HC 1048-III Health CommitteeWritten evidence from the Department of Public Health, Liverpool Primary Care Trust (PH 166)
Consideration of the integration of health care, social care and public health and necessary structures should have preceded proposals for the reform of the National Health Service.
Excision of public health expertise from the NHS and dispersal into local authorities and Public Health England will tip the balance in a different direction rather than providing equality of resource.
Health and Wellbeing Boards should have the power to sign off area commissioning plans that are based on the JSNA and have been developed to achieve the outcomes of the Joint Health and Wellbeing Strategy.
The Director of Public Health should have executive director status within the local authority and report direct to the Chief Executive.
Links between Public Health and NHS Commissioning
1. In response to the call for evidence to be submitted to the inquiry into Public Health, we would wish to suggest that the scheduling of health and care reform as put forward by the Government has been incorrectly ordered, leading to confusion about the role of public health in the local authority, the role of the local authority in public health and the need to integrate NHS services, social care and public health. Proposals on the future of population health since April 2010 have lagged behind proposals on the intended form of healthcare structures.
2. The introduction of the health and social care bill after the government’s response to Liberating the NHS but before a response to the Public Health White Paper has meant that public health staff have been working with a future NHS model that does not include public health, while the future relationship of population health with health and care services is still the subject of consultation. It was notable that the “Pause, Reflect, Listen, Improve” listening exercise was based on the future NHS model without public health and there was no reference to public health even under the “Advice and Leadership” topic.
3. The web channel on health and care changes on the Department of Health website is titled “Modernisation of health and care” rather than NHS reform, highlighting the barrier of regarding the NHS as a static entity dealing with “health” or “ill-health” rather than as part of a complex system. We would suggest that a return to the aims of improving health, care and wellbeing outcomes through modernisation may clarify possible relationships of health system elements and the role of public health as part of that system.
Role of Public Health England
4. Public Health England (PHE) is expected to form through taking on the functions of the Health Protection Agency, and the Public Health Observatories (PHOs). PHE would become part of the Department of Health. Both the Health Protection Agency and the Public Health Observatories have two functions that are not compatible with PHE becoming part of the Department of Health: recognition of the independence of their advice and expertise, and the generation of income from supplying knowledge and expertise. Additionally, they both require a sub-national structure in order to perform their functions effectively.
5. The structures through which health protection will be delivered and the accountabilities within those structures are not clear which is concerning given that these proposals form the majority of the specification of PHE. The responsibilities of local health protection units and DsPH need to be specified more completely, both for ongoing health protection work and emergency situations. DsPH must have the power to require any agency to respond if needed in preparation for or during incidents.
Public Health Observatories
6. Public Health Observatories (PHOs) located in universities are a valuable academic link and take both a regional perspective and a lead on agreed areas of public health intelligence. Nationally, public health information needs to be more closely linked to the Information Centre which will process inputs and outputs relating to the NHS and Social Care Outcomes Frameworks. PHOs provide input at all stages of the population health commissioning cycle and its subsets. Clarification on what resource would be available through the PHOs for local authorities and NHS bodies would be necessary. The reduction in funding for PHOs and the loss of expert staff through uncertainty will result in a lack of capacity for an already scarce resource just as GP Consortia and Local Authorities need intensive support.
7. If the NHS is to become a “health” service rather than an “ill-health” service then the logic of removing a population prevention and protection function from it is not apparent, particularly if part goes to the Department of Health and part into Local Authorities, breaking the NHS link in two directions.
Public Health Leadership
8. PHE has been proposed as a “national” public health service but currently has only specified roles for the agencies that are to form it, and for Directors of Public Health (DsPH). It is unclear how PHE expects to fulfil its national leadership role for the whole of public health across the three domains of health improvement, health protection and health services, or what its relationship would be with the National Commissioning Board. PHE needs to be established as an NHS body such as a Special Health Authority to fully utilise its specialist public health functions..
Public Health Workforce
9. All public health staff need to retain their link with NHS health services and should be part of the national public health service through their terms of employment, wherever their working location (public health specialists have roles in universities, trusts and other locations and may in future work in other areas in addition to local authorities and consortia).
10. Taking public health staff out of the NHS in entirety would mean the loss of expertise developed since the function moved into the NHS, especially the positive advisory relationship with other health services and organisations that needs to be maintained and enhanced from local authorities.
Public Health Training
11. PHE having the role of public health staff employer would mitigate against fragmentation of the public health workforce and enable the continuance of the public health specialist training scheme to build necessary capacity. Public health training should be equivalent to that for other health professionals and delivered through Health Education England via the existing Deanery network.
Public Health Specialists
12. The public health workforce has been categorised as specialists, practitioners and the wider public health workforce who may not be working within public health teams.
13. Consideration of the future of the public health workforce has primarily been in terms of specialists, who have achieved or are working towards, registration by the GMC or UK Public Health Register according to Faculty of Public Health standards. Registration can be achieved through the Faculty training scheme, by conversion from another medical or dental specialty, or through voluntary registration by submission of a portfolio for those who have public health expertise but have not been on the training scheme.
14. Those public health professionals who are not clinically registered are not statutorily regulated and cannot be held to account. Statutory regulation of public health specialists will provide equity and public accountability.
15. Consideration needs to be given to registration for existing practitioners and future routes into such roles. Beyond these two categories it is possible that all NHS and local authority staff may be said to have public health aspects to their roles, and therefore to be available to DsPH as a resource to deliver on population health, but it is not clear whether only staff in specialist and practitioner roles would be designated as public health staff in local authorities. GP training and continuing professional development in public health should be strengthened and some form of accreditation considered.
Role of the Director of Public Health
16. Directors of Public Health will oversee and direct work in all three areas of public health. The DPH role is that of the linchpin of the local NHS, social care and public health system, bringing structures together and making them stronger by their presence. In order to fulfil the “Vision of the role of the Director of Public Health” (Annex A Healthy Lives, Healthy People) the prime importance of the DPH role must be recognised and the following will need to be implemented:
The DPH must be required to have specialist public health registration and be appointed through an equivalent formal Appointments process to that currently in place.
Every first tier local authority must appoint a DPH with accountability to the Chief Executive, executive team membership and direct access to elected members and their executive group.
The DPH must be able to express professional, independent views as the advocate for the health of the local population.
The DPH will be the principal adviser to the Health and Wellbeing Board on health matters and all local authority functions and their impact on the health of the population.
The DPH must have sufficient resources including professionally trained staff with the knowledge and skills to deliver strategic public health advice and plan and implement public health programmes across the three public health domains.
Function of Health and Wellbeing Boards
17. Health and Wellbeing Boards (HWBs) should be the driving force behind needs assessment, prioritisation and collaborative commissioning for local population health. They will work towards the integration of NHS services, social care and public health, with the aim of ensuring provision of seamless, person centred services. HWBs will oversee local commissioning for populations and for services to individuals. HWBs should take responsibility for ensuring heath equity in all policy.
18. HWBs should aim to implement person centred elements of Liberating the NHS such as provision of appropriate information and involvement in decision making across all locally commissioned health, care and wellbeing services. HWBs will have the responsibility for Strategic Needs Assessment and Health and Wellbeing Strategies and should have the power to sign off commissioning plans that should deliver within the population health commissioning cycle.
Health, care and wellbeing needs should be determined for local authority populations.
Health, care and wellbeing outcomes should be agreed in accordance with the local authority responsibility for population health improvement, health protection and reduction of health inequalities, to be achieved within agreed time periods and performance measured by agreed instruments.
A Health, Care and Wellbeing Strategy should set out how the outcomes are to be achieved.
A set of commissioning plans should set out the specifications for the services to deliver the outcomes and how resources will be used.
Activity should be performance managed, performance should be evaluated and population needs reassessed.
Joint Strategic Needs Assessment
19. The Joint Strategic Needs Assessment process has been a joint responsibility of Local Authorities and Primary Care Trusts. Much of the input to JSNA will have been public health expertise, addressing all three of the domains of public health: health improvement, health protection and health services. The Strategic Needs Assessment process should not be “Joint” in name, but through the requirement on all parties to engage. The current proposal to share responsibility for ensuring the process is undertaken between GP Commissioners and Local Authorities with a lead role for the DPH needs to be underwritten with a requirement for any health and social care funded body to contribute information and expertise, and for Local Authorities to be able to require the same in relation to economic, social and environmental determinants of health. GP Consortia will need to be engaged in and provide leadership for the JSNA process as it will form the foundation of commissioning decisions. Public Health expertise will be invaluable in changing primary and secondary care culture to consider population need as part of the commissioning cycle and in designing care pathways.
Public Health Intelligence
20. Public health intelligence is needed at national, regional and local levels to specify what data is collected, and in what way, to analyse it and interpret it in context. Public health intelligence is the driver for evidence based commissioning for population health. Public health provides some of the strongest tools for assessment, such as asset based approaches, impact assessment and participatory research. Public health also takes a population view of consultation, engagement and involvement, recognising that health, care and wellbeing are whole population issues, rather than just the population accessing services.
21. The Public Health Intelligence workforce has always been a highly skilled but scarce resource that does not necessarily sit within NHS Public Health departments. Given the current lack of incentive for public health intelligence staff to define themselves as such, the reforms could precipitate the loss of this resource just as it comes under pressure to support the new roles of GP commissioners and the Health and Wellbeing Boards. Developing secure training routes for the public health intelligence workforce will be a priority as well as ensuring continuing professional development opportunities and support networks for this distributed workforce.
Public Health Outcomes
22. The Public Health Strategy for England and the Public Health Outcomes Framework were both issued for consultation some months after the proposals in Liberating the NHS and the NHS and Social Care Outcomes Frameworks. The government has yet to respond to the public health consultations, but the initial NHS and Social Care Outcomes Frameworks have both been finalised. The outcome frameworks to deliver population health have therefore been agreed prior to consideration of wider issues, not only the determinants of health, but international and global priorities such as demographic change and health threats. One outcomes framework with associated responsibilities for implementation would be preferable.
23. The result of the Strategic Needs Assessment process that engages all relevant bodies should be a strategy that is owned by the local authority and its population. The strategy should describe the activity that is to be prioritised, the evidence for it and what it aims to achieve.
Public Health involvement in Commissioning
24. Several sets of commissioning plans will be needed to implement the strategy (GP commissioning, public health commissioning, social care commissioning, children’s, employment and skills etc) and should reference each other. The HWB must coordinate the commissioning plans for consistency, efficiency and quality and should sign them off as the set of plans that will deliver for the Health and Wellbeing Strategy. HWBs should be able to hold GP consortia to account for public health outcomes.
25. Public health involvement in commissioning must be recognised at all levels from the National Commissioning Board to GP consortia, with a requirement for all commissioners to seek and take account of public health advice. The expertise of public health in commissioning of health services should be highlighted.
Commissioning Public Health programmes
26. Responsibility for Public Health commissioning should originate at local authority level through the DPH with regional or national commissioning only where local commissioning is inefficient. Anomalies such as the divide in children’s commissioning must be resolved.
27. Public health funding proposals offer perverse incentives, literally in the case of the health premium. Premiums should be attracted to populations with the worst health and wellbeing without performance conditions. Evidence of collaborative use of premiums directed through the HWBs would be more appropriate.
Public Health Budget
Ring fenced budget
28. The proposal for a ringfenced public health budget holds out the illusion of dedicated funding for population health activity but is a tenuous concept with no indication of what it might have to fund and who might be able to access it. If local authorities are to embrace their population health responsibilities, it must be clear that any ringfenced budget is funding the transition of a public health service, while core funding will be used to deliver outcomes. Public Health departments should be asked to list essential public health delivery functions for sustainable inclusion in local authority responsibilities, rather than list what a (possibly time limited) ringfenced budget should fund.
29. Considerable efforts have been made by health and wellbeing partnerships to maximise the impact of health inequalities funding such as Neighbourhood Renewal Fund and single budgets such as Area Based Grant on population health and wellbeing through public health delivery programmes. The 2010–11 in year savings requirements and abolition of Area Based Grant caused the loss of exactly those partnerships and integrated programmes that the Public Health White Paper exhorted public health to develop on its publication three months later. It is concerning that the government appeared unable to recognise the impact withdrawal of Area Based Grant would have for health and wellbeing commissioners across the health economy.