Health and Wellbeing Strategic Scrutiny Select Committee

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REPORT OF

Director of Public Health

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TO

Health and Wellbeing Strategic Scrutiny Select Committee

ON 5th June 2013

TITLE: Transfer of public health responsibilities.

Recommendation

Note the contents of the report

Executive Summary

This paper provides an overview of the transfer of public health responsibilities to Salford City Council which came into effect on the 1st April 2013 as a result of the Health and Social Care Act 2012.

This paper contains details of the role of public health in the local authority. It provides details of the public healthcommissioning responsibilities, services and budget allocations that now fall within the remit of the local authority. It also provides an overview of the transition process, the key milestones, the new operating model, theoutstanding issues from the transition and the wider transformation of public services by the integration of public health.

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BACKGROUND DOCUMENTS:

Healthy Lives, Healthy People: Our Strategy for Public Health in England (2010), Healthy Lives, Healthy People: Transparency in Outcomes, proposals for a public health outcomes framework (2010) Healthy Lives, Healthy People: Consultation on the funding and commissioning routes for public health (2010) Healthy Lives, Healthy People: Update and Way Forward (2011); Public Health in Local Government Commissioning responsibilities (2012)

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KEY DECISION:No

DETAILS:

1. Background: 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 authoritiestook on new duties for improving the health of their population from 1st April 2013, with 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.

2.1Commissioning responsibilities for Public Health

In Healthy Lives, Healthy People: Update and Way Forward the Government published a provisional list of what should be funded from the public health grant. 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

• Alcohol and drug misuse

• Seasonal mortality excess deaths

• National Child Measurement Programme*

• Local nutrition initiatives

• Increasing physical activity

• NHS Health Check assessments*

• Public mental health services

• Dental public health services

• Accidental injury prevention

• Population level interventions to prevent birth defects

• Behavioural and lifestyle campaigns to prevent cancer and long term conditions

• Workplace health

• Review and challenge of screening, immunisation

• 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)

• Health protection incidents, outbreaks and emergencies*, impacts of environmental risks

• Public health aspects of community safety, violence prevention, and response, social exclusion

Source:Public health in Local Government Commissioning Responsibilities Factsheet 2012

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 services 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*.

2.2The Public Health Grant

Salford received a Public Health grantof £17.075m (approximately £71/head of population) for 2013/14 to resource these responsibilities. The grant levels have been set for two years with Salford seeing an increase in the 2014/15 allocation to £18.777m. This will still leaves a 6% gap to the target figure set by the government suggesting further above inflation rises may follow in subsequent years.

Whilst this is a positive settlement for Salford it is probably no more than a realistic reflection of the existing need and the level of historical investment by NHS Salford in Public Health programmes. The previous actual investment in public health by NHS Salford equated to £22,283,125 which left a potential shortfall in 2013/14 of £5.2M. To help manage this gap the Clinical Commissioning Group agreed to retain a range of contracts (totalling £2.7M) including those which cover services at the most clinical, higher tier of provision.This list of contracts to be retained by the CCG was agreed by the City Mayor at the City Issues briefing on January 22nd. As well as this agreement, a range of savings proposals were enacted by 31st March to ensure the City Council received the Public Health commissions in a financially sustainable position. A full suite of Equality Impact assessments were carried out to inform this process.

A Section 75 agreement has subsequently been developed to bring together the elements of the pathways commissioned by CCG and Public Health to ensure joint commissioning underpins their management and future development. This was developed and agreed by both City Council and CCG by 31st March. The combined expenditure by programme area within the Section 75 is set out in Appendix 1

2.3 Population healthcare advice to the NHS

Clinical Commissioning Groups have a duty “to obtain advice...from persons who...have a broad range of expertise in: prevention, diagnosis and treatment; protection or improvement of public health”. Local Authorities must provide this advice and 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 the Faculty of Public Health. It should be linked to the outcomes frameworks, priorities identified by the JSNA and Joint Health and Wellbeing Strategy. A Memorandum of Understanding is now in place between the City Council and the CCG (approved by Assistant Mayor for Health and Wellbeing through delegated authority from the City Mayor) underpinned by an annual workplan.

2.4 Health protection

The Health Protection and Local Government Fact Sheet (available as part of a set of key fact sheets at issued in August 2012 describe the arrangements for preventing, planning and responding to health protection incidents and outbreaks:

2.4.1 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.

2.4.2 Planning and preparedness

• Upper tier local authorities have a new duty in support of the Secretary of State’s health protection duty which 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 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 doe’s 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.

2.4.3 Putting the health protection function into practice

The focus will be on developing plans with Public Health England 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 Team 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)

A local health protection forum linked to the Health and Wellbeing Board is currently being established to support the delivery of this role and ensure appropriate governance lines are in place.

3. Transition process and the current position for DPH and Core Team in Salford

The Public Health Team although formally transferred on 1st April has been hosted within City Council since January 2012. It has established firm working relationships across the Council Directorates and has integrated into City Council policy and practice. The Director of Public Health reports directly to the Chief Executive but the team is currently aligned with Community Health and Social Care for its support and accountabilities. Public Health work is mainly routed through the briefings for the Assistant Mayor for Health & Wellbeing although it has also reported through other Assistant Mayoral briefings where appropriate.

The transition process for transfer of Public Health Responsibilities was managed as a discrete project with reporting arrangements through the Assistant Mayors briefing into City Council and directly to City Mayor at key points in the process e.g. at the point when the Grant allocation was announced. The headline milestones of this process can be seen in the process map in Appendix 2, suggesting the range of tasks and challenges which the project team were faced with in the transition year. A significant range of risks were identified at commencement of the project and these were routinely managed as part of the project governance. From the lengthy list of risks which were managed throughout the year only two remain (Appendix 3). These are predominantly those requiring a national solution eg access to public health data.

On 1st April 34 Public Health staff transferred to the City Council, the composition of the team which transferred is shown in the table below. An indication of the quality and the range of activity it has been engaged in can be seen in the highlights from 2012/13 included in this year’s business plan:

• The Team was awarded the NHS Salford (Shadow) Clinical Commissioning Group’s (the CCG) prize for Team of the Year 2012.

• Two team members were nominated for the CCG’s prize for Contribution to Improving the Health of Salford, with one being the outright winner.

• Salford achieved Stage One of Baby Friendly accreditation in 2011. After a year during which 100% of health visiting staff and Children’s Centre Workers attended the 2-day breastfeeding management training, Salford is now able to apply for Stage 2 accreditation one year earlier than usual.

• Salford has exceeded the National Chlamydia Screening Programme target achieving a Diagnostic Rate of 2891 per hundred thousand (or 2.89%). This ranks Salford 2nd in Greater Manchester, 3rd in the North West and 15th nationally. Salford has the best Positivity rate (10.8%) in both Greater Manchester and the North West and is ranked 3rd nationally. The Positivity rate indicates how well the screening programme is finding the young people most at risk of sexually transmitted infections.

• The introduction of a city wide behaviour change programme ‘Making Every Contact Count’ which is embedding conversations about wellbeing consistently into many staff and organisations contacts with the public.

• Development of a unique tool in partnership with John Moores University to help target resources into those programmes which will improve how long people live.

• Alcohol services have been redesigned and there is now a new outreach team which is delivering good improvements. There has been a reduction of repeat hospital attendees of 67%.

• The co-ordination of a whole range of local and national cancer awareness initiatives for early recognition and detection of cancer. Evaluations have started to show an impact; for example with bowel cancer in one area of Salford there was an increase in cancers diagnosed at an early stage from 2011 to 2012 of 44% to 77%.

• The team were nominated for 6 awards at last year’s Northwest Public Health Conference.

• Salford’s transition approach was singled out as a national example of best practice by the Department of Health and the LGA and an extensive case study used in its “Transition to Transformation” bulletin (Appendix 4)

1. A new business model for public health in Salford

Salford’s ambition is to develop a new business model for public health and the wider workforce in Salford. This will support tackling the big health and wellbeing issues that both arise from and contribute to worklessness, family poverty and deprivation. In preparation for the transfer to City Council and the broader roles this would require, the core public health team has been reshaped and structured to ensure it can flex roles to support the achievement of a wider range of outcomes. This reform is linked to the integrated commissioning hub development programme which the Director of Public Health leads.

It is the intention that when the structural integration is delivered, the core public health team will be integrated into the intelligence, research, policy and strategy functions of the hub, ensuring it has a broad capacity to support future development and commissioning activity.

The aim is for the Mayoral team and the wider Council to have excellent commissioning and procurement support and advice within a single integrated cycle to help members make decisions that secure improvements in service and public value. We believe that integrated service models with partners across the public sector are an important way forward so that we can develop better models of care, increase self care and build on personal and community strengths and assets.

Appendix 1

Appendix 2

Appendix 3
Outstanding risks from the Transition

Appendix 4

From Transition to Transformation Newsletter

KEY COUNCIL POLICIES: The Salford Strategic Partnership and the JSNA both have an explicit commitment to tackling Health Inequalities, to improve the Health and Wellbeing of the residents of the City and to address the causes of ill-health. The Council has well developed approaches to Smoking, Weight, Infant Feeding, Alcohol and Wellbeing which are multi-agency, whole system approaches to Health and Wellbeing.

The Council has adopted a whole system approach to addressing Health Inequalities through the existing Health and Well Being Board – which is in the process of reviewing and updating it’s Terms of Reference based on the new duties outlined in the NHS White Paper ‘Liberating the NHS’