Select committee inquiry
The role of local authorities in health issues
Closed
What the inquiry looked at
“Further information Report: Volume I (PDF 2.18 MB) Report: Volume II (PDF 507 KB) Oral evidence Terms of reference”
The committee's words, from the inquiry page on parliament.uk ↗.
What the government said
8th Report - The role of local authorities in health issues - Volume II (Volume II Additional written evidence)
No government response is linked to this report.
8th Report - The role of local authorities in health issues (Volume I: Report, together with formal minutes, oral and written evidence)
The government responded on 18 July 2013.
Read the government's response ↗ Read the report ↗ Report an error
How the inquiry ran
Each dot is a dated item listed on this page, from the inquiry's opening on 17 July 2012 to 18 July 2013.
- Report 2 reports
- Government response 18 Jul 2013
What it recommended 19 recommendations · 26 conclusions
1We welcome the return of public health responsibilities to local government and in particular: •...
Concluded (the committee's words)
We welcome the return of public health responsibilities to local government and in particular: • the introduction of Health and Wellbeing Boards (HWBs), which will count local councillors among their members and, in many cases, senior councillors as their Chairs; • the transfer of directors of public health and their teams from the NHS to local authorities; • the opportunity for local councils to focus all their activities, from education to housing, on the health and wellbeing of their local residents. These changes are part of a complex set of reforms across local government and nationally. Local authorities and, in particular, Health and Wellbeing Boards will have to work hard to involve local people in their work, and we expect that the operation of the new arrangements will be reviewed by a select committee in two years’ time.
2We conclude that the successful operation of Health and Wellbeing Boards is crucial to the...
Concluded (the committee's words)
We conclude that the successful operation of Health and Wellbeing Boards is crucial to the new arrangements. Boards should aim to be creative by including where possible those individuals with responsibility for the social determinants of health, including those working in education, planning and economic development. The obvious danger with the new Boards, however, is that the initial optimism surrounding their establishment and first year or two in operation will falter and go the way of previous attempts at partnership working that failed and became no more than expensive talking shops. To succeed, Health and Wellbeing Boards will need to work on the basis of relationships and influence, and this will depend on both people and structures. This can be a strength, as it will, for example, allow for local discretion over Board membership, but also a weakness, because a Board will have few demonstrable powers with which to require council departments, clinicians and the local arms of national bodies to adhere to its strategic priorities, as set out in its Joint Health and Wellbeing Strategy. Local authorities will need to rely not only on the organisations and structures that they create, but on the relationships that they develop with individuals and groups if they are to grasp this opportunity and work effectively with these partners. This is the right approach but could make demands on local authorities’ leadership and relationship-building skills.
3Local authorities should use the limited central prescription on their Health and Wellbeing Board membership...
Concluded (the committee's words)
Local authorities should use the limited central prescription on their Health and Wellbeing Board membership in combination with their influence across the local community, to work with a range people and bodies most closely linked to their areas’ health needs and objectives. They might do this either by including them on 76 The role of local authorities in health issues the main Board or by creating a range of other relationships. These can be informal, through the cultivation of partnerships with, for example, the voluntary sector, or formal, with the development of Health and Wellbeing Board sub-committees, partnership bodies, and community groups.
4Health and Wellbeing Boards have been given a substantial mandate to encourage integrated working between...
Concluded (the committee's words)
Health and Wellbeing Boards have been given a substantial mandate to encourage integrated working between the NHS and public health and social care services. They also need to maintain a strategic and balanced outlook on their new responsibilities, focusing on promoting the health of their local population, rather than becoming exclusively preoccupied with the detail of health and social care commissioning and integration. Given that people are living longer and the cost of health care is rising, Boards will need to draw on the public health, clinical and social care expertise of their members to promote healthy and independent living among all age groups, young and old, if they are fully to take advantage of the opportunity provided by their creation to embed health promotion and disease prevention in all local services.
5Given the Health and Wellbeing Board’s pivotal role in the new local health system, as...
Recommended (the committee's words)
Given the Health and Wellbeing Board’s pivotal role in the new local health system, as the forum for local government, the NHS, the public and providers, each Board must be held accountable for its work. But it is unclear whether HWBs will be held responsible for health outcomes in an area. We have heard differing accounts from Communities and Local Government and Health Ministers as to how or, indeed, whether they will be. Accountability clearly cannot take place just through the election of the Board’s local councillors, and this seems to be an area of real confusion. The questions are, what are HWBs to be accountable for, given their lack of powers; and, what sort of accountability is appropriate: democratic, procedural or financial? We were concerned also by the suggestion that the Director of Public Health, a member of the Board, would inform the scrutiny committee if the Board were performing poorly. This would place Directors of Public Health in an invidious position, and we therefore do not consider this to be a satisfactory or robust mechanism to hold Boards to account. We recommend that the Government clarifies the procedures for holding Health and Wellbeing Boards to account, including the role it expects local overview and scrutiny committees to play and the role of the Director of Public Health, given their position as a Board member. Directors of Public Health should also report directly to the local authority’s chief executive, and we urge the Government to reassert its understanding of this point, too.
6We have heard about the importance of people having a voice in the development of...
Recommended (the committee's words)
We have heard about the importance of people having a voice in the development of local services, but Local Healthwatch, the organisation intended to give people such a voice locally, has not been established consistently throughout the country. Its development has been variable, and the establishment of strong and properly resourced Healthwatch bodies must be made a priority as local authorities and their The role of local authorities in health issues 77 Health and Wellbeing Boards take on their new responsibilities in April 2013. We call on Healthwatch England and the Government to work with local authorities to ensure that a Local Healthwatch representative is available to take part in the deliberations of every Health and Wellbeing Board throughout the country by the end of the year.
7Health and Wellbeing Boards are an innovation.
Concluded (the committee's words)
Health and Wellbeing Boards are an innovation. While there are some guidelines in place, there is no template to follow and all HWBs are different. They will, however, need advice, guidance and evidence of best practice, as county councils and municipalities in Sweden have found. The job of providing this material will be in part for the renamed National Institute of Health and Care Excellence, which will have a remit to work more closely with local authorities, including from April 2013 on quality standards for social care. There will also be a role for Public Health England, as yet undefined. With its staff and resources derived in part from the NHS, it may not initially have the capacity or expertise to advise local authorities. Local government should therefore look not only to NICE and Public Health England, but to itself. As the reforms bed in, local authorities should seek out support and improvement among themselves, including, for example, through the Local Government Association’s Knowledge Hub resource.
8The NHS Commissioning Board, as the commissioner of primary care and significant public health services,...
Concluded (the committee's words)
The NHS Commissioning Board, as the commissioner of primary care and significant public health services, will have a major influence over the way in which health care is prioritised locally, but its status in relation to Health and Wellbeing Boards is unclear, its interaction with other health bodies is complex and it lacks local accountability. We do not wish to prescribe membership of Health and Wellbeing Boards, and we recognise that, for now at least, Health and Wellbeing Board members will have to work together to establish constructive relationships with as many relevant bodies locally as possible. We therefore urge Boards to work closely with their NHS Commissioning Board Local Area Teams at all times, not simply when discussing their Joint Assessments, Joint Strategies and the NHS Commissioning Board’s own commissioning plans. The best way to address these concerns would be to work face to face with the NHS Commissioning Board on a regular basis.
9There is no requirement for the NHS Commissioning Board and its Local Area Teams to...
Recommended (the committee's words)
There is no requirement for the NHS Commissioning Board and its Local Area Teams to adhere to a Health and Wellbeing Board’s Joint Health and Wellbeing Strategy, and there is no mechanism to hold them to account for their actions. In effect, the co-ordination of local strategies will rely on the pragmatism of local bodies, including the NHS Commissioning Board’s Local Area Teams. The Health and Social Care Act 2012 includes a duty on the NHSCB to “have regard” to the Joint 78 The role of local authorities in health issues Health and Wellbeing Strategy, but what this means in practice is unclear. We call on the Government to set out in detail what Health and Wellbeing Boards can do if the NHS Commissioning Board subsequently fails to commission services consistent with these strategies. We also ask the Government to clarify what the duty on the NHSCB to “have regard” to a Joint Health and Wellbeing Strategy means in practice.
10Health and Wellbeing Board meetings should be attended by a representative of the NHS Commissioning...
Concluded (the committee's words)
Health and Wellbeing Board meetings should be attended by a representative of the NHS Commissioning Board when Clinical Commissioning Group commissioning is under discussion. Indeed, they should be attended by a representative of the national body, given its prominent role in local health matters, whenever required.
11We are grateful to the Government for clarifying that the NHS Commissioning Board can direct...
Recommended (the committee's words)
We are grateful to the Government for clarifying that the NHS Commissioning Board can direct a Clinical Commissioning Group if it fails to discharge its functions of working with local authorities to develop a Joint Strategic Needs Assessment and a Joint Health and Wellbeing Strategy. We urge Health and Wellbeing Boards to refer cases to the NHS Commissioning Board and it, where necessary, to make full use of this power to direct. But this does not deal with the action that can be taken if a CCG fails to take account of a Joint Health and Wellbeing Strategy in its commissioning. We ask the Government to clarify what action can be taken if a CCG fails to commission services in accordance with a local Joint Health and Wellbeing Strategy.
12The importance of the Joint Strategic Needs Assessment should not be underestimated, as it will...
Concluded (the committee's words)
The importance of the Joint Strategic Needs Assessment should not be underestimated, as it will form the basis for the Joint Health and Wellbeing Strategy, one of the more critical health promotion measures any local authority will be involved with in terms of potential impact. The significance, resources and expertise attributed to both the assessment and the strategy will have a major bearing on the success of an individual authority’s local health care work, and that of the local NHS, at least in the short term. The Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategy must not therefore be viewed as tick-box forms to be produced and filed; they must be living, breathing documents to which all local health partners willingly contribute and adhere. Local authorities should look to innovative approaches, such as we saw in Kent, to use their assessments and strategies as an opportunity to devolve power and to identify local-level activity through which they can improve health and wellbeing in specific places, among certain groups of people and throughout their local area.
13Any joint assessments and strategies will only be as good as the information on which...
Recommended (the committee's words)
Any joint assessments and strategies will only be as good as the information on which they are based, but there is ignorance and misunderstanding of the current The role of local authorities in health issues 79 information-sharing arrangements. If strategies are to be based on sound evidence, the Government must involve the Information Commissioner in clarifying what data local authorities and the NHS can share. This should be done by the end of this year, so that authorities have time to use any new guidance in the development of assessments and strategies for 2014–15. We recommend that Public Health England publicise widely guidance on how local authorities can manage their data and information.
14Health and Wellbeing Boards will need to make themselves accessible to, and work closely with,...
Concluded (the committee's words)
Health and Wellbeing Boards will need to make themselves accessible to, and work closely with, the voluntary and community sectors and other providers not only to deliver services, but to draw on the valuable statistics and information that these groups can supply. We expect that local authorities, the Local Government Association and the Government itself will draw lessons from the four pilot areas establishing the readiness of these sectors. These lessons must be disseminated as soon as possible, so that, first, local government can work out how to create structured arrangements with the potential partners, including through community sector boards, and, second, each has a defined role in the creation of Joint Assessments And Strategies.
15Local authorities will need to collect more data on the people for whom they provide...
Recommended (the committee's words)
Local authorities will need to collect more data on the people for whom they provide services, and link that data to the development of strategies. There is, however, a lack of specialist analytical staff in local authorities to turn those data into strategies. We recommend that local authorities and the Government keep under review the role of staff in Commissioning Support Units to ensure they are sufficiently public-health focused and councils have access to an adequate number of public health analysts. They should also consider how staff from Public Health England’s local centres might assist in any local analysis.
16Conveying to different audiences—chief executives, councillors, providers and local residents—in clear and simple terms ‘the...
Concluded (the committee's words)
Conveying to different audiences—chief executives, councillors, providers and local residents—in clear and simple terms ‘the story’ of public health in their area will be vital if individuals are to engage in the improvement of their own wellbeing. This may amount to talking about population health in terms of enabling people to live longer lives of greater quality, and devising campaigns that highlight the role clinicians might play in identifying a particular health need. The way in which information from the Joint Strategic Needs Assessment is communicated to people will play an important part in maintaining the momentum gathering behind Health and Wellbeing Boards and in ensuring that they succeed. There will be a significant role for the Director of Public Health, who will be able to present ward-level data to ward-level councillors, and councils will themselves need to instigate training to ensure their councillors take advantage of these new arrangements.
17Given that Health and Wellbeing Boards will be required to use their influence to ensure...
Concluded (the committee's words)
Given that Health and Wellbeing Boards will be required to use their influence to ensure their health and wellbeing strategies are transformed into commissioned services, they will need to learn how to capture the imagination of councillors, commissioners and their communities. Local authorities, the Local Government Association, the District Councils’ Network and Public Health England should develop the skills required to communicate public health issues and ensure locally elected representatives, Board members and public health staff have access to such training when required. In order to convey to colleagues and residents what their local needs are, and how the Board intends to deal with them, local authorities should seek a Plain English Campaign endorsement of their Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies.
18District councils are responsible for many of the services that have a direct impact on...
Concluded (the committee's words)
District councils are responsible for many of the services that have a direct impact on the health and wellbeing of their residents. We accept that the omission of these lower tier authorities from Health and Wellbeing Boards and from participation in the Joint Health and Wellbeing Strategy was a potential cause for concern, but we have seen in practice that it has prompted some county councils to make their own arrangements to include district councils. This is entirely appropriate and welcome. County councils might develop a formal compact to devolve some decision making so that districts are recognisably involved in public health matters, or create local HWBs, forums or sub-groups to enable district councils to work more easily with local Clinical Commissioning Groups. We encourage all county councils to develop agreed working arrangements with district councils.
19We consider that all upper tier councils, including unitary authorities, should set an example to...
Concluded (the committee's words)
We consider that all upper tier councils, including unitary authorities, should set an example to central Government by demonstrating and embedding effective localism themselves. They can do so by devolving certain responsibilities and, where possible, budgets to councillors and committees at ward and area levels. All authorities should look to each other, including through the Local Government Association, for peer support and mentoring. They should also explore the powers and information currently at their disposal, through mechanisms such as the Joint Strategic Needs Assessment and the Joint Health and Wellbeing Strategy, to describe the health situation at ward level and to include local councillors and, therefore, communities in decision making.
20We acknowledge the importance of housing in determining people’s health and wellbeing.
Concluded (the committee's words)
We acknowledge the importance of housing in determining people’s health and wellbeing. It is important that this service is included in the ‘voluntary’ arrangements we have described. We suggest that councils explore ways to include housing in their work, either by establishing housing sub-groups of their main Health and Wellbeing Board or by addressing housing in their Joint Strategic Needs Assessment, Joint Health and Wellbeing Strategy and when reporting on progress with public health outcomes.
21We are concerned to ensure that the new responsibilities for health and, in particular, public...
Recommended (the committee's words)
We are concerned to ensure that the new responsibilities for health and, in particular, public health are not monopolised by senior councillors and the local authority executive; all councillors in an authority must play a part at all levels, including framing strategy. The role of the Clinical Commissioning Group involves the establishment of overarching priorities to improve the health of local people, not purely clinical decisions such as choosing which drugs and procedures should be used. While one purpose of health care reform is to remove politicians from day-to- day clinical decision making, the purpose of localism is to bring decision making closer to local people, to make it accountable to local people and to allow local people to develop the relationships that work for them locally. It is not clear to whom Clinical Commissioning Groups are intended to be accountable, and we were not entirely persuaded by Ministers’ arguments for not allowing councillors to sit on Clinical Commissioning Group Boards. We do not intend to press for the inclusion of locally elected representatives on these boards; instead we recommend that they are not specifically excluded. In the spirit of localism, such issues should be left to local resolution.
22Local authorities, if they are to grasp fully the opportunity afforded to them by the...
Concluded (the committee's words)
Local authorities, if they are to grasp fully the opportunity afforded to them by the return of public health, will need to look beyond those services traditionally considered to be “public health”, such as health protection, health promotion and disease prevention, and tackle the causes of the causes of poor health, working with local partners and using all the powers, personnel and services at their disposal. The evidence we received makes it clear that people, particularly in vulnerable groups, are more likely to exhibit a range of unhealthy behaviours. Single initiatives targeting individual lifestyle choices, such as drinking or smoking, have been shown not to work, especially among people at the lower end of the social gradient of health. Authorities should be willing to take one step back from treatment to look additionally at by-laws, education campaigns and how to involve, for example, GPs, pharmacies or debt management and housing services in a more holistic attempt to deal with the multiple reasons behind complex health problems.
23Local authorities will of course wish to base their public health work on their Joint...
Concluded (the committee's words)
Local authorities will of course wish to base their public health work on their Joint Strategic Needs Assessments, but we note how several councils have placed early years interventions—literacy, readiness for school and childhood obesity programmes—high on their list of priorities. We commend authorities to bear this in mind when making their decisions, given the importance of early years development in people’s later health and wellbeing.
24We are pleased that local authorities are looking at the evidence and adopting an evidence-based...
Recommended (the committee's words)
We are pleased that local authorities are looking at the evidence and adopting an evidence-based approach to health and wellbeing. Evidence shows that being and 82 The role of local authorities in health issues staying in work has a significant effect on a person’s health and wellbeing; unemployment is one of the causes of the causes of poor health. It follows that a strategy to combat worklessness might be one of their public health initiatives from April 2013. This requires the Government and, in particular, the Department for Work and Pensions to adopt a more localist approach and to devolve more powers to councils, as we said in a report back in 2011. We note that local authorities already support apprenticeships and back-to-work schemes, but the Government should consider devolving to local government further measures, including elements of the Work Programme, in order to address at a more local level unemployment and, in turn, one reason why people may adopt unhealthy lifestyles.
25Some public health issues, such as alcohol misuse and obesity, may require central Government leadership...
Concluded (the committee's words)
Some public health issues, such as alcohol misuse and obesity, may require central Government leadership and action, including legislation, if a big difference is to be made to the health of local people. Central Government action will not be a panacea, but to effect change local authorities may require the support of complementary national-level initiatives to make the most of their own strategies, powers and influence. In the meantime, councils do have options available to them, including, setting up or expanding local Public Health Responsibility Deals, with local businesses, on which Government guidelines were published in January 2013. What is clear is that there is no single solution; multiple solutions will be required to deal with the multiple causes of unhealthy behaviour.
26Since the disbandment of the Cabinet sub-committee on public health, public health issues fall to...
Recommended (the committee's words)
Since the disbandment of the Cabinet sub-committee on public health, public health issues fall to be discussed and decisions taken in domestic policy committees. We note also plans within the Department of Health to engage with the Home Affairs policy committee, and the discussions that the Department has already had with the Department for Education, which should be encouraged elsewhere in government. Policy alignment nationally will assist councils’ efforts to improve health and wellbeing locally and avoid the potential for mixed messages. Given the way in which local health issues span at least two Departments, Health and Communities and Local Government, local authorities need confidence in their contact with Government. In the spirit of close working throughout government, both centrally and locally, we recommend that the Department of Health and the Department for Communities and Local Government set up a single point of ministerial contact to which local authorities can turn for support in their new health care role.
27The transfer of functions from central to local government during the relocation of responsibilities for...
Concluded (the committee's words)
The transfer of functions from central to local government during the relocation of responsibilities for public health must not become an end in itself. Local authorities will need to provide within an agreed period evidence of an improvement in the health and wellbeing of their population. With these new powers comes the responsibility to deliver results, and local authorities will need to balance local and The role of local authorities in health issues 83 national objectives and short-term and long-term aims. Given the complex, multi- faceted nature of the social determinants of health, however, determining the success of general—population-wide—or specific initiatives will be difficult, time-consuming and may ultimately distract those working on them from making progress. Short- term success can be demonstrated relatively quickly, and without distracting from longer-term objectives, by, for example, improvement in readiness for school rates, the number of NEETs (those not in education, employment or training) in a local area and by all Health and Wellbeing Board members working to increase patient registration with GPs in order to identify those with long-term conditions and to prescribe treatment for them.
28Good local authorities may already be tackling the difficult challenges posed by unhealthy people and...
Concluded (the committee's words)
Good local authorities may already be tackling the difficult challenges posed by unhealthy people and communities, so in the short term at least it would be unfair and possibly counter-productive to start “naming and shaming” councils without taking into account historical and demographical factors. With Public Health England in its infancy it makes sense to restrict its role to that of critical friend. On matters of scrutiny and regulation, local authorities should not hide behind a national body such as Public Health England. We encourage them, in the spirit of localism, to take responsibility for these issues themselves, through overview and scrutiny committees and Local Healthwatch.
29Surveys—self-assessments—are a useful measure of wellbeing: they quantify the less specific but no less important...
Concluded (the committee's words)
Surveys—self-assessments—are a useful measure of wellbeing: they quantify the less specific but no less important objectives of independence and social participation, and they engage individuals in the development of their own wellbeing. Councils might make such surveys one aspect of agreeing their contracts with voluntary groups.
30In previous chapters, we have remarked on the need for local authorities to develop sound...
Recommended (the committee's words)
In previous chapters, we have remarked on the need for local authorities to develop sound working arrangements with health partners based on trusted relationships, leadership, persuasion and influence, but, when it comes to protecting the population in the event of a health emergency, those involved need to know unambiguously what their role is, understand who is in charge and have in place clear lines of accountability. Despite the assurances of Public Health England and of the Department of Health, we heard from witnesses who were still unclear about the details of this vital new responsibility, including who would be in charge locally in the event of a regional or national outbreak. This is a worrying state of affairs so late in the transition process. We therefore recommend that the Government sets out clearly and unambiguously the lines of responsibility, from Public Health England down to public health staff in local authorities, and confirms that Public Health England will have sufficient staff throughout the country to assist in the local and regional, as well as national, responses, in the event of a health emergency. We note that four contingency exercises have been planned before April 2013 but, to ensure that 84 The role of local authorities in health issues local authorities throughout the country are not only aware of, but practised in, the new procedures, we call on the Government to work with them to organise a continuing programme of such exercises.
31The inclusion of the NHS Commissioning Board and its 27 local area teams in the...
Recommended (the committee's words)
The inclusion of the NHS Commissioning Board and its 27 local area teams in the health protection system, with its role in mobilising the NHS in the event of an emergency, and combined with the 39 Local Resilience Forums and 15 local Public Health England centres, adds a further layer of complexity and introduces potential variation to the new arrangements, with all the attendant risks. Local authorities will need to be completely clear about whom they speak to in the NHS locally in the event of an emergency, so we reiterate our recommendation that the Government and the NHS Commissioning Board ensure that these relationships are made unequivocally clear to public health staff in local government.
32We acknowledge the legal issues, raised by the Department of Health, which might arise from...
Concluded (the committee's words)
We acknowledge the legal issues, raised by the Department of Health, which might arise from giving local Directors of Public Health a similar duty to the Secretary of State to protect the health of the population, but our main concern is with the practicalities. Given the importance that the Government has attached to the role of the Director of Public Health, it must make sense to include them as fully as possible in ensuring, rather than simply advising on and promoting, adequate preparation for local health protection arrangements. The Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) Regulations 2012 risk diminishing the authority of the Director of Public Health and creating delays while concerns about local preparedness are taken to Public Health England. We therefore recommend that the Government review these regulations, in order to enhance with identifiable authority the power, respect and status that the Government suggest should be accorded to Directors of Public Health.
33We heard serious concerns about the new arrangements for screening and immunisation, particularly the fragmentation...
Recommended (the committee's words)
We heard serious concerns about the new arrangements for screening and immunisation, particularly the fragmentation of staff and organisations responsible for these services. We accept that local authorities will be able to work with the 27 NHS Commissioning Board Local Area Teams, but as we have already noted―there are concerns about the ability of local government to influence the Board’s decisions. In addition, when it comes to screening and immunisation there are additional concerns about the number of bodies the Director of Public Health will have to work with, and the Board’s ability to reflect local diversity and to reach into local populations as effectively as local authorities can. We urge the Government and the NHS Commissioning Board to listen to local authorities, to respond to their calls for reassurance and we recommend that the Government reviews the arrangements with a view to devolving these services to public health staff within local government.
34Given the importance of early years interventions, and the reach that local authorities have into...
Recommended (the committee's words)
Given the importance of early years interventions, and the reach that local authorities have into their communities, the Government should work with councils on devolving further responsibilities for children’s public health, such as the Healthy Child programme, to local government—and guarantee at least that responsibility for health visiting will be transferred to local authorities in 2015, or when the target for increasing health visitors has been met, whichever is earlier. The Government should, as part of a general move to locate children’s public health services in local government, also agree to a timescale for placing childhood immunisation services under the control of Directors of Public Health, in acknowledgement of their previous responsibility for this area and of the pivotal position that they now occupy in local public health provision.
35We welcome the increase—when compared with the draft interim allocation—in public health funding to local...
Concluded (the committee's words)
We welcome the increase—when compared with the draft interim allocation—in public health funding to local authorities. We recognise that to create a public health budget where none has previously existed, to finalise a formula and to consult with all those affected is not a task to be taken lightly or rushed, but the 11 months required to complete the final allocations process, with totals being announced on 10 January 2013, only 79 days before health responsibilities transferred from the NHS, left local authorities with a great deal of work to do in a short period. Local government understandably planned for the worst based on the interim February 2012 and June 2012 allocations, and, while the subsequent increases are welcome, the delay caused some problems for local authorities and their budgeting arrangements.
36Given that local authority public health budgets have now been set for 2013–14 and 2014–15,...
Concluded (the committee's words)
Given that local authority public health budgets have now been set for 2013–14 and 2014–15, the Government has time to plan with local government a managed approach to allocating the budgets for 2015–16. We therefore recommend that the Government puts in place a timetable for publishing and consulting on the 2015–16 allocations with a view to finalising them by October 2014, so that commissioners and providers have at least six months in which to plan strategically the services that will contribute most effectively to local people’s health and wellbeing in 2015–16.
37We acknowledge that the current formula is an improvement on the interim model and allows...
Concluded (the committee's words)
We acknowledge that the current formula is an improvement on the interim model and allows local authorities to target pockets of deprivation in their areas. We note the perverse incentive in the medium term, however, of basing funding on improved health outcomes, given that areas which perform well risk having their funding reduced. Public health is not short of data, and it should be possible under the new arrangements to begin to base funding on observable trends in health locally and— using Joint Strategic Needs Assessments, for example—for local government to use its allocations in a more precise manner. This places a responsibility on councils and 86 The role of local authorities in health issues their Health and Wellbeing Boards to produce comprehensive and rigorous Joint Strategic Needs Assessments.
38We recommend that the Government not only ensures the Advisory Committee on Resource Allocation (ACRA)...
Recommended (the committee's words)
We recommend that the Government not only ensures the Advisory Committee on Resource Allocation (ACRA) makes good on its commitment to review the allocation formula, but clarifies the timetable for revising it—and whether this means a revised formula in time for the 2015–16 allocations. Just as local authorities need to know well in advance when budgets will be published, they require also some certainty about the formula that will be used to calculate them.
39The Government’s approach to public health funding leading up to and after 2015–16 seems confused...
Concluded (the committee's words)
The Government’s approach to public health funding leading up to and after 2015–16 seems confused and should be clarified. It says it has no timetable for modifying the current funding formula, but accepts that, given the impact of the Health Premium, the formula will need to be developed in 2015–16. Local authorities will need to know, first, when they can start planning their budgets for 2015–16, second, when the Government intends to redevelop the funding formula, and, third, that any system of reward will complement their main source of funding.
40The Government has acknowledged that the perverse incentive in the current funding formula would be...
Recommended (the committee's words)
The Government has acknowledged that the perverse incentive in the current funding formula would be particularly marked if it were still in place when the Health Premium was introduced. This suggests that the current funding formula and possibly the Premium need to be revised. A funding system which at the same time disadvantages and rewards improvements in public health cannot be fit for purpose. The Government has said that 2015–16 will be a key year in the development of the formula. We recommend that a parallel system of reward should not be implemented in the same year. It should be delayed until the funding formula has been redesigned.
41The costs of demand-led services, such as sexual health provision, are increasing and in some...
Recommended (the committee's words)
The costs of demand-led services, such as sexual health provision, are increasing and in some cases could account for a considerable proportion of the public health ring- fenced grant from April 2013. It has been argued that the current formula fails to account adequately for the cost of these services, and we have received evidence detailing alternative funding criteria that might correspond more accurately to the care that local authorities have been mandated to provide. The Advisory Committee on Resource Allocation, while acknowledging these concerns, maintained that no immediate alternative appeared to work across the country. We recommend that the Government and the advisory committee, as part of their commitment to keep this area under review, consider alternative formulas for calculating the overall ring-fenced grant, such as the index of multiple deprivation, and how such allocations might take better account of local circumstances.
42We call on ACRA and the Government to work with local authorities on the issue...
Recommended (the committee's words)
We call on ACRA and the Government to work with local authorities on the issue of non-residents’ use of demand-led services. Given that many people work or go out in The role of local authorities in health issues 87 one borough and live in another, people’s use of services in this way should not be underestimated. Attempting to resolve that either by pooling resources or by re- charging has the potential to become complicated and contentious.
43We urge local authorities and the Government to explore innovative approaches to funding public health...
Recommended (the committee's words)
We urge local authorities and the Government to explore innovative approaches to funding public health services. One route might be to determine the actual cost locally of demand-led services and to separate funding for them from the rest of the public health budget. The remaining public health provision could then be determined using a formula, such as the standard mortality ratio, and either continue to be ring fenced or stand apart from the rest of the authority’s budget. Alternatively, the remainder might, as witnesses suggested, correspond to the remainder of the local authority’s overall budget and become in all but name a community budget.
44We agree with the Department of Health that, although funding mechanisms are important, shared objectives...
Recommended (the committee's words)
We agree with the Department of Health that, although funding mechanisms are important, shared objectives on how the money is spent are crucial. While the Department for Communities and Local Government recognises that local government does not like ring-fenced grants, we accept that, at least in the short term, some ring-fencing may be needed. But this should not become a permanent feature of the public health funding system in England. The Department of Health says it wants to learn from the Community Budget pilots on health and social care. We urge the Department of Health to work with the Department for Communities and Local Government and to share that learning as soon as possible, in order to clarify what funding mechanism will be proposed for the financial year 2015–16 and beyond—with a view to removing the ring fence and moving to community budgets. In addition, we urge the Government and, in particular, the Department of Health to recognise that if public health is to become an overarching priority for all local authority departments, it will require an overarching budget which reflects that approach. If the evidence from the completed Total Place and ongoing Community Budgets pilots continues to point to their effectiveness, we recommend the Government provides local authorities with community, place-based, budgets for the direction of resources at people and places rather than at organisations.
45There is also a role for Health and Wellbeing Boards to play, given their duty...
Concluded (the committee's words)
There is also a role for Health and Wellbeing Boards to play, given their duty to encourage integrated working, by devising joint strategies that allow local authorities to use existing levers in the final funding settlement to pool public health budgets with those of other departments and across authorities, thereby demonstrating to central Government how shared resources can improve outcomes. In this endeavour, Directors of Public Health will remain central to the budgeting process if and when the ring fence is removed.