Contents

Preface by Rhion Jones, Programme Director, The Consultation Institute

1. Context: the overall health White Papers

2. Scope and transition

3. Outcomes

4. Budgets and reducing inequalities

5. Community involvement

6. The consultative and legislative process

7. Some critical questions

Preface

The Government’s principles for Public Health are of great significance for public engagement and community involvement.

By placing the function under the control of local authorities we are introducing a degree of local democratic accountability for around £4bn of expenditure which was preciously managed from within the Department of Health.

This  raises many questions, some of which form part of the government’s brief consultation on public health. But it also opens up new opportunities to engage with local citizens and the organisations that represent them.

We are grateful to Gabriel Chanan for writing this introduction as a contribution to the debate. We hope that readers who find this of interest may be able to join us on Wednesday 9th February when issues considered in the paper will be discussed in detail.

Rhion Jones

Co-Founder and Programme Director

The Consultation Institute

Context: the overall health White Paper

Published on 30 November 2010 the Public Health strategy1 was the tail end of the health White Paper process, which began very soon after the national election. The big news then, which still reverberates like the echo of the Big Bang, was the plan to abolish Primary Care Trusts which have controlled health spending for the past ten years, and hand over control of the bulk of health spending to consortia of GPs. GPs’ own remuneration will be controlled by the Department of Health. The transition process is scheduled to take just over two years, to April 2013.

The general grounds for this massive and controversial shift of responsibility were given as being that GPs are closer to the needs of the patient. PCTs, by implication, are remote, opaque bodies, difficult to hold accountable. However it is they who must prepare the change, whilst keeping all the plates spinning in the air during 2011 and 2012.

The direction of change accords with the general ethos of patients and public having more control over how and where they are treated. But it may have been driven rather more by the belief that putting more control in the hands of GPs would put the onus on them to bring down the hospital bills which form a massive 70% of the whole cost of the health system.

It is now becoming clear that the GP consortia, originally expected to cover just parts of local authority areas, are likely to be around the same size as PCTs, i.e. mostly covering a whole principal local authority area. They will need to employ a range of experts in health economics and accounting to do most of the detailed work, so in the end this may be more of a change in the composition of the board than a deep change in the culture of the system. Nevertheless there are important other changes in the more detailed aspects, of which the changes in public health are one.

1 Healthy Lives, Healthy People: Our Strategy for Public health in England, HM Government, Secretary of State for Health, CM7985, 30 Nov 2010. Figures in brackets throughout this briefing refer to the numbered sections in the White Paper.

Scope and transition

To people unfamiliar with the way things are categorised in the health system it may seem strange that the term public health refers to only a small and ill-defined fraction of the service. Broadly it covers the promotion of good health and prevention of ill health, as distinct from treatment, cure and care of ill health once it occurs. Prevention may include everything from health visiting and immunisation against epidemics to campaigns for healthy eating and projects to reduce smoking, encourage more exercise and avoid accidents in the home. ‘Public health will fund those services that contribute to health and wellbeing primarily by prevention rather than cure’(4.39).

A separate paper on adult social care2 was published just before this and exhibits a similar approach, with even more emphasis on  boosting the role of local communities.

The new White Paper defines the scope of public health as being:

• Health protection
• Emergency preparedness
• Recovery from drug dependency
• Sexual health
• Immunisation
• Alcohol prevention
• Obesity, smoking cessation
• Nutrition, health checks, screening
• Child health promotion, including heath visiting and school nursing
• Dental public health. (4.40)

It is not clear whether this list fully covers:

• reductions in health inequalities such as the gap in life expectancy between rich and poor neighbourhoods;
• depression and mental health;
• accidents in the home and at work.

These are discussed elsewhere in the paper. The fact that they are overlooked at this point suggests that the new logic is still not fully coordinated. Numerous studies, and the early sections of the White Paper itself, show that poor neighbourhoods make exceptionally high demands on the health budget and that there are intimate connections between mental and physical health.

2 Department of health: A Vision for Adult Social care: Capable Communities and Active Citizens, 16 Nov 2010 www.dh.gov.uk/publications

The big change in responsibility is that Public Health will now move over from PCTs to local authorities (where it used to be till about 1970). Launching the Paper, the health Secretary said: ‘People’s health and wellbeing will be at the heart of everything local councils do. It’s nonsense to think that health can be tackled on its own. Directors of Public Health will be able to champion local cooperation so that health issues are considered alongside housing, transport, and education.’

Cooperation with the new GP consortia would also be built into the system: ‘GP Consortia and local authorities …will have an equal and explicit obligation to prepare the JSNA … Joint health and wellbeing strategies (will be) based on…their JSNA’ (4.11 – 13). ‘There will be stronger incentives for GPs so that they play an active role in public health’ (Chapter 4, Summary).

Outcomes

The way that the scope is categorised at different points is important because it will form the basis for a new outcomes framework. As in the main health White Papers, this is said to be quite different from ‘targets’: ‘Top down targets will be replaced by a new outcomes framework’ (4.2).

The Paper proposes to structure the outcomes framework by five ‘domains’. These are phrased at a level of abstraction which leaves it unclear whether they are mutually exclusive and where some of the main issues fit:

Domain 1. Health protection and resilience: protecting people from major health emergencies and serious harm to health

Domain 2. Tackling the wider determinants of ill health: addressing factors that affect health and wellbeing

Domain 3. Health improvement: positively promoting the adoption of healthy lifestyles

Domain 4: Prevention of ill health: reducing the number of people living with preventable ill health

Domain 5: Healthy life expectancy and preventable mortality: preventing people from dying prematurely (2.9)

Presumably these would cross-cut with specific areas of action and that is what differentiates them from targets but the detail about how they are populated will surely (and rightly) pose similar dilemmas regarding choice of priorities.

Budgets and reducing inequalities

In launching the new public health White Paper, Andrew Lansley admitted that it had been a Cinderella service: ‘Too often in the past, public health budgets have been raided by the NHS to tackle deficits. Not any more. The money will be ringfenced to be used as it should be – for preventing ill health’3.

As well as ringfencing the PH budget  DH will keep a degree of directiveness over it through the framework of outcomes and a specific division in the Department of Health, Public Health England, which will also ‘maintain a source of independent expert advice’ (4.65).

In early 2010 the Audit Commission judged public health to attract about 4% of the total NHS budget, which would then have equated to about £4bn. The new White Paper appears to expect expenditure to remain around this level: ‘Current spend on areas that are likely to be the responsibility of Public Health England could be over £4bn… though still subject to efficiency gains required throughout the system… This estimate will be revised…’(4.29). This would be a percentage reduction to about 3.6%, given that the health budget as a whole has been increased.

The budgeting arrangement will include both some weighting in favour of areas with poorer health (which are mostly  areas of higher deprivation in general) and a system of rewards or ‘premiums’ for higher achievement. The framework for this has yet to be worked out:  ‘We will only set out a detailed model when we have established the baseline and potential scale of the premium and have agreement about the outcomes’ (4.35)

The strategy is prominently committed to reducing inequalities in health, not least because areas with the poorest health are frequently  the areas making most demands on the health budget. Budgeting and outcomes will be geared to ‘improving the health of the poorest fastest’(4.1). The ringfenced budgets allocated to upper tier and unitary local authorities will be ‘weighted for inequalities ’ (4.31).

Additionally there will be rewards for progress: ‘Disadvantaged areas will see a greater premium if they make progress, recognising that they face the greatest challenges’ (4.33). ‘To incentivise action…we will introduce a new health premium… building on a baseline… weighted towards areas with the worst health outcomes and most need. LAs will receive an incentive payment or premium … that depends on the progress made …based on elements of the proposed outcomes framework’ (4.32).

3 Press release by Wandsworth Council, 3 Dec 2010, ref eryans@wandsworth.gov.uk

Community involvement

The White Paper makes great play with the notion of boosting the community role:
‘The new service will harness the efforts of the whole government, the NHS and the big society’ (4.3). ‘The DH is designing the new system based on principles of empowering people… and ensuring that communities lead efforts to improve health wherever possible, using evidence-based services and innovations tied to evaluation’ (4.5).

However, ‘community’ is used in different senses at different points, some strong and some weak. At its clearest, community appears to mean the collective efforts of local people to create mutual aid networks: ‘As part of building capable and confident communities, areas may wish to consider grant funding for local communities to take ownership of some highly focused preventive activities, such as volunteering peer support, befriending and social networks’(4.23).

At other points, community is used to mean problem families: ‘Many areas are developing …community budgets to support…collaboration (between) health, local government, police and others… in partnership with local communities’ (4.15) (‘Community budgets’ are budgets for managing families with multiple difficulties).

Mostly, however, the Paper echoes recent Cabinet Office documents on the big society4 which (in our view) confuse the strengthening of communities with the taking over of public services by social enterprises: ‘DH expects that the majority of services will be commissioned, given the opportunities this would bring to engage local communities more widely in the provision of public health’ (4.24). ‘Such efforts will be supported by the proposed new right for communities to bid to take over local state-run services, and the new Big Society bank, which will lever in new social investment for charities and social enterprises, helping to create an environment in which innovative approaches to social investment and social enterprise flourish’ (4.25).

There is a problem with the overlapping perceptions of the community role and the social enterprise role. Organisations which are contracted to deliver public services cannot at the same time be the voice of the users of those services, no matter what sector they are in. Communities are strengthened most by supporting the mass of community groups which are not social enterprises and do not get – or seek – full cost recovery for their work.

4 Cabinet Office. (2010). Supporting a Stronger Civil Society. Consultation paper. Office for Civil Society. London: HM Government.

Cabinet Office. (2010). Building A Stronger Civil Society: a strategy for voluntary and community groups,

charities and social enterprises. Cabinet Office, Offers for Civil Society. London: HM Government. Francis Maude and Nick Hurd, Letter to VCS organisations, Cabinet Office, Nov 2010 (undated)

Cabinet office (2010) Modernising commissioning: increasing the role of charities, social enterprises, mutuals and cooperatives in public service delivery. Undated. Issued 7 Dec 2010.

There is little either in the health policy or the big society policy about the fundamental role of community groups, i.e. to spread mutual aid, build social capital, carry out independent activities and voice community concerns. There is a general assumption that by acting more like social enterprises they would be more independent of state support but in fact they are much less dependent on state support than social enterprises are.

The kinds of support appropriate for community groups were established by a national inquiry in 20045. They consist in a broad community development agenda, including organising meeting spaces, small grants, networks for cooperation and learning about citizenship. In January 2010 DH commissioned the Health Empowerment Leverage Project (‘HELP’) to demonstrate the business case for the use of an accelerated form of community development in health. The project’s first full report will be in March 2011 but an outline of its methods and findings are available now.6

Additionally there is a ‘level playing field’ problem for social enterprises which do originate in the local community. The Adult and Social Care White Paper recognises to some degree the problem that small social enterprises can rarely compete successfully with large ones from outside the local community or with private suppliers: ‘A first step in market shaping is for councils with their NHS partners to move away from traditional block contracts… there should be a fair playing field for providers, particularly for small providers who often struggle to engage with formal tendering processes but can offer very individualised solutions’7. Other ways in which authorities can legally design local social objectives into their procurement processes are available8.

5 Firm Foundations, Home Office, 2004

6 See www.healthempowermentgroup.org.uk

7 Care White Paper (see note 2) section 5.3 – 5.4

8 See Anthony Collins Solicitors, Social Enterprise and the Public Sector, BEST Procurement, 2010,

www.equalworks.co.uk/resources/contentfiles/3244.pdf

The consultative and legislative process

The consultation is open till 8 March 2011. The new system will be set out in a forthcoming Health and Social Care Bill. ‘Local authorities will have a duty to take steps to improve the health of their population’(4.7). They will be required to appoint Directors of Public Health, whose tasks, reflecting the Paper as a whole are set out at 4.20. The new arrangements will come into effect on 1 April 2013 (4.7).

Meanwhile ‘there will be shadow allocations … providing an opportunity for planning before allocations are introduced in 2012/13. During the transitional year 2011/12 the forthcoming NHS operating framework for 2011/12 will operate’ (4.38).

Responses to the consultation are guided by five specific questions at section 5.18 –

20. These are limited to certain technical points, implicitly suggesting there is little scope to change the main thrust of the policy. Two broader questions are scheduled

for a fuller consultation to follow, but people who want to comment on more fundamental issues in the Paper will need to make a point of doing so.

These are the formal questions

1. Role of GPs and GP practices in public health. Are there additional ways in which we can ensure that GPs and GP practices will continue to play a key role in areas for which Public health England will take responsibility?
2. Public health evidence. What are the best opportunities to develop and enhance the availability, accessibility and utility of public health informational den intelligence?
3. Public health evidence. How can Public Health England address current gaps such as using the insights of behavioural science, tackling wider determinants of health achieving cost effectiveness and tackling inequalities?
4. Public health evidence. What can wider partners nationally and locally contribute to improving the use of evidence in public health?
5. Regulation of public health professionals. We would welcome views on Dr Gabriel Scally’s report9. If we were to pursue voluntary registration, which organisation would be best suited to provide a system of voluntary regulation for public health pursuits?

The text adds: ‘Forthcoming consultation documents will set out questions on the proposed public health outcomes framework and the funding for commissioning of public health.’

9 Section 4.96 refers to a separate report by Dr Scally, Review of the Regulation of Public Health Professionals, DH, Nov 2010, www.dh.gov.uk/en/Publicationsand Statistics/Publications/PublicationsPolicyandGuidance/DH_122089. This provides a useful review of options for regulating PH staff but tends to give the impression thereby that PH is limited to specialist roles, rather than being also the concern of all parts of the NHS and indeed partner agencies as well. In light of the big society theme and emphasis on the input of partner agencies it would have been valuable to discuss in particular the cross‐cutting role of community development workers.

7. Some critical questions

Compartmentalisation. How can the move to the local authorities be used to ensure better integration with other factors known to affect public health, especially housing, environment, transport, employment, education? Is there a risk of any loss of connection with mainstream health? Public health was already somewhat marginal within PCTs. Are there still missing links with mainstream health? For example what should be the role of hospitals and GP consortia themselves in public health?

Resources. For all the organisational ‘radicalism’, the White paper doesn’t address the huge underlying question raised by WHO and many others over a generation of debate of how we can design a better relationship between prevention and cure. If we doubled investment in prevention, could we triple or quadruple savings in cure? Are not the huge costs of acute treatment traceable more to social than medical factors – poverty, obesity, smoking, alcohol, domestic violence and sheer longevity? And should we not therefore be putting much higher priority on better management of these factors?

Community involvement.  There is a danger of confusing the community as providers with the community as users. The great majority of community groups cannot operate as social enterprises. But it is the great majority of community groups, operating as themselves which are the key to community health and economy. Can the policy succeed in mobilising greater community effort by commissioning social enterprises or is a parallel policy needed to boost the role of the mass of independent community groups?

About the Author

Gabriel Chanan is a leading exponent of community involvement and development, focusing on innovation and outcomes. He directed policy and research at CDF for many years and is now an independent consultant and a Visiting Research Fellow at the Policy Studies Institute. He directed the first cross-nations research for the EU on community involvement in regeneration in the 90s and carried out influential studies for the Home Office and the Office of the Deputy Prime Minister in 2002-4. From 2005-8 Gabriel was seconded into the Department for Communities and Local Government. In 2008-9 he led, with Colin Miller, the HCA Academy’s project on spreading empowerment skills across occupations. He is currently working with the DH-sponsored Health Empowerment Leverage Project and with Community Places in Northern Ireland. He was awarded an MBE for services to community development in 2009. His recent writings on the big society and other issues are available at www.pacesempowerment.co.uk

This is the 25^th Briefing Paper; a full list of subjects covered is available for Institute members and is a valuable resource covering so many aspects of consultation and engagement