The New Local Government Network have produced an interesting report looking at the new powers around public health that local authorities are to assume in full from April next year.
A lot of the policy discussions I’m having increasingly see the reform of public health as offering a singular opportunity to see preventative services to gain resources that are otherwise very scarce.
The NLGN paper offers some challenges to this easy assumption. They argue:
If local authorities are to succeed in reducing demand for acute services, they will need to shift resources to prioritise preventative measures. However there is often a lack of preparedness to use budgets differently and additional incentives will be needed to promote pooling of budgets between HWB [Health and Wellbeing Board] members.
They report that in 42 per cent of authorities, the newly appointed Director of Public Health (DPH) will be a subordinate to the Director of Adult Social Services or reporting to a ‘super-director’. There might then be a challenge to get attention to children and young people’s prevention interventions.
The report also makes clear that the relationship with the centre will continue to be important. Talking about Public Health England (PHE), which takes over from the National Treatment Agency (NTA) and the Health Protection Agency, they say:
PHE will work with partners to provide evidence and analysis to enable local government, the NHS, voluntary and other sectors to invest in prevention, health promotion and protection. For the time being, the nature of the relationship between DPHs and PHE remains uncertain.
For us I think this suggests that we need to develop relationships with Public Health England in ways that we only sporadically were able to manage with the NTA.
The majority of respondents to the NLGN survey do not yet have plans in place to assess performance in achieving public health outcomes or in improving service delivery. Through the interviews HWB members report there is often a lack of clear responsibility for the identified outcomes.
One of the areas where the change of government in 2010 has led to some uncertainty is about what mechanisms will be used to achieve accountability for outcomes, we’ve seen ‘armchair auditors‘ and ‘open data’ touted as an alternative to the Labour government’s reliance on National Indicators. But there are clearly problems with this approach:
Nevertheless, there seems to be a fair amount of optimism at a local level that the HWBs will make a difference, with pooled budgets and training leading the way in making that happen. The report argues that for health economies to be made there will need to be a focus on prevention, but acknowledges this won’t be easy to achieve:
For resources to be shifted away from reactive services to preventative services, local authorities and the NHS will need to work together to work out decommissioning priorities, a transition plan and a clear message to the public about the benefits of the decision. These priorities will need to extend beyond the remit of HWB members and into the wider local authority commissioning powers.
To support these decisions the report suggests that PHE and NICE will be critical in providing the evidence base that can be relied on to support the debates that will take place. Talking about NICE briefings the report suggests:
The briefings will not be in the form of ‘must dos’ for local authorities but rather consist of a menu of cost effective and evidence based actions which local could be used depending on the local priorities and on the needs of local communities. The approach provides clear and concise information about ‘what good looks like’ i.e what works, how it can be achieved and how to demonstrate progress.
As a final note the report is quite gloomy about engaging schools, recognising that pull of education policy towards more autonomous schools and even more focus on academic qualifications may make their commitment to the health of their pupils weaker:
Other health services provided at school might also be at risk if they are not seen as a necessary part of education. These include those aimed at reducing teenage pregnancy, childhood obesity and substance abuse, all indicators outlined by the Public Health Outcomes Framework. Although children and young people are entitled to the universal offer of public health, it is up to the school whether the universal offer is available through schools.
There are several reasons for schools not to engage with public health initiatives. First of all, certain religious schools might find initiatives such as sexual health advice contrary to their beliefs. Second, some schools might not consider health as the key priority of their establishment and do not directly reap the benefits from such initiatives. Some governing bodies would like minimum distractions to the schools day have the space available.