April 15, 2013 by Protect Our NHS
The role of local authorities in health issues: CLG Committee new report
Author: Janet Sillett
Date: 11 April 2013
This briefing can also be viewed as a PDF
The Communities and Local Government Select Committee published its report on the role of local authorities in health issues on 27 March 2013.
The report considers what the arrangements for public health will look like at local level, including the integration of public health with health and social care, and in particular the role of health and wellbeing boards; the JSNA and joint health and wellbeing strategies: analyses the national perspective, including the preparedness of Public Health England and local authorities to deal with a health emergency; the wider causes of poor health and what a multi-faceted approach to the issue looks like; and the financing of the new public health system.
This briefing will be of interest to all tiers of councils and particularly to officers and members working in public health and social care and those working for or represented on health and wellbeing boards.
Briefing in full
The report starts by reminding us of the long history of local authority involvement with public health; from the local health boards of the 19th century, through to the creation of the National Health Service in 1948; and to 1973, when in the National Health Reorganisation Act, the public health functions of local authorities were transferred to the NHS. It was rightly stressed by witnesses, however, that councils never lost responsibility for certain public health functions, such as environmental health and that many other of their functions and services are vital contributors to health and wellbeing.
The Health and Social Care Act 2012 did, though, place new statutory duties in relation to health and wellbeing on upper tier councils and, in that sense, could be said to have brought back to councils many of the responsibilities for public health (these are outlined in the recent LGiU briefing Health Reforms Go Live; what happens next?
The committee’s report considers the arrangements for public health, including its integration with health and social care, and in particular looks at the role of health and wellbeing boards and assesses the joint strategic needs assessment and joint strategies; looks at the causes of the causes of poor health and what a multi-faceted approach to the issue looks like, including the role of local authorities, communities, providers and central government; analyses the national perspective, including the preparedness of PHE and local authorities to deal with a health emergency; and finally, it examines the way in which the new public health system will be financed.
The role of health and wellbeing boards
Evidence to the inquiry from a wide range of organisations showed a consensus of support for the new HWBs. There was somewhat less agreement about whether they were ready to take on the new responsibilities – the LGA saying that 95 per cent were “in an advanced state of readiness” but Professor Chris Bentley, an independent population health consultant, had reservations. He said that commonly HWBs were planning to meet quarterly and questioned:
“How much momentum can be generated and maintained that way? […] How can the HWB become the ‘beating heart’ of local process for improving health and wellbeing? A number of these meetings will then have a large membership, and impossibly long and tight agendas”.
Professor Bentley, and some other witnesses, was also concerned that the HWBs did not “bring powers”: Instead, the system would rely on bringing people together in the same place, their agreeing to a decision and taking it back to their individual organisation to implement it. This in turn would rely on leadership and relationships, which he said “brings more patchiness into the system”.
The committee concluded that the successful operation of Health and Wellbeing Boards is crucial to the new arrangements. Boards should aim to be creative by including where possible those individuals with responsibility for the social determinants of health, including those working in education, planning and economic development. They pointed out, though that “the obvious danger with the new boards is that the initial optimism surrounding their establishment and first year or two in operation will falter and go the way of previous attempts at partnership working that failed and became no more than expensive talking shops. To succeed, Health and Wellbeing Boards will need to work on the basis of relationships and influence, and this will depend on both people and structures”.
There were concerns expressed by some organisations, such as the King’s Fund, that there is a risk of a short-termist approach being adopted by HWBs – “Boards need to be clear about what they want to achieve […]. There is a danger that stronger emphasis on overseeing commissioning will hinder efforts to promote integrated care”. The UK Healthy Cities Network said that “much of the current [Department of Health] thinking seems to translate ‘action’ around wellbeing and health into the commissioning and provision of services,” and Dr Mike Grady (of the University College London Institute of Health Equity) warned of a danger that the focus of public services would shift to prioritising the most vulnerable rather than seizing the opportunity for more radical reform, which “would seek to transform the ways in which services are designed and framed, taking an upstream view of the whole population”.
Some witnesses, though generally optimistic about the potential of HWBs, had concerns over whether they could fulfil that potential, given the limited evidence that previous partnerships produced sustained health improvement. There were high expectations of HWBs that might be difficult to fully meet.
Holding HWBs to account
Accountability was an important issue discussed here (and throughout the report). How can HWBs be held accountable? Some local authority witnesses believed that health overview and scrutiny committees would hold the boards to account for the outcomes achieved, even if there were still issues outstanding about how this all would work. Other organisations, however, were unsure about how HWBs would be held to account, for example, for the effectiveness of their joint assessments and strategies.
The Under Secretary of State for Health, Anna Soubry MP, the Minister with responsibility for public health, was asked when an intervention might take place on a poorly performing HWB. She suggested that an HWB would be responsible not for health outcomes, but for measuring and making representations to those who would be responsible: “I do not think you would have health outcomes coming from the Health and Wellbeing Boards. It is the job of the Health and Wellbeing Board to look at the outcomes in their area and start to take action.” The Under-Secretary of State for Communities and Local Government, Baroness Hanham, acknowledged that performance monitoring would “come partly through the local authority. All of them will have health scrutiny committees,” and she suggested that, if a HWB were performing poorly, “it would be the director of public health who would be responsible for making sure the committee knew.”
The committee noted, however, that the Director of Public Health will be a member of the HWB itself.
The committee believed that this is an area of real confusion: the questions are, what are HWBs to be accountable for, given their lack of powers; and, what sort of accountability is appropriate: democratic, procedural or financial?
They were unhappy about the minister’s suggested role for directors of public health and said that they did not consider them acting in the way outlined to be “a satisfactory or robust mechanism to hold boards to account”. They want to see the government clarifying the procedures for holding boards to account, including the role it expects scrutiny committees to play.
This section considered how the national organisations such as Public Health England and the NHS Commissioning Board (NHSCB), would relate to and advice the boards. Professor Bentley pointed to a potential clash of cultures:
“A lot of the resources in Public Health England are coming from the Health Service, and I think the question is how much local-authority-based evidence do they understand, and how they take it on board to be able to be the advisors on it”.
Department of Health officials did seem to acknowledge that the DH would need to change and not be so “top down”.
The report notes the risks of confusion over the NHSCB’s status in relation to HWBs. There have been contradictory statements from different interested groups, such as commissioners of primary care, with some writing that the commissioners of primary care, dentistry and pharmacy “are not occupying seats round the HWB table”, whilst others have said that representatives of the NHSCB “will be arriving later than other members”.
In fact, the Health and Social Care Act 2012 has not prescribed NHSCB membership of the HWB, but it has provided that the NHSCB must appoint a representative to join the HWB in order to participate in its preparation of a JSNA or a JHWS. There is some uncertainty, however, about how these representatives would see their role – would they see themselves, for example, as inspectors?
These potential weaknesses and concerns were reflected in evidence from the King’s Fund, which said that many HWBs were “concerned that national policy imperatives will over-ride locally agreed priorities and are uncertain about the extent to which they can influence decisions of the NHS Commissioning Board.”. Richard Humphries from the King’s Fund said:
“If the new boards are to promote the strategic co-ordination of all local services relevant to health and well-being, they will need to influence all commissioning activity affecting their local population, including the NHS Commissioning Board”.
The committee called on the government “to set out in detail what Health and Wellbeing Boards can do if the NHS Commissioning Board subsequently fails to commission services consistent with these joint strategies. We also ask the Government to clarify what the duty on the NHSCB to “have regard” to a Joint Health and Wellbeing Strategy means in practice”.
Joint strategic needs assessments and joint health and wellbeing strategies
The committee stressed the importance of the JSNA – as it forms the basis of the joint health and wellbeing strategy:
“The significance, resources and expertise attributed to both the assessment and the strategy will have a major bearing on the success of an individual authority’s local health care work, and that of the local NHS, at least in the short term”.
Access to data seemed to be a source of frustration for many of the witnesses. HWBs need full access to a range of data – from health, public health and social care. This means cultivating positive relationships with local partners and the input of evidence from PHE and NICE. However, it will also mean changes to the way in which information – non-patient- specific information, in particular – can be shared between the NHS and local government:
“Sheffield City Council, noting the need to combine health and local authority data in order to provide services such as home insulation, extra care for older people and support for vulnerable adults, told us: “We still seem unable to exchange data for these important issues due to data protection or organisation ‘security'”. Kent County Council, too, explained that, “A crucial outstanding issue relates to Information Governance and the ability to share non-patient specific information between the NHS and local authorities.”
Baroness Hanham admitted that information sharing across government and departments “is fraught” and that:
“The issue is that local authorities do not know what they can pass on to the health service […]. There is a huge area that we need to get to grips with in government. We need to involve the Information Commissioner, but the whole issue of information sharing, particularly now within the Department of Health and public health, will hold us up”.
The committee stressed that:
“Any joint assessments and strategies will only be as good as the information on which they are based, but there is ignorance and misunderstanding of the current information-sharing arrangements. If strategies are to be based on sound evidence, the Government must involve the Information Commissioner in clarifying what data local authorities and the NHS can share. This should be done by the end of this year, so that authorities have time to use any new guidance in the development of assessments and strategies for 2014-15. We recommend that Public Health England publicise widely guidance on how local authorities can manage their data and information”.
The engagement of councils and councillors in drawing up strategies was discussed, particularly the involvement of district councils. The 2012 Act requires that CCGs and local authorities continue to include the relevant district council when preparing a JSNA, but it does not provide a role for districts in preparing the joint strategy. However, as the report notes, many services that affect the social determinants of health are split between the two tiers. There is clearly still frustration from districts and from the District Councils’ Network (DCN) about their role in relation to HWBs generally and in the joint strategy development in particular. The DCN said that:
“In some counties there continues to be reluctance to have sufficient representation on boards (including voting rights) or to effectively communicate HWBs developments and the role of district councils locally.” The DCN concluded that “the need for district council input must be a constant, not variable factor.”
The Local Government Association took a different view, recommending that counties and districts work together to decide how districts should contribute to public health planning, and that “Districts need to find a way of cooperating among themselves to develop and present a ‘district perspective’ and collective voice on HWBs.”
Although it was accepted that good personal relationships could be as important as structures to make partnerships work, Councillor Alan Connett of the DCN stressed that “while recognising that “in most places […] there will be very good informal links,” that is not the same as being part of the decision-making process. Given the role that districts have, that seems to be an omission.”.
The committee believed that there was a potential cause for concern here, but they did not recommend the formal arrangements should change and said only that “all county councils should develop agreed working arrangements with district councils”. They also referred to the importance of housing in determining health and wellbeing and suggested that councils “explore ways to include housing in their work either by establishing housing sub-groups of their main Health and Wellbeing Board or by addressing housing in their Joint Strategic Needs Assessment, Joint Health and Wellbeing Strategy and when reporting on progress with public health outcomes”.
Councillors and clinical commissioning group boards
The committee highlighted what they said seemed to be an anomaly that councillors are excluded from membership of a CCG board but a GP who is part of a CCG can be a member of their local HWB, especially given that there is a general move to involve councillors in more health care decision making locally.
The committee asked ministers why there was a bar on councillors on CCGs. Anna Soubry explained that it “was to remove the political influence in what should be clinical decisions.”. The minister said that in such situations, HWBs would be “the overseers, the checks and the democratic process”. Tim Baxter, head of the public health policy and strategy unit at the Department of Health, added that, if a CCG ignored the HWB, the NHSCB “can take action”.
Members of the committee suggested that this meant that CCGs would not be accountable to local, elected officials. The minister said that in the past, health service decisions had often been based on “political opportunism”. The committee, however, found little evidence to support this view. The minister stressed that public accountability is through the health and wellbeing boards but the committee concluded that “the exchange shows that the Department of Health may have further to go then Communities and Local Government “when it comes to embracing localism”.
Public health in practice
This section focused on the issues around tackling the social determinants of health – the social, economic and environmental reasons why people experience ill health or develop unhealthy behaviour. It considered what this should mean in practice and how the impact of councils’ work should be measured.
Witnesses stressed the need for public health functions to be integrated with the council’s existing responsibilities and services. There was concern from some witnesses from outside local government that certain councils may not recognise this or that this approach needs to go beyond just commissioning to “one about empowering communities and creating social cohesion” . Witnesses from local government, however, gave examples of their work in this area. Newcastle City Council. on the example of dealing with alcohol-related harm, said that:
“Instead of simply looking at alcohol treatment services, which is dealing with the problem too late, we are looking at the environment in which people think about and consume alcohol. That includes looking at the availability of it through not just pubs and clubs but also off-licences”.
The report then considered specific issues, such as early years and employment and how interventions and initiatives in these areas could help to tackle health inequalities. Newcastle and Sheffield councils said that their authorities would focus at least some of their work on unemployment. Councillor Mary Lea from Sheffield added that:
“We would like to see maybe more powers devoted to local government so that we can tackle more of the social determinants of poor health and inequalities. In particular, maybe we are looking at the Work Programme. That may be something that we would like to see devolved down to local authorities, because we think we can maybe make a better job of that than is currently happening”.
Witnesses from the BMA referred to the public health outcomes framework as a way of monitoring what is going on locally but that there might need to have a more overarching national framework around integrated care.
Westminster City Council, while it found the absence of clear objectives from the government “provided space for local authorities to determine local objectives which fit local needs,” noted:
“Where the lack of national clarity may be problematic is balancing the local approaches to public health with the Department of Health’s approach to measuring the impact of the new arrangements”.
Witnesses stressed the challenges around assessing what works. Newcastle City Council while acknowledging the importance of measuring health and wellbeing, and any changes in inequalities in health and wellbeing, stated that:
“There is a risk such measurement becomes an end in itself […]. Measuring impact in the short-term can lead us to focus on individual interventions where there is a greater evidence base, rather than enable us to use our energy and resources to drive social change that will lead to sustained improvements for wellbeing and health for this and future generations”.
Sheffield City Council pointed out that measuring the impact of public health programmes on populations continued to be a challenge:
“This is because public health initiatives take place in the context of continuing change within society, which in turn impacts on health […]. Thus, for example, the current economic recession is likely to have far more extensive impact (negatively) on the health of the population than locally managed, relatively poorly resourced, public health programmes”.
The committee recognised the challenges here:
“The transfer of functions from central to local government during the relocation of responsibilities for public health must not become an end in itself. Local authorities will need to provide within an agreed period evidence of an improvement in the health and wellbeing of their population. With these new powers comes the responsibility to deliver results, and local authorities will need to balance local and national objectives and short-term and long-term aims. Given the complex, multi-faceted nature of the social determinants of health, however, determining the success of general—population-wide—or specific initiatives will be difficult, time-consuming and may ultimately distract those working on them from making progress”
They advised councils to take responsibility themselves for measuring success – through overview and scrutiny committees and Local Healthwatch.
The final section in the report considers how public health in local government will be financed.: the formula used in 2012; the new formula produced in January 2013 and the government’s arrangements for redeveloping it; and how this relates to the Health Premium.
The committee welcomed the increase in the final grant when compared with the draft allocation. They accepted it was difficult to create a new public health budget in the time allowed but stressed the delay in announcing the final allocation was equally difficult for councils trying to plan.
They also acknowledged that the current formula is an improvement on the interim model and allows local authorities to target pockets of deprivation, but they noted “the perverse incentive in the medium term, however, of basing funding on improved health outcomes, given that areas which perform well risk having their funding reduced”. They recommend that the government remains committed to reviewing the formula and clarifies the timetable for doing so:
“The government’s approach to public health funding leading up to and after 2015-16 seems confused and should be clarified. It says it has no timetable for modifying the current funding formula, but accepts that, given the impact of the Health Premium, the formula will need to be developed in 2015-16. Local authorities will need to know, first, when they can start planning their budgets for 2015-16, second, when the Government intends to redevelop the funding formula, and, third, that any system of reward will complement their main source of funding.
The government has acknowledged that the perverse incentive in the current funding formula would be particularly marked if it were still in place when the Health Premium was introduced. This suggests that the current funding formula and possibly the Premium need to be revised. A funding system which at the same time disadvantages and rewards improvements in public health cannot be fit for purpose. The government has said that 2015-16 will be a key year in the development of the formula. We recommend that a parallel system of reward should not be implemented in the same year. It should be delayed until the funding formula has been redesigned”.
This report is timely – it highlights important issues that will dominate the local public health agenda in the coming months and years and makes some welcome recommendations to the government over outstanding issues, such as those relating to data and sharing information.
The report, reflecting some of its witnesses from outside local government, could, however, be seen as rather pessimistic about the readiness of local government to take on its new responsibilities. Although everyone would accept that there have been major challenges in implementing such far reaching change, local government on the whole believes that it was ready for the new system and has taken on new roles with creativity and energy. Councils have never stopped being instrumental to promoting the health and wellbeing of their residents and widely welcomed a stronger role and new responsibilities.
What is perhaps lacking in the report is any sense of the wider context in which these changes are happening – particularly the cuts to local authority services, the pressures on the voluntary sector and welfare reform.
Two key related themes of the report are accountability and relationships. Committee chair Clive Betts MP said:
“Under the reformed system, considerable power is to be invested in a range of new bodies. With such power must come accountability. The purpose of localism is not only to devolve decision making to a local level, but to make it accountable to local people. With these changes it is clear that there is a shift of power and money from the Whitehall to local government and I welcome that. But the new arrangements are complex and responsibilities are shared across several bodies. The result is that lines of local accountability are fragmented and blurred.”
The committee highlights, for example, that there is no requirement for the NHS Commissioning Board and its local area teams to adhere to the joint health and wellbeing strategies and no mechanism to hold them to account for their actions. The NHSCB has to “have regard” to the joint strategy, but as the committee points out, what this really means is unclear. In relation to the accountability of HWBs, councils may think the committee is unduly pessimistic – health overview and scrutiny committees and Local Healthwatch should be holding them to account.
Where the committee feels there is still uncertainty is around health protection. The committee is correct in saying that when it comes to protecting the population in the event of a health emergency, those involved “need to know unambiguously what their role is, understand who is in charge and have in place clear lines of accountability”. The LGA, however, in response, has said that the various roles and responsibilities for dealing with health emergencies are clearly specified in the regulations of the Health and Social Care Act “and the LGA has been working with the newly-formed Public Health England (PHE) to develop guidance and run regional scenarios to help councils understand their role in dealing with anything from an outbreak of SARS to a nuclear meltdown. Councils will continue to work with PHE to ensure a joined up response to emergencies when they occur.”
On localism generally, the committee makes an apt comment about the Department of Health which, hopefully, the government will take notice of:
“The Department of Health has further to go than the Department for Communities and Local Government. The new arrangements for screening and immunisation services have been criticised as complex, fragmented and restrictive. They are the responsibility of the NHS Commissioning Board, which may not reflect local diversity or reach into local populations as effectively as local authorities. Early years interventions are important to later health and wellbeing, and, with the NHSCB also responsible for children’s public health, the Government will need to work with councils to move more of these services and, in particular, childhood immunisation services into local government under the control of Directors of Public Health”.
The report concluded by considering how public health services could be funded in the long term. The committee accepted that, at least in the short term, some ring-fencing may be needed. But as they say, this should not become a permanent feature of the system. The committee suggests that the government should, as soon as possible, share the learning from the community budget pilots with a view “to removing the ring fence and moving to community budgets. In addition, we urge the Government and, in particular, the Department of Health to recognise that if public health is to become an overarching priority for all local authority departments, it will require an overarching budget which reflects that approach”.
The strengthening of the local authority role in health is a major opportunity for local government to show how a whole system approach, bringing together local services, from environmental, planning and housing to social services and children’s services, can make a real difference to the health and wellbeing of communities. Local authorities are being given a degree of freedom to decide on local priorities and have been given a central role through health and wellbeing boards. There are still, however, improvements that can be made to the system and it will be interesting to see how the government responds to the select committees recommendations, many of which would be welcome to local government and would help the government to achieve its objectives for this part of the Health and Social care Act 2012.
Health reforms go live: what happens next?
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