Public health white paper: Healthy Lives, Healthy People: our strategy for public health in England The NHS Confederation s response to the Government s Healthy Lives, Healthy People: Our strategy for public health in England white paper sets out our views on: 1.1 making the new public health system work Public Health England local authorities and health and well-being boards accountability and democratic legitimacy GPs - commissioners and providers. 1.2 funding and commissioning for public health 1.3 public mental health and well-being 1.4 children s public health 1.5 public health intelligence and evidence 1.6 outcomes 1.7 managing the transition 1.8 public health workforce. Drawing on extensive feedback from our members, this document includes an executive summary with our detailed recommendations for policymakers to address before the public reforms go any further. The main body of the document then sets out our views on the welcome elements as well as the issues in the proposed reforms, where we think further clarity is needed, and our responses to specific white paper questions. We will publish separate responses to the two detailed consultation documents that accompanied the white paper: Transparency in Outcomes: proposals for a public health outcomes framework Consultation on the funding and commissioning routes for public health.
Consultation with the NHS The NHS Confederation consulted extensively with NHS organisations on the white paper between November 2010 and March 2011. Our membership includes ambulance trusts, acute and foundation trusts, mental health trusts and organisations and primary care trusts including public health teams, the Health Protection Agency, and a growing number of independent healthcare organisations that deliver services on behalf of the NHS. They contributed to this consultation response in the following ways: 45 members debated the key challenges and opportunities at a white paper engagement event on 2 February 2011, 68 discussed the reforms at a Service Delivery Organisation network event on public health research on 15 February 2011 and 95 members exchanged views at the public mental health and wellbeing summit on 8 December 2010. We have engaged with 105 of our network members through board meetings, other events, policy seminars, telephone conversations and email. This overall response identifies the policy proposals that we feel are particularly important, how we think they can be taken forward as quickly as possible. It sets out the risks our members have identified and recommended actions for averting them. It covers areas of the white paper where the NHS Confederation believes our collective experience and knowledge can have the greatest impact. 2
Executive summary NHS Confederation consultation response to the Healthy people, healthy lives public health white paper The NHS Confederation is the only independent membership body for the full range of organisations that make up today s NHS. We represent over 95 per cent of NHS organisations as well as a growing number of independent healthcare providers. We consulted extensively with our members on the white paper and our submission aims to address the issues they identified. We strongly welcome the white paper s aim of making public health a top priority in both health services and local government. We believe this provides a major opportunity to introduce changes that could significantly improve the health of the population. In particular, we support the increased priority given to ensuring closer joint working between local government and the NHS, as well as addressing the root causes of poor health and well-being. We are pleased the white paper encourages a commitment to partnership working at a local level. We also welcome the strengthened role of local government, which is uniquely placed to work across sectors including education, leisure, transport, housing and economic development. We agree that by bringing together all the key players, health and well-being boards could improve integration between different services locally and take on the role of local system leadership. However, we have identified a significant number of proposals in the white paper that we believe the Government should rethink so that its objectives can be met. The majority of our response focuses on our views on these issues. 1. Our members are concerned that local authorities may not have enough money to commission and deliver all the public health services for which they will be responsible. While the public health budget will be ring fenced, we emphasise that it is not easy to define public health, identify public health activity and spend accordingly. Adequate funding is particularly important, given the expense of many public health services and the impact on the rest of the health service if public health needs are not met. 2. Extra funding for more deprived areas is to be welcomed. However, we are deeply concerned about unintended consequences that are likely to result from the Government s plans to use a health premium to reward those areas that reduce health inequalities with extra money. We fear that this may not fairly reward progress and may lead to areas losing money where there is actually most need. High levels of population movement make it much harder to make progress on health improvement indicators. We are concerned that areas with high levels of population movement which are often the most deprived could unfairly lose funding due to this slower progress. We also note that high levels of deprivation can be found in pockets of more affluent 3
areas as well as across whole boroughs. The health premium would work very differently in these areas, meaning that a one-size-fits-all approach would not be appropriate. It is also difficult to robustly measure changes in health inequalities over a short period of time. Finally, if the current approach to funding allocations continues, this could mean that areas that succeed in reducing health inequalities are rewarded by the health premium but may be simultaneously be penalised by a reduction in their overall public health funding allocation due to the improvement in their deprivation indicators. In further developing the health premium, we believe the Government should: review the health premium mechanism and evaluate it as it is put into practice take local circumstances into consideration through proportional benchmarking of local areas with similar levels and patterns of deprivation, population movement and demography develop other levers and incentives to catalyse action to reduce health inequalities across the NHS, local government, voluntary sector and businesses work to avoid unintended consequences from the interaction of the health premium with other funding mechanisms. 3. More thought needs to be given to how the different elements of the system will work together and where specific responsibilities will sit so that the system functions as a coherent whole. Commissioning services, like immunisation, sexual health, mental health, safeguarding and children s services, is often a complex, interdisciplinary and interagency process and should not be disaggregated. Under the current proposals services in each of these areas will be commissioned by multiple bodies. This could result in people falling through the gaps between commissioners. To avoid this risk, we believe that each of these services should be commissioned as a package. 4. While we welcome the pivotal role given to health and well-being boards, their ability to hold organisations to account needs to be strengthened. These new organisations will not achieve their potential if they are given the responsibility for strategy but not the capability to deliver it. Health and well-being boards need to be sufficiently powerful to hold organisations to account if outcomes are not delivered or engagement is lacking. Much of their ability to act as a local system manager will depend on the capacity, resources, relationships and behaviours that are developed at a local level. As they are set up, clear, consistent advice, guidance and support will be important. Members will need training and support to take on their new roles, particularly during the transition. 5. Public health professionals have a key role in providing expertise in the new system. GP commissioning consortia will need to make use of public health expertise in commissioning health services more broadly. We are concerned that there is currently no mechanism for connecting the expertise of public health professionals with NHS commissioning decisions. We believe that the 4
role of health and well-being boards should be developed further to address this. Our members also strongly believe that provisions are required to ensure that directors of public health retain the ability to independently assess and report on public health. They need to be able to make evidence-based statements that may not coincide with the views of their local authority employers, without fear of losing their jobs. It is crucial that the new public health system is and is seen to be independent, impartial and evidencebased. 6. During the transition period, expertise could be lost and public health services could fail to deliver. In making interim arrangements for handling public health emergencies, both our preparedness and our response, we need to ensure there is a stable transition period and existing capabilities are maintained. Clear agreement is needed on the roles and responsibilities at national and local levels, and we need to understand how the new system will work across geographical boundaries of local authorities and the devolved administrations. 7. We believe it will cost the Government more to abolish the Health Protection Agency (HPA) than to keep it as a separate organisation because of the loss of finance that the HPA is able to generate as an independent organisation. This additional funding supports the development of the HPA s capacity to respond to emergencies and learn from international examples of good practice. A robust solution is required to ensure that the existing research capacity of the HPA continues to be funded and contributes towards the Government s capacity to respond to emergencies. 8. Finally, in this consultation response, we emphasise the need for long-term stability in the new public health system, especially given that improvements in public health can only be made over the long term. The system must be allowed time to bed in and it will be important to avoid radical changes early on. National and local politicians responsible for public health must continue to recognise that public health problems are generational and cannot be fixed through short-term solutions that fit within a political cycle. 5
Detailed recommendations The new system The new system will need to maintain an impartial evidence-based approach to improving the public s health. The Government needs to ensure consistency and clear lines of accountability in the commissioning arrangements for public health and avoid splitting responsibilities for functions such as sexual health among multiple agencies. The Government must allocate clear responsibilities in the new system for safeguarding children and vulnerable adults and ensure safeguarding is included in the outcomes frameworks for public health, social care and the NHS in an explicit and coherent way. The future of public health observatories is unclear. The Government must ensure their functions providing local public health intelligence and data, as well as expertise in a range of specific areas are retained to support the new public health system. The Government must set out what it will do to ensure a stable transition to the new system, particularly for emergency preparedness. With reforms to the NHS already underway, this clarity is needed as soon as possible. Funding The Government must ensure local authorities have enough money to commission and deliver all the public health services they will be responsible for. In further developing the health premium, the Government should: o take local circumstances into consideration through proportional benchmarking of local areas with similar levels and patterns of deprivation, population movement and demography o develop other levers and incentives to catalyse action to reduce health inequalities across the NHS, local government, voluntary sector and businesses o work to avoid unintended consequences from the interaction of the health premium with other funding mechanisms o review and evaluate the health premium as it is put into practice. More information is needed on how place-based budgeting such as Total Place could operate more generally and enable the pooling of NHS, public health and local government funding streams to support work to tackle shared priorities locally. Public health professionals GP commissioning consortia will need engagement and support from public health professionals to make informed commissioning decisions. The role of health and well-being boards should be developed to facilitate this. Provisions are required to ensure that directors of public health retain the ability to independently assess and report on public health enabling them to make evidence based statements that may not coincide with the views of their local authority employers and without fear of losing their jobs. 6
Developing a clearly defined career pathway for public health specialists in the new system could help prevent losing expertise and ensure future development of the required skill base. Children s services To improve outcomes for parents and children, the health visitor service needs to be a multidisciplinary public health service and health visitors need to be integrated with other teams of public health professionals. The Government should consider establishing a specialist subgroup of the health and well-being board to encompass responsibilities for providing integrated children s services and safeguarding. Commissioning children s health services is often a complex, interdisciplinary and interagency process and it is not clear who will commission which elements in the new system. Health and well-being boards Clear and consistent advice, guidance and training are required to support health and well-being board members to take on their new roles and facilitate effective evidence-based decision making. The ability of health and well-being boards to hold organisations to account needs to be strengthened. Public mental health We strongly support the Government s focus on improving public mental health. To improve overall public health outcomes, all those involved in commissioning and delivering public health services must include mental health prevention, health promotion and early intervention as key elements. A better understanding of public mental health and well-being is required to inform commissioning decisions. Health protection The Government must find a robust solution to maintain the independence from Government of the scientific advice and intelligence currently provided by the Health Protection Agency (HPA). Current proposals to include these functions in Public Health England could jeopardise the HPA s contracts with organisations in the UK and abroad, which generate tens of millions of pounds and help the UK maintain a high level of expertise and capacity. Without such a solution, we believe it will cost more to abolish the HPA than to keep it. Clarity is also needed on how health protection functions will interact with other organisations nationally, locally and in the devolved administrations, both day to day and in national emergencies. 7
1.1 Making the new public health system work Our members support the Government s objectives of making public health more of a priority and addressing the root causes of poor health and well-being. In bringing public health functions together at a national level, abolishing the Health Protection Agency (HPA) and increasing the powers of the Secretary of State, the public health white paper represents an attempt to strengthen government involvement in public health on one hand while trying to increase the role of localities and communities on the other. However, the success of the new structure will determine the level of improvement made in population health. It needs to be built around achieving improvements in public health, rather than reconfiguring services at national and local levels. It is not clear how much power the centre will have over decisions made locally, or if the local public health system will be able to implement self-determined initiatives rather than centrally governed programmes. It is also not easy to define public health and identify public health activity and spend, particularly as the work of many healthcare professionals and others combines prevention, treatment and long-term care in a way that is practically difficult to separate and apportion. Separating the public health budget from the NHS budget could lead to fragmentation of the system. We believe that the public health reforms should be based on the principle that decisions for improving population health should be made as locally as possible and informed by evidence of what works. Further clarity is required on what incentives there will be to encourage each part of the system to work together and who will have accountability for outcomes and performance. Public Health England Health protection Currently the HPA delivers an internationally respected, integrated health protection service. The HPA s work encompasses threats ranging from common infectious diseases, through exotic and imported diseases, pandemics, chemical spills and radiation incidents to natural events such as flooding. A key to its success has been the integration of the agency both horizontally across a range of threats and vertically from national centres of excellence to local delivery. To ensure that England continues to enjoy effective quality health protection, the new system will need to build on the most successful parts of the existing system. The HPA provides independent scientific advice. In the new system it will be difficult for advice and intelligence provided by Public Health England, a government department, to be seen as independent. This will have an impact across the system and safeguards are required to ensure intelligence and advice is seen to be evidence based rather than to be influenced by political opinion. Improving public health outcomes requires a long-term approach, which may not sit comfortably with the 8
need for political parties to show progress. Public health is the part of the health reforms that will be measured over a long period of time rather than through short term gains. Although assurance to maintain the principles and practice of independent scientific public health advice is given in the white paper, it is not clear how the structure of expert committees will operate under the Government s chief scientific adviser. Clarity is required about how the independence and the public and professional perception of independence of public health intelligence and information will be maintained. The HPA generates approximately 140 million of non-grant-in-aid income annually. Approximately half of this funding is sourced commercially, whereby the HPA is contracted by companies and organisations in the UK and abroad as an internationally recognised specialist health protection body. Much of this externallyfunded activity directly contributes to delivering key health outcomes and increases scientific knowledge. It also provides additional resources to fund the HPA s primary duty by reducing the cost of maintaining the UK s preparedness and response capacity (including skilled staff, facilities and technology) or enhancing capacity at no extra cost to the public sector. Currently, the HPA is eligible for government funding for research through the National Institute for Health Research, the Medical Research Council and the European Union. In the future Public Health England as a government body will not be eligible for such funding. Much of the research capacity of the HPA contributes towards its capacity to provide expertise during an emergency response. Clarity is required about how the new system can ensure that this activity continues and contributes towards the development of England s new public health service. The new system will need to develop an integrated, coordinated and resilient response capacity. The proposed public health system needs to be flexible enough to respond to local and national emergencies. Previously, intermediary bodies such as SHAs and PCTs have provided a key function in managing emergencies and the proposed changes might not provide sufficient capacity to manage an emergency at a population level in a given region, particularly coordinated and consistent actions on certain issues that already well known locally. The proposed public health system needs to be flexible enough to fill this gap and structures to enable local public health functions to work together and strengthen the system. Duties for providers to participate in emergency preparedness and response will need to be included in their contracts and resources are required to ensure sufficient capacity exists within the system. The new system should draw on lessons from the management of the 2009 swine flu pandemic to identify what roles might need to be fulfilled and identify who should undertake them in the absence of SHAs and PCTs. 9
The white paper does not say how it will maintain capacity for emergency preparedness and response. Whatever the new structure, there must be robust interim arrangements to ensure there is a stable transition period. Public Health England will need to build on the HPA s strengths in using national centres of excellence. We welcome the plans to continue to build on local public health structures such as the health protection units in tier two of local authorities. Public Health England will need to have the capacity to coordinate a complex multiagency response required to manage major incidents and more chronic health protection issues and to mobilise resources across the sub-national/supra-local and local public health structures (directors of public health and their teams and health protection units) to ensure resilience capacity. There needs to be clear agreement on the roles and responsibilities for directors of public health and health protection units to ensure health protection work carried out in tier two of local authorities is connected with coordination and planning mechanisms organised in tier one of local government. These responsibilities will need to reflect both day-to-day working and emergency situations. The existing local resilience forums will continue to play an important role in supporting coordination of health protection functions locally but again how this forum will connect with the new public health structures is not clear. Interface with devolved administrations and across boundaries Public health outbreaks and challenges are not confined to geographical boundaries. The public health systems in Scotland, Wales and Northern Ireland rely on expert advice and assistance from colleagues in the HPA at a national level in relation to emergency preparedness and response. The HPA provides advice either directly or via a public health body to the devolved administrations, where a particular agency does not have the necessary specialist expertise. In some cases these agencies provide advice to the HPA. Public health agencies in devolved administrations work closely with health protection units in England, not only during emergencies but also in relation to routine public health functions, such as the management of communicable disease outbreaks that cross borders. We believe it is essential that, in the new system, Public Health England and the NHS liaise closely with public health agencies in the devolved administrations to ensure that cross border support remains robust at all times and that the support required, together with the mechanisms for accessing such support, remain in place and clear during and after the reforms are implemented. Health protection and the NHS We support the proposals for the NHS Commissioning Board to be responsible for mobilising NHS providers in the event of an emergency. However, it is not clear how Public Health England will work with the NHS Commissioning Board in this regard. 10
Clear mechanisms are required for how Public Health England and the NHS Commissioning Board will work together to commission and deliver public health services, including the use of public health expertise to inform commissioning of health protection and health services. Clarity is required about which part of the system will lead responses to incidents at local and sub-national/supra local or regional levels. It is clear that the NHS Commissioning Board will be responsible for assuring NHS preparedness and resilience but the white paper does not outline which part of the system will be responsible for providing expert advice to local NHS institutions such as acute hospitals as well as care homes on issues such as surveillance and monitoring of health care associated infections and managing outbreaks in health and social care settings. The issue of reducing healthcare associated infections and antimicrobial resistance is not covered in the white paper and needs to be more adequately addressed in the new system. PCTs and SHAs are currently responsible for performance managing acute trusts and other NHS bodies to control healthcare associated infections. Currently the Care Quality Commission (CQC) expects the HPA to give advice, support proactively, and to follow up and ensure NHS bodies are compliant with the regulations. It also requires that performance managers should be notified when appropriate action is not taken by trusts. In the new system it must be clear how and which organisation providers report healthcare associated infections. Clarity is required on the way healthcare associated infections will be managed in the proposed new system. Public Health England will need to have sufficient capacity and expertise to train the NHS and local teams in health protection areas such as chemical incident management, infectious disease outbreak management and decontamination of casualties. Public Health England will need to provide exercises to develop expertise and experience in managing health hazards and incidents. Whichever part of the system is responsible for leading a response to a public health incident will need to have access to resources such as community and school nurses. It is currently not clear how this would happen. If the director of public health leads a response to a public health incident at local level, it is not clear what authority they will have to command the resources of Public Health England including the local health protection unit and local health services other than those that are commissioned by public health from the local authority. Clarity is required to outline how and who will be responsible for responding to a public health incident at local, regional and national levels. Close collaboration between Public Health England, the NHS Commissioning Board, local authorities and GP commissioning consortia will be required. As one of our members told us, a 11
general duty of cooperation across the sector won t deliver [a response to public health emergency] at 8 o clock on Friday night. Sub-national and supra- local ways of working As the white paper rightly points out, local and regional variations require a tailored approach and the example of the Altogether Better Community Health Champions demonstrates the positive impact regional initiatives can have. The regional Growth Fund is also a welcome initiative to support the creation of economic growth. We agree that Public Health England will need to be organised and aggregated at different levels and welcome maintaining the health protection units. Ensuring there is a critical mass of expertise is essential for response to incidents and emergencies, concentrating expertise in larger units, as is done across medical specialties, with professionals who handle specialist issues regularly, will deliver better outcomes than dispersing specialist staff into small, professionally isolated teams. We believe it makes sense to ensure that specialist functions, such as some sexual health services, are commissioned and organised at a supra-local level. It would be useful for models to be developed to demonstrate how local public health partnerships will work and how to ensure a degree of concentration of specialist resource. Such models could include networks or the hub and spoke model and should be assessed against evidence and best practice guidance. Local authorities and health and well-being boards The NHS Confederation welcomes the strengthened role of local government in public health, including public mental health and well-being, given the impact that local government can have across departments and sectors including education, transport, leisure, housing and economic development. We welcome the minimum membership requirements set for the health and well-being boards at least one elected representative, GP commissioning consortia representative, director of public health, director of adult social services, director of children s services, local HealthWatch and, where appropriate, participation of the NHS Commissioning Board. Local authorities and GP commissioning consortia will need to engage other key local government departments including housing, transport and planning as well as health providers such as mental health, acute and community trusts and social enterprises when making commissioning decisions, redesigning care pathways and integrating services. Foundation trust governors are a well established local structure and they play a central role in delivering accountability in healthcare provision on behalf of local communities and should therefore have a place on the health and well-being boards. This view is also held by the Foundation Trust Governors Association. To ensure that the health and well-being boards remain an efficient executive committee adept at making informed decisions, it would be useful to include other key local government directors including housing, transport and planning and health providers but keep the membership to a minimum and have a second tier structure to fulfil stakeholder and community engagement functions. Emergence of the health 12
and well-being boards presents an opportunity for localities to be innovative at engaging stakeholders and communities. The health and well-being boards could make a valuable contribution to providing oversight for the three domains of public health, including health services and health service design and strategy and take on the role of local level system leadership. This might help to address some of the concerns about the loss of a system manager within the NHS and across public health and social care to oversee the local health economy. However, it is not clear that the health and well-being boards will have sufficient powers to undertake these functions. GP commissioning consortia are primarily accountable to the NHS Commissioning Board. In some areas partnerships between GP commissioning consortia and local authorities through the health and well-being boards may be unbalanced if either party is responsible for significantly more resources than the other. GP commissioning consortia governance arrangements will impact on how consortia engage with health and well-being boards. Much of the health and well-being board s ability to act as the system manager will depend on the capacity, resources, relationships and behaviours that are developed at a local level. There is a danger that health and well-being boards become overburdened with those PCT functions that do not fit elsewhere in the system and this may distract them from their core functions. When establishing health and well-being boards, it will be important to build on existing structures in local authorities such as the local strategic partnerships and related sub-boards and consider and how other boards and committees are reorganised accordingly. Health and well-being board development would be assisted through the provision of clear, consistent advice guidance and support. This should include the principles to underpin the workings of the board, and draw on good practice and learning from existing partnership working and emergent health and well-being arrangements. As health and well-being boards develop, tensions may arise regarding different responsibilities and there may be a lack of understanding in terms of language and culture between NHS and local government organisations. The health and wellboards won t be fully functioning unless each board member is skilled in the task they are required to perform. Health and well-being board members will need to understand each others roles and how their services operate. If the transition in some areas happens very slowly partners may lose interest. It will take time for the new structures and organisations to build capacity and operate effectively. To carry out commissioning functions effectively, health and well-being boards will require a degree of local freedom to make evidence based decisions for their population. Providing decisions are evidence-based and work locally, subsidiarity should be the underlying principle for the boards and public health reform. 13
Throughout the transition, support is required to train and support members to take on their new roles. Integrated working It is important that any new arrangements build on the extensive learning from the wide range of existing partnership working in which our members have been involved. These include local strategic partnerships, existing health and well-being boards, integrated care organisations, whole system demonstrator sites and other examples. Public health and mental health services particularly have developed effective approaches to integrated working, with joint appointments across local government and the NHS, as well as organisations working to improve the wider determinants of health such as employment for people with mental health problems. The development of place-based budgeting could also offer opportunities to support integration. The Total Place pilots demonstrated the potential to facilitate integrated working that is broader than just health and social care. This can be particularly helpful in tackling shared priorities, such as action on drugs and alcohol, and holds the potential to support improvements for public mental health. More information is needed on how place-based budgeting could operate more generally, and enable the pooling of NHS, public health and local government funding streams. Much of the success of integrated initiatives has depended on stable and committed leadership, which has helped to create new working cultures and a shared vision, rather than any structural arrangements. Our work on integrated working for health and social care 1 highlighted the importance of local factors and relationships in establishing effective partnerships, and identified several elements that provide the basis for effective integrated working including: a focus on outcome measures rather than targets developing understanding of cultures within council, health and social care services to facilitate supportive environments for change integration that is based on place not organisation which can help foster a mentality to reframe service redesign focused on the user delegation of functions to each partner rather transferring responsibilities to partners can avoid power struggles that can often result from formal arrangements clinical and professional engagement across public health, health and social care so that front line professionals are involved in and accountable for the overall priorities of a locality. There need to be incentives within the system to encourage integrated and joined up working. Currently we believe that there are more incentives to create competition between providers than to strengthen cooperation. Opportunities for joint 1 PCT Network Discussion Paper 8 Where next for health and social care integration (June 2010) 14
appointments and collaborative commissioning between the NHS and local government should continue. To ensure the quality of services, standards will need to be set to benchmark local authority and GP commissioning consortia performance. Without a formal performance management mechanism it may be difficult for communities and Public Health England to monitor progress. This issue is particularly pertinent for our members as the NHS is the body responsible for treating public health crises. It will be important for health and well-being boards to monitor all commissioning activity across local government and the NHS to ensure that services are being commissioned in line with the public health, NHS and social care outcomes frameworks. Strengthening performance, prevention and early intervention will benefit all public services. Our members agree that larger boards across borough boundaries in metropolitan areas such as London and Manchester would benefit large scale population wide public health initiatives. Mandated services In some areas, the voting public may not be in favour of the local authority providing essential public health services such drug addiction or sexual health services for young people. The Secretary of State through Public Health England will need to mandate local authorities to provide such services to ensure comprehensive public health services are available to protect and improve community health. Accountability and democratic legitimacy The NHS reforms are designed to put more power in the hands of professionals and to take it away from politicians and managers but there is potential tension between this approach and that of the public health reforms which propose increasing political involvement in public health. Despite the required membership of a representative from the local HealthWatch and a local councillor, we do not believe that the health and well-being board will automatically strengthen local democratic legitimacy and enhance the local power and influence of local communities, patients and carers. This will depend in part on local relationships and behaviours. We have also highlighted to the Health and Social Care Bill Committee that it is important for the legislation to create the right architecture for the local health and well-being board to support these ends. It is unclear how the health and well-being board would be held accountable by the local community, other than through the involvement of locally elected councillors. If communities as well as local government are going to be responsible for reducing health inequalities, clear mechanisms are required for involving communities. Many members of communities are already actively involved in their local area but are not necessarily well connected to local authority and statutory bodies. 15
Health and well-being boards will need to develop a new and more equal relationship with communities working in partnership and using asset based approaches to assessing population needs. Support to existing as well as newly developing community groups and strengthening mechanisms to involve community members will be required to enable the Government s Big Society vision to happen and increase people s responsibility for improving their own health. HealthWatch England and local HealthWatch organisations will represent the views of users of health and social care services and members of the public. Provision should be made to strengthen the independence and autonomy of Healthwatch England so it is able to act as an independent and representative voice for communities, patients, users of health and social care services and sufficient funding is required to make this happen. Local HealthWatch should be representative of the local community or take regular and systematic steps to gather the representative views of the local community. This should be a key part of any assessment of their effectiveness. Where local people feel the local HealthWatch is failing to represent the views of key groups of service users adequately, there should be provision to raise this with the local authority and/or HealthWatch England. HealthWatch England should be able to provide mandatory advice to the local body on how to ensure it reflects the range of community views. It will be important for health and well-being board decisions to be guided by independent evidence and not constrained by local politics. While community groups will have the ability to talk to their elected local councillor this may result in interest groups lobbying around their chosen cause which could distort decision making. The election timetable for councillors will also impact upon the behaviours of local councillors. All members of the health and well-being boards will need adapt to new ways of working and develop effective decision-making processes in order to make the best use of resources for improved population health. Keeping local decisions evidenced based must be a priority. By moving to local authority employment, public health staff loose the protection provided by the NHS Constitution and the right to whistleblow. Our members strongly believe that provisions are required to ensure that directors of public health retain the ability to independently assess and report on public health enabling them to make evidence based statements that may not coincide with the views of their local authority employers and without fear of losing their jobs. The freedom of directors of public health to speak out independently on public health should extend beyond simply producing an independent annual report. 16
Joint strategic needs assessment (JSNA) and pharmaceutical needs assessments (PNA) Collaboration is required to develop the joint strategic needs assessment which will form the basis from which strategies and decisions will be made. Collecting diverse ranges of evidence and involving multi-sector stakeholders will ensure the assessment reflects the reality of local needs as much as possible as well as the community assets on which to build programmes and services in partnership with communities. Systematic processes that are proportionate and add value are required to include information from front line providers in the JSNA. The Marmot Review and other recent evidence such as the report regarding the cost effectiveness of mental health promotion and prevention interventions 2 provide a good basis to guide localities in determining interventions to improve public health. Making the JSNA a statutory responsibility will increase its importance and provide localities with an opportunity to engage more with communities and share the findings more broadly than previously. The JSNA will play an important role to support integrated care packages and pathways particularly for marginal groups such as offenders with those with mental health needs. Making decisions informed by the JSNA will be balanced by the availability of funding. In the proposed new system, the NHS Commissioning Board will be responsible for commissioning core pharmacy services and the local authority will be responsible for carrying out the pharmaceutical needs assessment (PNA). In reality there may be tensions between the needs determined by the local authority and the NHS Commissioning Board such as decisions about opening and closing pharmacy services. The NHS Commissioning Board will have the ultimate power to decide. It will be important not to lose the benefits of pharmacies having close connections with their local communities. Giving local authorities the responsibility for conducting the assessment provides an opportunity to strengthen links between the PNA and the JSNA. PNAs are the means by which commissioners assess the pharmacy needs of their local population, this includes medicine management as well as locally enhanced services. Completing a PNA requires medicine management and pharmacy commissioning expertise. We believe that Public Health England will need to support and ensure health and well-being boards conduct JSNAs collaboratively, involve all key parties including marginal groups and adopt an evidence-based approach. Resources are required for local authorities to access expertise to conduct the PNA through the GP commissioning consortia or other bodies. Guidance and support from the NHS Commissioning Board in collaboration with Public Health England is required to assist local authorities to carry out the PNAs. Local authorities and GP commissioning consortia will also need to develop links with the local pharmaceutical committee. 2 Knapp M, McDaid D, Parsonage M: Mental health promotion and prevention: the economic case. PSSRU, London School of Economics, Jan 2011 17
Voluntary and independent sector and other providers The NHS Confederation supports the involvement of voluntary and private sector organisations in delivering public health services and we support the principle of subsidiarity. However, our members are concerned there may be limited local influence over contracts negotiated at a national level. They are concerned that larger national organisations will have significant advantages when bidding against smaller local organisations. The health and well-being boards and Public Health England will need to ensure localities make best use of voluntary and independent sector capacity to support implementation of local health and well-being strategies. GPs commissioners and providers The NHS Confederation is concerned about whether the accountability arrangements for NHS commissioners (GP commissioning consortia and NHS Commissioning Board) to the health and well-being board and the local community are sufficiently well articulated and whether they will be strong enough in practice. GP commissioning consortia or a representative from GP commissioning consortia are required to sit on the health and well-being boards and they have a duty to jointly conduct the joint strategic needs assessment and have regard to it and the health and well-being strategy when commissioning services. In reality it will be up to the GP commissioning consortia to decide how to interpret the JSNA and health and well-being strategy as well as balance financial and demand management pressures when making commissioning decisions. Significant engagement from GP commissioning consortia leadership about their role on the health and well-being boards will be essential to joining up public health and health service commissioning. In some areas, GP commissioning consortia will have a different geographical footprint to the health and well-being board and may have to relate to multiple health and well-being boards. This will make it difficult for GP commissioning consortia to commission on a population wide basis in collaboration with local authority colleagues. Local or sub-national/supra local mechanisms are required to facilitate GP commissioning consortia to commission population wide services. GP commissioning consortia may need support and advice as to how to reach parts of the population which are unregistered and invisible to general practice, including offenders. This may mean exploring creative and proactive ways of engaging with and meeting the healthcare needs of complex groups with potentially multifaceted health needs. GP commissioning consortia and the NHS Commissioning Board will require engagement and support from public health professionals to support inform commissioning decisions and will need adequate funding for this. It is important to ensure public health expertise is used when commissioning providers to deliver integrated health services as well as health improvement and health protection services across primary, secondary and tertiary care. Support to GP commissioning 18
consortia is required to ensure public health improvement becomes more integrated and a core priority. To deliver on the public health outcomes framework directors of public health and GP commissioning consortia will need to coordinate commissioning functions to invest in upstream interventions. Lines of accountability still need to be clearer for commissioning public health services at national and local levels between the Secretary of State/Public Health England, the NHS Commissioning Board, local authorities, health and well-being boards and GP commissioning consortia. A shift in focus is required for GPs as providers to act as commissioners, taking into account wider use of evidence of population needs. GPs local knowledge could bring advantages, strengthen understanding of local circumstances in commissioning and align perspectives with council-led public health work. It will be important that commissioning of public health programmes is of the same quality, and carries the same weight as other mainstream commissioning through the local authority or the NHS. GP commissioning consortia, together with their public health colleagues in local authorities, will need to adopt high professional standards when commissioning health services, incorporating public health expertise into decision making. Public health professionals currently provide ready access to: the considered evidence base of interventions and elements of delivery; examples of good practice; modelling techniques; and expertise and health economic expertise such as advice on measures of return on investment as well as adaptable frameworks to inform quality business planning. Continuous professional development is required for public health specialists and they will need to remain connected to academic public health research connecting researching activity with commissioning and service provision. This will ensure there is a competent local multidisciplinary public health workforce in place to address public health and health service commissioning and service delivery needs across local authorities and the NHS. White paper question: Are there additional ways to ensure that GPs and GP practices will continue to play a key role in areas for which Public Health England will take responsibility? GP providers deliver a large proportion of health improvement interventions and incentives will be required to deliver results and encourage GPs to reach out to disadvantaged groups. Although the health and well-being boards will be able to report to the NHS Commissioning Board if they are not satisfied with GP performance, the NHS Commissioning Board will need to performance manage those elements of the Quality and Outcomes Framework (QOF) that relate to prevention and public health and ensure that GPs take action on reducing health inequalities. 19