A guest briefing from Jim McManus on the health secretary’s recent comments on public health commissioning
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There has been much noise on the remarks by Matt Hancock, secretary of state for health, about the idea that there may be a “take back” of some public health services to the NHS, notably sexual health, health visiting and school nursing.
Hancock talks about “moving things which are closer to the NHS” back to the NHS. If that logic stands, why should social care or child care stay in local authorities? This is a false logic.
But before we get into the merits of this, let’s discuss what the NHS plan actually says.
The plan itself talks about a review, not a shift. It says: “As many of these services are closely linked to NHS care, and in many cases provided by NHS trusts, the Government and the NHS will consider whether there is 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.” Government seem to be sending very mixed messages on this.
Jeanelle de Gruchy, the president of the Association of Directors of Public Health, has given her take on this in her recent blog and to my mind, nails it.
She wrote: “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.”
The case for this move does not stack up. Let’s consider why.
First, it’s one thing to review how joined up we are, another to reorganise at a time when the Treasury has made clear our focus should be on delivery. Making sure we’re joined up is a welcome and laudable thing. Moving deckchairs about has been an NHS default way of doing things for decades and ties us up in months of reorganisation, energy, cost and transfer for what seems entirely no gain.
Second, it is a commonplace in the health quality and outcomes literature that UK healthcare reorganises too many things too often, and always much too early before they can embed properly and deliver. Let’s not repeat that error here. We have neither money nor time for it. It is a weapon of mass distraction, not a recipe for improvement.
Third, there is no justification for this move based on outcomes. Not one shred of evidence has come from NHS England or the Department of Health & Social Care to the effect that local government has been any worse than commissioning was within the NHS. In fact, there is evidence to the contrary. Public Health England gave evidence to the Commons health committee which concluded that 80% of outcomes in public health had improved or stayed the same. Almost all of these are the responsibility of councils. This was never a drag and drop exercise.
Councils have managed a 13% increase in sexual health attendances and an overall drop in sexually transmitted infections alongside a significant move to digitisation of services while having funding cut. Imagine if Councils had the money and the duty to commission cervical screening? If you’re going to move anything, give responsibility to councils and fund it, then watch us deliver.
Let’s not make the work local authorities and providers are on track with yet another example of wasted energy. The answer here is to invest in that success and fund it properly to do more for our health, not reorganise it.
Fourth, the NHS hasn’t shown this performance. Prison health, immunisation, vaccinations and screening, especially cervical and breast cancer screening and the performance of other public health services commissioned by NHS England, have worsened. We have seen a fall in breast screening since 2013, a Commons health committee report recently slated unacceptable deterioration in Prison Health and fact cervical screening rates are at their lowest for almost two decades.
Why would you give public health services back to an agency which can’t seem to deliver on the ones it already has? We ought to be shocked by this decline – after all they haven’t seen the cuts on public health imposed on local authorities - not thinking of handing over more. Surely the focus should be on how we work together to join up and improve delivery of what the NHS already has, not adding more strain to an evidently failing commissioner.
Fifth, fragmentation is not a justification for moving. Services were all within the NHS before 2013 and there is report upon report pointing out fragmentation since 2005. I remember the old DH national support teams making clear that sexual health and child health were fragmented despite there being one commissioner. Moving responsibilities won’t solve that. It will be a massive distraction of time, energy and cost at a time when we should focus on delivery, together, across outcomes we all want to see. That can be done through shared vision and values. Or does the NHS long term plan not believe its own rhetoric on this?
Sixth, we should put energy and resource into joining up and delivery, not process. Making a move to shift services would require laying regulations before Parliament at the very least. And it ignores both the story on the outcomes and the story on the integration work councils have been doing since transfer.
Add to it that a number of national bodies representing some of the things which would be moved are saying to they don’t want this and several (council and non-council bodies) are already consulting their lawyers on judicial review options about whether the whole thing has been pre-empted, and we risk a noisy and deeply distracting mess at a time when we should be pulling together, not apart.
Seventh, there is no real appetite for this outside NHS England. A growing consensus across provider and representative agencies is that proper resourcing of public health in the spending review, not tinkering with responsibilities, is the answer. You add to proper resourcing a requirement for all commissioners to work together on outcomes and pathways and better behaviours across the system and we can resolve fragmentation without costly reorganisation and unpicking.
Eighth, the case for the 2013 transfer is stronger than ever. The rationale for the transfer in 2013 was that over 40 years the NHS had not sufficiently addressed poor health outcomes, Public Health had become the Cinderella of the NHS, and things look school nursing and sexual health were Cinderellas within that. Outcomes had not improved based on the investment put in. Budgets were raided every time there was an NHS deficit. The then chief medical officer Sir Liam Donaldson decried this in a chapter in his 2005 report saying “Raiding Public Health Budgets can Kill.”
The outcomes data and the commissioning story local authorities can tell is that this rationale is proving itself. Not one shred of evidence has been advanced by NHS England or DHSC to the contrary.
Ninth, Hancock’s own logic undermines this proposal. Hancock himself said before the select committee:
“I think it is right that the broad public health budget is held by local authorities because of the links to other local authority functions not least social care – both children’s and adult – and housing, which is very important.”
I agree. You look at any sexual health service or health visiting service and the idea that it is purely clinical and too close to the NHS is a massive simplification. Health visiting services are a crucial developmental service which sit better alongside other children’s services. To that extent most councils are busy either integrating them with family centres or have already done so. Putting them back in the NHS would just rip that apart. Working together to look at how we join up pathways is the answer, not lifting and shifting commissioning responsibilities.
Let’s look at drug and alcohol services. Hancock said the case for leaving drug and alcohol services with public health because of their alignment with social care and housing is sound. But let’s look at this closely
- · Drug and alcohol services do complex clinical work with people, both psychological, social and physical (treatments)
- · So do sexual health services
- · So do health visiting services
- · So do school nurses
Hancock’s stated logic falls. Sexual health services, health visiting services and school nurses passport and pathway people more into local authority services than NHS hospital services, even though these links are important.
In summary, this proposal simply does not stack up. Some insiders have suggested to me that what is going on here is an attempt to grab back those bits of public health which some NHS folk can understand – the clinical bits – and leave behind the bits they don’t want – drug and alcohol services and health promotion. That would worsen, not lessen, fragmentation. And it would further the trend in the NHS plan to a world where the solutions to health are entirely clinical.
What’s the goal here? Delivery or outcomes? Because this proposal delivers neither, and runs entirely contrary to the stated aim of the NHS plan. The problem is not where sexual health or health visitors are positioned. It’s the fact government doesn’t seem to want to pay for it.
Jim McManus, vice president of the Association of Directors of Public Health, Health Foundation GenerationQ fellow and director of public health at Hertfordshire CC