Public Health Health Advice NHS Core Offer (HP5)
This core offer includes services that the council is legally obliged to provide. The link below provides detailed information about what is included.
Core HP5 (Public Health Health Advice NHS Core Offer)
Thank you for the opportunity for NHS Darlington Clinical Commissioning Group (DCCG) to respond to the consultation on the Medium Term Financial Plan (MTFP) for Darlington Borough Council (DBC). As a key local strategic partner and having worked closely with the Council as part of the Health and Wellbeing Board, the CCG fully appreciates the scale of the financial challenges faced by the Council and the difficult prioritisation process that will need to be undertaken to finalise a sustainable financial position for the future.
We have reflected on your proposals and the impact assessment work completed to date in order to provide a considered response through the consultation process. We have particularly focused our comments described below, on those planned changes that we consider will be detrimental to the overall health and wellbeing of the population of Darlington now and in years to come. We note and appreciate the rationale for the two phase approach to the MTFP for 2016/17 to 2019/20. The scale of the financial challenge over this period is indeed unprecedented. The CCG has noted the projection that the Council will have lost £44.0m of Government Funding over the period 2010-2020 and acknowledges the need to first and foremost, focus effort and resource on discharging statutory duties and the need to systematically review those discretionary services that may be most valued by the public. That said we are keen to see and work with the council, to consider a transformational approach to demand management rather than simply shrinking services.
There are some key areas which the CCG would like to highlight where the planned actions may well impact directly on health services but most importantly on the overall health and well-being of the population. A number of the changes planned appear to be in direct conflict with “Fair Society, Healthy Lives” (Marmot, 2010) and specifically with the Darlington Health
Profile data which describes the needs of our local community and key areas of priority to improve health and wellbeing and reduce inequalities namely:-
Giving every child the best start in life;
Tackling alcohol related harm, and
Promoting mental health and wellbeing
Children and Young People in Darlington
It is widely accepted that giving children a good start in life and prioritising children’s services is key to improving life outcomes. Planned reductions such as removing elements of the positive support pathway for young people and cessation of funding to the Aspire Service are a matter for concern. We know that early help and support ensures young people, and specifically those with learning difficulties, are able to live happy and productive lives often then reducing their dependency on more costly care provision. We therefore consider this planned reduction in services will impact on our statutory health services as well as the long term health and well-being of children and young people.
We have noted the proposal to change the operating model for Children’s Centres to a hub and spoke arrangement. This would appear to provide a useful and innovative way to preserve access to an important service although we have a degree of concern with respect to the potential impact of greater centralisation when we know that some of the most vulnerable families and children may fall away if services are not more local. This will require careful monitoring over coming months to ensure that the most needy continue to access the care and support they require.
Within the consultation documents other planned changes in the Children and Young People’s Portfolio such as changes to the Early Help and Looked After Children contact services and removal of discretionary early support service are considered critical to supporting vulnerable families. We are significantly concerned that such changes will inevitably hit the most vulnerable and will focus on crisis management rather than supporting early identification and prevention. This may result in increased pressure on other services including but not exclusively, healthcare where we know that these families typically use health services more than other groups in the population.
The MTFP describes a range of cuts to the provision of services for preventing and reducing obesity in adults and children, including no direct intervention programmes and the removal of the Healthy Darlington Hub, the Move More Team and the Schools Sports Partnership Programme. This is disappointing given the poor Child Health Profiles for Darlington including higher than average deprivation, poor life expectancy, which is 11.8 years lower for men and 9.4 years lower for women in the most deprived areas of Darlington than in the least deprived areas of the town (2015),and that about 20.6% (4,100) children live in poverty.
Our health profiles tell us that improvements in child health are needed given that for example, 11.2% of children aged 4-5 years and 18.4% aged 10-11 years are classified as obese and Darlington is worse than the England average for adult obesity (29.3% vs 23% England average). The Healthy Hub has been highly valued by our GP community and we understand that almost 2/3 of referrals to the Hub are from Primary Care. Proposed changes to the service will have a direct impact on GP colleagues and their ability to signpost the most needy in the population to services that appropriately focus on support, empowerment, self-care and primary prevention thus avoiding over medicalisation and dependence. The Healthy Hub has provided a key point of contact for advice and support programmes in the
community to encourage the right wellbeing choices and not being reliant on a health service solution. Again applying the Marmot principles we need to work as a system to ensure we are focussed on improving outcomes for children and vulnerable groups which will impact on longer term health. Planned changes by the Council to the obesity prevention and support services appear to conflict with this local priority and will impact on services available to the population, young and older, to “eat well and move more” and constrain their ability to achieve a healthier lifestyle.
Vulnerable Groups in the population
We are concerned that several of the planned changes appear to affect those most at risk and the vulnerable in our society, in particular those with a learning difficulty, the homeless and those who are often known to several organisations as high impact users with complex and chaotic lifestyles.
The MTFP describes removal of posts in the Drug, Alcohol and Tobacco Team and removal of the contribution to BALANCE and FRESH. These actions will impact on the capacity to deliver national campaigns and allow a local focus. We believe that BALANCE and FRESH deliver significant local benefits and by working at scale should provide good value. Services such as these have critical importance in raising awareness, prevention and improving health outcomes for the population which in turn is important to maintaining a healthy workforce and economic prosperity. The local health profiles for Darlington highlight both alcohol and smoking as key priorities. We know the rate of alcohol related hospital stays among the under 18s is worse than the England average; the rate of alcohol related harm in adults is worse than the England average; the rate of self-harm hospital stays is worse than the England average; the rate of smoking at time of delivery is worse than the England average and whilst the rates of smoking in Darlington have begun to decline over recent years, they remain unacceptably high and the rates of smoking related deaths is worse than the England average. There may therefore be scope in reshaping services to ensure that those services that are funded have a high probability of delivery of the expected impact.
Public mental health services, such as the removal of the Arts on Prescription service and the community based mental health improvement training, provide additional support for people living with mental health issues. We know improved mental health and wellbeing is associated with a range of better outcomes, including improved physical health, increased life expectancy and employment rates and reduced risk-taking behaviours such as smoking and drug and alcohol misuse.
For all these areas there are direct impacts on individuals, but they also place avoidable economic pressures on NHS and social care resources. We believe that a reduced focus on these priority areas could produce detrimental medium and longer term impacts on the health and wellbeing of the population and widen the inequalities gap we are trying so hard to collectively reduce.That said we do acknowledge the challenging reductions in the public health grant and the difficulty in identifying those interventions that are evidenced based and will deliver the greatest health and wellbeing impact. We will be keen to work with you over the coming months to understand better how these effects could potentially be mitigated.
We acknowledge the considered approach taken to streamline the Sexual Health Services however, we have already had a degree of concern raised from Primary Care with respect to the new arrangements for sexual health and need to ensure that our organisations are working together to commission services that are accessible and appropriate to provide for the immediate needs of individuals and to prevent longer term ill health.
We note a planned removal of the contribution to the Home Improvement Agency which would inevitably reduce the provision of services with a possible impact seen again on those most vulnerable and those from a low income homes with respect to ensuring a safe and accessible home environment and thereby reducing the need for higher cost alternative care provision.
Darlington’s Voluntary and Community Sector (VCS)
Darlington has long been regarded as having a vibrant and active VCS and a pivotal role in delivery of care outside of mainstream services; indeed to date DBC and the CCG have jointly sought to strengthen the capacity and capability of the sector in order to ensure we have services aligned to key joint priorities and plans such as the Better Care Fund projects which are critical to delivery of our Darlington 2020 Vision and priority focus on self-management, optimising independence and care outside of hospital. We know VCS organisations provide extremely cost effective alternatives in certain areas of provision as well as meeting key gaps in provision in the end to end care pathway. The planned impact of removing the engagement team support to the VCS, cutting of the Strategic Grant to organisations (including Age UK Darlington, Citizens Advice Bureau, Darlington Action on Disability and First Stop), together with stopping the discretionary rate relief will no doubt place significant pressure on VCS organisations and impact on their viability long term. Sadly we know that it will take many years to re-build this capacity and expertise once it has gone.
We are surprised and disappointed in the planned and marked reduction in the Healthwatch Darlington (HWD) funding arrangements from 2017/18. We and other organisations very much value the work of HWD, particularly with specific seldom heard groups in our population such as children and young people and BME communities. Such funding pressures on HWD alongside other funding impacts on the VCS give major cause for concern in the context of achieving the ambitions of the 2020 Vision, Better Care Fund and indeed the Healthy New Towns initiatives.
We are keen therefore to explore the potential for a more strategic approach to developing and sustaining the VCS and review how we collectively channel our resources with others to commission these important supporting services. Indeed we acknowledge your support for this approach and are pleased with our early discussions on this subject.
Public Health Core Offer
The MTFP highlights a range of reductions to the Public Health Grant many of which we have already commented on above. Whilst we have had a number of helpful discussions with the Director of Public Health and other DBC colleagues in respect of the impacts and mitigations, we remain concerned that such significant and far reaching changes are planned within the context of the Five Year Forward View (July, 2014) which requires a very clear system wide focus on prevention. We note that you intend to serve notice on the contract for Tees Valley Shared Services which raises significant concerns from the CCG in terms of delivery of the required Public Health core offer within a local and more limited team. We have welcomed the discussions already started with the Director of Public Health on how this core offer can be met and the challenges that may present, however we would like to understand better how DBC will fulfil its required duties in providing the required advice and support in terms of access to data, analytical capacity and the full range of expertise we currently enjoy, given our shared responsibilities for closing the health and wellbeing gap articulated in the Five Year Forward View and to be delivered through the Sustainability and Transformation Plan.
In summary, we have articulated our concerns in relation to those areas that we believe will specifically impact on the health and wellbeing of Darlington residents, recognising the difficulties in identifying alternative proposals that could deliver the required reduction in spending. We genuinely recognise the difficult prioritisation process DBC faces and very much wish to place on record our commitment to work collaborative with the Council to strategically consider how we mitigate the impact of planned changes to ensure the most advantageous health and wellbeing outcomes for local people.
We look forward to discussing with you in due course the outputs of the consultation.
Darlington Clinical Commissioning Group
Cllr Bill Dixon
Cllr Wendy Newall
Cllr Andy Scott
Core HP6 (Public Health NHS Health Checks)
I recognise that councils are facing a further period of financial stringency, which includes a reduction in the size of the public health grant As a consequence, I fully accept that councils will need to closely inspect current and future spend and identify savings that can be made to remain within budget.
The Grant is given for the purposes of contributing to the council’s activities ensuring good public health outcomes for residents. We therefore expect any proposed savings to be informed by the JSNA, the local Health & Wellbeing Board’s priorities; an assessment of current performance; and the efficiency with which services and functions are currently delivered. It remains essential that the Grant is only spent on activities whose main or primary purpose is to improve the public health of local populations. The Director of Public Health will need to be in a position to sign a statement of assurance at the end of each financial year.
Given these expectations, I would like to register two specific concerns about the proposals for the prescribed public health services i.e. those that Councils are mandated to ensure provision for. There appear to be specific implications for sexual health and for the “core offer” to Clinical Commissioning Groups/NHS Advice.
The proposals for sexual health categorise sexual health services as part of the “Core Offer” of the Council. The proposals make very clear the responsibilities of the authority under the Act and, even for the remodelled service, retain open access to GUM services. However, to achieve the required efficiencies it is proposed that the service will be remodelled to be more targeted to those at greatest risk of early unintended pregnancy and poorer sexual health. It is specifically proposed that both the local trust contract and the out of area costs for GUM are reduced by 5%. It is unclear how this 5% reduction will be achieved for GUM whilst retaining the open access requirement for GUM and we would welcome clarification on this specific issue.
The proposals for the delivery of the “Core offer” to Clinical commissioning groups/NHS advice outline significant reductions to the available capacity and expertise to deliver this important function both directly within the team and that purchased from a shared public health service in Teesside. The proposals state that “The Director of Public Health will access highly specialised Public Health advice including Public Health Medicine, pharmaceutical, infection control and specialised epidemiology through procurement arrangements”. We would urge that the budget allowed for such procurement is sufficient and would welcome the opportunity to discuss in more detail the arrangements for this advice to be assured of future provision.