To improve public health and realise the prevention agenda, local authorities, NHS commissioners and providers must work together, writes Emily Jones, senior policy officer at NHS Clinical Commissioners.
Nestled among the 136 pages of the NHS Long Term Plan was a statement that the government and the NHS will consider whether there is a stronger role for the NHS in commissioning certain areas of public health, namely sexual health services, health visiting and school nurses. With these services currently commissioned by local authorities, the statement came as a surprise to many and it would be fair to say it caused a bit of a stir.
It is right to consider areas of public health that are not working well and are in need of improvement. However, looking at the challenges in public health through the sole lens of commissioning responsibility misses the bigger picture: there are key issues in the public health system that need to be addressed. Of fundamental importance is funding. Current funding for public health is far below what is required; the Health Foundation estimates that extra funding of £3.2 billion per year is needed to reverse the impact of cuts to the public health grant and to ensure it is re-allocated according to need. This has meant that just as clinical commissioning groups (CCGs) have had to take difficult decisions about how to make best use of limited financial resources to meet the needs of their local populations, so have local authorities.
Yet the impact of cuts has been worrying in terms of the reduction of key prevention services being commissioned by local authorities. One example is smoking cessation, where government cuts to the public health grant have led to a 30 per cent reduction in local authority spending on tobacco control and smoking cessation between 2014/15 and 2017/18. Such services are crucial if we are to reduce future demand on the NHS and prevent avoidable ill-health. The sustainability of the NHS depends on a sufficiently funded public health system. That’s why public health funding must be urgently addressed in the upcoming spending review, and clarity and certainty over funding in the longer term needs to be provided.
Alongside increased funding, would shifting commissioning responsibility for the particular areas of sexual health, health visiting and school nurses be helpful? To explore this and to better understand the future direction of public health that clinical commissioners would like to see, I recently spoke to a number of NHS Clinical Commissioner’s members. All recognised the financial strain local authorities are under. All recognised the importance of public health teams as system partners. All want to work collaboratively with local authority public health colleagues. But there was little appetite to reclaim commissioning responsibility.
One key way to achieve greater collaborative working between CCGs and local authorities in the area of public health is through joint commissioning arrangements. These arrangements recognise the inter-related nature of local authority public health commissioned services and CCG commissioned services. For example, the extent to which local authorities suitably commission tier 1 and 2 obesity services (prevention and community-based weight management services) will impact upon CCG-commissioned tier 3 and 4 services (covering services for people with severe and complex obesity and bariatric surgery for adults). Bringing CCGs and local authorities together to plan and commission for pathways has the potential to reduce fragmentation and duplication, and to ensure that early intervention is prioritised.
The answer to fragmentation and funding challenges in public health isn’t to shift commissioning responsibility. We need to recognise public health as a shared endeavour. That’s why the NHS is speaking up on the importance of sufficient and sustainable public health funding.
Read NHS Clinical Commissioner’s position statement on public health.
Emily Jones is Senior Policy Officer at NHS Clinical Commissioners (NHSCC). Follow NHSCC on Twitter @NHSCCPress