MAIDSTONE BOROUGH COUNCIL
CABINET MEMBER FOR COMMUNITY SERVICES
REPORT OF THE HEAD OF CHANGE AND SCRUTINY
Report prepared by Orla Sweeney
Date Issued: 24 March 2011
1. HEALTHY LIVES, HEALTHY PEOPLE – CONSULTATION RESPONSES
1.1 Issue for Decision
1.1.1 To agree the consultation responses to the Department of Health’s Healthy Lives, Healthy People White Paper:
- Transparency in Outcomes, Proposals for a Public Health Outcomes Framework; and
- Consultation on the funding and commissioning routes for public health.
1.2 Reason for Urgency
1.2.1 The deadline for responding to the Department of Health’s consultation is 31 March 2011; therefore a decision needs to be taken in time to return the response.
1.2.2 The response has been produced by the Maidstone and Tunbridge Wells Joint Health Overview and Scrutiny Committee. As Overview and Scrutiny have given the response due consideration it is recommended that the call-in period be waived in order to meet the consultation deadline.
1.3 Recommendation of Joint Health Scrutiny
1.3.1 It is recommended that the Cabinet Member agrees to support the responses to the consultation documents (Appendix A and Appendix B) in response to the Departments of Health’s Healthy Lives, Healthy People White Paper formulated by the Maidstone and Tunbridge Wells Joint Health Overview and Scrutiny Committee.
1.4 Reasons for Recommendation
1.4.1 The White Paper Healthy Lives, Healthy People describes a new era for public health and sets out the Government’s overarching ambition for public health in the future. A fundamental part of this will be the establishment of Public Health England as part of the Department of Health ‘and the return of local public health leadership and responsibility to local government.’
1.4.2 The consultation document ‘Transparency in Outcomes’ considers the new Outcomes Framework for public health at national and local levels. It will be ‘evidence-driven, taking into account the different needs of different communities.’ One of the aims of the Public Health Outcomes Framework will be to promote joint working where local organisations share common goals. To ensure the Framework works from the outset and to break down barriers to delivery, the consultation document seeks views on the approach proposed, asking how it can be improved.
1.4.3 The consultation on the ‘funding and commission routes for public health’ is to consider the proposed ‘ring fenced public health funding within the NHS budget.’ Local authorities will have a new role in improving the health and well being of their communities as part of the new system. The majority of the public health budget will be spent on local services by local authorities through a ring fenced budget or via the NHS. The consultation document describes in more detail the proposed key public health functions and responsibilities, setting out the proposed commission and funding arrangements for delivery. The document asks questions on how the proposals should be implemented.
1.5 MAIDSTONE BOROUGH COUNCIL AND
TUNBRIDGE WELLS BOROUGH COUNCIL – JOINT RESPONSE
1.5.1 The following is the response of Maidstone and Tunbridge Wells Joint Health Overview and Scrutiny Committee’s response to the questions raised in the Department of Health’s consultation paper entitled “Transparency in outcomes – proposals for a public health outcomes framework”.
1.5.2 In formulating this response, the Joint Scrutiny Committee heard evidence from a range of witnesses, including local authority professional staff.
1.5.3 The Joint Committee was mostly supportive of the key proposals set out in the Outcomes Framework. Issues of concern at district council level are largely related to understanding the level of activity that will be devolved by the County Council. There is a strongly-held belief – backed up by evidence – that it is at district council level where most of the knowledge, experience and awareness of greatest need lies.
1.5.4 Two key points: (a) it would be unacceptable to waste the beneficial outcomes that district councils have achieved to date, should they fail to be given the opportunity to continue their targeted health improvement work; (b) West Kent might be seen as having a relatively healthy population, but significant inequalities still exist across this part of the County (e.g. a 7-year age gap in life expectancy) and require a continuation of this targeted – and demonstrably effective – work.
1.5.5 Alongside the key issue of district council involvement is one of the associated funding, to be able to commission and deliver the health improvement work. Finally, there is real concern about the transitional arrangements; this is hardly a new concept but it is vital it is planned thoroughly, in order to protect (above all) the most vulnerable people.
1.5.6 There will therefore need to be regular and detailed discussions held between Kent County Council and the district councils.
1.5.7 Question 1. How can we ensure that the Outcomes Framework enables local partnerships to work together on health and wellbeing priorities, and does not act as a barrier?
Key points: You cannot over-stress the importance of continuing 2- way communication;
Many of the outcomes fall within the remit of district councils (e.g. housing, leisure etc) and many are cross-cutting, involving both counties and districts which, taken across the board, results in a good understanding of the outcomes and a healthy willingness to work together towards improvements; and
Vitally, the need for a ‘bottom up’ approach from parishes and communities.
1.5.8 Question 2. Do you feel these are the right criteria to use in determining indicators for public health?
Generally, yes, with support for the principles behind the Marmot Report of a whole-life approach, but with a greater focus on early years’ provision.
In addition, it was suggested that more qualitative measures would be helpful and that there should be flexibility so as not to be bound by national indicators alone. This would allow local areas to address their local issues, reflecting the localism agenda. In counties such as Kent, districts can have very different priorities and so the indicators should be flexible enough to reflect this.
1.5.9 Question 3. How can we ensure that the Outcomes Framework and the health premium are designed to ensure they contribute fully to health inequality reduction and advancing equality?
There needs to be clarity as to which level the health premium and outcomes framework can be applied for example will it be at upper tier level or can districts and parishes also seek health premium funding?
In addition, concern was voiced about the retrospective nature of the health premium, which might deter innovation and activity in a time when other resources are scarce.
1.5.10 Question 4. Is this the right approach to alignment across the NHS, Adult Social Care and Public Health frameworks?
Generally, yes.
1.5.11Question 5. Do you agree with the overall framework and domains?
Again, generally yes.
1.5.12Question 6. Have we missed out any indicators that you think we should include?
Possibly ‘inequalities over access to health services’, but generally not in favour of adding too many more indicators.
It was also felt that some indicators might be difficult to collate at a local level so it was important to choose those where one could differentiate amongst some very small geographical areas.
1.5.13Question 7. We have stated in this document that we need to arrive at a smaller set of indicators than we have had previously. Which would you rank as the most important?
‘Early years’ are seen to be crucial and those indicators which relate to the first years, including the ante-natal period, of a child’s life should be retained, including wider determinants such as housing.
Apart from that, the strongly-held view is that the choice of ranking indicators should be very much a local decision.
1.5.14Question 8. Are there indicators here that you think we should not include?
General comment: it is better to use indicators that are strongly embedded, that have a proven track record in terms of showing trends.
The Joint Committee discussed that while some indicators could be seen to be unnecessary for the measurement of health such as ‘life years lost from air pollution’ indicator (under Domain 1), these should be kept due to the serious and long term health risks
1.5.15Question 9. How can we improve indicators we have proposed here?
In two ways:
By ensuring the measures use established indicators therefore allowing comparison and the ability to assess change and improvement; and
By ensuring they are accessible in a centrally-held place and available at the lowest spatial level possible.
1.5.16Question 10. Which indicators do you think we should incentivise? (consultation on this will be through the accompanying consultation on public health finance and systems)
Again, two key points:
By concentrating on those behaviours which are the most disadvantageous to health (e.g. smoking, excess drinking, obesity etc); and
Incentives should only be provided for outcomes, not processes, for example incentives for successful weight loss rather than for simple weighing or counting.
1.5.17Question 11. What do you think of the proposal to share a specific domain on preventable mortality between the NHS and Public Health Outcomes Frameworks?
Key points here were:
Hospitals also have a vital role to play in prevention/health improvement and this should also be linked with successful outcomes; and
From local experience, there exists a need to better engage GPs in the referral of patients for initiatives such as ‘good neighbour programmes’, to ensure positive outcomes and a lower risk or re- admittance.
1.5.18Question 12. How well do the indicators promote a life-course approach to public health?
There might be scope for further development of ‘key transition events’ which people experience, e.g. starting school or beginning work or becoming a parent for the first time, where there might be greater willingness towards healthier behavioural changes;
Is there scope for better-informed dietary habits to be formed through the school curriculum? (The old ‘domestic science’ approach, the principle of which had significant advantages, but within a modern context.); and
Another key life-course period is at pre-natal stage, so that reducing teenage pregnancy rates and avoiding smoking during pregnancy are both major issues.
Maidstone Borough Council and Tunbridge Wells Borough Council – Joint Response – The funding and commissioning routes for public health.
1.6 MAIDSTONE BOROUGH COUNCIL AND
TUNBRIDGE WELLS BOROUGH COUNCIL – JOINT RESPONSE
1.6.1 The following is the response of Maidstone and Tunbridge Wells Joint Health Overview and Scrutiny Committee’s response to the questions raised in the Department of Health’s consultation paper entitled “The funding and commissioning routes for public health”.
1.6.2 In formulating this response, the Joint Scrutiny Committee heard evidence from a range of witnesses, including local authority professional staff.
1.6.3 The Joint Committee was generally supportive of the key proposals on funding and commissioning routes, with some important observations: (a) the need to allow for local flexibility to the maximum; and (b) the importance of ‘up-front’ payments as much as possible, in order to provide for proper planning and reassurance for voluntary/independent service providers.
1.6.4 Question 1. Is the health and wellbeing board the right place to bring together ring-fenced public health and other budgets?
The view of the Joint Committee was that while this might be acceptable at a County Council level, there should be the flexibility to devolve responsibility to a district council level – or even to a smaller (parish or community) more local level. This would provide a better focus for examining local issues and would better fit with the Coalition’s emphasis on localism..
1.6.5 Question 2. What mechanisms would best enable local authorities to utilise voluntary and independent sector capacity to support health improvement plans? What can be done to ensure the widest possible range of providers are supported to play a full part in providing health and wellbeing services and minimise barriers to such involvement?
The Joint Committee felt there were three important factors:
a) The availability of any ‘willing provider’ and the use of local knowledge to encourage that;
b) The assurance that needs to be given to voluntary/independent organisations of continued funding, beyond a 1-year limit; and
c) The option to commission services at a local (i.e. district) level.
1.6.6 Question 3. How can we best ensure that NHS commissioning is underpinned by the necessary public health advice?
Two key points:
a) The need to ensure that a joint strategic needs assessment is built into the working arrangements; and
b) Where possible, commission to accredited service providers or else to service providers who can demonstrate they are fulfilling NICE guidelines. The NHS might look to establish accreditation for service providers where a gap exists, e.g. with obesity.
1.6.7 Question 4. Is there a case for Public Health England to have greater flexibility in future on commissioning services currently provided through the GP contract, and if so how might this be achieved?
The Joint Committee – and the witnesses reporting to it – were unclear about the intention and purpose of this question and needed greater clarity over what was being asked.
1.6.8 Question 5. Are there any additional positive or negative impacts of our proposals that are not described in the equality impact assessment and that we should take account of when developing the policy?
There is a need to consider the impact of the proposals on other, related services. In other words, the proposals cannot be considered in isolation but account must be taken of the accumulative effect on services such as adult social care, housing, elderly people services etc.
1.6.9 Question 6. Do you agree that the public health budget should be responsible for funding the remaining functions and services in the areas listed in the second column of Table A?
There was a strong feeling that there should be flexibility applied, to allow local priorities to be agreed from the list. One size does not fit all and local knowledge and circumstances must be the determining factors.
1.6.10Question 7. Do you consider the proposed primary routes for commissioning of public health funded activity (the third column) to be the best way to:
a) ensure the best possible outcomes for the population as a whole, including the most vulnerable; and
b) reduce avoidable inequalities in health between population groups and communities?
If not, what would work better?
Generally, yes, and there was support for the principle of other services (health visiting was one area) which might more naturally and effectively be undertaken by local authorities, to link with their new responsibilities.
1.6.11Question 8. Which services should be mandatory for local authorities to provide or commission?
The Joint Committee agreed with the view expressed by Kent County Council, i.e. this should be determined locally, according to what is most suitable at a county level.
1.6.12Question 9. Which essential conditions should be placed on the grant to ensure the successful transition of responsibility for public health to local authorities?
Three key points, which generally align with Kent County Council’s position
a) The grant monies need to be paid in full at the start of the year, to ensure security of funding and a proper level of forward planning;
b) The level of grant should be based on 2009/10 actual expenditure, as this reflected realistic service provision, before cuts were applied; and
c) Shadow budgets should be issued as soon as possible, to allow for a realistic level of forward planning to take place.
1.6.13Question 10. Which approaches to developing an allocation formula should we ask ACRA to consider?
The Joint Committee voiced support for the preference (and reasoning) expressed by Kent County Council for the ‘population health measures’ option. This was largely on the basis that the remaining options worked against local (i.e. Kent County) conditions.
1.6.14Question 11. Which approach should we take to pace-of-change?
This was difficult to express a view on until key issues such as transitional funding and the full impact of changes were better understood.
1.6.15Question 12. Who should be represented in the group developing the formula?
The Joint Committee was not able to assist with this and assumed that national experts on the health premium issue were advising.
1.6.16Question 13. Which factors do we need to consider when considering how to apply elements of the Public Health Outcomes Framework to the health premium?
Two key points:
a) The need to know whether the health premium can be paid to levels below County Council; and
b) The need for clarity over the timing of payments, i.e. a preference would be for half the premium to be paid in advance and the remainder retrospectively. This would have a significant impact on planning service provision and any other process would detract from voluntary/independent commitment.
1.6.17Question 14. How should we design the health premium to ensure that it incentivises reductions in inequalities?
Key points:
a) Some of the funding needs to be ‘up-front’, to provide the necessary incentives; and
b) Clarity is needed in measuring achievements. For instance, take life expectancy: this requires much longer timescales to make a judgement and what geographical area will be used for a comparison to be drawn?
1.6.18Question 15. Would linking access to growth in health improvement budgets to progress on elements of the Public Health Outcomes Framework provide an effective incentive mechanism?
There was a strong feeling that no, this would not be the right approach. For instance, some areas face a significant challenge in bringing about health improvements, with external factors (e.g. large-scale unemployment through the loss of a major employer or if in a largely middle-class area where there is a higher level of positive response to health messages) skewing the outcomes. Such circumstances could lead to unfair treatment and penalty.
1.6.19Question 16. What are the key issues the group developing the formula will need to consider?
Income
Social profile
What spatial levels will be used? (County? District? Parish/Community?)
Up-front funding
The importance of not overlooking the general benefit of public health improvement by over-concentrating on areas of deprivation and poverty.
1.7 Alternative Action and why not Recommended
1.7.1 The Cabinet Member could decide not to support this consultation which could result in a missed opportunity to feed into the policy making process.
1.8 Impact on Corporate Objectives
1.8.1 The
proposals in the consultation could impact on two of the Council’s strategic
priorities: A place that is clean and green and A place with efficient
and effective public services A place that has
strong, healthy and safe communities..
1.9 Risk Management
1.9.1 There are no risks associated with choosing to respond to this consultation.
2.0 Other Implications
2.1
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1. Financial
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2. Staffing
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3. Legal
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4. Equality Impact Needs Assessment
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5. Environmental/Sustainable Development
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6. Community Safety
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7. Human Rights Act
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8. Procurement
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9. Asset Management
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2.2 There are no implications at this stage.
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How to Comment Should you have any comments on the issue that is
being considered please contact either the relevant Officer or the Member
of the Executive who will be taking the decision. Cllr John Wilson Cabinet
Member for Community Services Telephone:
01622 720989 E-mail:
JohnAWilson@maidstone.gov.uk Orla Sweeney Overview
& Scrutiny Officer Telephone:
016222 602524 E-mail:
OrlaSweeney@maidstone.gov.uk
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