With thousands of public health specialists awaiting concrete news of their destiny, today’s update paper on Healthy Lives, Healthy People published by the Department of Health, offers further clarity on the future of public health delivery, but some of the big questions about power and responsibility in the new system are yet to be answered.
The report follows the publication of White Paper last November, and serves as a stop-gap ahead of a set of ‘Public Health System Reform Updates’ that will lay down the operational design of the system including a public health outcomes framework, all due in the autumn. But the pressure to show progress is now building. Can the Government rally the support required to achieve the transition to Public Health England (PHE) by 2013, establish confidence and stability in the system, and deliver positive news headlines to see off its political opponents? Public health benefits are slow to yield, but the political cycle will not wait. This blog considers some of the pressing issues to be resolved.
PHE is the organisation that will operate as an executive agency of the Department of Health from 2013, to provide overall professional leadership and oversee the improvement and protection of public health through a public health outcomes framework.
Despite the adoption of the Future Forum’s recommendation to locate PHE outside the DH, concerns remain over its independence and the credibility of its advice, given its executive status and lack of policy making power, notably with regard to the outcomes framework. The tension between localism and centralism will no doubt continue to dominate each aspect of the health reforms as we await decisions on the detail of new funding and commissioning routes. This detail will be crucial towards understanding the balance between central spend and control, and local autonomy.
For now, the update paper suggests that most of the £4billion plus pot will be spent by local authorities on functions as diverse as mental health promotion and prevention, nutrition, physical activity, obesity programmes, substance misuse and tobacco control, with clinical commissioning groups (CCGs) maintaining a lead role in immunisation, screening programmes, HIV treatment, and contraception. This raises practical issues for local commissioning across the NHS and public health service which are explored further below.
Meanwhile PHE will ask the NHS commissioning board (and indirectly CCGs) to commission specific services from the public health budget. In screening, for example, all funding would derive from PHE for the design, quality assurance and monitoring of programmes, and it will host the National Screening Committee, but the NHSCB will be responsible for commissioning the programmes. Given that design and quality assurance are bound up in the commissioning function, how will the two organisations work together, and will NHSCB be appointed lead partner where functions are unequivocally clinical, as is suggested for immunisation programmes?
Further confusion lies in the synergies between the respective outcome frameworks (domain 1 in health and domain 5 in public health) and more clarity is needed to support clear lines of responsibility further down the food chain.
As for PHE, it will take the lead on the provision of scientific advice, health protection and emergency preparedness, and will act as a hub for public health data and intelligence, bringing together the work of the cancer registries, the National Cancer Intelligence Network, and public health observatories. There will also be a role for PHE in some national awareness campaigns like Change4Life, but not others. Campaigns on early diagnosis, such as a potential national bowel cancer symptom campaign might sit better with the NHSCB given the critical role of GPs in diagnosis, but a decision either way is needed soon.
We are left with a complex picture. Indeed close examination of the institutional and structural mechanics of the new system have overshadowed (for now) the early debates on the ideology behind the public health reforms (covered previously on this blog). Just as the theoretical framework for Equity and Excellence was so heavily challenged, will some of the laudable ideas behind the public health vision work in practice, particularly given the established difficulties in making ring-fenced funding work?
Mirroring the debates on commissioning consortia, professional bodies including the BMA and the Faculty of Public Health, and public health academics have led the critique on the proposed new model. Among their concerns are the fragmentation of the workforce, loss of expertise and the public health ‘critical mass’, and the perceived fragility of ring-fenced budgets housed within cash-strapped local authorities. Others feel that public health expertise in the NHS should not be confined to clinical senates, a concern addressed somewhat today by a new statutory duty on DsPH to provide public health advice to the CCG as well as through the Health and Wellbeing Board (HWB).
Perhaps unsurprisingly, these are the same issues used to defend the changes by Professor Dame Sally Davies, the Chief Medical Officer, and Anita Marsland, Transition Managing Director for Public Health England, in their appearance before the Health Select Committee this week. They cited integration, a greater focus on health improvement, improved efficiency, enhanced intelligence and scientific excellence as the top benefits. Others, like Dr Gabriel Scally the South West Regional Director of Public Health have argued against creating a public health enclave but members of the Committee were unhappy with what they heard, arguing that “hope and intent” were substitutes for leadership and a robust evidence base for the reform.
Frustrating though the lack of answers on PHE institutions and duties at this stage may be this assessment seems unfair. Part of the challenge is the more piecemeal approach adopted by the Health Secretary this time round (having learnt lessons the hard way). On one hand this offers “leeway for discussion and development” (and today’s paper explicitly responds to concerns raised), but on the other but it fails to provide the stability hoped for by the public health workforce. It is also interesting that the Future Forum’s extended role will be felt within public health, beefing up engagement with health leaders and stakeholders throughout the development and roll-out of reforms.
The update paper is most decisive on which services will be mandated by the Secretary of State for provision by local authorities, but less clear on how this will happen in practice (mandating is not after all a proxy for consistency and quality). Beyond the duty to provide advice to CCGs as part of a core public health offer, these include the provision of sexual health services, the development of plans to protect the health of the population, the NHS Health Check and elements of national child health programmes by local authorities (subject to secondary legislation).
Meanwhile the status of the DPH is given a boost, described as a “critical”, “principal” adviser, but with anticipated rather than mandated chief officer status, and the promise that PHE will promote their position within local authorities. This provides some reassurance that the ring-fenced budget won’t be raided to fund traffic calming schemes or to plug gaps elsewhere in local government, but there are no firm guarantees regardless of job title.
On the equality front, no more news as yet on the public health premium, intended to provide an incentive payment to local authorities according to the progress they have made in improving the health of the local population and reducing health inequalities. Fine tuning is needed to ensure that decision making is not distorted, while the potential for perverse effects have already been raised.
Still the million dollar question is how the NHS, public health and social care teams locally will work together to make it all happen when services cut across some or all areas. In obesity for example, what is the best way to plan, fund and integrate different interventions such as the promotion of physical exercise, dietary advice, access to weight management services, pharmacological and surgical responses which may not occur in a neat sequence, but in combination? Similarly, what happens to children aged five, as responsibility moves from the NHS to PHE, and how will the prevention and management of mental health be effectively disaggregated?
The hope is that the HWBs will tease out the discussions between the NHS and public health service, and that through the JSNA and the HWB strategy, integrated commissioning solutions will be developed, drawing on different funding pots as appropriate.
It seems like a big ask, but as with most of the reforms, it is local leadership and emerging practice that is likely to define the policy and not the other way around. So far little is known about the preparedness of local authorities in establishing powerful new roles and institutions since the call was made for HWB early implementers in January.
For some in local government, decision making in health has been coveted from afar, but outcome variation is likely to remain a defining feature (at least in the medium term) as some authorities seize opportunities to test the boundaries and work in new ways while others choose to learn from example and take longer to get to grips with their new responsibilities. In the age of cost containment the stakes are high for the Government and for local budget holders, but quick wins in this area are hard to come by. The challenge is to establish stability and build effective and lasting partnerships across health, social care and public health boundaries on the long and winding road towards health improvement.