Select Committee on Health Appendices to the Minutes of Evidence


Letter from the Co Chairs, Southwark Health Alliance, to the Clerk of the Committee (PH 20A)


  Further to our telephone conversation, please find enclosed a summary update of the Southwark Review of Specialist Health Promotion and Public Health Resources. We are currently feeding back the results of the review and consulting on potential re-configuration options. This consultation will continue into the New Year.

  We would welcome the opportunity to share with you the outcome of the consultation. Both the Local Authority and Health Authority are facing significant "modernising" challenges and we believe that a strengthened and locally accessible Specialist Health Promotion and Public Health Resource will help us deliver the increasingly tough health improvement objectives and targets that we have set in Southwark. Our review is also reinforcing the value of "public health alliance" partnerships in providing strategic co-ordination in health improvement in area based initiatives, of which Southwark has a high number.

  We would like to emphasise our view as expressed in our submission that health promotion and public health are at a pivotal point nationally. The Southwark review is confirming to us what we need and what works. We hope the Health Committee will consider this when making its national recommendations.

  Thank you for contacting us for this further submission.

1 December 2000


  We are writing to you as joint Chairs of the Southwark Health Alliance to assist your work in reviewing the future of public health and health promotion. We hope that the Committee will find this brief submission helpful. We would be pleased to supply more detail. We would be delighted to receive the Committee's comments on this submission.


  The two communities of Health and Local Authorities have a shared responsibility for leadership at Borough level on public health, public protection and health promotion. Locally, the Health Authority and Health First, the specialist health promotion agency commissioned by the Health Authority, have been the principal source of health promotion and public health expertise. However, there are well established arrangements by which this expertise is shared with the Local Authority and voluntary sector community. The Southwark Health Alliance which has been pivotal to partnership working on public health issues and health improvement is currently undergoing review in order to better meet new challenges.

  Recent Government proposals relating to both the NHS and local government have created a need at a local level to re-think how public health and health promotion expertise can be strengthened to support the challenging "modernising" agenda. Southwark partners in considering and implementing the Government proposals, are beginning to recognise the potential transmutation of the Health Authority into a sub-regional body focussed on performance management of PCGs/PCTs and specialist commissioning, and the general priority given to improvements in clinical primary care. Simultaneously, the Local Authority is prioritising the establishment of the Local Strategic Partnership, while giving careful consideration to how it can best utilise its power to promote well-being and fulfil its duty of community planning. Additionally, our specialist health promotion agency, Health First, is considering its role in relation to the Health Development Agency.

  Southwark's Health and Local Authorities are now consulting their partners on the precise form that any revised organisational arrangements might take. This may well involve the pooling of public sector health promotion budgets and the strengthening of the public health function which is currently based at the Health Authority in new configurations over the next year or so.

  This submission covers:

    —  our starting point—what we mean in Southwark by public health and health promotion;

    —  the importance of distinguishing health promotion planning or strategy from operational activity;

    —  the organisational arrangements up to now, and the reasoning behind them;

    —  our views on why that position is changing; and

    —  what any new organisational arrangements might look like.

  The key messages from the Southwark review of public health and health promotion are:

    —  the roles of organisations are changing as structures change in response to the national agenda;

    —  there is an increasing role for the local authority in the wider health agenda in particular in relation to inequalities, regeneration and probity;

    —  public health expertise is required to inform this, with increasing demands made on current public health resources;

    —  there is a cogent case for strengthening links between public health and local authorities and increasing public health and health promotion support and public health skills at a local authority level. However, public health still needs to be a part of a coherent public health function and maintain professional accountability for example via local or regional links; and

    —  in practice, the public health function will also need to link with local health agencies to ensure the effective use of resources in relation to health needs and effective intervention.


A shared view of public health and health promotion

  Health promotion is about causes, not symptoms. Current thinking is that the roots of ill-health and health inequality lie in social ills such as poverty, poor housing, weak educational systems, general environmental issues such as pollution, as well as in individual behaviours such as poor nutrition, bad parenting, and life style "choices" from drug taking to lack of exercise. Changing individual behaviours and tackling some of the contextual social ills is seen as the long term solution to many health concerns. Such preventative work is better and cheaper than costly clinical intervention further down the line. It follows that the best health promotional work is not at the point of clinical intervention but is further up stream than that.

  With the above in mind, Southwark partners consider health promotion as one of the core components of the public health function. Components of the public health function will also include, amongst other things, surveillance and assessment of the population's health, managing knowledge and getting research into practice, developing and influencing policy and informing on priorities in health and health care.

Distinguishing health promotion strategy from operational activity

  We find it helpful to draw a distinction between the co-ordination, planning or strategy around health promotional activity and the doing or delivery of health promotional work.

  Leaving to one side for a moment the individuals whose health we are trying to improve, many public, private and voluntary institutions and possibly individuals have a stake in and a useful contribution to these activities. They need to be involved for at least two reasons. Firstly, we need to pool their insight and knowledge in order to get the best possible view of the local determinants of ill health and of the best way of intervening. Secondly, many of the institutions are sovereign bodies, and will need to be party to the discussions and be convinced by them if they are to change their own behaviour or priorities to help affect the health of the community.

  In our view the strategy or co-ordination of health promotion activities and of the various stakeholders that contribute to them needs a clearly defined focus. In some ways, it hardly matters who holds that co-ordinating role, so long as it is clear and they are equipped for it. However it is helpful to be clear where the primary accountability for co-ordination lies. In Southwark, the review establishes that this lies with the Health Alliance, demonstrating the important role that a healthy alliance partnership plays in ensuring strategic co-ordination, especially in areas where there are high numbers of area based initiatives (there are at least nine in Southwark, including HAZ, Education Action Zone, mini EAZ, Surestart, New Deal for Communities, SRBs, Employment Action Zone, Sports Action Zone).

  What follows in this submission is not concerned here with the delivery of health promotion activities or interventions, except to say that will continue to be shared among many partners, and will continue to be a balance between one off projects and complex programmes, between short and long term work, between opportunistic and planned, and so on.

The position up to now

  It would be fair to say that for some years the prime responsibility for public health and health promotion have rested with health authorities and their predecessor organisations. Most recently, Directors of Public Health under the aegis of their Health Authority have led this process.

  In Southwark, the Health Authority has of course recognised that the pivotal role of both the Local Authority and the voluntary sector. That led to the establishment of the Southwark Health Alliance in 1993 with the Chair shared between the two Authorities. This shared arrangement has served Southwark well. It has allowed us to develop and initiate a series of programmes to shift health outcomes, and led to a broader contribution (from non-health service organisations) to the Health Improvement Programme and (from non-local authority agencies) to the Local Authority Community Plan than might otherwise have been the case.

  We need to emphasise the role of the voluntary sector. They are key partners in the planning and the delivery of health promotional activity. Local organisations have been vigorous contributors to both the strategy and the delivery of health promotion.

The position for the future

  We think that the time is ripe for a rethink of the institutional relationships in this field. In broad terms our views are that:

    —  The Health Authority, tasked with the establishment of PCG/PCTs, is in a transitional phase. Current indications from the Department of Health and elsewhere is that Health Authorities will amalgamate into sub-regional structures with a monitoring and review role, and a specialist commissioning role.

    —  PCG/PCTs on the other hand, have three objectives: to develop primary care, to undertake local needs assessments and to commission services. It is clear from the range of targets and the broad managerial ethos emerging from the Department of Health that the improvement of primary care is their overriding priority. PCG/PCTs will have a powerful role to play, and a strong interest in, broad health promotional issues. But they will have less influence on the determinants of ill health than some other bodies. And it is probably not realistic to expect that they will lead on the whole gamut of health promotion activity.

    —  There is some concern that the health promotion expertise currently provided by Health First and valued by the Local Authority and the voluntary sector may be lost or become less accessible in any potential realignment with regional health promotion resources such as with the Health Development Agency. The Southwark review is showing that easy access to locally based expertise will play an important role to ensure that health issues are addressed in an evidence based manner in major area based initiatives.

    —  The Local Authority, in the meantime, is finding its remit extended significantly. Local authorities are being given the powers and the duty to integrate health issues into the wider processes of community planning at Borough level. Change to the political system will accentuate this. The emergence of individually accountable and powerful local politicians in a Cabinet or as Mayors, and the expansion of the scrutiny function of local authorities to embrace health, will have an impact. Together these issues are forcing local partners to re-think how the public health function can be strengthened in order to better provide specialist and expert public health support to the Local Authority.

    —  As if to re-enforce this trend, the system of Public Service Agreements may allow Councils that can demonstrate that their Local Strategic Partnerships are effective and exceeding Government targets may have access to un-hypothecated funding, and a release from at least some of the burdensome and over-prescriptive planning frameworks imposed from the centre.

    —  Finally, but not least Southwark partners have to some extent recognised that the Local Authority is well placed to integrate health promotion with their wider educational and regeneration roles; regeneration in Southwark is of course particularly active. It is a route to public and private funding on a scale that dwarfs any other conceivable source.

  The above is making us re-consider the organisational arrangements that underpin public health and health promotion and to look at ways to strengthen that activity during the transitions of the next few years.


  It follows from this that the current arrangements for public health and health promotion may have to change. For a variety of reasons, the Health Authority may not be able to sustain the energy it puts into Borough based health promotional work, and in any case must integrate its work with the evolving PCG/PCTs as well as support the potential demands on public health resources from the emerging Local Strategic Partnership. The Local Authority, on the other hand, is challenged by the duty of well-being and the powers of community planning to facilitate that integration. Both communities have an interest in strengthening the Borough's strategic or co-ordinating capacity in health promotion and in public health expertise.

  The practical issue we must now face is whether and how to combine the limited budgets of time, money and energy Southwark partners hold in different ways. We already pool resources to fund both strategic and operational activity. Perhaps we need to pool more in order to be certain that the longer term and sometimes diffuse work around public health and health promotion hold its ground—and preferably advances—through the organisational turbulence of the foreseeable future.

  We have therefore initiated a consultation process with the relevant partners in public health and health promotion in Southwark to test their views. On the whole they share our view that it is time for change and that there must be some more formal pooling of effort between the two authorities, and that we must work to integrate our efforts with the wider strategic partnership.

  Our consultation is not yet concluded but might encompass the establishment of a core health promotional team, organisationally equidistant between the health and local authorities, with a remit to force the pace on health promotion strategy and commissioning and to integrate that with the local strategic partnership. In addition, there is a need to strengthen local public health expertise in order to support the Local Authority's additional roles around health improvement and scrutiny. This may involve change to the current public health arrangements which are primarily Health Authority based. Funding these developments may involve some hard choices for both the Local and Health Authorities. There are other options, although the status quo is probably not one of them.

  The Southwark consultation continues into January 2001 and we will welcome the opportunity to update the Health Committee on the outcome.

1 December 2000

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