The Committee urges councils to fully grasp this opportunity by using every lever at their disposal to adopt a holistic approach to public health.
The report also, however, raises concerns over the complex accountability mechanisms of the reformed system. In particular, it argues it is not clear who will be in charge in the event of a health emergency and urges the Government to set out clearly and unambiguously the lines of responsibility. Finally, the Report notes a perverse incentive in the funding formula and calls for it to be reviewed.
Conclusions & recommendations
On concerns about health emergencies
- It is still not clear who would be in charge in the event of a regional or national outbreak. Government should set out clearly and unambiguously the lines of responsibility. [para 114]
- We heard serious concerns about the arrangements for screening and immunisation. We urge the Government and the NHS Commissioning Board to review the arrangements with a view to devolving these services to public health staff within local government, who have the local knowledge to make the system work. [para 125]
Commenting on the issue, Committee Chair Clive Betts MP said:
"Without clarity there is only confusion, and a health emergency is no time for muddle. The Government must set out unambiguously the lines of responsibility, and it must do so now as a matter of urgency. These arrangements need to be clear and in place on day one, 1 April. Anything else is unacceptable."
On accountability mechanisms of the reformed system
- How, and for what, Health and Wellbeing Boards are to be held accountable appears to be an area of real confusion. They draw up a strategy which local Clinical Commissioning Groups and others should take account of and implement. The Government has to clarify lines of responsibility. [para 31]
- At the top of the pyramid is the NHS Commissioning Board but it lacks local accountability and its status in relation to Health and Wellbeing Boards is unclear. [para 41]
- Nor is it clear to whom Clinical Commissioning Groups, the bodies that commission local services, are to be held accountable and the Committee is not persuaded by the Ministers' arguments for not allowing councillors to sit on them. Who should sit on a local Clinical Commissioning Group is a local matter that should be left to local resolution. [para 81]
- The Government should set out in detail what a Health and Wellbeing Board can do if the NHS Commissioning Board or Clinical Commissioning Groups fails to commission services consistent with its strategies. [para 43 & 46]
Clive Betts MP said:
"Under the reformed system, considerable power is to be invested in a range of new bodies. With such power must come accountability.
The purpose of localism is not only to devolve decision making to a local level, but to make it accountable to local people. With these changes it is clear that there is a shift of power and money from the Whitehall to local government and I welcome that. But the new arrangements are complex and responsibilities are shared across several bodies. The result is that lines of local accountability are fragmented and blurred."
On adopting a more holistic approach to public health
- Local authorities must look beyond services traditionally considered as public health and adopt a holistic approach to tackling the factors affecting complex health problems. [para 88]
- To succeed, Health and Wellbeing Boards won’t have budgets or powers to direct and so will need to become proficient at building relationships and influence. They should not focus exclusively on the detail of health and social care commissioning, but should look to be creative by including individuals with responsibility for the social determinants of health, including those working in education, planning and economic development. [para 22 & 27]
- Strategies will only be as good as the information on which they are based, but the current information-sharing arrangements are inadequate and need to be improved. 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 the year. [para 53]
- The Government should consider devolving further responsibilities to local government, including elements of the Work Programme and the Healthy Child programme, to address at a more local level the determinants of poor health. [para 92 & 128]
- If public health is to become an overarching priority for local authorities, it requires an overarching budget. The Government should work to clarify the funding formula for 2015-16 with a view to removing ring-fencing and moving to community budgets. [para 161]
Clive Betts MP said:
"The return of a responsibility to improve the health and wellbeing of local people represents an exciting opportunity for local authorities. They must grasp this with both hands, using all resources at their disposal to tackle not just the causes of poor health, but the causes of the causes.
Initiatives targeting individual behaviours in isolation have been shown not to work. Councils must take a more holistic approach that addresses the multiple causes of complex health problems.
Housing, employment, and early years education are all vital determinants of people’s later health and wellbeing. Policy in these areas should not be considered in isolation, but must underpin local authorities’ public health strategies. To aid this, the Government should consider devolving more responsibilities to local government, and must be prepared to use national levers to support local level initiatives.
An overarching strategy needs an overarching budget. Community budgets, which allow all providers of public services to share budgets, are being piloted and in the medium term they may provide this, ensuring that money is directed at people and places, rather than organisations."
On the funding formula
- It took 11 months to finalise the allocations for 2013-14 with the final allocation only announced on 10 January 2013. The process left local authorities with a great deal of work to do in a very short period. [para 137]
- The Government should put in place a timetable for publishing and consulting on the 2015-16 allocations and finalise them by October 2014. This will provide those commissioning services and providers with at least six months in which to plan. [para 138]
- The Committee notes the perverse incentive of basing funding on health outcomes, as councils that improve the health of local people will have their funding cut. The Government should ensure the Advisory Committee on Resource Allocation reviews the allocation formula. [para 141-142]
Clive Betts MP said:
"Under the current funding formula, areas that perform well and improve the health of their residents will have their funding cut. This perverse incentive will become even more marked if still in place when the Health Premium is introduced and areas are simultaneously financially rewarded and punished for good performance.
The funding formula must be reviewed and the timetable for doing so should be set out now. Furthermore, a parallel system of reward should be delayed until this review has taken place. We have to get the new arrangements right."