The NHS Long Term Plan has finally arrived. There is much in the plan that Directors of Public Health would support:
- The shift in focus to primary and community services
- Extra funding for those places with the greatest health inequalities
- Training of medics on nutrition in all hospitals
- Action on air pollution within the NHS fleet
- Action on screening and vaccination inequalities
- £30M for rough sleeping initiatives
- Additional NHS gambling clinics
- Important focus on children and young people, cardiovascular disease, musculoskeletal disease, mental health and falls prevention.
- Alcohol care teams to be developed in collaboration with local authority commissioners.
We welcome too the strong focus on smoking; but this, and in fact every commitment above, needs to be done in collaboration with LA commissioners.
Our members are less welcoming of the doubling of the Diabetes Prevention Programme, and I’m sure could have found a more effective use of the £105m already invested in it.
The press release on the NHS Plan’s commitments on alcohol and tobacco preceded the full plan by two days. We responded positively to this as they heralded the good intention for the NHS to do more to prevent modifiable factors damaging patient’s health. However, we waved three red flags of concern - the plans were ‘undeliverable’ without a good spending review settlement for public health; bold national policy change is needed to address the social determinants of health; and thirdly, the NHS needs the support and contribution of local authorities and the Director of Public Health to deliver the plans efficiently – we need to operate as a public health system.
Cuts are the issue – more restructuring is not the solution
But let me turn to some of the disappointing aspects of this plan. Imagine our surprise when the full NHS plan arrived the day after our welcome with the proposal to: ‘consider the potential for a stronger role for the NHS in commissioning sexual health services, health visitors, and school nurses, and what best future commissioning arrangements might therefore be.’
Unacceptably, ADPH was neither involved nor informed about the inclusion of a review of our commissioning responsibility – by NHSE, another public sector commissioner. At best this is a well-intentioned but extraordinarily ham-fisted effort to deal with public sector funding cuts – at worst, it is an unwelcome distraction from cross-sector collaboration to manage those cuts to ultimately improve citizen’s health and wellbeing. Cuts are the issue – restructuring is simply not the solution.
Fighting among ourselves will deliver a worse outcome; how you do things does matter. So in that spirit, and for the NHS’ own good, we’re pushing back and saying there can be no review of the commissioning of public health services without the full involvement of Directors of Public Health. Reviewing what we do can be productive in illuminating areas for improvement – and we would support a review which looked at how public health services could be sustained and improved.
I have raised our concerns with DHSC and have been reassured that they want to work closely with ADPH and public health stakeholders on this review.
System challenges
Austerity has been a major driver of change for over a decade. In part it has driven necessary transformation and efficiencies within public services; but for the most part, it has driven unnecessary demands on those services and arguably is now costing the government more than it is saving – as well as leading to all sorts of distortions within the public sector. Indeed problems which properly funded public health teams could prevent are now being displaced to the NHS, with avoidable extra cost.
It was within this challenging context that public health moved from the NHS to local government in 2013. The case for the transfer of public health responsibilities remains unchanged – indeed we would argue, it is stronger than ever. Directors of Public Health are providing leadership and expertise to tackle the social determinants of health and deliver strong place-based population health approaches – as well as leading the transformation of those services we’re responsible for commissioning – substance misuse, sexual health, 0-19 year old’s health and wellbeing.
There is much more to public health than the NHS – the Clean Air Strategy published this week has significant roles for local government and the Serious Violence Strategy advocates a public health approach. We need to challenge this default ‘NHS first’ logic if we are to build a truly preventative system.
Public health commissioning has delivered improved outcomes
The completely false presumption in the Long Term Plan is that council commissioning is delivering worse outcomes. This is simply not true. It is not borne out by outcomes data. There are several national reports that show local government has been successful in delivering services under difficult circumstances and has prioritised increasingly scarce resources effectively.
We’ve brought new energy and rigour to the commissioning of these community services, often transforming who delivers them, where and how, making integration and partnership-working real – and, in the context of rising demand and huge cuts, largely delivering good outcomes. Redesign in many areas has focused on integration – integration with other public services, such as criminal justice, adult services, children and young people services; and integration across the wider health economy. It has also looked to commission the community and voluntary sectors and to increase social value through its contracts.
‘Be careful what you wish for…’
When public health was in the NHS, we know that the funding for prevention was always on a shaky footing – there in good times, the first to go in difficult. This was also true of the funding of many non-acute, preventative community services, including those now commissioned by local government. As Jim McManus has blogged: ‘it was not better in the glory days’. We inherited long-standing challenges – from the underfunding of school nursing and fragmentation in health visiting, including poor links with GPs – to overly medicalised and expensive sexual health services, or drug services focused on clinical treatment and not yet recovery; and Directors of Public Health have worked hard to innovate and introduce new models to deliver improved outcomes for less. Local authorities have also taken some decisions that the NHS could not or would not make.
In December 2018, our successful ADPH conference focused on ‘disruptive leadership’ – the kind of leadership that understands that improving outcomes often needs challenge and change, that isn’t afraid of challenging ‘the norm’ to enable innovation, and that knows how to be pragmatic and savvy while doing this. This is the kind of leadership that we so desperately need in the public sector – leadership to enable the reforms needed to better serve a population with changing needs and expectations.
But commissioning can be a thankless task; with a focus on improving population outcomes with efficiency, it’s not often that providers thank commissioners for their efforts. It can lead to experienced professionals being asked to do things differently, or to change a service skill mix or integrate with other providers, or to change the location or mode of the service to make it more accessible for residents and patients. Often, the best innovation comes through commissioners and providers working in creative tension together - and there are very many examples of this leading to fantastic services.
Joint commissioning of local health and care services in integrated care systems is becoming increasingly important to enable local government and the NHS to shape effective services – and indeed is already happening in many areas.
It’s time to work as a system. With each part funded appropriately and sustainably. We will focus on articulating that. We all need to join together and end the unhelpful “us and them” discourse.
