Public health post-2013 Contents

---

3The new system

Systematically improving public health and addressing unnecessary variation

Summary

42.The public health system is now firmly centred on the principle of localism—local public health strategies designed by local teams, to meet the specific needs of local populations. This means that a degree of variability is inevitable and indeed desirable if it reflects local priorities.

43.We chose two distinct areas of public health as case studies to examine in more detail—health in all policies, and health protection. Subsequent chapters discuss these functions in more detail. We found that both functions were noticeably better developed in some areas than in others. This suggests that while some areas may be making solid progress, a considerable challenge remains to bring the worst performers up to the level of the best. Professor John Ashton of the Faculty of Public argued that:

44.Andrew Furber of the Association of Directors of Public Health gave a more positive view. He said in terms of the proportion that are succeeding, “I would say maybe it is 80:20, or 90:10. There are a handful of local authorities where it is still not working quite as we would hope.”18

45.One public health trainee who had worked in different local authority areas noted variability, and remarked that in her current posting:

46.When we asked about the mechanisms for sharing best practice, and also who holds the ring where a system is failing to deliver improved public health outcomes for its population, we were not persuaded by the answers we received.

Sector-led improvement

47.Local authorities are meant to share best practice with one another and improve their performance through a process called ‘sector-led improvement’ rather than through a central performance management system. In this, local authorities are supported by national organisations—the LGA, the ADPH and PHE:

48.We also asked how well this ‘sector-led improvement’ was working in the area of health protection, but there was less confidence in the process:

Public health outcomes

49.To determine whether improvement is taking place, outcomes need to be consistently and transparently monitored. When we asked about public health outcomes, we were told they had remained broadly stable since the changes:

50.The three areas of concern highlighted by PHE are sexual health, breast feeding, and uptake for two cancer screening programmes. PHE argue that “Nevertheless, it is still an overall positive picture on the outcomes.”19 However Martin Reeve, a local authority chief executive from London, gave a more challenging view of the data:

51.The Five year Forward View is clear that a step change in public health was required if the NHS was to deliver the ambitious savings set out:

52.When pressed on exactly how much savings the radical upgrade of prevention and public health needed to deliver, Simon Stevens put the figure at between £0.5 billion and £1 billion.20

53.We heard of some local authorities measuring outcomes. For example, Shirley Cramer of the Royal Society for Public Health described progress on improving cardiovascular outcomes in Wigan and Leigh:

54.Coventry reported improvements in physical activity levels, as well as other indicators relating to the broader determinants of health.21

55.However on the whole there appears to be a disconnect between the official ambition to deliver significant savings though a radical upgrade of public health and prevention and the lack of rigour in implementing this ambition, with little systematic monitoring of local authorities’ progress towards specific public health goals at a national level.

56.While availability of information about public health outcomes has improved, there are 144 separate indicators in the public health outcomes framework, making the data available complex to interpret. A simplified version of this information is also available for members of the public on the My NHS Website. However, it is still difficult for us, as a Parliamentary Committee, to scrutinise and compare the performance of local authorities robustly and objectively.

57.Individual local authorities agree local priorities for public health, and the best outcomes for monitoring them, through their Health and Wellbeing Strategies—but these plans are not subject to external quality assurance, and information about local authorities’ performance against local priorities is not collected systematically. Health and Wellbeing Boards are not required to implement their Health and Wellbeing Strategies, and nor are they held to account for delivering them.

58.Public Health England have made it clear that they “are not the performance manager of local government”.22 They did describe a protocol for managing the risk of underperformance which they have developed with the LGA and ADPH, around giving extra support to local authorities which need it, as well as weekly and monthly contact with local authorities. PHE also gave an example of when they had stepped in to influence a particular local authority which was proposing substantial reductions to its service for 0–5 year olds, a proposal that was then withdrawn as a result of PHE’s intervention.23 While it is reassuring that this case was picked up by PHE and acted upon, the mechanism for public accountability and transparency about public health decision making and performance at a local level is far from clear.

59.Ultimate accountability for local authorities’ performance on public health now lies with elected members of local authorities, and with the public through the ballot box. However, for accountability to be exercised, the public need a clear articulation of the actions their local authority is taking and their planned impact, underpinned by a benchmarking framework that allows for informed comparison and challenge between local authority areas, to provide a mechanism for closing the loop so that local authorities can be held to account.

60.A return to a centralised system which sets a national public health strategy for all local authorities and enforces progress against it is not likely to be possible or workable, or necessarily desirable. However, as improvements in prevention and public health are crucial to the ongoing sustainability of the health service, it is essential that the contributions local authorities are making towards this national goal are measured and underperforming areas are supported to improve, and held to account if they do not.

61.Prevention is intended to be an important element of local Sustainability and Transformation Plans, and guidance has been issued to local areas setting out national expectations in this area. However, planning in most, if not all, areas is still at an early stage, and it is not clear how rigorously this guidance will be enforced or what will emerge when the STPs are finalised. The funds earmarked to support STPs are likely to be under intense pressure, which is once again likely to marginalise public health.

Conclusions and recommendations

62.There is variation between local authority areas in terms of their public health provision. The system of ‘sector-led improvement’ is beginning to be used to good effect in some areas, and clearly has potential to deliver performance improvements. However, in our view, this programme needs to be given added impetus and more clearly linked to accountability and performance.

63.Currently local Health and Wellbeing Strategies identify priorities and targets at a local level, but progress against these is not enforced or monitored. Sustainability and Transformation Plans may offer another opportunity to embed public health and prevention targets, but these plans are at an early stage in development. While ultimate accountability for local authorities’ performance now rests with the voting public, there is a lack of comparable, comprehensible information on public health performance for the public to access easily.

64.We recommend that local authority directors of public health should be required in their statutory annual reports to publish clear and comparable information for the public on the actions they are taking to improve public health and what outcomes they expect to achieve, and to provide regular updates on progress. While public health priorities may be different for different areas, which is entirely appropriate, they should be presented in a standardised format, and underpinned by a benchmarking framework that allows for informed comparison and challenge. The Chief Executive of Public Health England, in his capacity as accounting officer, should publish an annual report drawing together and analysing local progress towards agreed plans.

65.We also reiterate the recommendation of our recent report on the impact of the Spending Review on health and social care that the Government should set out clear milestones of what it expects public health spending to achieve, and by when.

Politics and evidence

66.Locating public health within local government has also placed it at the heart of local democracy. Many described the boost that political leadership could give to public health which was lacking when the NHS had lead responsibility for the function.

67.Others raised concerns about politics rather than evidence determining spending priorities, which could be of particular detriment to services for more marginalised or stigmatised groups:

68.A particular issue was the whether the director of public health was able to give a truly independent view:

69.Many services that used to be provided by the NHS—including smoking cessation services, drug and alcohol treatment services, and sexual health services—have been recommissioned by local government. We heard significant concerns about this recommissioning from those involved in running such services, including claims that services were being restricted or were of a poorer quality than previously.24 However we also heard an opposing view that although the changes may have been unsettling for established providers, in fact new commissioning arrangements had resulted in services which delivered better value for money, better matched to local needs than previously, and accessible and appreciated by service users.25

Conclusions and recommendations

70.It is clear that good political leadership for public health has enormous potential to deliver positive change. However, amongst some public health professionals, concerns remain about the tension between evidence-based decision making and political priorities. In particular, concerns were raised about the potential for services such as sexual health and drug and alcohol to be neglected, if felt not to be political priorities, and are unlikely to generate demonstrations on the steps of the town hall. To address these concerns, benchmarking standards for all local authorities’ prescribed public health functions should be introduced, which should be transparently monitored to enhance accountability and provide reassurance that these functions are being maintained at an appropriate level.

Boundary issues and fragmentation

Summary

71.With a wider range of different organisations now involved in the commissioning and delivery of public health services, complexity and fragmentation was a common theme in the evidence we received. In some cases our witnesses were clear that the system was not ‘broken’, but that it had left them with a greater number of boundaries and relationships to negotiate.26 We also heard that two-tier local authorities face particular challenges.27 Drawing on their assessment of the new public health system, the University of Kent offered the following observation28:

72.Sexual health, screening and immunisation are examples given where fragmentation has been detrimental:

Health and Wellbeing Boards

73.The Health and Social Care Act 2012 placed a statutory duty on local authorities to create a Health and Wellbeing Board (HWB) as a committee of the authority. HWBs bring together partners within the NHS, public health, adult social care and children’s services as well as elected members and representatives from Healthwatch, in an effort to ensure strategic planning based on local health needs. Local authorities have statutory duties to develop Joint Strategic Needs Assessments (JSNAs) and Health and Wellbeing Strategies (HWSs) to be discharged through the HWB. These are the principal mechanisms by which HWBs and partners are able to jointly plan and support delivery of improvements to the health and wellbeing of local populations, although they have no powers to ensure the implementation of the HWS.

74.The available evidence indicates considerable variation in the configuration and operation of HWBs.29 Promoting integration across sectors and delivering strong leadership across organisational boundaries have proved to be especially challenging for HWBs, which have very few powers to make things happen.30 Their authority does not lie in having executive powers but in their capacity to influence others through the persuasiveness of their arguments and success in building sound relationships.

75.The evidence we received concerning HWBs and their performance was mixed. Whereas the Public Health System Group maintained that HWBs ‘are becoming a key forum where local partners can agree how to harness the sum of local resources to address key health challenges’31, NHS Clinical Commissioners gave a less positive view. They believed that HWBs were struggling with achieving ‘clarity around the role and purpose of the Board’ with CCGs in particular not yet seeing HWBs as ‘conducive environments for meaningful discussions about public health’.32 The University of Kent research found that the HWB ‘is crucial in ensuring local governance and stewardship’ and that Boards ‘could play a crucial role in bringing together a fragmented system’. However, they were still considered to be in ‘early development’.33

76.The latest evidence suggests that most HWBs continue to address the challenges they face with variable success. Progress is slow and subject to constant changes in, and demands from, national policy. This can result in Boards losing focus and in trying to do everything, with ‘mission creep’ a real and present danger.34 A key conclusion to emerge from the evidence is that the majority of HWBs have yet to position themselves as the key strategic forum for driving the health and wellbeing agenda.35 Despite these difficulties, there is cautious optimism about the future of HWBs and their ability to bring and hold the health system together thereby reducing the fragmentation that threatens it in many places.36 It is generally acknowledged that HWBs have a critical role to play in creating the conditions in which discussions can take place between councils, CCGs and service providers on the future shape of local health and social care systems.37

Commissioning of Pre-exposure Prophylaxis for HIV

77.The recent issue of commissioning of Pre-Exposure Prophylaxis for HIV is another example of the new structures causing fragmentation and confusion. In September, 2014, NHS England announced that PrEP would be put through the NHS England specialised commissioning prioritisation process, and it proceeded through this process for 18 months. In March this year NHS England announced that in fact commissioning of HIV prevention services was the responsibility of local authorities rather than NHS England.38 In response to the considerable concern expressed at this decision, NHS England are now seeking further clarification on the legal position, but the situation has clearly caused confusion and delay, rather than concentrating efforts on the evidence for PrEP and how it can be resourced.

Conclusions and recommendations

78.The new system for public health is more complex following the changes made by the Health and Social Care Act, and fragmentation has caused difficulties in a number of areas. Any system will have boundaries but further large scale restructuring would not, in our view, be advisable. There is a need to address the system boundary issues that have negative consequences and make sure that they are addressed in the best interests of patients.

79.The outstanding issue of who is responsible for commissioning PrEP for HIV needs immediate resolution, and we recommend that NHS England and DH clarify the position without delay.

80.Where boundary issues are identified around responsibilities, PHE should set out the options for them to be addressed in the best interests of patients and the public and ensure that they are resolved without further delay.

Leadership for public health at a national level

81.Just as the risk of fragmentation exists at local level, with the onus on Health and Wellbeing Boards to provide system leadership, there is also a risk of fragmentation at the centre. Nationally, responsibility for public health is split between the Department of Health, Public Health England and NHS England. There are also arm’s length bodies, notably Health Education England (HEE) and NICE, which have a role in public health in regard to workforce training issues and providing guidance on what works and does not work in public health respectively. In addition, the Local Government Association seeks to support local authorities through a series of publications demonstrating good practice and by offering a peer review system to local authorities wishing to assess their performance. In such a crowded landscape, clarity over system leadership at national level is lacking.

82.The University of Kent researchers who have completed a study of the public health system in England told us that directors of public health:

felt poorly supported by national and regional organisations such as the Department of Health, NHS England and Public Health England—a perception echoed by elected members.39

Health in All Policies nationally

83.While embedding health in all policies is being actively encouraged in local authorities, with some impressive projects emerging, as we saw during our site visit to Coventry, the same commitment needs to be given higher priority nationally in central government. However, we were encouraged to hear from the Parliamentary Under-Secretary of State for Public Health that the Government’s life chances and childhood obesity strategies are examples of cross-government working.40

84.We have called for bold and brave action if the Government is to tackle health inequalities and improve life chances for the most disadvantaged.41 When it comes to taking action on public health there are steps, such as introducing a sugary drinks tax on manufacturers of full sugar soft drinks, that only national Government can take and we support this measure and urge the new Chancellor to implement it.

Cabinet sub-committee for public health

85.We received differing views as to the value of having a cross-departmental Cabinet Sub-Committee on Health similar to that which existed until 2012. Overall, the evidence we received did not persuade us that such a sub-committee had been a key driver for change or that it should be re-established. Jonathan McShane from the Public Health System Group and LGA had “no idea how effective Cabinet Sub-Committees are as a way of driving change, but public health is much higher up on the agenda than at any time I can remember”. He added that he would “always be wary of a solution to a problem that sets up a committee”.42

86.This view was echoed by the then public health Minister Jane Ellison MP, who told us that she preferred to work “with a very defined outcome, a policy objective, a strategy or a new policy to deliver”.43 She thought it far “better to meet with a purpose” rather than “talking for its own sake” and “then we can be judged by our output and outcomes”.44 Both the Minister and Duncan Selbie, chief executive of PHE, told us about joint working in the area of health and work between the Department of Health and DWP.45

87.The Faculty of Public Health suggested that in place of reinstating a Cabinet Sub-Committee, consideration might instead be given to having a Minister for Public Health located in the Cabinet Office.46

Relationship between DH and PHE

88.We are aware of potential overlap and duplication between the public health group in the Department of Health (DH) and Public Health England (PHE). The Committee of Public Accounts has previously investigated this relationship and was not convinced that there was no avoidable overlap or duplication of effort.47 We are aware that DH is conducting a review of the respective roles and activities of the DH and PHE. The Department of Health has also recently announced an internal restructuring. This may provide an opportunity to reconsider the existing relationship between DH and PHE with a view to using limited resources, both human and financial, more effectively.

Relationship between PHE and NHS England

89.Following publication in October 2014 of the NHS Five Year Forward View, NHS England has assumed a more prominent role in driving prevention within the NHS. As we have already pointed out, much of the success of the Five Year Forward View is predicated on the successful achievement of a radical upgrade in prevention and support for wider public health measures.

90.While welcoming a renewed focus on public health and the NHS’s significant contribution to it, we wish to be reassured that PHE and NHSE are working in tandem on this agenda rather than in a silo-based manner. The partnership between PHE and NHSE over the diabetes strategy is an example of good practice and we hope that such a joined-up approach will become the norm for future initiatives.

Conclusions and recommendations

91.National system leadership is important to signal clarity of purpose and commitment to the local system when it comes to improving health and wellbeing. In order to demonstrate where national leadership for public health lies, and to avoid confusion and the risk of giving conflicting advice to the local system, the Government should produce a clear statement of who does what in respect of the main system leaders, namely, the Department of Health, Public Health England and NHS England.

92.Embedding health in all policies is important at both national and local level. But while there is evidence of progress locally, there is less evidence of such an approach becoming embedded across Government departments. We urge the Government to take bold and brave action through its life chances and childhood obesity strategies in order to improve public health and reduce health inequalities.

93.How most effectively to secure joined-up working across Government is a complex challenge to which there is no single or simple solution. The issue is not amenable to a simple structural fix—building sound relationships is a key step in the process.

94.A Cabinet Sub-Committee on Public Health is unlikely in itself to be the answer to securing more effective joined-up policy to improve health and wellbeing. We consider instead that the strengthened cross-departmental working which is required is more likely to be achieved by vesting responsibility for providing political leadership for public health at a national level in a Minister in the department responsible for coordinating cross-departmental work, the Cabinet Office. We recommend that a Minister in the Cabinet Office be given specific responsibility for embedding health in all policies across Government, working closely with the Minister for Public Health in the Department of Health.

95.Since Public Health England was established, the interface between it and the DH has lacked clarity. We therefore urge the Government to review the relationship between the DH’s Public Health Group and PHE. The ‘tailored review’ of PHE which DH is currently carrying out offers a good opportunity to do so.

96.Likewise we urge NHS England and PHE to clarify how the two organisations are seeking to pool their expertise and resources around public health in order to ensure that the local health system feels adequately supported and not conflicted by confusing messages or requirements.

---

18 Q7

19 Q279

20 Q348

21 Coventry City Council (PHP0137)

22 Q284

23 Q300

24 Informal roundtable session with public health practitioners

25 Q21

26 Q249

27 Q108

28 University of Kent (PHP0022)

29 Coleman A, Dhesi S and Peckham, “Health and Wellbeing Boards: The new system stewards?” In: Exworthy M, Mannion R and Powell M (eds) Dismantling the NHS? Bristol: Policy Press, 2016

30 Hunter DJ, O’Leary C, Visram S, Adams L, Finn R, Forrest A and Gosling J (2015) Evaluating the Leadership Role of Health and Wellbeing Boards as Drivers of Health Improvement and Integrated Care across England. Interim report no. 2: Mapping the configuration and operation of Health and Wellbeing Boards across England. Durham: Centre for Public Policy and Health, Durham University.

31 Public Health System Group (PHP0065) p2

32 NHS Clinical Commissioners (PHP0084) para 3.6

33 University of Kent (PHP0022) para 2.16

34 Shared Intelligence, The force begins to awaken: A third review of the state of health and wellbeing boards, 2016

35 Peckham S, Gadsby E, Coleman A et Al, Public Health and Obesity in England – the New Infrastructure Examined. Final report.PRUComm: Policy Research Unit in Commissioning and the Healthcare System. Canterbury: University of Kent, 2016

36 Shared Intelligence - as above

37 Local Government Association and NHS Clinical Commissioners, Making it better together: A call to action on the future of health and wellbeing boards, 2015

38 NHS England, Update on commissioning and provision of Pre Exposure Prophylaxis (PREP) for HIV prevention, March 2016

39 University of Kent (PHP0022) para 2.20

40 Q378

41 Health Committee, First Report of session 2015-16, Childhood Obesity - Brave and Bold
Action, HC 465

42 Qq 56–57

43 Q379

44 Q379

45 Qq378–379

46 Q57

47 Oral evidence taken before the Committee of Public Accounts on 19 January 2015, HC (2014-15) 893, Qq131–133

---

© Parliamentary copyright 2015

30 August 2016