Written evidence submitted by the UK Faculty of Public Health (HSC0026)
The UK Faculty of Public Health (FPH) is a joint faculty of the three Royal Colleges of Physicians of the United Kingdom (London, Edinburgh and Glasgow). We are a membership organisation for approximately 4,000 public health professionals across the UK and around the world and our role is to improve the health and wellbeing of local communities and national populations. We do this by supporting the training and development of the public health workforce and improving public health policy and practice in partnership with local and national governments in the UK and globally.
The Department of Health and Social Care published proposals for new legislation in February 2021. The white paper largely focuses on the organisation of the NHS in England, but also contained more limited proposals on social care and public health, with the major changes to be implemented from 2022. The four main strands of the white paper were:
This paper will look at each of these briefly.
Working together and supporting integration
The white paper sets out a proposal to establish integrated care systems (ICSs) as statutory bodies in all parts of England. The ICSs will be made up of two parts – an ‘ICS NHS body’ comprised of the different NHS bodies required to collaborate and an ‘ICS health and care partnership’ comprised of the NHS and local government, along with the wider stakeholders with whom the NHS works (e.g. voluntary/third sector).
The Faculty strongly supports the drive to integrate care systems and reduce barriers to effective collaboration, although health reorganisations of the past have shown that changing cultures can be harder than changing the architecture and making the ‘neural connections’ in a new system a much longer task. FPH has previously indicated its support for the statutory footing proposed for ICSs but we note, in the context of a major reorganisation of the public health system, the need to maintain a robust and well-resourced national, regional and local structure for public health as the most effective way to improve population health outcomes. The new arrangements for the public health system have not yet been fully explained so it is unclear where the new arrangements will sit within an integrated system. The last 12 months has shown that public health must be central to the operation of an effective health system, not a ‘bolted-on’ component with barriers to effective partnership working and all parts of the proposed ICS NHS body should have access to specialist public health expertise.
The move away from a focus on internal competition is welcome, along with the emphasis on collaboration, partnership, and integration. The recognition of different requirements in areas and populations, and the possibility of different models to address these requirements is welcome, if the ICSs have clear accountability to local populations, and not just the centre.
This section of the white paper contains a number of proposals aimed at changing how competition law applies to the NHS, how procurement works and how the payment system operates, including the removal of the Competition and Markets Authority’s (CMA) role in reviewing NHS and removing NHS Improvement’s competition functions.
As noted above, the Faculty welcomes a shift in focus away from competition and towards co-operation and collaboration. The COVID-19 pandemic has highlighted the extraordinary ways the health and social care system is able to work together and legislation to further enable this is to be encouraged. It is also important that any new approach encourages a diversity of providers, including the voluntary and charity sectors, who play such a vital role in delivering health and care services.
Enhancing public confidence and accountability
The white paper sets out proposals to merge NHS England and NHS Improvement and for broad intervention powers for the Secretary of State over the functioning of the NHS, including the powers to direct NHS England in relation to ‘relevant functions’ and transfer functions to and from arms’ length bodies (ALBs) and abolish ALBs.
FPH welcomes the proposals to place NHS England and NHS Improvement on a statutory footing as a single organisation and this is a logical and coherent step forward. In relation to the Secretary of State’s powers in respect of direction of NHSE/I, local configurations and ALBs, we expect these to generate some debate over the rationale and the circumstances in which they might be used. Similarly, allowing the Secretary of State to intervene at any stage of a reconfiguration process may increase ministerial involvement in operational issues and risks politicising reconfiguration decisions.
Legislation to provide the professional regulators with more flexibility to make changes in the way they operate has been long anticipated and we look forward to seeing greater clarity on the mechanisms to add a profession into regulation. From a public health perspective, it is vital that consultants and specialists in public health, regardless of background, continue to be registered and regulated to maintain the high professional standards in the specialty.
There are specific proposals in the white paper relating to workforce, including a proposal to place a new duty on the Secretary of State to publish a document on workforce planning every parliament (every five years).
Given the longstanding nature and the scale of the workforce challenges across the health and social cares sectors, public health included, we feel this commitment should be further strengthened. Effective workforce planning is highly complex and demands transparency around existing workforce data, along with a broad consensus on the workforce requirements in specific staff groups and across the workforce. The Faculty has advocated for:
The commitment in the white paper to legislate to ensure a more agile and flexible framework for national bodies that can adapt over time also needs to be matched by a commitment to support flexibility in the workforce. Maintaining an effective and flexible health and care workforce requires staff to be able to move between employers during their career without detriment. Removing bureaucratic barriers, such as loss of continuity of service, needs to be addressed urgently.
Delegated powers for screening and immunisation
The white paper proposes a new power for the Secretary of State for Health and Social Care to require NHS England to discharge public health functions (often referred to as ‘section 7A services’) such as national immunisation and screening programmes. While broadly welcoming of this proposed power, the Faculty believes it is critical to have experienced public health leadership of both screening and immunisation programmes and any legislation should reflect this.
The white paper also sets out a range of specific and targeted proposals relating to social care, public health, and quality and safety, to ‘support the health and care system to recover and reform’. Other organisations will be better placed to comment on the measures set out relating to social care and quality and safety, so the observations of FPH are restricted to the public health measures in the paper.
The white paper sets out plans to implement the Government’s obesity strategy, by introducing new strengthened food labelling requirements, mandatory alcohol calorie labelling and further restrictions on advertising products high in fat, sugar or salt being shown on TV before 9pm.
Obesity is one of the biggest health problems this country faces. The number of children admitted to hospital for obesity and related conditions has quadrupled in the last decade and obese children often leads to obese adults, with a higher risk of heart disease, type 2 diabetes, several types of cancer and fatty liver disease, and premature death. Obesity starts in childhood and is rooted in inequality and these inequalities have been exposed and exacerbated by COVID-19. The Faculty welcomes the measures in the white paper and has previously called for tighter controls on the advertising of HFSS foods. We also note benefits of the minimum unit pricing of alcohol in Scotland and would urge the government to consider a similar measure in England.
The white paper notes some of the challenges local authorities have encountered in exercising their power to propose and consult on new fluoridation schemes and varying and terminating existing schemes. It is proposed to give the Secretary of State these powers in relation to fluoridation schemes. Given the role that tooth decay and poor oral health has in causing hospital admissions amongst young children, FPH supports ensuring adequate fluoride supplementation in water supplies to prevent tooth decay in areas that have high levels of tooth decay. However, water fluoridation must not be imposed on communities without their consent and such schemes should only be introduced as part of a wide public consultation. Other measures to prevent tooth decay would also be supported by FPH, such as the promotion of tooth brushing and use of fluoride toothpaste.
Public health post-COVD-19
The public health measures that are in the white paper are generally welcome and will contribute to the health and wellbeing of the population. However, it is also a missed opportunity to place public health in the centre of the nation’s healthy recovery from COVID-19 and to start addressing in a systematic and comprehensive way the iniquitous inequalities in health that have been exposed and exacerbated by COVID-19. There is an urgent need to address these inequalities, through a balanced, well-funded and well-resourced public health system.
The Faculty of Public Health is happy to expand on any of the points in this submission orally or answer any queries.