The Health and Social Care Act 2012 moved the Public Health function out of the NHS and into local authorities, with effect from April 2013. The House of Commons Health Committee undertook an inquiry to consider the overall impact of these structural changes and on the effectiveness of the delivery of public health functions. The inquiry heard oral evidence over four sittings and received 128 pieces of written evidence.
The report, Public Health post-2013, echoes the findings of the QualityWatch Public health and prevention report published in February this year. Three years after the transition, a cohesive picture has started to emerge of how Public Health looks in the local authority setting.
What are its key findings?
- There was broad consensus that the move into the local authority has allowed Public Health to influence the wider determinants of health and embedded these in local agendas.
- However, local authorities are under financial pressure, and continued budget cuts mean that local public health departments increasingly find themselves being asked to deliver more with less. Many departments have responded with innovative solutions to make savings when recommissioning services, but there is a limit to how much further they can go without causing adverse effects. On top of cuts which have been made to date, there is apprehension about future changes to funding structures: the removal of the ring-fence around public health funds in 2018-19 and a move to business rates.
- A radical upgrade in prevention is the linchpin of the Five Year Forward View. When asked by the committee, Simon Stevens said that £0.5 - £1 billion worth of savings would have to be delivered through public health driven prevention savings. The committee drew on the QualityWatch report to highlight that the top three causes of premature death in the UK arise from amenable behaviours. However, this strategic focus on prevention is not matched with sufficient funding and the £200m budget cuts were identified as a false economy by the committee.
- Given that Public Health is now delivered at a local level, a certain degree of variation was expected across localities. However, it appears that there is an unacceptable level of variation across the system. Particularly with regard to funding, which the committee plans to review in more detail. There are examples of good practice around the country, but a feeling that these learnings are not effectively shared nationally.
- Placing Public Health in the local authority puts it at the heart of democracy and chief executives of councils can drive children’s services, education and transport in a way that the NHS cannot. However, there is tension between political priorities and evidence-based decision making, the former often driving spending decisions, to the detriment of marginalised or stigmatised groups. It is important that Directors of Public Health remain independent with their Annual Public Health Report and do not come under pressure from the council.
- As shown in our Public Health and Prevention report, there is a lot fragmentation in the system, particularly around sexual health services. Here, there are a large number or boundaries and relationships to negotiate. Similarly, there is confusion and duplication of efforts around health protection, and a lack of clarity in funding responsibility with regard to this.
- This system fragmentation is also reflected in the national leadership picture across the governmental bodies involved in Public Health decision-making: Department of Health, Public Health England, NHS England. This has implications for workforce planning, whereby Public Health staff do not have continuity of service recognised as they move between the bodies, and there are large differences in terms and conditions in each organisation.
- Data access was a particularly significant issue, which needs to be addressed to be able to appropriately inform service planning.
- The NHS needs to do more about prevention. Although Public Health has moved out of the NHS and into local authorities, this does not absolve the NHS of its responsibilities in the delivery of improved Public Health, from CCG population planning, to health professionals making every contact count. Simon Stevens acknowledged that if preventive services such as drug and alcohol, or sexual health services are cut, the extra demand will appear within more expensive parts of the NHS within 12 months rather than years. Organisational territorialism has no place in making progress on population health issues.
In summary, the House of Commons Health Committee report identifies many of the same issues as our work on public health and prevention. The move of Public Health into local authorities allows a more meaningful interaction with the wider determinants of health, but is constrained by tightening budgets, local political priorities, and data issues. System fragmentation has become quite evident and all organisations, including the NHS, need to get on board to deliver the prevention agenda.