.8 & 4.5 Back
30
Qq 14-17, 91, C&AG's Report, para 4.7 Back
31
Qq 118-120; C&AG's Report, paras 4.19 & 4.21 Back
32
Q 120, C&AG's report, para 4.21 Back
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