Great expectations - public health is coming home


Public health is coming home to local government.The publication in July 2011 of “Healthy Lives, Healthy People - Update and way forward” has confirmed the key role to be given to local councils as community leader for health improvement and the reduction of health inequalities. Local authorities already make a difference to health and wellbeing through their emphasis on people, places and empowerment. They are well-placed to tackle the wider determinants of health and to promote better health and wellbeing across the life course, for example through early years services, education, culture, sports and leisure, spatial planning, transport, housing, economic development and regeneration. They are involved with promoting 'health supporting behaviours' across the full spectrum of interventions from health education and promotion in schools, workplaces and communities. Local authorities will be involved in everything from regulation for alcohol, tobacco and buildings and environmental protection. Improving health is already the business of local government, and this will now be strengthened with the advent of Health and Wellbeing Boards and the transfer of local public health functions to local councils.

Local councils are to provide the democratic “adhesive” that binds together the local effort for health improvement. Previously, their aspirations were hindered by the organisational separation of health and local government. Now local councils are to have a wider strategic responsibility, through their Health and Wellbeing Boards, for integrated action across the whole system of health and public service in their areas. Good health, education and employment are the building blocks for local success, and they are mutually reinforcing. Councils and their Health and Wellbeing Boards are to be supported in their work by their Directors of Public Health and local public health teams, and by Public Health England, the new national Executive Agency. They will also take on responsibility for some specific public health functions that are to be transferred from Primary Care Trusts, and offer public health support to the new Clinical Commissioning Groups.

Public Health is Coming Home

So public health is coming home! Of course, it is not the same public health. Knowledge and skills have moved on since 1974, and there have been massive improvements in education and training. The evidence base is much better, and the Public Health Observatories have provided high quality information. The specialist public health profession has been opened up to non medics, and the core competencies provide a comprehensive platform for practice. Neither is it the same local government. Modern councils look at their whole population and specific segments within it, and they are more interested in the wellbeing of local people and arranging services for them than in direct provision. Councillors and managers are better prepared and equipped to handle the pressures facing local government. The public has also changed, expecting far more responsive and personalised attention from their local councils, and perhaps being more dependent on them than in the 1970s.

There are two more points about the homecoming. Firstly, not all of public health is moving into local government - Public Health England will be a significant employer of public health specialists. And not all public health left local councils. Environmental health officers, who are scientifically educated public health specialists, never left. In addition, there are thousands of other local government staff involved in health education, supporting sport and physical activity, working on health and wellbeing in neighbourhoods and communities, improving health through spatial planning and regeneration, and protecting health through regulatory services. There is already a lot to build on, and now there is a huge opportunity for local councils

The Local Government Association has helped to shape the reforms

The Local Government Association has been active in preparing for the transfer of local public health and the new responsibilities that are coming to local councils. The LGA has lobbied for changes and improvements in the Health and Social Care Bill, and engaged with the Department of Health, the public health sector and primary care on issues of policy and practice. Wherever possible, a common policy front has been presented, and where there have been different viewpoints, these have been identified, discussed and debated. The Community Wellbeing Board has been closely engaged with the development of policy, and Councillor David Rogers, the Chairman, has given evidence to the Health Committee and All Party Parliamentary Group on Primary Care and Public Health.

There has been a programme of roundtables and events looking at both high level policy issues and practical issues for development. The Local Government Association argued effectively for a statutory basis for the proposed Health and Wellbeing Boards, for the power of “sign-off” for primary care commissioning plans, and for the retention - and extension - of the councils` power of health scrutiny. It also argued (less successfully) that the White Papers and the Bill underplayed the importance of district and borough councils in supporting local health and wellbeing. Despite this omission, the verdict from local government at this stage is “so far, so good.” This is the view of most lead councillors, who can see the potential for their local populations and are keen to make the transfer of public health a success. The renewed and strengthened position of health scrutiny has also been welcomed, after the earlier false start.

Work has been done across the Local Government Association to prepare for change. This has involved the Healthy Communities Programme , the Ageing Well Programme, Adult Social Care, Children`s Services, Local Regulators, Local Partners and Local Government Employers. The Centre for Public Scrutiny has been very active in policy debates, and has developed a model for public health scrutiny. The Healthy Communities Programme has worked with local councils and their partners on leadership for health improvement, the start-up of Health and Wellbeing Boards, the relationship between GPs and Elected Members, the redesign of joint strategic needs assessment to meet new demands, community engagement and asset-based community development, the wider determinants of health, tobacco control and the business case for public health investment. This work has been supported by a lively website and an active Community of Practice network. The Programme was created five years ago with DH support to help raise the confidence and capacity of local government for health improvement and the reduction of health inequalities. It has played an important part in encouraging local councils to understand what they can do to improve health and wellbeing, and to prepare them for their new responsibilities under the Bill. The Programme is due to finish in the autumn. A new programme, specifically for Elected Members and also to be run by the Local Government Association, has recently been announced by the Secretary of State.

Health and Wellbeing Boards - Committees of the Council

Local government is pleased that the sector is moving centre stage for public health, and that there is a strong policy emphasis on locally-led systems. This fits well with the responsibility of councils for people and places, and with the drive towards localism, community budgeting and greater public service efficiency. The new system, from this perspective, is likely to be more democratic, more effective and more efficient. The future balance between delivering national outcomes, developing stronger joint commissioning and ensuring the closer integration of health, public health, social care and children`s services will be a matter for local attention through the Health and Wellbeing Boards.

It is important that they are to be statutory committees of the council, with responsibility for developing joint strategies and holding partners to account for delivering better outcomes. They will be consulted about local CCG configurations, and about their commissioning plans, and the CCGs will have members on the Board.

This statutory role will need to be carefully constructed, because to function well, the Boards will need to operate in a way that is different from the experience of most traditional local government committees. They will need to be extremely nimble and creative, and focus on making things happen. Local people will need to be convinced that the Boards can make a difference. Helen Bevan, from the NHS Institute, has suggested it would be better to focus attention on the concept of the “Health and Wellbeing Movement” rather than the “Board”. This underlines the new ambition, which is about the mobilisation of energy and effort across the whole health and wellbeing system. The Director of Public Health and the local team will need to help the Board to look outwards and engage with local people and stakeholders in a dynamic relationship of dialogue and co-production of health and wellbeing.

A Major Transition - or simply the transfer of hosted services?

The potential is there for a major transformation. Will the transfer of public health responsibilities mobilise widespread action for health improvement across the whole of the council and other public services? Or be more like the transfer of a bundle of “prescribed” and “hosted” services that will be centrally performance managed to the nth degree? The answer may depend on the level of trust given and earned by the major partners, and the initial design principles for the national architecture for health improvement. Local government has been closely engaged with the Department of Health in looking in particular at the interface between local councils, Public Health England and the NHS Commissioning Board. David White, the Chief Executive of Norfolk County Council, has recently chaired an important event exploring the issues with local government, the public health sector, Department of Health leaders and commissioners. Along with more obvious and well-discussed issues, such as funding, terms and conditions and reporting lines for Directors of Public Health, the question of performance improvement was a major theme for participants. The Outcomes Frameworks offer an approach that is meant to feel very different to the previous regime of national targets and indicators. They are to set out the national expectations for improvement and leave room for local decisions. The local government philosophy of improvement through the ballot box and sector-led support was considered at the event in the light of the previous approaches, and it was clear that there was concern from many public health colleagues about the dismantling of the national traffic light system.

Public Health England is currently in formation, and the organisation will define to a considerable degree the new public health system. It will need to show how it can become a good friend to local councils and their Health and Wellbeing Boards - a critical friend on occasions but nothing like a traditional regulator.

There is some good news - the teams designing the new national organisations do understand local government. Dr Ruth Hussey and Anita Marsland, who are helping to develop Public Health England, have been strong advocates for partnership working across the whole system in the North West. The recent appointment of Bill McCarthy as Managing Director for the NHS Commissioning Board, with his Department of Health and NHS background and experience as Chief Executive of York Council, should help to make sure that arrangements between the Board, Public Health England and local government will be productive.

However, there is still much to be done by all the partners in this venture. The recent “Update” shows work in progress . (It is not yet the formal government response to the Public Health White Paper that will come later in the summer.) There is still a great deal to sort out. There will be further consultations with local government and the public health sector on a range of specific issues, including the conditions for transferred funds and the Health Premium, the Public Health Outcome Framework, the list of transferred public health responsibilities and child and adolescent public health. While much of this will be about matters of detail, there are still some important high level issues of finance, human resources and governance to be resolved. It is these unresolved “big ticket” items that are likely to determine whether the public health reforms are to amount to a radical transformation of the public health system rather than simply the transfer of a diverse range of hosted NHS services.

This makes it a good time to take stock and gather-in the views of a range of participants.

The Community of Practice forum and hotseat of health professionals - 5 September 2011

The presentations gathered together for this Community of Practice discussion show the huge potential of the transition of public health to local councils, and some of the concerns. The Local Government Association has been working closely with the Faculty for Public Health, the Royal Society for Public Health, the BMA and the Association of Directors of Public Health to identify areas of commonality and difference. At the radical wings of the debate,

Professor Martin McKee recently argued in his Lancet article for a unified national public health system with all specialist contracts held by an independent PHE, and Phil Coppard, the Chief Executive of Barnsley Council cautioned against the importation of clinical issues into local government - he argued that their business is with the wider determinants, health behaviours and public mindsets, not medical issues. These arguments, in a way, mirror each other in their clarity. However, there is a complex and substantial set of issues in the space between them. Many public health specialists have welcomed the chance to influence the whole of local government from the inside. They believe the prize is worthwhile - this is the position presented by Dr Hugh Annett. It is shared by Caroline Tapster, the Chief Executive of Hertfordshire County Council, and Peer Members for the Healthy Communities Programme who have explored these issues. Local public health should therefore be located within local government. The transfer of functions and staff, of course, immediately raises the question of public health support back into the NHS. Most public health specialists have urged that the three domains of public health (prevention, protection and health service improvement) should be kept together, especially given the relatively small number of specialists and the high risk of professional fragmentation. From this perspective, if public health is to be located in local councils, then they should be required to offer public health expertise back to the Clinical Commissioning Groups, and also take a lead role for local health protection.

This is the view presented by Dr Frank Atherton, speaking for the Association of Directors of Public Health and this has now been endorsed in the “Update”. Some council Chief Executives, remembering their previous experience of Directors of Public Health who spent most of their time on PCT clinical business, have asked whether the available resources will stretch to cover this “three-way-spread”, without reducing the efforts made on the wider determinants and health behaviours. They have also expressed concern about the possible dominance of clinical commissioning matters within the Health and Wellbeing Boards. These questions will be important for the Health and Wellbeing Boards, and they underline the importance of opportunities for proper Board Development given the enormity of the tasks they are taking on.

Two longer items

There are two longer items in this CoP collection. We were fortunate that Professor Hunter, from Durham University, who edited the first Healthy Communities publication on Directors of Public Health, has prepared an extensive commentary on the proposed changes. He has encouraged local councils to seize the opportunity that they present to focus attention upstream on the wider determinants, and rebalance the attention given to clinical matters.

Jude Williams, previously the Deputy Director of the National Support Team for Health Inequalities, has prepared a discussion paper based on her experience of health improvement work. The NSTs emphasised the importance of systematic and comprehensive approaches to local health improvement. Focused thematically, they have drawn wisdom from the field about what works, and this legacy is of great value to the Health and Wellbeing Boards. Both David and Jude have been good friends to the Healthy Communities Team over the past five years, and these are important contributions to the debate.

In Conclusion

This CoP event has been planned by Liam Hughes and Tess Gool from the Healthy Communities Team, with the help of Jude Williams. The Team would like to thank all the writers and participants associated with planning and taking part in this CoP programme for their enthusiasm and commitment. A summary of the key issues raised in the discussions will be prepared and posted on the CoP as soon as possible.

Liam Hughes, National Adviser for Healthy Communities
Tess Gool, Consultant

2 September 2011

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