ITEM NO.

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REPORT OF

Director of Public Health

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TO

Cabinet

ON

26 February 2013

TITLE: Transfer of Public Health responsibilities April 2013.

Recommendation

  1. That Cabinet notes Salford City Council’s position as a national exemplar for good practice in relation to public health transition.
  2. That Cabinet notes the future statutory requirements for the City Council in respect to the transference of public health responsibilities, including those for the Director of Public Health and agrees the implementation arrangements to date
  3. ThatCabinet are updated on the future Public Health responsibilities of the Council.
  4. That the final transfer scheme from the Department of Health is delegated to the Chief Executive to ensure this is concluded at or before 1 April 2013.

Executive Summary

In February 2011 Salford Cabinet received a paper setting out the new public health responsibilities and a process for transfer to the City Council from NHS Salford following the significant reforms in the NHS White Paper: “Equity and excellence: Liberating the NHS” now enshrined in the Health and Social Care Act 201.

This reportprovides an update on the reform proposals set out in Healthy Lives, Healthy People: Update and Way Forward and subsequent factsheets on Public Health in Local Government;Directors of Public Health in Local Government - Roles, responsibilities and Context and Guidance on appointing directors of public health

The reforms build on local government’s long and proud history of public health leadership and provide the opportunity for putting health and wellbeing at the heart of the business of the City Council.

As part of these reforms the majority of public health commissioning responsibilities will transfer to local authorities. These responsibilities contain a set of mandated services which include population healthcare advice to the NHS, the national child measurement programme, sexual health services and cardiovascular health checks.

The statutory role of the Director of Public Health will be a jointly appointed between the Local Authority and the Secretary of State for Health. The expectation is that the Director of Public Health will be responsible for all the new public health functions of local authorities and the legal responsibilities will translate into the Director of Public Health acting as the lead officer for health and championing health across the whole of the local authority business.

The report set out the Salford and Greater Manchester context and updates on the current transition of the public health function. It notes that Salford is a regional and national exemplar of good practice. Developing clear delegated responsibilities for the Director of Public Health during this transition year would help further prepare the City Council for in preparation for the future statutory function.

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BACKGROUND DOCUMENTS:

Salford City Council:

Cabinet: Public Health Transition 8 March 2011, LA Public Health Grants Nov 2011

Leaders Briefing: Public Health Spend Briefing, Feb 2012, April 2012

Lead Member Adult, Health and Social Care: Public Health Finance Allocation, 31 Oct 2011, GM PH Transition Programme, 14 Nov 2011, DPH Briefing, 12 Dec 2011, PH Transition Assurance, 23 Jan 2012, PH Assurance Plan 2 April 2012, PH Baseline Allocation 16 April 2012, PH Transition Project Initiation Document, 5 March 2012.

Assistant Mayor Health and Wellbeing: A response to the draft funding formula for the public health allocation, 16 July 2012; Release of LA PH Grants Baseline Allocation, 16 July 2012;Responsible officers in the new health architecture: A Public Consultation on the Amendments to the Medical Profession (Responsible Officers) 2010 Regulations, July 2012. Proposed process for prioritising contracts 17 August and 17 September 2012; Final public health core team structure,17 Sep 2012; Public Health roles and responsibilities, 28 Sep 2012; Hundreds Health Salford MOU,17 Aug 2012; Public Health transition self assessment, 28 September 2012 Public health overheads,28 Sept 2012: Transition Highlight Reports in 17 Aug, 17 Sep, 15 Oct 2012;

Department of Health:

-Directors of Public Health in Local Government (i) Roles, responsibilities and Context; (ii) Guidance on appointing directors of public health from 1 April 2013 (5 October, 2012)

-The new public health role of local authorities (5 October, 2012)

-Health Protection and Local Government Fact Sheet, Aug 2012

-Public health in Local Government Commissioning Responsibilities Factsheet 2012

LGiU Policy Briefing: Transferring public health to local authorities new guidance on directors of public health and local authority responsibilities, Christine Heron (24 Oct, 2012)

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KEY DECISION:YES - the public heath transition is in forward look

DETAILS:

  1. Background

1.1What is public health?

The UK Public Health Association summary definition is:

  • an approach that focuses on the health and well being of a society and the most effective means of protecting and improving it.
  • It encompasses the science, art and politics of preventing illness and disease and promoting health and well being.
  • It addresses inequalities, injustices and denials of human rights, which frequently explain large variations in health locally, nationally and globally.
  • It works effectively through partnerships that cut across professional and organisational boundaries and seeks to eliminate avoidable distinctions.
  • It relies upon evidence, judgment and skills and promotes the participation of the populations who are themselves the subject of policy and action.

1.2 What are the changes for the NHS and public health

The publication of the “Equity and excellence: Liberating the NHS” in July 2010 signalled a major reform programme for the NHS that included the abolition of Primary Care Trusts and the transfer of commissioning responsibilities toGPs and an independent NHS Commissioning Board. The Public Health White Paper introduced a new dedicated national public health service (Public Health England) and the transfer of significant responsibilities for local public health services and for improving health to local authorities. These proposals are now enshrined in the Health and Social Care Act 2012.

  1. Public Health in Local Government

All unitary and upper tier local authorities will take on a new duty for improving the health of their population from 1st April 2013.There will be a set of responsibilities that clearly demonstrate the Council’s leadership role in: tackling the causes of ill-health and reducing inequalities, promoting and protecting health and promoting social justice and safer communities.

Local authorities will have an important leadership role in putting health and wellbeing at the heart of everything they do. This means:

  • Including health in all policies so that decisions seek the most health benefit for the investment
  • Investing the new ring fenced grant in high quality services
  • Encouraging health promoting environments, for example access to green spaces and transport and reducing exposure to environmental pollutants
  • Supporting local communities by promoting community renewal and engagement and developing social networks.
  • Using a holistic approach to tailor wellness services that address multiple needs
  • Making effective and sustainable use of resources.

In Healthy Lives, Healthy People: Update and Way Forward the Government published a provisional list of what should be funded from the public health budget and the principal commissioner. The final list of new local authority responsibilities was set out in the Public Health in Local Government Commissioning responsibilities:

Local authoritypublic health commissioningresponsibilities

  • Tobacco control and smoking cessation
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  • Alcohol and drug misuse
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  • Seasonal mortality excess deaths

  • National Child Measurement Programme*
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  • Local nutrition initiatives
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  • Increasing physical activity

  • NHS Health Check assessments*
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  • Public mental health services
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  • Dental public health services

  • Accidental injury prevention
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  • Population level interventions to prevent birth defects
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  • Behavioural and lifestyle campaigns to prevent cancer and long term conditions

  • Workplace health
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  • Review and challenge of screening, immunisation
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  • Sexual health services* (outside of GP contract and HIV)

  • Public health services for children and young people 5-19 (and by 2015 public health services for children and young people)
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  • Health protection incidents, outbreaks and emergencies*, impacts of environmental risks
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  • Public health aspects of community safety, violence prevention, and response, social exclusion

Source:Public health in Local Government Commissioning Responsibilities Factsheet 2012

2.1Mandatory steps

The Health and Social Care Act includes power for the Secretary of State for Health to prescribe some services either because uniformity of provision is required or where there is a legal duty (e.g. provision of contraception). Other steps are deemed critical to the new public health system running effectively at local level, for example ensuring that NHS commissioners get public health advice. The mandatory commissioned services are noted in the table above and are in bold*.

2.1.Population healthcare advice to the NHS

Clinical Commissioning Groups will have a duty post March 2013 “to obtain advice...from persons who...have a broad range of expertise in: prevention, diagnosis and treatment; protection or improvement of public health”. National guidance focuses on healthcare public health advice only. Local Authorities must provide this advice free though Clinical Commissioning Groups are able to buy it from elsewhere if they wish to.Nationally it has been estimated that 40% of specialist public health team activity will be engaged in this work. Advice must come from “accredited public health” specialists as defined by Faculty of Public Health. It should be linked to the outcomes frameworks, priorities identified by the JSNA and Joint Health and Wellbeing Strategy. There should be an MOU in place, underpinned by an annual workplan with reports on how the service has been provided.

2.2Role of the Director of Public Health

The Department of Health have set out the role of the Director of Public Health in the fact sheet Public Health in Local Government. A summary of the key points in the document are set out below.

Each authority must, acting jointly with the Secretary of State for Health, appoint an individual to have responsibility for its new public health functions, known as the Director of Public Health. That individual could be shared with another authority where it makes sense (the example given is where a shared management team is in place across more than one authority and the authorities are geographically contiguous).The Department of Health is developing guidance for appointing to vacancies and managing the transition.A local authority may terminate the appointment of its Director of Public Health. Before terminating the local authority must consult the Secretary of State and must have regard to any guidance given by the Secretary of State in relation to its Director of Public Health including appointment, termination, terms and conditions and management.

Directors of Public Health will be added to the list of statutory chief (N.B. This guidance is awaited.)The legal responsibilities are expected to translate in the Director of Public Health acting as the lead officer in a local authority for health and championing health across the whole of the authority’s business whilst the Public Health function is located in the CHSC/Cluster 2. Direct accountability is expected to be with the local authority Chief Executive and will

  • Be responsible for all the new public health functions of local authorities including any conferred on by regulation
  • Produce an annual report on the health of the local population
  • Be a statutory member of the health and wellbeing board
  • Act as a lead officer in a local authority for health for elected members and other senior officers to consult on a range of issues from infection control to local health services.
  • Work with local criminal justice partners and the new Police and Crime Commissioners to promote safer communities.
  • Have day-to-day responsibility for the grant is delegated to the DPH.
  • Become part of the Council’s Senior Management and incorporate the statutory role into the Constitution.

2.3 Health protection

The Health Protection and Local Government Fact Sheet issued in August 2012 describes the arrangements for preventing, planning and responding to health protection incidents and outbreaks. The document describes:

2.3.1 Prevention

The Director of Public Health will ensure that the local authority and partners are supporting preventative services that tackle key threats to health e.g. integrated services for tuberculosis, minimising drug related harm through transmission of blood-borne viruses, preparing for extreme weather events and working with environmental health colleagues to improve local air quality.Local authority teams will need to work closely with Public Health England (PHE) centres. PHE centres will provide a range of health protection services and collect, analyse and interpret data.

2.3.2 Planning and preparedness

There is a new role for upper tier local authorities in support of the Secretary of State’s health protection duty. This will be a statutory requirement which will be placed under section 6C regulations of the NHS Act 2006 (as inserted by section 18 of the Health and Social Care Act 2012). The new duty requires local authorities to take steps to protect the health of their populations from all (health protection) hazards, ranging from relatively minor outbreaks and contaminations (all kinds including chemical and radiation), to full scale emergencies, and to prevent as far as possible those threats arising in the first place. The role for responsibilities for infection control are still being clarified nationally.

The Director of Public Health on behalf of the authority will provide advice, challenge and advocacy to protect the local population. Responsibility for responding to this local authority advice rests with other organisations as does accountability for adverse impact if the advice is not heeded.Local authorities will have a key lever to improve the quality of health protection plans through the effective escalation of issues with partners, with the Health and Wellbeing Board or with commissioners.

Local health resilience partnerships (LHRP) will be established to provide a forum to facilitate consistent health sector preparedness. These will be co-chaired by a lead DPH and the NHS Commissioning Board Local Area Team lead for emergency preparedness. For Salford this is already in place at a Greater Manchester level.

2.3.3 Surveillance

PHE will continue surveillance work (scrutiny of the occurrence and spread of disease to inform and direct public health action) building on the work of the current Health Protection Agency. PHE will keep the Director of Public Health and other partners informed of trends and potential threats to health.

2.3.4 Relationships and accountabilities

The Secretary of State will expect PHE to cooperate with local authorities and support them in exercising their functions. PHE will agree a Memorandum of Understanding with local authorities setting out the specialist advice and support services they will provide.

The NHS Commissioning Board and Clinical Commissioning Groups have a duty to cooperate with local authorities on health and wellbeing under the NHS Act 2006. This includes cooperating around health protection, including the sharing of plans. The Department of Health is exploring the appropriateness of requiring healthcare providers to cooperate with local authorities as part of the mandated requirements for contract terms.

2.3.5 Putting the mandated function into practice

The focus will be on developing plans with PHE and key health and care partners in Salford. There will be as much room as possible for local discretion over the new health protection function. The Department of Health does not expect local authorities to produce a single all encompassing health protection plan but rather to ensure that partners have effective plans in place. This includes commissioning:

  • Arrangements for managing cross border incidents and outbreaks
  • Exercising and testing and peer review
  • Arrangements for stockpiling essential medicines and supplies
  • Escalation protocols and arrangements for incident and outbreak control
  • Arrangements for review (at least annually)

The suggestion is that local authorities establish a local forum for health protection issues, chaired by the Director of Public Health, to review plans and issues that need escalation. This forum could be linked to the Health and Wellbeing Board.

3. Public Health in Salford

Salford has a rich public health history stemming back to the nineteenth century when it was one of the first local authorities to install intercepting sewers to the Irwell. This had a significant impact on reducing cholera and typhoid – both major causes of early death and poor life expectancy in Salford at the time. Dr Lance Burn Salford’s medical officer for health in 1948 was instrumental in Salford becoming the first city in Great Britain to wipe out diphtheria and one of the first to tackle TB with mass X-Rays.

Whilst many of the communicable disease risks from the past have reduced we now find some such as TB re-emerging and HIV becoming an increasingly important public health issue. Lifestyle issues such as smoking, alcohol and diet continue to impact on people’s health in Salford and we are much more aware of the need to improve mental well being for our population. In Salford people still die young from preventable diseases such as cancer (lung cancer is most common), heart disease and respiratory disease. Some of our children are not getting a healthy start in life – breastfeeding is low, smoking in pregnancy is high, teenage pregnancy is high; we don’t yet know the full impact of high consumption of alcohol on Salford’s children. Underlying challenges are family poverty, parenting, worklessness and crime.

Although there is more work to be done there are significant achievements to be celebrated; the gap in life expectancy in Salford is reducing for both males and females and we have improved the take up of childhood immunisations and now have some of the best rates of uptake of MMR in the country. Salford can be rightly proud of its public health history and continues to build on the foundations set by Lance Burn and others through a strong community strategy vision of a healthy city focused on a public health approach with an emphasis on prevention rather than cure.