Wednesday, 12 December 2012

£46m Health and Wellbeing Committee for Lancashire all set to fail?

Dear Board Members,

I write with a great deal of concern for the future of health and wellbeing in Lancashire. The purpose of the Health and Wellbeing boards is to integrate health and wellbeing into local government service provision. However, the recently constituted and launched Health and Wellbeing Board in Lancashire seems to be largely comprised of clinicians, the result of which means that the Board is focused on clinical needs, not the health and wellbeing needs of the people of Lancashire.

Wrong body for these priorities

The Health and Wellbeing Board’s stated priorities are:
  1. · Smoking in pregnancy
  2. · Loneliness in older people
  3. · Affordable warmth
  4. · Early response to domestic violence
  5. · Support for carers
  6. · Alcohol liaison nurses
  7. · Identify those who are at risk of admission into hospital and provide appropriate intervention
  8. · Self-care – encourage people to take control of their own health & wellbeing
  9. · Healthy Weight – Environmental measures
  10. · Joined up support for vulnerable families (first pregnancy)
I am deeply concerned that the majority of these are clinical issues that fail to tackle the bigger issues such as obesity, poor housing, under employment that contribute to poor health and wellbeing. The result is that the Board simply functions as a crutch for the NHS in Lancashire.
Background note for readers:
One of the implications of the Health and Social Care Act 2012 is that almost half of NHS funding on public health services is to be transferred to local authorities in 2012/13. Using baseline expenditure data from 2010/11 he Department of Health have estimated that a projected £4.6 billion pounds will be spent on public health in 2012/13 and £2.2 billion of this will be spent on services that will fall in within the responsibilities of local authorities. These services are to be funded by a ring-fenced grant distributed directly to local authorities.

In February 2012 the Department of Health published their first estimation of how much might have been included in the local authority ring fenced grant for public health in 2012/13. The estimate for Lancashire was that £45.9 million would have be allocated to the local authority in 2012/13. (Source: DH Baseline spending estimates for the new NHS and Public Health Commissioning Architecture)

Please note that this is an indicative allocation of what might have been allocated in 2012/13 – the grant is not actually in existence yet -  the final allocations for 2013/14 are yet to be published. However, the indicative allocation for 2012/13 will be used to determine the eventual 2013/14 allocation.

It is not possible to make any projections of allocations for future years; they will be determined within the confines of the NHS funding settlement determined by the Government in future years and associated resource distribution formulae.
The shadow Boards proposals are important health needs, but on the whole – do not meet the test of significantly improving the health and wellbeing of the majority of people in Lancashire. I am concerned that overlap with NHS services and lack of a wider health and wellbeing focus could lead to a poorer, confused provision of these NHS/Police/Adult Social Care services.

Smoking in pregnancy should be within the scope of NHS smoking cessation services, and alcohol liaison nurses are the remit of the NHS. Loneliness in older people and support for carers are local authority matters within the remit of adult social care; affordable warmth falls under the local authority remit under the Green Deal and I am not convinced any conversation has occurred with local authorities on this matter alone. Domestic violence is a police matter, and vulnerable families is a multiagency policy area. Moreover I would state that the aims to identify those at risk of admission to hospital and to encourage self-care are incredibly vague aims that merit further explanation. The priority to mitigate cuts seems to be the overriding priority.

Wrong priorities for this body

I want to see a much broader and more ambitious set of aims; tackling obesity should be Lancashire’s number one priority and if we are to break the cycle of poor health and wellbeing a focus on early years intervention. There needs to be an increasing provision of better housing, better open spaces, better access to better recreational facilities. For too long local authorities have been left on their own to deliver these health and wellbeing services.

According to East Lancashire PCT, 31.95% of 10-11 year olds are overweight or obese. This is an absolutely shocking fact. According to the NHS’s National Obesity Observatory, there are 125 fast food outlets per 100,000 people in Hyndburn, one of the highest in the country; and according to the Health Survey for England, the adult obesity rate has increased from 17.9% to 23.9% in males (1998-2010), and from 21% to 23.5% in females.

A recent report compiled by University College London put several Hyndburn wards in the bottom 1% for heart health in the UK, with amongst the highest mortality rate in the country. Quoted in the Accrington Observer, NHS East Lancashire stated that cardiovascular disease is responsible for almost one third of all deaths in the county. The cost to the NHS of poor health and wellbeing in this Lancashire is £000,000,000’s millions.

It seems clear to me that the cost of inaction makes obesity and the related illnesses too high to ignore, and ought to be the central focus of the board. While the other priorities can be dealt with most effectively by other bodies. The Health and Wellbeing board is ideally placed for this.

Blackburn with Darwen – BeeZ Card

The Beez card is available free to people who live, work, attend full time education or who have a GP in Blackburn or Darwen. It entitles them to access leisure schemes and leisure facilities across the borough free of charge. I understand that participation rates measured by 30 minutes of cardiovascular activity rose by over 10% as a result of this bold brave and intellectual initiative. The priorities laid out by the current shadow board will never match such an outcome.

This is the kind of project that the Health and Wellbeing Board should be supporting across Lancashire. I regularly receive correspondence from constituents saying that they have family in Blackburn with Darwen who benefit from the BeeZ card, and always they ask why we do not have it in Hyndburn, or across the rest of Lancashire.

The Olympic legacy risks passing Lancashire by if a greater emphasis is not put on providing low-cost or free leisure services. The people of Lancashire want it, and it would make the greatest difference.

Urban open spaces and health town planning

The second thing we need is more focus on health lifestyles for the many, not the few for if the H&WB focus on the few as it intends, the legacy will be a costly failure and neglect of a broader need. I am very pleased that “Healthy weight – Environmental Measures” made it on to the Board’s list of priorities, however I would like to see this closer to the top of the list, with a much great emphasis put on it. It’s vagueness suggests that it is there because of it is listed in as a suggested step to improve public health under Section 12 of the Health and Social Care Act 2012 – not because it is an actual spending priority.

Those priorities are:

1. carrying out research into health improvement, providing information and advice (for example giving information to the public about healthy eating and exercise);

2. providing facilities for the prevention or treatment of illness (such as smoking cessation clinics);

3. providing financial incentives to encourage individuals to adopt healthier lifestyles (for instance by giving rewards to people for stopping smoking during pregnancy); and

4. providing assistance to help individuals minimise risks to health arising from their accommodation or environment (for example a local authority may wish to improve poor housing where this impacts on health).

It would appear to me Lancashire’s Health and Wellbeing Board priorities are not evidence based – it fails to pick up on previous government reports on tackling health inequalities. It only suggests the facilities are made available for smoking cessation. I believe these facilities exist in Lancashire (such as Health Centres in Hyndburn) and it is for CCG’s to allocate their budgets in purchasing human resources within these facilities. The third suggestion could not be directive towards the Beez card and the fourth instructs the H&WB to work with Local Councils on a wide range of services they provide in mitigating against unhealthy lifestyles.

There is a vast amount of research that points to the benefits of providing the public with places to exercise – research that I am sure you are aware of. Lancashire’s towns – particularly those that I represent – could benefit disproportionately. This is an area which the Health and Wellbeing Board is very well equipped to deal with, by working with local authorities to promote healthy spaces in our towns, and town planning which takes into account the need for spacious healthy housing. To work with local authorities responsible for drawing up plans for the Energy Company’s Obligation in their area. I suspect most clinicians being form an exclusive NHS background are totally unaware of other services and service providers that could make a real difference.

Hyndburn, as with many of the conurbations in Lancashire, is cramped and has poor provision of urban open spaces, poor housing and high rates of obesity. The NHS cannot provide parks, recreational areas and other means of getting the public involved in sport. The Health and Wellbeing Board, with its mandate to work on a cross-organisational budget, can. I urge you to seriously prioritise tackling obesity, poor housing, increase access to recreational activity, and provide universal education – and to promote - the benefits of a healthy lifestyle and leave the NHS and other services to provide specialist services.

I am also concerned that the Department of Health has published a short guide to HWBs alongside the Act which advises ‘Boards will strengthen democratic legitimacy by involving democratically elected representatives and patient representatives in commissioning decisions alongside commissioners across health and social care. The boards will also provide a forum for challenge, discussion, and the involvement of local people.’ I cannot see how Lancashire’s HWB which is made up primarily of unrepresentative elected membership (Conservatives) and clinicians, will facilitate the involvement of local people and provide a forum for challenge. I am also concerned that no MP sits on the board given this advice within the Act.

Health inequality is a huge problem in our region, the Health and Wellbeing Board has a duty to deal with it. It must be proactive, coordinated and with an emphasis on preventative systemic ways to reduce inequality in Lancashire, not simply a crutch on which other bodies lean. This risks duplication of responsibility, inefficiency, poorer outcomes and a missed opportunity to make Lancashire a genuinely more healthy place.

Yours sincerely,

Graham Jones MP



Background on the legislation

Health and Social Care Act 2012: Health and Wellbeing Boards.

The Health and Social Care Act 2012 requires local authorities to establishe health and wellbeing boards (HWBs) as a forum for leaders from the health and care systems to improve the health and wellbeing of their local population. Boards are expected to operate in shadow form during 2012-13 before taking on their statutory functions from April 2013.

HWBs are also intended to bring local democratic accountability to health services and to promote integrated working between the commissioners and providers of health services, public health and social care. The 2012 Act also sets out their role in preparing joint strategic needs assessments and a new joint health and wellbeing strategy (JHWS). The Department of Health has published a short guide to HWBs which sets out what it expects them to do:
· Health and wellbeing boards will have strategic influence over commissioning decisions across health, public health and social care.

· Boards will strengthen democratic legitimacy by involving democratically elected representatives and patient representatives in commissioning decisions alongside commissioners across health and social care. The boards will also provide a forum for challenge, discussion, and the involvement of local people.

· Boards will bring together clinical commissioning groups and councils to develop a shared understanding of the health and wellbeing needs of the community. They will undertake the Joint Strategic Needs Assessment (JSNA) and develop a joint strategy for how these needs can be best addressed. This will include recommendations for joint commissioning and integrating services across health and care.

· Through undertaking the JSNA, the board will drive local commissioning of health care, social care and public health and create a more effective and responsive local health and care system. Other services that impact on health and wellbeing such as housing and education provision will also be addressed.[1]
Section 194 of the Health and Social Care Act 2012 prescribes the minimum membership requirements for HWBs, which must include the director of children’s services, the director of adult social services and the director of public health. There must be at least one elected representative, which may be the elected mayor or leader of the council, or a councillor nominated by them. The local HealthWatch organisation and each relevant clinical commissioning group (CCG) must also appoint representatives.

Section 193 imposes a duty on HWBs to encourage integrated working between commissioners of NHS, public health and social care services for the benefit of the health and wellbeing of the local population. The HWB must provide advice, assistance or other support to commissioners of NHS, public health and social care services in order to encourage the developing of agreements to pool budgets or make lead commissioning arrangements under section 75 of the NHS Act 2006.

During the passage of the legislation the Government introduced amendments intended to strengthen the role of HWBs in relation to commissioning, in response to the recommendations of the NHS Future Forum. In particular, CCGs will have to involve the HWB in the preparation of their commissioning plans, including consulting them on whether they have taken proper account of the JHWS. HWBs also have the power to refer commissioning plans to the NHS Commissioning Board if they feel plans do not have proper regard to the strategy (it would be for the NHS Commissioning Board to decide whether to take action).

Further information on HWBs is provided by the Department of Health website:

http://www.dh.gov.uk/health/2011/10/health-and-wellbeing-boards/

http://healthandcare.dh.gov.uk/hwb-guide/

The National Learning Network for health and wellbeing boards, which is supported by the Department of Health, NHS Confederation, Local Government Association and NHS Institute for Innovation and Improvement, has been working with HWB members to develop a series of publications and online resources to share learning and support the establishment of well functioning boards. The publications can be found on the Knowledge Hub website (requires registration): https://knowledgehub.local.gov.uk and the NHS Confederation website: www.nhsconfed.org/hwb

The Department published some draft guidance on Joint Strategic Needs Assessments for consultation, in July 2012. This also provides some further information on the functions of HWBs:

http://www.dh.gov.uk/health/2012/07/consultation-jsna/

For further information you might like to look at the following:

· The Department wrote to local authorities in June 2011 outlining how the Government’s response to the NHS Future Forum will affect them:

http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_127760

· Briefings from the Local Government Association are available here:

http://www.local.gov.uk/web/10161/health-and-social-care-bill/-/journal_content/56/10161/2965509/NEWS-TEMPLATE

[1] http://healthandcare.dh.gov.uk/hwb-guide/ 


Public health functions of local authorities under the Health and Social Care Act 2012


This Library briefing provides information on local authorities’ new duties to improve public health under the Health and Social Care Act 2012. The Act will abolish PCTs and transfer much of their responsibility for public health to local authorities from April 2013. From this date the Department intends to allocate a ring-fenced public health budget to local authorities (this grant would be made under the Local Government Act 2003 so there are no specific provisions about this grant in the Act).[1]

Section 12 of the Act would give all upper-tier local authorities a duty to take appropriate steps to improve the health of the people who live in their areas (with the Secretary of State having overall responsibility for improving the health of the people of England – national public health functions would be delegated to a new executive agency called Public Health England). This section introduces a new section 2B into the National Health Service Act 2006 (the “2006 Act”). Section 12 lists some of the steps to improve public health that local authorities and the Secretary of State would be able to take. These include:
· carrying out research into health improvement, providing information and advice (for example giving information to the public about healthy eating and exercise);

· providing facilities for the prevention or treatment of illness (such as smoking cessation clinics);

· providing financial incentives to encourage individuals to adopt healthier lifestyles (for instance by giving rewards to people for stopping smoking during pregnancy); and

· providing assistance to help individuals minimise risks to health arising from their accommodation or environment (for example a local authority may wish to improve poor housing where this impacts on health).
There is also a power for local authorities to make grants or lend money to organisations or individuals in order to improve public health; it would be for the local authority to determine the appropriate of the terms of such grants or loans under Subsection 12(4).

Section 30 of the Act inserts new section 73A into the 2006 Act, the effect of which is to require each local authority, acting jointly with the Secretary of State, to appoint a director of public health; this would apply to upper-tier local authorities. PCTs are currently required to appoint directors of public health to provide local leadership and co-ordination of public health activity, this section transfers that requirement to local authorities. The intention is that the director of public health role will become integral to the new duties for health improvement and health protection that the Act confers on local authorities.

The Explanatory Notes to the Act set out the responsibilities of directors of public health (as defined under Subsection 30(1)) as including:
a) the new health improvement duties that this Act would place on local authorities;

b) the exercise of any public health functions of the Secretary of State which the Secretary of State requires the local authority to exercise by regulations under section 6C of the NHS Act;

c) any public health activity undertaken by the local authority under arrangements with the Secretary of State;

d) local authority functions in relation to planning for, and responding to, emergencies that present a risk to public health;

e) the local authority role in co-operating with police, probation and prison services in relation to assessing risks of violent or sexual offenders; and

f) other public health functions that the Secretary of State may specify in regulations (e.g. functions in relation to making representations about the grant of a license to use premises for the supply of alcohol).
Section 31 of the Act inserts new section 73B into the 2006 Act to require local authorities to have regard to guidance from the Secretary of State when exercising their public health functions; in particular this power could be used to require local authorities to have regard to the Department of Health’s proposed public health outcomes framework. The Explanatory Notes state that “the public health outcomes framework sets out the Government’s goals for improving and protecting the nation’s health and for narrowing health inequalities through improving the health of the poorest, fastest.”

The Explanatory Notes state that Subsection 31(5) and (6) would also “require directors of public health to publish annual reports on the health of their local population and that local authorities publish that report. The reports are intended to help directors of public health to account for their activity and to chart progress over time”.

The new section 73C of the 2006 Act, inserted by Section 32, gives the Secretary of State powers to make regulations setting up procedures for dealing with complaints about the exercise of public health functions by local authorities in England.

Section 29 of the 2012 Act would amend the 2006 Act so as to transfer Primary Care Trust’s (PCT) existing functions around dental public health to local authorities, and extend to local authorities a duty to help deliver and sustain good health among the prison population.

Section 237 of the 2012 Act enables provision to be made for the replication of the existing funding direction to require the NHS to fund drugs and treatments recommended by NICE technology appraisal guidance. However, as the Bill originally drafted, it would not have enabled guidance to apply to local authorities. As the legislation also make provision for local authorities to fund public health drugs and treatments, during the Lords Report stage Conservative Peer Lord Ribeiro moved Amendment 256 to permit regulations to require local authorities to comply with NICE recommendations to fund treatments under their public health functions. The Government supported the amendment and it was agreed by the House.

[1] The Government has asked an independent expert committee called the Advisory Committee on Resource Allocation (ACRA) to advise on a public health formula to inform the distribution of this grant across local authorities. The Government has said that the public health budget will continue to fund the NHS to commission certain public health services such as national screening and immunisation programmes, public healthcare for those in prison and children’s public health services from pregnancy to age 5, including health visiting.