The Government’s plans for radical change in the way in which public health is delivered in localities have changed less during the Government ‘reforms of its reforms’ than almost any part of its NHS programme.
There is a lesson in this rarely demonstrated ability to hold the line. Why is it that they have changed nearly everything else – including the national picture of public health – but have been able to stay constant on the radical change to localities?
Their policy on devolving responsibility for most of public health to local government has been maintained because – unlike other parts of their proposed NHS reforms – they plan to use an existing political organisation to carry out part of the reform. It may seem obvious given the political importance of local government to both national and local politics that if the Secretary of State decides to use local government to deliver some resources and powers, local government will support the reforms.
Compare this with other aspects of their reforms. In many areas of NHS reform the Government were either creating new organisations (GP Commissioning Organisations) or using organisations that do not have a history of mobilising political support (Monitor). Or, most weirdly as far as the public were concerned, were trying to give organisations powers and responsibilities that the organisations themselves did not want. Thus when the BMA and the RCGP started to attack GP commissioning, the public were bemused about the government’s reasons for handing over all this power to GPs.
As we have seen over the last year this is very bad politics and will always undermine the case for reform. If the very people the Government want to take on new powers do not themselves want them, why should the public trust the Government’s judgement?
But with the transfer of local public health to local government, the government were giving power, authority and resource to organisations that wanted power authority and resource and could carry out their duties.
In one form or other local authorities have existed and delivered services for at least 130 years. They know what they are doing, can take on board new functions – and just get on with it.
So the uncertainty and anxiety that exists in abolishing other parts of the NHS and giving their powers to organisations that, as of today do not exist, are not there for the transfer of local public health to local government.
Amid the skid marks left by the screaming tyres of Government policy U turns on most NHS reform this part, more than any other, has left the road to reform largely unmarked.
Its problem is not the politics of the reform but its practicalities. If you give most public health staff and resources to local government, what then will be the relationship between that activity and the NHS?
The consultation paper published in early July tried to go into more detail than had been achieved before. It was clear that it was maintaining the direction of the policy but had recognised that having given these powers to local government the relationship with the NHS had become a problem.
‘2.5 Locally, we will empower local leaders to shape their own approach to addressing local needs and tackling the wider problems that undermine health. Through health and wellbeing boards we will ensure that NHS commissioning plans are integrated with and reflect local joint health and wellbeing strategies. We will also ensure that the NHS continues to receive high quality public health advice, whilst encouraging NHS clinicians to use every clinical encounter to promote better public health.’
The document gives a lot more detail on how local government will carry this out,
‘2.15 During consultation there was concern expressed that the local government role in public health beyond health improvement was not clear. We can confirm that local authorities will have a role across the three domains of public health. The Health and Social Care Bill gives upper tier and unitary local authorities a new duty to take such steps as it considers appropriate for improving the health of the people in its area. We plan to give local authorities new functions through regulations for taking steps to protect the local population’s health, and for providing clinical commissioning groups with population health advice.’
This is the core of the policy change. The new duty for health improvement will be laid on upper tier authorities. Established readers of my blog may recall that I spent much of the 1980s and 90s working in local government both as a senior manager and later on as a consultant. Throughout my experience in local government I discovered that many councillors were very interested in the health improvement of their local populations. I remember that in areas which used to have heavy industries it was the local councillors that were active in campaigning about the bad health outcomes of those industries on their local population. And in rural areas, whilst the health problems were different, the concern of councillors for health improvement was very similar.
That meant that by the late 1990s when local authorities were setting up local strategic partnerships (LSPs) they recognised the importance of health and health improvement to their local population. Before anyone had thought of health and well being boards, many LSPs had developed important health improvement policies and practices and were working closely with public health staff from the NHS.
So for some the taking on of these powers will be a genuinely organic activity. It will be a strengthening of what they already do.
But for others health will be a new duty and the problem will be the capacity of the local authority – at a time of deep cuts to local government funding and personnel – to take this on. The anxiety for public health will be whether its budget will be raided to be used for other purposes.
The consultation paper goes on to say,
“Local authorities will be funded to carry out their specific new public health responsibilities through a ring-fenced grant. We consulted on what conditions should be placed on this grant; we have decided that to maximise flexibility we will place only a limited number of conditions on the use of the grant. The core conditions will centre on defining clearly the purpose of the grant, to ensure it is spent on the public health functions for which it has been given, and ensuring a transparent accounting process. We will work with stakeholders to consider if any possible additional conditions might be necessary, although in considering any possible additional conditions we will need to be mindful of the need to maintain local flexibility.”
The problem with the policy is that it wants both to recognise the right of local government to develop its own local flexibility and to ensure that there is a national system. In other areas of local government services, where the national government has felt the need to intervene to ensure a national service, it has led to very difficult and prolonged tensions. A local authority might interpret the spending of its public health money on gritting the roads in the winter as legitimate use, but if the local public health director appeals that this money is coming out of their budget, will the DH ‘allow’ the local authority such flexibility? There is a strong case that road gritting should be paid for out of public health resource, but will a national Public Health Service allow local differentiation?
In its July 2011 paper the DH tries to get round this local/national dilemma that following way,
“With this in mind, the Health and Social Care Bill allows the Secretary of State to prescribe that certain services should be commissioned or provided by local authorities, and certain steps taken. We consulted on which services should be prescribed in this way. Our decisions have been guided by the following principles. We will require local authorities to deliver or commission particular services where:
- services need to be provided in a universal fashion if they are to be provided at all (this is particularly relevant to health protection, because if certain health protection services are not provided in a universal fashion, or not provided at all, there may be risks to population health and wellbeing);
- the Secretary of State is already under a legal duty to provide a certain service, but in practice intends to delegate this function to local authorities. Mandation will ensure that these obligations are met;
- certain steps that are critical to the effective running of the new public health system.
Reflecting on the consultation responses and following the above principles, we plan to prescribe that local authorities deliver the following services or steps:
- appropriate access to sexual health services;
- steps to be taken to protect the health of the population, in particular, giving the Director of Public Health a duty to ensure there are plans in place to protect the health of the population;
- ensuring NHS commissioners receive the public health advice they need;
- the National Child Measurement Programme;
- NHS Health Check assessment;
- elements of the Healthy Child Programme
As this new system beds down I am afraid I foresee a lot of appeals to the DH from public health officials who see the powerful parts of established local government raiding their resources and their powers.
But this is not the main problem for the proposed architecture. That lies in the relationship between the new public health staff and resources of the local authority, and the NHS. Local NHS services will be commissioned by clinical commissioning groups (CCGs), their relationship with local authority public health staff will be through the Health and Well Being Boards. In the HWBs the CCGs will be expected to get their strategic commissioning plans OK’d by the Boards.
Mostly this will be fine, but there will be occasions when local councillors will be lobbied about the clinical impact of a local CCG decision that a lobby group does not like.
Under these circumstances the HWB will try and stop the CCG and the Board will become a site of conflict between clinicians and councillors. This in turn means it will not be a useful place for public health to influence NHS commissioning decisions.
The detail of how the NHS obtains good public health advice will become the problem in many localities. The Government expects that this will happen through the powers of partnership laid upon Health and Well Being boards, and in some places that will work, but in other places the directors of public health sitting in their new offices at the town halls will be seen by clinical commissioning groups as ‘over there’ and not a part of the NHS.