Response to Public Health White Paper: Healthy Lives and Healthy People

This paper responds to the Public Health White Paper: Healthy Lives Healthy People: Our Strategy for Public Health in England, including response to the specific consultation questions and comments on the two subsequent consultation papers on: the funding and commissioning routes for public health and the outcomes framework for public health. Public Health is “The Science and art of promoting and protecting health and well being, preventing ill health and prolonging life through the organized efforts of society”(definition in public health white paper from the Faculty of Public Health).In order to improve the health of the public it is essential to:

address the wider determinants of health e.g. unemployment and their impact on health, particularly in the most disadvantaged
base actions upon best evidence and a focus on outcomes
involve communities in their own decisions about health and health care
take a life course approach to health improvement
encourage early diagnosis and prevention rather than later treatment
maximise the use of mechanisms of health protection, legislation and regulation to improve health

The SHA recognizes the opportunities through shifting much of the public health function to within local government and the potential to introduce democratic legitimacy to health and strengthen the balance of power to local communities. However, there are risks that need to be addressed and much clarity still required on roles, responsibilities and resources if the disruption from these reforms is to be of benefit. In addition the SHA is of the view that the wholescale re-disorganisation of the NHS and welfare state and the cuts to the NHS and public sector will lead to poorer health outcomes for more deprived communities and will contribute towards widening health inequalities.

Key Messages

The move of the public health function, led by the Joint DPH (JDPH), from NHS to local government creates an opportunity to improve the health of the population in particular by joint work on the wider determinants of health e.g. housing and through joint commissioning.
To achieve this potential the JDPH must be free of political interference
Health and Well Being boards, whilst arguably well intentioned, need stronger powers to achieve joined up commissioning and effective partnership working to improve health where others have failed
There are advantages but risks of a ring fenced budget: it is unclear how in a financially challenged time, when there is greatest risk of cost shunting, sufficient funds will be allocated to public health programmes
The public health responsibility deals and ladders of interventions give too much freedom for the industry to influence lifestyle choices and do not recognize that a mixed policy including statutory agreements with industry is needed – voluntary agreements have failed.
Key elements of the paper are welcomed e.g a life course approach of the Marmot report, outcome focus and sharing of information
To improve health and address health inequalities the proposals must ensure democratic accountability for policy at local and national levels, increased resources into public health and joint commissioning based upon evidence and with regard to equality.
The white paper should put more emphasis on strengthening community engagement.
The wider reforms of the NHS and public sector, and severe cuts will lead to fragmentation of service provision and of planning for population health and to widening inequalities and must be halted

The Public Health White Paper – A Radical New Approach?

The government refers to this as a radical new approach to be achieved by a new system:

Protect the population from health threats – led by central government – creation of Public Health England as part of the DH
Local leadership – local government – with new powers, responsibilities and ring fenced budgets
Focus on outcomes – essential continuation of previous policy
Freedom and Fairness and Responsibility to promote healthy lifestyles and a ladder of interventions – roles for government and industry and empowering local people to improve their own health
Choice and further engagement of the public in local decisions e.g. through Health Watch

These tenets of this white paper are now considered in turn.

Public Health England and the role of Central Government

Key messages:

Public Health England (PHE) provides an opportunity to give prominence and coordination to public health. In order to do this it needs to be fully resourced by skilled professionals and encompass the three elements of public health: health protection, health improvement and improving quality of health and social care
Cuts and cessation of key services threaten this coherence e.g. reduction of the HPA (an essential front line public health service) and cessation of the seminal work on health inequalities of the National Support Team,
Responsibility deals with industry are not in the public interest and should be stopped
PHE should play a powerful role in monitoring key public health outcomes and inequalities at a national and regional level to mitigate against inappropriate local variation in policy or outcomes. The role of PHE in achieving this is unclear.

Local Leadership by Local Government

New responsibilities of local government:

Overall we welcome the move of public health and public health function to local government to work more closely on wider determinants of health e.g. education and housing as addressing these provides the greatest opportunity in the long term to address health inequalities
For this to be effective, and to improve upon current partnership arrangements, the powers of the Joint Director of Public Health (JDPH), local government and Health and Well Being Boards need to be strengthened.
There is a strong risk that the move results in public health – prevention and links with the expertise of public health specialists – disappearing from consortia’s consciousness. It is important to ensure that does not happen.
Local authorities should make strong links with academic institutions with relevant expertise

Joint DPH:

We welcome the role of JDPH – however the JDPH and staff must be free of political interference and remain an objective and independent advocate for the population. There is too much power invested in Secretary of State if they are able to ask for a review of JDPH performance.
Local authority employment of JDPH may impact on successful recruitment and retention from NHS – where PH are trained
Only those with PH training, skills and background should be appointable to JDPH posts
The White Paper is not clear how the JDPH post will be supported: in financially restrained circumstances, there is a real danger that the local authority located JDPH post may not have the full range of PH expert advice and support that is currently available.
The JDPH post must be positioned at the executive / strategic director level of the Local Authority if the post is to be able to influence decisions and policy making such that the key determinants of health are to be addressed.

Health and Well Being Boards:

The proposals build on partnership structures already in existence in most boroughs. The board needs stronger powers to enforce commissioning decisions to improve the health of local population. It is not sufficient for boards to sign off consortia’s commissioning plans.
The key role of Joint Strategic Needs Assessments is welcomed
The democratic accountability of the boards should be increased e.g. through greater representation of councilors and voluntary sector and Health Watch (by statute) and local people (similar to parent governors)
Again to be effective support and advice from public health specialists will be essential for these boards to achieve their goals.

Health Premiums:

Protected funds for public health in this financial climate
The formulae for setting public health budgets and premiums must allow for deprivation and other factors e.g poorer health
Performance related premiums risk more deprived areas doing worse, even if they are given greater funds initially. PHE should monitor and have the power to take action where appropriate to ensure narrowing inequalities across England.
The total fund must be rapidly increased year on year to redress the balance between prevention and treatment
There should be clear national definitions of what can and cannot be counted within public health budgets and what comes out of usual local government funds in order to prevent raiding of public health budgets for a wide range of activities e.g. waste disposal
We are generally in agreement with the logic of the funding and commissioning routes for public health outlined in the subsequent consultation paper. The NHS ability to deliver on elements with the current massive structural change and financial challenges ahead of GP consortia being set up is questionable. There are also serious questions of monitoring and co-ordination across sectors with limited managerial capacity and fragmentation of the wider NHS reforms. Again PHE should take a strong monitoring role.

Focus on Outcomes

A focus on outcomes is recognised as ideal and important. For some areas of practice this is difficult e.g. mental health. In these cases process measures are appropriate but should be linked with national evidence of what works.
Many of the proposed indicators in the subsequent consultation paper – are already in use. Some organizations have found that they are a more powerful monitoring tool if grouped into related indicators e.g. infant mortality is grouped with low birth weight and teenage pregnancy
It is unclear who will monitor these outcomes and they will be used to incentivise actions via premiums. As above, this must be set up so as to reduce inequalities.

Public Health Responsibility Deals and the Ladder of Interventions

Improving life styles requires a range of interventions rather than a ladder
Lifestyle choice is not a real choice amongst many disadvantaged communities as their decision making is framed, for example, by low income and relatively poor physical environment. We strongly feel that for key causes of ill health (ie smoking, alcohol and diet), the ladder of intervention must move beyond ‘nudge’ to address the very real barriers to lifestyle changes.
Voluntary agreement with industry hasn’t worked – we don’t need to try for longer and review as suggested in the white paper. Indeed it is likely that voluntary agreements with industry will widen health inequalities. There are clear conflicts of interest by having industry as part of the policy making process
Legislation, enforcement and regulation are essential to have an impact on health, especially of the poorest in society. We therefore propose stronger legislation including pricing of alcohol and alcohol zoning, tobacco control and contraband tobacco, clear food labeling, banning of hydrogenated fats and licensing control of fast food outlets. Additional taxation (national or local) should fund local evidence based programmes to support health improvement amongst more deprived communities.
The proposals for improving workforce health are important but need to be properly prioritized and resourced to be meaningful, especially at a time of many redundancies and further reform in the public sector which will have a negative impact on physical and mental health of employees.

Choice and Public Engagement

We welcome involvement of public and patients in decision making through Health Watch. Detail is required to ensure that this approach will give greater benefits than the current systems that will be dismantled.
There should be statutory representation of Health Watch, public (similar to parent governors) on the Health and Well Being Boards. The National Commissioning Board should hold GP consortia account for their public engagement mechanisms.
Wider mechanisms for community engagement should be prioritized and strengthened. Community development, for instance, builds and strengthens social networks which the evidence tells us leads to improved patient and public involvement and responsiveness from statutory agencies and helps to address inequalities in access and outcomes of care.
While we welcome the focus on the health improvement roles for the Big Society and local communities, it is clear that there are more health challenges and greater social fragmentation in many deprived and inner London areas. Emerging findings show that Big Society approaches eg to running libraries, leisure centres and befriending schemes have worked better in less deprived communities and / or stable communities.
For the Big Society to work effectively, there needs to be a massive injection of social capital, skills, knowledge and empowerment into local communities: the White Paper fails to identify how this will be achieved, especially at a time when the Public Sector is cutting back on Third Sector and community funding.

Responses to Specific Consultation Questions

See Table below

The Impact of NHS and public sector reforms and cuts on delivering the Public Health White Paper:

The SHA submitted a response to Equity and Excellence: Liberating the NHS. Since then NHS and public sector reforms and cuts have progressed at a pace. The NHS and Public health White Papers talk of evidence base but no there is evidence base to support these approaches. The SHA believes these seriously undermine the aims and ambitions of the Public Health White Paper. Key issues:

Quality and equality requires good governance and monitoring – market forces work against this
Quality commissioning requires skills and resources. The GP consortia do not have skills or expertise in this and should be required to use the relevant knowledge and experience of commissioners and public health specialists in supporting commissioning and sitting on their boards.
Massive reorganization and reduction of PCTs, SHAs and other key bodies such as National Support Team and Health Protection Agency is likely to undermine public health programmes and the health of the population. Re-organisations do not work and there is no mandate for this one
Improving the health of the population requires working with partners – it is much more difficult if council and consortia are not co-terminous
People are not in equal positions to make choices about health care, social care and preventative programmes within a market. This is clear in any review of outcomes and research on inequalities e.g. Marmot. The market approach and limited legislative approaches are likely to increase inequalities.
Public Sector reform and cuts are likely to hit the poor hardest and thus undermine the aims outlined in this white paper linked to the Marmot review.
The impact of other legislation on both short and long term Public Health outcomes must not be ignored – in particular the Health & Social Care Bill and the Welfare Bill. For the disabled, sick and elderly, these bring with them a projected increase in poor mental health, for example. For young families on low incomes, a range of long term detrimental impacts.

Conclusion

The White Paper is encouraging in that it proposes some solutions to age old thorny issues such as addressing the democratic deficit in health and strengthening actions to address the wider determinants of health. It also raises the profile of public health and proposes a ring-fenced budget. However it falls to give the detail on required powers, resources and coordination to prevent fragmentation of the public health function and ensure its goals are achieved. There is insufficient emphasis on community engagement and public accountability and too strong a role given to industry and politicians. More importantly the cuts and reforms of the wider NHS and public sector present a serious risk that the whole public health system will be rushed into introducing changes and will ultimately fail to deliver on what the White Paper promises, that is improved health and reduced health inequalities. Instead it will see disadvantaged communities with poorer health outcomes and widening health inequalities.

Responses to Specific Questions in the Consultation

Question heading	Question	Key Messages
Roles of GPs and GP practices in PH	in areas for which PH England will take responsibility?	Power and responsibility of the well being board and GP engagement in it should be strengthened Set targets for GP consortia with performance monitoring by the National Commissioning Board – including narrowing inequalities Make co-terminousity with councils and total population coverage by GP consortia mandatory Be clear what the 15% of QOF indicators that will be evidence based public health and primary prevention indicators will mean in practice
Public Health Evidence	What are the best opportunities to develop and enhance the availability, accessibility and utility of PH information and intelligence?	PHE functions to include continuation of ONS, APHOs, NICE and the National Support Teams (NSTs). Maintain independence of the information sources Ensure free availability of information in a range of formats
Public Health Evidence	How can PH England address current gaps such as using insights of behavioural science, tackling wider determinants of health, achieving cost effectiveness and tackling inequalities?	Public Health England to link with universities on behavioural science research and to continue the work of NSTs The issue is more about implementation and using the evidence e.g. demonstrated importance of legislation and enforcement in addressing inequalities
Public Health Evidence	What can wider partners nationally and locally contribute to improving the use of evidence in public health?	Basic training in how to improve the use of information/evidence for: voluntary sector, local authority, councilors, GPs Partners to be further engaged in developing information sources – especially the public
Regulation of public health professionals	We would welcome views on Dr Scally’s report. If we were to pursue voluntary registration, which organization would be best suited to provide a system of voluntary regulation for public health specialists?	The evidence-base behind Dr Scally’s proposals is not clear. A case should be made for changing the current systemThere should be a national system for mandatory accreditation. JDPH roles require the expertise of a public health specialist.