In her first speech as Prime Minister, Theresa May put reducing health inequalities first on her list of ‘burning injustices’ that need to be tackled. We agree. Action should go beyond tackling the difference in life expectancy to include the inequality in the years lived in good health between the most and the least advantaged in our society.
We welcome the focus on public health but recognise that reducing health inequality will also need to address the wider determinants of health, such as education, employment, housing, and the environment. This will require cross-Government working. We recommend that a Cabinet Office minister be given specific responsibility for embedding health across all areas of Government policy at national level.
We welcome the move of public health to local authorities in 2013. They are well placed to deliver these same objectives across their communities and in doing so can harness a far wider network of individuals who can help to improve public health.
Local authorities face a number of challenges and have had to cope rapidly with major system change. In addition they face real terms cuts to public health budgets, including last year’s in-year cut of £200 million. As a result, they are trying to deliver more with less. Whilst we have seen examples of innovative practice, local authorities are now at the limit of the savings they can achieve without a detrimental impact on services and outcomes. There is a growing mismatch between spending on public health and the significance attached to prevention in the NHS 5 Year Forward View.
Cuts to public health and the services they deliver are a false economy as they not only add to the future costs of health and social care but risk widening health inequalities.
The new public health system is designed to be locally driven, and therefore a degree of variation between areas is to be expected. However, we are concerned that robust systems to address unacceptable variation are not yet in place. The current system of sector-led improvement needs to be more clearly linked to comparable, comprehensible and transparent information on local priorities and performance on public health. Changes to local government funding, especially the removal of ring-fencing of the public health grant, must be managed so as not to further disadvantage areas with high deprivation and poor health outcomes.
While strong local political leadership can bring enormous benefits for public health, there is also the potential for tension between political priorities and evidence-based decision making. Clearer standards should be introduced and monitored transparently to improve accountability and to make sure that services to underrepresented or politically unpopular groups are maintained at an appropriate level.
We also recommend that local authorities be given greater powers to directly improve the health of their local communities and reduce health inequalities by including health as a material consideration in planning and licensing. We commend the proposals for a tax on the manufacturers of sugary soft drinks and call for further bold and brave cross-Government action to be included in the childhood obesity strategy and life chances strategy.
Commissioning for certain services is divided between different bodies, creating the potential for confusion and fragmentation. Where these boundary issues are identified there needs to be faster progress on resolving them in the best interests of patients and the public. Sexual health provides a clear example of such fragmentation and, in particular, clarity is urgently needed over the responsibility for and funding of pre-exposure prophylaxis, PrEP, for HIV.
We were told of significant problems with public health teams not being able to access the right level of information they need to do their jobs effectively. In some cases these problems may not have been a direct result of the move of public health teams to local authorities, but nonetheless they need to be addressed with urgency. We recommend that the Department of Health review the barriers which exist to greater information-sharing, and that Public Health England and NHS Digital (the Health and Social Care Information Centre) address the specific issues which have been drawn to our attention.
The public health workforce—both the specialist workforce and the wider workforce—is essential to delivering improved outcomes. We heard of the importance of Directors of Public Health as leaders, advocates and facilitators in local systems. Barriers to workforce mobility must be removed, and given that public health specialists may increasingly come from unregistered disciplines, the Government should review the regulation of public health specialists to ensure the protection of the public.
Health protection—encompassing prevention, preparedness and response to outbreaks and other health threats—is a critical public health function. Despite several sets of guidance on responsibilities we heard that confusion, duplication and lack of clarity persist in some local areas. Public Health England must ensure that local areas are clear about their responsibilities and equipped to deliver a seamless and effective response to outbreaks and other health protection incidents.
As Simon Stevens, Chief Executive of NHS England, has repeatedly emphasised, the NHS itself—both through NHS Trusts, CCGs, GPs and other service providers and as a major employer—has a critical role to play in public health. We agree but note that this is not yet happening at sufficient scale. The NHS needs to significantly improve its own performance on prevention.
30 August 2016