Initially we welcomed the principles behind these reforms – including the focus on outcomes, the bigger role for local government, and the recognition that the ultimate test is improving the health of the poorest fastest, this government's code for inequalities. In our submission to the Department on the reforms, we made more than 40 detailed recommendations, but the Committee needs to focus on four critical issues.
First, the money and how it's allocated. The Department has tried to calculate how much the NHS spends on public health in order to make a simple transfer of those amounts to local authorities, who will hold the budget in future. But the more fundamental question remains – is this amount big enough? The government's own evidence review sets out a litany of public health challenges that are only set to increase. And the way the money will be allocated means that local authorities can only increase their share by doing well through the health premium. Allocations will not reflect underlying changes that local authorities can do little – if anything – about. For those authorities with significant population churn (where the young and healthy routinely move on and the poor and unhealthy move in) this is likely to widen the health gap rather than narrow it. And some areas may never be able to break out of a cycle of chronic underfunding.
Second, the balance of accountabilities, incentives and performance support in the new system. The public health outcomes framework is a big step forward, it shows the government has listened and recognised that nudge and information are important. But so too are the places and economic conditions in which we live and the people with whom we live. While the framework recognises this, there are no teeth to it. Current plans do not attempt to define levels of performance against the framework, weakening authorities' accountability for billions of pounds of taxpayers' money. Instead the government is putting its faith in the premium and local transparency of this system. Public Health England will be publishing and comparing results, but doing little else with the information. This isn't good enough for us – either as national taxpayers or as local citizens.
The third area is the relationship between local authorities and the NHS. We welcome the introduction of health and wellbeing boards. The Bill also introduces important new duties on the NHS Commissioning Board and consortia to tackle inequalities in health, but this is restricted to inequalities in access to, and outcomes from, NHS care. This should be broadened to reflect the fact that the NHS is an economic powerhouse and major employer in local communities, directly affecting the determinants of health by its actions. There are no equivalent duties on local authorities to tackle inequalities – this should go along with the shift of budgets and responsibility for public health. GP consortia also need to be given responsibility for population health, beyond the duty of caring for unregistered patients, if primary care's role in public health is to be fully recognised.
Fourth, and underpinning all of this, is the information and intelligence that keeps the system working. The Health Select Committee is looking into the role of the regional Public Health Observatories, bringing their function under Public Health England. While this may save the centre some money it risks creating a less effective local public health intelligence network and significantly higher overall costs as directors of public health each seek to replace the lost capability in their own patches. More fundamental still is the issue of co-terminosity between consortia and local authorities. The freedom to define membership of consortia has unwittingly created huge technical challenges of co-ordinating and supporting the data flows that inform the decisions of the health and wellbeing boards and others. The Committee needs to press the Department on how it is to tackle these problems.
Overall there is a lack of attention to how the various elements fit together, a consequence of too little time to get the thinking straight. The guiding philosophy behind the reforms in public health seems to be promoting increasingly devolved and local decisions on public health. But the logic of this would lead to a non-ringfenced budget coupled with strong accountability for performance on the outcomes framework to protect the interests of national taxpayers whose money is being used to finance it. Instead the government proposes a ringfenced static budget that doesn't properly reflect changing needs, coupled with extraordinarily weak accountability. This seems the worst of both worlds – not really allowing the space for local authorities to innovate or holding them to account for the outcomes that really matter.
In the next few weeks the Committee will need to be as challenging as it has been on the NHS reforms to help the government get its thinking straight, our future health will depend on it.