The Health Select Committee, with the Department of Health, is expected to publish its response to consultations on Healthy Lives and Healthy People before their summer break and has focused its attention on public health reforms.
We initially welcomed the reforms, including their focus on outcomes and increased local government involvement. However, we were not happy with the government’s inequalities code, which aims to improve the health of the most vulnerable people the fastest. Our submission to the Department regarding the reforms included more than forty detailed recommendations. However, the Committee must focus on four key issues.
The first thing to consider is the allocation of money. The Department tried to estimate how much money the NHS spent on public health to transfer to the local authorities who will be holding the budgets in the future. The more fundamental question is if this amount is enough. The government’s evidence review outlines a number of challenges to public health that will only increase. Local authorities will only be able to increase their share of the funds if they do well with the health premium. Local authorities will have little or no influence on the allocations. This will likely widen rather than reduce the health gap in those areas with high population turnover (where young healthy people move away and poor and unhealthy people move in). Some sites may not be able to break free from a chronic cycle of underfunding.
The second is the balance between accountability, incentives, and performance support within the new system. The framework for public health outcomes is a huge step forward. It shows that the government has listened to its citizens and acknowledged how important nudges and information can be. The places, economic conditions, and people we live with are also important. The framework recognizes this, but it is not a force. The current plans don’t attempt to define performance levels against the framework. This weakens authorities’ accountability over billions of pounds in taxpayers’ funds. The government instead places its trust in this system’s local transparency and premium. Public Health England is only going to publish and compare results. We are not happy with this, either as taxpayers at the national level or as citizens in our local communities.
Third, we have the relationship between local governments and the NHS. The introduction of the health and wellbeing boards is welcomed. The Bill introduces new duties for the NHS Commissioning Board, as well as consortia, to combat inequalities. However, these are limited to those inequalities that affect access to and outcomes of NHS care. The Bill should reflect that the NHS is a major employer and economic force in the local community, directly impacting the health determinants through its actions. Local authorities do not have the same duties to combat inequalities. This should be accompanied by a shift in budgets and responsibility for public health. If primary care is to be recognized fully, it must also be able to take on responsibility for the health of the population, in addition to caring for unregistered people.
The fourth and most important factor is information and intelligence. This keeps the system running. The Health Select Committee has begun to examine the role of regional Public Health Observatories and is bringing them under Public Health England. This may save money for the center, but it could also lead to a less efficient local network of public health intelligence and higher costs overall as each director of public health tries to replace lost capabilities in their patch. The issue of coterminosity is even more fundamental. Inadvertently, the freedom to define the membership of consortia created a huge technical challenge in coordinating the data flow that informs the decisions of health and wellbeing boards. The Committee should press the Department to explain how it will address these issues.
There is not enough time to think clearly. The reforms in the public health sector promote a philosophy of decentralizing and localizing decisions about public health. The logic behind this would result in a non-ringfenced but accountable budget that is based on outcomes to protect national taxpayers’ interests. The government instead proposes a static ringfenced budget that does not reflect changing needs and is accompanied by weak accountability. It seems like the worst of all worlds: not allowing local authorities to innovate and holding them accountable for important outcomes.
Our future health depends on the Committee’s ability to challenge the government in the coming weeks to get it thinking right.
The new OHID faces a daunting task. The new OHID faces a daunting task.