Analysis of NICE webinar: Public Health - Managing the Transition
Feb 24, 2012
Below are some of the observations following the NICE Webinar: Public Health - Managing the Transition
Chair: Mike Kelly (MK), NICE
Rachel Flowers (RF), DPH Newham (started work as an environmental health officer in a local authority)
Susan Biddle (SB), Independent Public Health advisor, formerly LGA
Frank Atherton (FA), Chair of Association of Directors of Public Health
- All panellists welcome the transfer of public health (probably specialists, responsibilities and resources) to local authorities.
- The background contexts are increasing resource scarcity and devolution of decision making closer to the people.
Local authority DPHs are expected to be very influential. Their effectiveness will depend on making the right relationships in the local authority and with other partners. The degree of public health integration between local authorities, the NHS (and probably other partners) is very variable.
- Local authorities’ priorities may be different, and this is seen as reasonable. There will therefore be variation in the priorities given to particular services. This is also seen as both reasonable and inevitable.
- Local authorities don’t have a habit of making systematic use of evidence (there are exceptions). The transfer of public health should help. NICE is expected to produce evidence of effectiveness and best value from a national perspective. It is hoped that Public Health England will help make this more granular for local use. Local authorities will view evidence through the lens of their own perspectives (political and Political) and priorities.
- The NHS and local authorities may view the same problems from different perspectives. Local authorities will tend to focus on wider determinants (e.g. housing, leisure etc.) whereas the NHS will tend to focus on clinical issues/outcomes (e.g. obesity, diabetes etc.)
- Almost nobody believes the Government’s responsibility deal will work. At best, it should be seen as a minor part of the approach to changing behaviour. It is possible that the Government is realising this.
Topic 1: How can NICE help as responsibility for commission public health moves to local authorities?
All panellists are looking forward to the transition (back) to local government. Existing relationships between local authorities (LA), NHS and public health vary greatly across local authorities. It will be vital for local PH personnel and DPHs in particular, to make the right personal contacts, which will be different in every LA. This could be more complex in two-tier authorities.
Although some LA officers do habitually use evidence to inform decision making, this is not generally the case and evidence is not usually used systematically. The transition of PH into LAs provides an opportunity to improve the use of data and evidence.
NICE has undertaken preparatory work and has learned not to regard all LAs as the same. They are very proud of their independence and it is likely that they will need to be approached individually and may need different sorts of products (or products presented in different ways).
It is 18 months since the PH White Paper and the “devil is in the detail”. Some LAs will inherit PH budgets (and/or teams/resources) that are in relative deficit due to underinvestment or under resourcing.
There will be two public health workforces:
- Local authority
- Public Health England
There is, therefore, a risk of less integrated public health services. NICE could help by producing guidance applicable to all sectors. Current NICE public health guidance is good, but needs to be repackaged and presented anew. It is also important to realise that LAs will want to consider such nationally provided evidence “through their own lenses” i.e. considering how it will affect their communities. LAs will want evidence to help decide services for example:
- particular community groups
- families with complex needs
- communities with multiple inequalities
LAs will need to better understand what information/evidence is currently available and to make their own decisions about priorities. It will be very helpful for them to have the information necessary to support a case for how to spend money at a local level when commissioning care.
NICE has a committee that is working on a number of public health briefings for LAs. These will be discussed at the NICE Conference in May 2012. They are intended to be available to LAs from 1st April 2013.
Audience poll 1: What is the biggest public health issue facing your community?
- Obesity – 53%
- Substance misuse – 14%
- Tobacco – 13%
- Teenage pregnancy – 3%
- Pollution – 3%
- Others – 14%
NB: Alcohol wasn’t on the list of options
The panel noted that most of the audience registered for the webinar were from the NHS and the results were fairly typical of an NHS audience. It was suggested that local authority participants would have been more likely to prioritise wider determinants of health, e.g. youth unemployment – the “causes of the causes” to use Michael Marmot’s terminology. The panel suggested that NICE should think about how to produce guidance relevant to the wider determinants of health.
Topic 2: Value for money
NICE is responsible for providing evidence to help the NHS and LAs to get the best value for their resources. This is in the current context of severe public sector cut backs. It is expected that local DPHs are very interested in securing best value for money.
Localism represents a fundamental shift with potentially more opportunities to use evidence as some national services become local services (e.g. health checks or chlamydia screening). Geographical variations in services are inevitable, but this is reasonable, because local authorities have different priorities based on the different needs of their populations. Evidence could help to decommission services where appropriate as part of the local prioritisation process.
NICE is undertaking a project on how to support LAs in the use of their resources, considering evidence:
- what works
- what is best value
Current NICE processes are based on cost-utility analysis with a national perspective. Advice on value for money from smoking cessation services is due to be published [date not stated and not found on NICE website]. This will need to change to take account of LAs’ perspectives. NICE expects to produce a national evidence base on evidence of effectiveness. It expects PHE to produce the more “granular” evidence to support local decision making.
There is an issue about who decides what is commissioned. Some services or issues are so important that local variation might not be permissible, e.g. abortion services as part of a comprehensive package of sexual health services. This may be managed in the short term by giving responsibility for commissioning to the NHS Commissioning Board. However, other services - e.g. drug and alcohol services - do not appear to be receiving the same degree of protection. It is possible that some services may transfer from NHS to LA [commissioning] with 2-3 year contracts - providing some short term stability.
There is a huge opportunity for local DPHs to influence the local prioritisation process. The panel could not conceive of a situation where a health and wellbeing board might ignore the advice of the DPH. The panel accepted that LA elected members are committed to doing the best they can for their communities.
Audience poll 2: Should there be a ring-fenced budget for public health?
- Yes – 94%
- No – 6%
This result was expected. It may protect public health resources to fund transferred services from being raided to fund other LA services that could be seen as public health, e.g. housing. LAs do not welcome the ring-fence, because they believe they are best-placed to make decisions for their own communities. They understand that it is intended to protect services transferred from the NHS in the short term, but they don’t like it. Some services will remain with the NHS, e.g. alcohol.
The panel discussed how PH might influence planners, and it was suggested that local public health personnel should make links with their planning departments. Section 106 funding was mentioned specifically. The “real prize” is the opportunity to influence planners in their daily role. NB: they may not have the power to force some of the changes that PH would like to see (such as preventing fast food outlets opening near schools). Some national plans override local discretion, e.g. the Olympics.
The panel is hoping for NICE guidance on spatial planning. This does not appear to be imminent.
Audience poll 3: Will the Government’s responsibility deal work?
- No – 87%
- Yes – 13%
Frank Atherton is a member of the subgroup that is considering behaviour change. The Government no longer appears to be so committed to this as a mechanism for improving health. It appears to be considering other options such as regulation and legislation, but the responsibility deal should still be part of a package. All panel members agreed. Nobody has seen the evidence base used to justify the responsibility deal. RF has not seen ministers talking about the use of regulation or legislation at a local level.
- There needs to be an integrated public health system. NICE has a role to play in this.
- This transition is a huge opportunity for public health to help LAs to take a whole life-course approach.
- It is vital to reduce inequalities between local authorities – not just within local authorities.
These will be important themes at the NICE conference in May.