Publc Health n Local Government Commssonng responsbltes Local authortes wll be responsble for: tobacco control and smokng cessaton servces alcohol and drug msuse servces publc health servces for chldren and young people aged 5-19 (ncludng Healthy Chld Programme 5-19) (and n the longer term all publc health servces for chldren and young people) the Natonal Chld Measurement Programme nterventons to tackle obesty such as communty lfestyle and weght management servces locally-led nutrton ntatves ncreasng levels of physcal actvty n the local populaton NHS Health Check assessments publc mental health servces dental publc health servces accdental njury preventon populaton level nterventons to reduce and prevent brth defects behavoural and lfestyle campagns to prevent cancer and long-term condtons local ntatves on workplace health supportng, revewng and challengng delvery of key publc health funded and NHS delvered servces such as mmunsaton and screenng programmes comprehensve sexual health servces (ncludng testng and treatment for sexually transmtted nfectons, contracepton outsde of the GP contract and sexual health promoton and dsease preventon) local ntatves to reduce excess deaths as a result of seasonal mortalty 1 the local authorty role n dealng wth health protecton ncdents, outbreaks and emergences publc health aspects of promoton of communty safety, volence preventon and response publc health aspects of local ntatves to tackle socal excluson local ntatves that reduce publc health mpacts of envronmental rsks. We have undertaken a further check of where commssonng responsbltes for a range of servces mght st n the future. As part of ths work we have taken the opportunty to look agan at where commssonng of aborton servces mght most approprately be placed. Gven the hghly clncal, and n most cases surgcal, nature of aborton provson we have reconsdered our earler decson to place these servces wth local authortes. We have provsonally concluded that aborton should reman wthn the NHS and be commssoned by clncal commssonng groups. However, we are keen to seek a range of vews on ths revsed commssonng route. A consultaton on ths revsed recommendaton wll begn n due course. In Healthy Lves, Healthy People: Update and way forward, we sad we were stll consderng where to place responsblty for sexual assault referral centres (SARCs) and for campagns to promote early dagnoss of, for example, cancer. We have
decded that, subject to resolvng some further ponts of detal, responsblty for sexual assault servces, ncludng SARCs, at least n the short to medum term, should rest wth the NHS Commssonng Board. Ths s n our vew the best way to ensure the delvery of unformly hghqualty servces across the country. On early dagnoss we are commtted to gvng both Publc Health England and the NHS Commssonng Board clear responsblty for delvery, based on a shared set of outcomes. Only some of the above servces are to be mandated. The commssonng of other servces wll be dscretonary, guded by the Publc Health Outcomes Framework, the local jont strategc needs assessment and the jont health and wellbeng strategy. There was consderable comment durng our consultaton on commssonng responsbltes about the splt of responsbltes for the publc health of chldren and young people, ncludng the Healthy Chld Programme, wth pregnancy to fve servces beng commssoned by the NHS Commssonng Board. We accept the many benefts to be had from the ntegraton of publc health nto the wder commssonng of chldren s and young people s publc health, partcularly n terms of the preventon and safeguardng agendas. Nurse Partnershp, gven the commtment to a 50% ncrease n the health vstng workforce and a transformaton n the health vstng servce by 2015, and to ensure assocated mprovements n support for famles. Our medum-term am s to unfy responsblty for these servces wthn local government by 2015 when the ncreased health vstng workforce and new health vstng servce model and the Healthy Chld Programme offer to famles should be n place. In lne wth ths drecton of travel, we are also transferrng responsblty for commssonng effectve Chld Health Informaton Systems to the NHS Commssonng Board, also to be funded by the publc health budget. Ths decson wll be revewed n 2015 to determne longer-term plans. We wll engage further on the detal of these proposals, partcularly n respect of transton arrangements and the best way to begn to nvolve local authortes n local commssonng of these servces n partnershp wth the NHS. In the meantme, Publc Health England wll retan a close nterest n the specfcaton of Chld Health Informaton Systems, to ensure publc health requrements, such as accurate and effectve collecton on the delvery of chldhood mmunsatons, are met. As we explaned n Healthy Lves, Healthy People: Update and way forward, we beleve that the NHS Commssonng Board wll be best placed to lead the commssonng of publc health funded servces for chldren under fve n the frst nstance, ncludng health vstng, the Healthy Chld Programme and Famly 2 The lst of commssonng responsbltes above s of course not exclusve. Local authortes may choose to commsson a wde varety of servces under ther health mprovement duty, and ndeed we would hope to see much nnovaton as local authortes embrace ther new dutes. Ths freedom s delberately wde, to encourage
the knd of locally-drven solutons that le at the core of localsm, underpnned by a robust analyss of the needs and assets of the local populaton. Publc Health England wll promote ths local nnovaton through encouragng peer sharng of best practce and learnng experences, and through supportng rgorous evaluaton of new approaches to mprovng and protectng publc health. Sexual health servces Local authortes wll become responsble for commssonng comprehensve open-access accessble and confdental contracepton and sexually transmtted nfectons (STIs) testng and treatment servces, for the beneft of all persons of all ages present n the area. Transfer of these servces offers great opportuntes to ntegrate sexual health servces and to lnk servces to wder servces, ncludng alcohol and drugs, for partcular target groups, such as young people, vulnerable people and other groups at rsk of sexual ll-health. We are gong beyond merely transferrng responsblty for sexual health servces to local authortes and actually mandatng them for two reasons. Frst, STI testng and treatment servces are a central part of protectng health. The Government therefore beleves that hgh-qualty servces must be avalable n all areas, although the servces provded wll be talored to meet local needs. these people, and the supply of any contraceptve substances and applances. Ths duty s currently delegated to prmary care trusts, who are requred to provde open-access servces whch are not lmted to ther own resdents. Mandatng these servces of local authortes n the future wll allow the Secretary of State for Health to meet ths duty fully, over and above what s provded for va current GP provson. Health protecton plans At present Drectors of Publc Health n prmary care trusts play a key leadershp role n plannng for, and respondng to, health protecton ncdents, supported by local Health Protecton Agency health protecton unts. Subject to Parlamentary approval, the Health and Socal Care Bll wll provde that the Secretary of State for Health s responsble for takng steps for the purpose of protectng the health of the populaton. However, we want the Drector of Publc Health to contnue to provde a coordnaton role to protect the health of the local populaton when transferred to local authortes. Our vson s that the local authorty, and the Drector of Publc Health actng on ts behalf, should have a pvotal place n protectng the health of ts populaton. We therefore propose to use a regulaton-makng power n the Bll to requre local authortes to take steps to ensure that plans are n place to protect the local populaton. Second, the Secretary of State for Health currently has a duty, reterated n the Health and Socal Care Bll, to provde advce on contracepton, medcal examnaton of people seekng advce on contracepton, the treatment of 3 Under ths duty, local authortes (and Drectors of Publc Health on ther behalf) would be requred to ensure that plans are n place to protect the health of the local populaton from threats rangng from relatvely mnor outbreaks to full
scale emergences, and to prevent as far as possble those threats arsng n the frst place. The scope of ths duty wll nclude local plans for mmunsaton and screenng, as well as the plans acute provders and others have n place for the preventon and control of nfecton, ncludng those whch are healthcare assocated. Where the Drector of Publc Health dentfes ssues t wll be hs or her role to hghlght them, and escalate ssues as necessary, provdng advce, challenge and advocacy to protect the local populaton, workng wth Publc Health England whch wll provde specalst health protecton servces ncludng, for nstance, coordnaton of outbreak control, and access to natonal expert nfrastructure as and when necessary. Hs or her role n delverng these functons wll be supported by the transparency n the system that wll allow the Drector of Publc Health and others rapd access to routne montorng data. Below we set out n bref how we envsage ths health protecton role workng. Wth regard to emergences, we plan the followng. At the Local Reslence Forum (LRF) level, a lead Drector of Publc Health from a local authorty wthn the LRF area wll be agreed to coordnate the publc health nput to plannng, testng and respondng to emergences across the local authortes n the LRF area. Publc Health England wll contnue to provde the health protecton servces, expertse and advce currently provded at an LRF level by the Health Protecton Agency. 4 The NHS Commssonng Board wll appont a lead drector for NHS emergency preparedness and response at the LRF level, and provde necessary support to enable plannng and response to emergences that requre NHS resources. Local Health Reslence Partnershps (LHRPs) wll brng together the health sector organsatons nvolved n emergency preparedness and response at the LRF level. LHRPs wll consst of emergency plannng leads from health organsatons n the LRF area and wll ensure effectve plannng, testng and response for emergences. LHRPs are a formalsaton of exstng health subgroups found n the majorty of LRF areas. They wll enable all health partners to nput to the LRF and n turn provde the LRF wth a clear, robust vew of the health economy and the best way to support LRFs to plan for and respond to health threats. Further work wll be done over the comng months to plot and plan the resourcng and operaton of LHRPs. The lead drector apponted by the NHS Commssonng Board and the lead Drector of Publc Health wll act as cochars at the LHRP durng emergency plannng. Resources wll be requred to support the LHRP to provde contnuous readness. More work wll take place n the comng months to develop operatonal gudance for the system-wde emergency preparedness, reslence and response model. The NHS lead drector wll represent the LHRP on the LRF, as now, snce most
emergences requre readness and nput of NHS resources. The lead Drector of Publc Health should also attend, and Publc Health England wll attend where the emergency requres ts presence. In terms of plans for screenng and mmunsng the local populaton we envsage a process as follows. The NHS Commssonng Board wll be accountable for delvery of the natonal screenng and mmunsaton programmes n accordance wth an agreement between the Secretary of State for Health and the Board whch wll set out the terms n whch the Board wll exercse a Secretary of State functon. Publc Health England wll provde publc health advce on the specfcaton of natonal programmes, and also a qualty assurance functon wth regard to screenng. Drectors of Publc Health wll advse, for example, on whether screenng or mmunsaton programmes n ther area are meetng the needs of the populaton, and whether there s equtable access. They wll provde challenge and advce to the NHS Commssonng Board on ts performance, for example through the jont strategc needs assessment and dscussons at the health and wellbeng board on ssues such as rasng uptake of mmunsatons and screenng, and how outcomes mght be mproved by addressng local factors. They wll also have a role n champonng screenng and mmunsaton, usng ther relatonshps wth local clncans and clncal commssonng groups, and n contrbutng to the management of serous ncdents. Drectors of Publc Health wll play a role n ensurng that mmunsaton care pathways for programmes such as neonatal hepatts B are robust. The Board wll reman accountable for respondng approprately to that challenge from local publc health teams, and for drvng mprovement. Ths local authorty role n health protecton plannng s not a manageral, but a local leadershp functon. It rests on the personal capablty and sklls of the local authorty Drector of Publc Health and hs or her team to dentfy any ssues and advse approprately. But t wll be underpnned by legal dutes of cooperaton, contractual arrangements, clear escalaton routes and transparency. Thus clncal commssonng groups wll have a duty of cooperaton wth local authortes NHS-funded provders can be requred through contracts to share plans and approprate nformaton Drectors of Publc Health can use ther annual report and membershp of the health and wellbeng board to rase concerns more formally and the Secretary of State for Health can use the Mandate and hs agreement wth the Board to ensure that the NHS Commssonng Board takes approprate account of the advce of Drectors of Publc Health. Fnally, there wll be a professonal relatonshp between Drectors of Publc Health and Publc Health England, and the Chef Medcal Offcer as professonal lead for publc health, whch wll gve drectors and ther teams a route for contrbutng to natonal thnkng about what s needed. The system ensures that accountablty s focused where t needs to be. The Drector of Publc Health wll be 5
responsble as the publc health lead n each local authorty for advsng on plans that are n place and dentfyng any problems, usng hs or her publc health expertse. NHS and other partner colleagues wll be accountable for takng approprate account of that advce. Ths s n lne wth the desgn of the new system overall: Publc Health England and Drectors of Publc Health are accountable for the provson of hgh-qualty publc health advce the NHS Commssonng Board, clncal commssonng groups and others are accountable for makng the approprate use of that advce. The Secretary of State for Health wll retan a central nterest n health protecton even where he has delegated functons to the local level. To ths end we wll publsh further detals as we develop polcy on the new system. In partcular we wll develop a statement on how we wll promote hgh performance and support performance mprovement. We also ntend to produce operatonal gudance to support ncdent management at a local level, whch wll cover the workng relatonshp between the NHS, Publc Health England and the local authorty. The gudance wll recognse the need for flexblty to enable each area to make plans most approprate to protect the health of ts populaton. Populaton healthcare advce to the NHS We wll also mandate local authortes to provde populaton healthcare advce to the NHS. Good populaton health outcomes, ncludng reducng health nequaltes, rely not just on health protecton and health mprovement, but on the qualty of healthcare servces provded by the NHS. That s why we are preservng a key role for local authorty publc health teams n provdng publc health expertse for the NHS commssoners of these servces. The need to secure provson of publc health expertse for healthcare commssoners (and to support health and wellbeng boards n producng the jont strategc needs assessment and jont health and wellbeng strategy) was a key theme of the consultaton on the publc health whte paper Healthy Lves, Healthy People. We have consulted a group of publc health and other experts who have developed a draft model for what such a publc health advce servce mght look lke, buldng on exstng work across the country. Appendx 1 sets out the group s recommendatons, algned aganst the stages of the commssonng cycle. Clncal commssonng groups wll requre a range of nformaton and ntellgence support va both the populaton healthcare advce servce based n local authortes and other commssonng support servces such as from Publc Health England where approprate. It s mportant to note that although there are some smlartes n the nature of these servces (e publc health populaton healthcare advce and the work of commssonng support organsatons (CSOs) n the future), they wll have a dfferent focus. 6
We envsage that publc health teams wll provde largely a strategc populaton focus, syntheszng data from a wde varety of sources and applyng ther publc health sklls to draw the mplcatons of that data for the local populaton. CSOs wll focus more on commssonng processes and clncal systems, ncludng detaled analyss of referrals and actvty, procurement and busness processes. Both are essental for drvng mprovements n servces. There would be nothng to stop local authortes from agreeng locally to offer a wder range of servces. Local authortes wll also be free to meet ths oblgaton n a varety of ways, for example n relatvely small authortes t may make sense to locate a team n a sngle authorty, actng on behalf of several. In addton, Publc Health England wll have a role through ts nformaton and ntellgence servce to support local authortes on ths mandatory duty. Ths could nclude, for example, provdng baselne data and analyss that local publc health teams would need to share wth the local NHS to nform dscussons about relatve needs and prortes. Gven close workng and responsveness between publc health teams and clncal commssoners we would expect clncal commssoners to make full use of the expertse of local publc health teams (as well as publc health expertse n clncal senates). Indeed we are confdent that as fully ntegrated commssonng teams are put n place throughout the country, the nature and extent of such assstance wll be an accepted and automatc core element of local commssonng practce. Ths wll be another means of takng forward the underpnnng localsm ambtons of ths polcy approach. Where there are concerns about the qualty of the advce receved we would expect ths to be rased at the local level ntally wth the local authorty. There may be an ssue of professonal development, n whch case we would envsage clncal commssonng groups nvolvng Publc Health England n dscussons. We are consderng further what role local publc health advce may play n supportng the NHS Commssonng Board n ts core responsbltes, for example wth respect to the qualty of local prmary care commssonng. The group of publc health experts and GPs who have advsed us on the development of the populaton healthcare advce servce are also workng wth us to consder how best to ensure that the provson of populaton healthcare advce meets the needs of clncal commssonng groups. Ths wll help ensure that clncal commssonng groups can be confdent that they wll receve the knd of hghqualty, responsve servce they need. Produced: December 2011 Gateway reference: 16747 Crown copyrght 2011 Produced by the Department of Health www.dh.gov.uk/publcatons 7