1 September 2011 | By Noel Plumridge
Away from the sound and fury of the controversial NHS changes, another revolution is quietly taking place – the transfer of public health to town halls. Noel Plumridge looks at what this will mean for local communities and how it will be funded
The Department of Health, according to its website, remains responsible for health protection, health improvement and health inequalities in England. Indeed, part of the Conservative pre-election vision was that it would evolve into a Department of Public Health, focusing on such strategic issues rather than merely treating patients and managing hospitals.
But soon many public health functions will be commissioned by local authorities, using a ring-fenced budget carved out of NHS funding. This strand of the government’s troubled health reform agenda stems from last November’s white paper, Healthy lives, healthy people, and continues to make steady progress. Perhaps £4bn of current spending – no mean sum – is at stake.
Across England, directors of public health are bidding goodbye to the fast-disappearing NHS primary care trust and starting new local government careers.
The transfer of public health funds and responsibilities appears to be less controversial than some of the other high-profile NHS changes, such as GP-led commissioning and the concept of ‘any willing provider’ that have upset doctors and politicians alike. In practice, however, these issues are inseparably entwined in the coalition vision of the future of the public sector in England. What, in an era of ‘small government’, is it proper for government to do and what should be left to non-government agencies to organise?
And tricky questions are bubbling to the surface. Many are about money: calculating the amount currently spent on public health is proving more complex and sensitive than anticipated. Directors of public health predictably favour including as much as possible within the ring-fence; PCT finance directors equally predictably see the world differently. Relations are becoming strained.
There’s also the delicate issue of reporting lines: where exactly should these new council employees fit into the slimmed-down management hierarchies? And, more fundamentally, what is expected of the new role? What does ‘public health’ actually mean?
Most medicine is essentially about the treatment and care of the sick, but public health medicine classically concentrates on the health of whole populations and the wellbeing that population-wide interventions can achieve.
It’s a long-established discipline. Clean water supplies in towns and the safe disposal of human waste feature on the list of ‘things the Romans did for us’.
In modern times, British pioneers include Edwin Chadwick, whose work on sanitation was prompted by typhoid and influenza epidemics in the 1830s, and John Snow who, in tracing an 1854 cholera outbreak in London to a polluted well, founded the modern science of epidemiology.
Tackling today’s causes of premature death and illness fits naturally enough with government expectations of councils, and will be enshrined in formal health and wellbeing boards once the Health and Social Care Bill becomes law. The government has already designated 132 local authorities as early implementers of the boards.
This follows various reviews on improving the health of the nation. Back in 2002, Derek Wanless’s seminal report, Securing our future health: taking a long-term view, recognised the crucial impact of public ‘engagedness’ in successful health improvement. The 2010 Marmot review of health inequalities, Fair society, healthy lives, emphasised investment in the health of very young children. It argued that health improvement – and its resulting economic benefits – can happen only if the wider causes of inequality in society are tackled. These causes, Marmot maintained, include employment, education, the environment and the distribution of wealth.
There has also been a growing trend to appoint a joint director of public health, uniting local government and health perspectives within broader partnership working. Joint strategies in such areas as drug and alcohol abuse, sexual health, teenage pregnancy and mental health have become commonplace, and are often backed up with formal partnership agreements under section 75 of the NHS Act 2006.
There’s also a pragmatic short-term reason for the transfer of responsibility for some public health areas to councils. Budgets for health promotion and the prevention of illness will always be eyed greedily by those treating today’s cancers and heart diseases. This applies both within the medical profession – where surgeons, physicians and obstetricians traditionally rule the roost – and among the wider public. With severe cuts taking shape in the NHS, perhaps local authority ownership might offer protection.
‘Too often in the past’, Health Secretary Andrew Lansley said when launching the white paper, ‘public health budgets have been raided by the NHS to tackle deficits.’
But it’s still not clear exactly what, or who, will transfer. Public health activity ranges from local encouragement of wise choices and provision of facilities, such as access to exercise and the creation of cycle paths, to national disincentives and restrictions, including taxing tobacco and alcohol and making the use of seatbelts mandatory. Where does ‘nudge’ end and legislation begin for a coalition government that instinctively dislikes intruding on personal liberty?
So some of the money, it has emerged, will transfer to the new NHS Commissioning Board to purchase immunisation, contraception, screening and health visiting programmes. And some is being drawn into Whitehall for a new central public health service, Public Health England, aimed at building ‘national resilience’ on population-wide issues.
Lansley won’t quickly forget his embarrassment last winter over shortages of flu vaccine: epidemics, and the fear of them, are a political as well as a public health issue. There’s also the small matter of next year’s Olympic Games to consider. Public Health England will remain under Department of Health control, with expert input from two arm’s-length bodies: the Health Protection Agency (with a remit including microbiology and radiation protection) and the National Treatment Agency.
The timetable for change, published by the Department of Health in March, expects the full definition of new structures to be confirmed by the end of August; agreement of funds flow and working relationships with local authorities by October; staff migrating to the new structure in April 2012 to work within shadow budgets during 2012/13; and public health grants made to upper tier and unitary local authorities in April 2013. It’s an ambitious programme, and success will as ever depend significantly on the money.
Ah yes, the money. That broad brush Department of Health estimate of £4bn appears consistent with the £3.7bn estimated to have been spent on disease prevention and public health in 2006/07, which represented about 4% of total health spending. The trouble is, the NHS doesn’t routinely collect such information, and definitions are confusing. That estimate came from Health England, a national reference group for health and wellbeing that reported in 2009. It used the health accounting definitions of the Organisation for Economic Co-operation and Development, which – for instance – omit spending on preventive pharmaceuticals. But its estimate also included all dental checks, whereas PCT accounting guidance restricts the classification to overtly public health aspects of dentistry, such as school lessons on how to brush teeth.
The £3.7bn figure might be a gross overestimate. Analysis by the Audit Commission, published in March 2010 as Healthy balance, found £1.5bn of it was spent centrally on dental check-ups, sight tests, and incentive payments to GPs under the Quality and Outcomes Framework, part of the General Medical Services contract for GPs. National immunisation and screening programmes account for a further £0.5bn, while the costs of central bodies add £0.3m.
That would leave some £1.4bn under the control of PCTs, but around half of that goes on maternity services and family planning. So the true value of funds for transfer might amount only to £0.7bn – a mere £5m per PCT.
Small wonder then, amid loose definitions and conflicting messages, that PCT accountants prepared starkly varying estimates of spending on public health for their 2010/11 accounts. Within London they ranged from Haringey, which seemingly spends £7 per needs-adjusted head on public health, to Westminster PCT’s £169 per head.
Unsurprisingly, the figures have been returned for review. With shadow allocations to councils due in December, financial rigour might yet prove to be a crucial issue. The need for interpretation is undeniable – for instance, on whether HIV spending is on treatment or prevention – yet robustness hasn’t been helped by the rapid consolidation of PCTs into ‘clusters’ as part of the NHS reforms, with consequent staff departures and loss of organisational memory.
One director of public health, who does not wish to be named, observes ruefully that the estimates were made by a temporary member of the finance staff who made no reference back to public health before submitting the data.
It’s a reminder that changes in public health, however well intended, are taking place within a difficult context. Both local government and health are struggling with extremely tight financial settlements. On paper, the NHS has fared marginally better but in practice the combination of no growth and a £20bn savings target, needed to pay for population growth, demographic changes and scientific advances, have left it feeling battered.
Meanwhile, it has been plunged into a chaotic and protracted reorganisation. PCTs, strategic health authorities and the majority of arm’s-length bodies are disappearing. They are to be replaced by a complex web of GP-led commissioning groups, an NHS commissioning board, senates and numerous other sketchily described entities emerging from Lansley’s ‘pause’ of the Health and Social Care Bill for his ‘listening exercise’.
Ironically, the days of both the Health Protection Agency and the National Treatment Agency, the two expert props of Public Health England, are numbered as a result.
What’s plain, however, is that directors of public health will lose their direct ability to steer health commissioning. Since 2001, when the first PCTs came into existence, medical leadership at local level has been shared between a director of public health, who is a full (though not always full-time) board-level PCT director, and the leaders of the GP community.
Some public health directors have stuck to traditional areas of public health medicine, preferring to let finance and commissioning professionals steer how most NHS money is spent. But others have risen to the commissioning challenge with relish, arguing that their greatest ability to influence the health of the population lies in an effective approach to prioritising expenditure.
Dr Peter Brambleby, joint director of public health for the London Borough of Croydon and NHS Croydon, for instance, has become a leading advocate of ‘programme budgeting’ in health, replacing incrementalism with a rational and transparent approach to setting medical priorities.
Now health commissioning is once again to become the preserve of GPs. However, elected council members will chair health and wellbeing boards. They will have the power to scrutinise both the intentions of commissioning groups, and the quality of health provision. Given teeth, they could yet be a vehicle for imposing democratic accountability on the NHS.
But what will they use for information? How will councils identify health and wellbeing expenditure? To work, the boards will need the same disciplines of definition, measurement and benchmarking as other spending departments. And their scope could be breathtaking: what meaningful definition of wellbeing would exclude educational attainment?
A challenge for accountants, perhaps, but the greater challenge is possibly for directors of public health. Ring-fencing, intended to stop councils from defining existing leisure and sports services (and what about street lighting?) as ‘public health’, might become a cage. Professor Lindsey Davies, president of the UK Faculty of Public Health, recently emphasised the need to ‘sit at the main corporate management table and influence across the whole local authority and health community’. But with new public health registrars increasingly unable to find jobs, uncertainty and anxiety within the profession are growing.
Lansley ‘expects’ directors of public health to be of chief officer standing, reporting to the chief executive. But the local government perspective in an era of slimmed-down structures might be rather different. An emphasis on formal reporting lines appears unenforceable and might prove counter-productive. Status is earned, not granted. The real test will be the success of public health in influencing council priorities and improving the health of the population.
‘We’re going into hot water, our natural environment,’ says Brambleby. ‘We can go in as an egg, with a hard shell around us; or as a coffee bean, which dissolves but flavours the entire pot.’
Noel Plumridge is a former NHS finance director and the author of CIPFA’s Payment by results
Away from the sound and fury of the controversial NHS changes, another revolution is quietly taking place – the transfer of public health to town halls. Noel Plumridge looks at what this will mean for local communities and how it will be funded
The Department of Health, according to its website, remains responsible for health protection, health improvement and health inequalities in England. Indeed, part of the Conservative pre-election vision was that it would evolve into a Department of Public Health, focusing on such strategic issues rather than merely treating patients and managing hospitals. But soon many public health functions will be commissioned by local authorities, using a ring-fenced budget carved out of NHS funding. This strand of the government’s troubled health reform agenda stems from last November’s white paper, Healthy lives, healthy people, and continues to make steady progress. Perhaps £4bn of current spending – no mean sum – is at stake.
Across England, directors of public health are bidding goodbye to the fast-disappearing NHS primary care trust and starting new local government careers.
The transfer of public health funds and responsibilities appears to be less controversial than some of the other high-profile NHS changes, such as GP-led commissioning and the concept of ‘any willing provider’ that have upset doctors and politicians alike. In practice, however, these issues are inseparably entwined in the coalition vision of the future of the public sector in England. What, in an era of ‘small government’, is it proper for government to do and what should be left to non-government agencies to organise?
And tricky questions are bubbling to the surface. Many are about money: calculating the amount currently spent on public health is proving more complex and sensitive than anticipated. Directors of public health predictably favour including as much as possible within the ring-fence; PCT finance directors equally predictably see the world differently. Relations are becoming strained.
There’s also the delicate issue of reporting lines: where exactly should these new council employees fit into the slimmed-down management hierarchies? And, more fundamentally, what is expected of the new role? What does ‘public health’ actually mean?
Most medicine is essentially about the treatment and care of the sick, but public health medicine classically concentrates on the health of whole populations and the wellbeing that population-wide interventions can achieve.
It’s a long-established discipline. Clean water supplies in towns and the safe disposal of human waste feature on the list of ‘things the Romans did for us’.
In modern times, British pioneers include Edwin Chadwick, whose work on sanitation was prompted by typhoid and influenza epidemics in the 1830s, and John Snow who, in tracing an 1854 cholera outbreak in London to a polluted well, founded the modern science of epidemiology.
Tackling today’s causes of premature death and illness fits naturally enough with government expectations of councils, and will be enshrined in formal health and wellbeing boards once the Health and Social Care Bill becomes law. The government has already designated 132 local authorities as early implementers of the boards.
This follows various reviews on improving the health of the nation. Back in 2002, Derek Wanless’s seminal report, Securing our future health: taking a long-term view, recognised the crucial impact of public ‘engagedness’ in successful health improvement. The 2010 Marmot review of health inequalities, Fair society, healthy lives, emphasised investment in the health of very young children. It argued that health improvement – and its resulting economic benefits – can happen only if the wider causes of inequality in society are tackled. These causes, Marmot maintained, include employment, education, the environment and the distribution of wealth.
There has also been a growing trend to appoint a joint director of public health, uniting local government and health perspectives within broader partnership working. Joint strategies in such areas as drug and alcohol abuse, sexual health, teenage pregnancy and mental health have become commonplace, and are often backed up with formal partnership agreements under section 75 of the NHS Act 2006.
There’s also a pragmatic short-term reason for the transfer of responsibility for some public health areas to councils. Budgets for health promotion and the prevention of illness will always be eyed greedily by those treating today’s cancers and heart diseases. This applies both within the medical profession – where surgeons, physicians and obstetricians traditionally rule the roost – and among the wider public. With severe cuts taking shape in the NHS, perhaps local authority ownership might offer protection.
‘Too often in the past’, Health Secretary Andrew Lansley said when launching the white paper, ‘public health budgets have been raided by the NHS to tackle deficits.’
But it’s still not clear exactly what, or who, will transfer. Public health activity ranges from local encouragement of wise choices and provision of facilities, such as access to exercise and the creation of cycle paths, to national disincentives and restrictions, including taxing tobacco and alcohol and making the use of seatbelts mandatory. Where does ‘nudge’ end and legislation begin for a coalition government that instinctively dislikes intruding on personal liberty?
So some of the money, it has emerged, will transfer to the new NHS Commissioning Board to purchase immunisation, contraception, screening and health visiting programmes. And some is being drawn into Whitehall for a new central public health service, Public Health England, aimed at building ‘national resilience’ on population-wide issues.
Lansley won’t quickly forget his embarrassment last winter over shortages of flu vaccine: epidemics, and the fear of them, are a political as well as a public health issue. There’s also the small matter of next year’s Olympic Games to consider. Public Health England will remain under Department of Health control, with expert input from two arm’s-length bodies: the Health Protection Agency (with a remit including microbiology and radiation protection) and the National Treatment Agency.
The timetable for change, published by the Department of Health in March, expects the full definition of new structures to be confirmed by the end of August; agreement of funds flow and working relationships with local authorities by October; staff migrating to the new structure in April 2012 to work within shadow budgets during 2012/13; and public health grants made to upper tier and unitary local authorities in April 2013. It’s an ambitious programme, and success will as ever depend significantly on the money.
Ah yes, the money. That broad brush Department of Health estimate of £4bn appears consistent with the £3.7bn estimated to have been spent on disease prevention and public health in 2006/07, which represented about 4% of total health spending. The trouble is, the NHS doesn’t routinely collect such information, and definitions are confusing. That estimate came from Health England, a national reference group for health and wellbeing that reported in 2009. It used the health accounting definitions of the Organisation for Economic Co-operation and Development, which – for instance – omit spending on preventive pharmaceuticals. But its estimate also included all dental checks, whereas PCT accounting guidance restricts the classification to overtly public health aspects of dentistry, such as school lessons on how to brush teeth.
The £3.7bn figure might be a gross overestimate. Analysis by the Audit Commission, published in March 2010 as Healthy balance, found £1.5bn of it was spent centrally on dental check-ups, sight tests, and incentive payments to GPs under the Quality and Outcomes Framework, part of the General Medical Services contract for GPs. National immunisation and screening programmes account for a further £0.5bn, while the costs of central bodies add £0.3m.
That would leave some £1.4bn under the control of PCTs, but around half of that goes on maternity services and family planning. So the true value of funds for transfer might amount only to £0.7bn – a mere £5m per PCT.
Small wonder then, amid loose definitions and conflicting messages, that PCT accountants prepared starkly varying estimates of spending on public health for their 2010/11 accounts. Within London they ranged from Haringey, which seemingly spends £7 per needs-adjusted head on public health, to Westminster PCT’s £169 per head.
Unsurprisingly, the figures have been returned for review. With shadow allocations to councils due in December, financial rigour might yet prove to be a crucial issue. The need for interpretation is undeniable – for instance, on whether HIV spending is on treatment or prevention – yet robustness hasn’t been helped by the rapid consolidation of PCTs into ‘clusters’ as part of the NHS reforms, with consequent staff departures and loss of organisational memory.
One director of public health, who does not wish to be named, observes ruefully that the estimates were made by a temporary member of the finance staff who made no reference back to public health before submitting the data.
It’s a reminder that changes in public health, however well intended, are taking place within a difficult context. Both local government and health are struggling with extremely tight financial settlements. On paper, the NHS has fared marginally better but in practice the combination of no growth and a £20bn savings target, needed to pay for population growth, demographic changes and scientific advances, have left it feeling battered.
Meanwhile, it has been plunged into a chaotic and protracted reorganisation. PCTs, strategic health authorities and the majority of arm’s-length bodies are disappearing. They are to be replaced by a complex web of GP-led commissioning groups, an NHS commissioning board, senates and numerous other sketchily described entities emerging from Lansley’s ‘pause’ of the Health and Social Care Bill for his ‘listening exercise’.
Ironically, the days of both the Health Protection Agency and the National Treatment Agency, the two expert props of Public Health England, are numbered as a result.
What’s plain, however, is that directors of public health will lose their direct ability to steer health commissioning. Since 2001, when the first PCTs came into existence, medical leadership at local level has been shared between a director of public health, who is a full (though not always full-time) board-level PCT director, and the leaders of the GP community.
Some public health directors have stuck to traditional areas of public health medicine, preferring to let finance and commissioning professionals steer how most NHS money is spent. But others have risen to the commissioning challenge with relish, arguing that their greatest ability to influence the health of the population lies in an effective approach to prioritising expenditure.
Dr Peter Brambleby, joint director of public health for the London Borough of Croydon and NHS Croydon, for instance, has become a leading advocate of ‘programme budgeting’ in health, replacing incrementalism with a rational and transparent approach to setting medical priorities.
Now health commissioning is once again to become the preserve of GPs. However, elected council members will chair health and wellbeing boards. They will have the power to scrutinise both the intentions of commissioning groups, and the quality of health provision. Given teeth, they could yet be a vehicle for imposing democratic accountability on the NHS.
But what will they use for information? How will councils identify health and wellbeing expenditure? To work, the boards will need the same disciplines of definition, measurement and benchmarking as other spending departments. And their scope could be breathtaking: what meaningful definition of wellbeing would exclude educational attainment?
A challenge for accountants, perhaps, but the greater challenge is possibly for directors of public health. Ring-fencing, intended to stop councils from defining existing leisure and sports services (and what about street lighting?) as ‘public health’, might become a cage. Professor Lindsey Davies, president of the UK Faculty of Public Health, recently emphasised the need to ‘sit at the main corporate management table and influence across the whole local authority and health community’. But with new public health registrars increasingly unable to find jobs, uncertainty and anxiety within the profession are growing.
Lansley ‘expects’ directors of public health to be of chief officer standing, reporting to the chief executive. But the local government perspective in an era of slimmed-down structures might be rather different. An emphasis on formal reporting lines appears unenforceable and might prove counter-productive. Status is earned, not granted. The real test will be the success of public health in influencing council priorities and improving the health of the population.
‘We’re going into hot water, our natural environment,’ says Brambleby. ‘We can go in as an egg, with a hard shell around us; or as a coffee bean, which dissolves but flavours the entire pot.’
Noel Plumridge is a former NHS finance director and the author of CIPFA’s Payment by results
