Long-standing readers will be aware that the Coalition Government's public health policies have not quite been to our taste.
We said a year ago that their White Paper "takes the piss more thoroughly than a phalanx of urinals".
Nothing since then has altered that view.
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Ten months ago, we published a guest editorial which pointed out that "councils can continue to cream-skim scrutiny funding budgets; that HeathWatch won't be very independent either locally or nationally; and that the position of advocacy, especially in social care, is seriously unclear".
It was therefore with a certain anticipation that we opened the health select committee's measured new report on public health.
It recommends that "the Secretary of State should be under a duty to reduce inequalities in relation to public health, as he will be in respect of healthcare under the Health and Social Care Bill".
It also suggests that plans to split the current Chief Medical Officer role such that the CMO will become the 'professional head of the public health profession', leaving the NHS Medical Director to provide professional leadership in respect of providing healthcare should not proceed.
The importance of visible independence for Public Health England is stressed, with emphasis that it should have "a clear structure of regional accountability, along the lines currently provided by the regional structure of the Health Protection Agency".
The committee's report adds that "that the lack of a statutory duty on local authorities to address health inequalities in discharging their public health functions is a serious omission in the Government's plans".
We love a mention of outcomes here at Health Policy Insight, and the select committee do not disappoint us: "Instead of the top-down frameworks previously used to drive targets and performance management, progress in public health will be measured through the Public Health Outcomes Framework. We welcome this but are disappointed that the first NHS and Social Care Outcomes Frameworks have been finalised before the Public Health Outcomes Framework.
"We recommend that outcomes data must be sufficiently localised and detailed to reflect accurately trends and patterns in the health of the public. Datasets must be of an adequate size to be able reliably to detect relevant characteristics of populations at the appropriate level, including at sub-local authority level. Data should also, as far as possible, be capable of disaggregation regarding the full range of protected characteristics under the Equality Act 2010". Amen to all that.
It's not all about the money, but money matters.
So do we have clarity about the money?
Ahem: "The Government has suggested that the current spend on public health services could be over £4 billion, but it has not explained how this figure was arrived at. We believe that this policy confusion is undermining confidence in the Government's public health strategy and making service planning impossible.
"The DH states that 2009-10 will be the historic baseline for future public health allocations. The Department must make clear how the actual level of funding will relate to this baseline. We seek reassurance that, in setting the public health budget both nationally and locally, the DH will take account of objective measures of need.
'The Department has also failed to give a convincing account of its distinction between frontline and non-frontline spending in public health services.'"The DH states that, in the current reduction of NHS management and administration costs, frontline public health services are being protected, but we have heard evidence to the contrary. The Department has also failed to give a convincing account of its distinction between frontline and non-frontline spending in public health services.
"Two parts of the ring-fenced PHE grant to local authorities (the recurring fixed "baseline allocation" for health improvement; and funding for mandatory services) will be allocated according to a needs-based formula. We note that the DH has asked the Advisory Committee on Resource Allocation to support the development of this. We are concerned by the government's decision to reduce the weighting for health inequalities in Primary Care Trust allocations for 2011-12 from 15% to 10%, which seems likely to impact on the future allocations formula.
'We believe there is a significant risk that, by targeting resources away from the areas with the most significant continuing problems, it (the Health Premium) will undermine their ability to intervene effectively and thereby further widen health inequalities'"The third part of the grant to local authorities will be the proposed "Health Premium". Authorities will only receive this additional funding for health improvement (over and above their fixed "baseline allocation") if they make progress in improving the health of their local population. We are concerned about the proposed introduction of the Health Premium. We believe there is a significant risk that, by targeting resources away from the areas with the most significant continuing problems, it will undermine their ability to intervene effectively and thereby further widen health inequalities.
'Even with ring-fencing, there is a risk of local authorities "gaming" the system and effectively raiding their public health allocations by "redesignating" services'"Ring-fencing allocations risks encouraging local authorities to see only spending from the ring-fenced budget as relevant to public health and runs counter to a "place-based" approach. Even with ring-fencing, there is a risk of local authorities "gaming" the system and effectively raiding their public health allocations by "redesignating" services. The Committee therefore proposes that the ring-fenced public health budget should operate for no more than three years"
What's going on
Public health, at its worst, can be fluffy, insubstantial and about people sitting in offices.
As well as top-level commitment, it requires a system of oversight - and the committee's report notes that "the work of the Public Health Observatories (PHOs) is an extremely valuable part of the public health system. While the Government has promised to continue the work of Observatories, there is a great deal of uncertainty, especially following the substantial cuts to their funding that have been made in the current financial year. We are concerned to hear that three of the Observatories, in London, the North East and the North West, face particular risk of closure. We recommend that Ministers clarify their plans for individual PHOs as a matter of urgency to ensure that this important resource is not lost before PHE is established.
"We welcome the intended continuing role of the National Institute for Health and Clinical Excellence (NICE) in evaluating the effectiveness and cost effectiveness of public health interventions. However, the Committee was surprised to learn that NICE's Public Health Interventions Advisory Committee has yet to meet this year, having previously met on a monthly basis. Ministers should make clear exactly what role NICE will play in future in respect of public health and how that role will be fulfilled".
Roles and responsibilities
The report is also concerned about accountability for public health: "The local DPH should be a member of the Board of each CCG. There should be a qualified public health professional on the NHS Commissioning Board; and the Board should routinely take advice from qualified public health professionals when commissioning decisions are being taken".
The committee observes that "Dr Gabriel Scally recommended that there should be statutory regulation of the profession, with the Health Professions Council regulating public health specialists as an additional profession, to accommodate specialists who are not members of a regulated healthcare profession. The Government, however, was sceptical, stating that its preferred approach was to ensure effective and independently-assured voluntary regulation. In view of the rising proportion of public health specialists that do not have a medical or dental background, the Committee recommends that the Government review its opposition to Dr Scally's proposal".
Bet you they won't.
The missing Marmot objective
The report welcomes the Government's acceptance of the key principles of the Marmot Review on health inequalities; "however, we are unclear why the Government only endorsed five of the six policy objectives outlined by Marmot, omitting that of securing a healthy standard of living for all".
Yeah, well ... "securing a healthy standard of living for all"'s probably top-down or something. Top-down is bad, remember? Unless it's Andrew Lansley single-handedly sacking boards.
It's over three years since Dr Tom Smith wrote a rather fine piece for us on the inadequacy of nudging in public policy, but it's no less topical.
The committee's view is sensibly rational: "As regards the national policy dimension of health improvement, the Government is taking an approach that it says marks a break with the "nannying" of the past. Drawing on the concepts of the "ladder of intervention" and "nudging", it says that it will aim to make voluntary approaches work before resorting to more intrusive, regulatory measures. A key vehicle for this "escalator" approach is the Public Health Responsibility Deal, based on voluntary agreements with business and other partners.
'The Committee were unconvinced that the new Responsibility Deal will be effective in resolving issues such as obesity and alcohol abuse and expect the Department of Health to set out clearly how progress will be monitored and tougher regulation applied if necessary. Those with a financial interest must not be allowed to set the agenda for health improvement'"The Committee does not oppose the exploration of innovative techniques such as "nudging", where it can be shown, following proper evaluation, to be an effective way of delivering policy objectives.
"The Committee were, however, unconvinced that the new Responsibility Deal will be effective in resolving issues such as obesity and alcohol abuse and expect the Department of Health to set out clearly how progress will be monitored and tougher regulation applied if necessary. Those with a financial interest must not be allowed to set the agenda for health improvement"