Abstract and Keywords
Policy commitments to promoting health and addressing health inequalities have not been reflected in a reorientation of health systems or in policy development that addresses social determinants of health and health equity. Empirical data from an extensive research study across England illustrates the extent to which governance principles and arrangements influence local decision-making for health and wellbeing. The chapter summarises the changing context for commissioning, discusses concepts of governance, commissioning and public health, which are contested and subject to multiple interpretations and demonstrates the congruence between principles of 'good governance' and core values underlying public health. It argues for a critical concept of 'public health governance' in order systematically to assess the extent to which health and wellbeing is reflected in decision-making, priorities for investment, performance management arrangements, and in the use of incentives and contracts
Aspirations to ‘move upstream’ and invest for health are of long-standing –as are criticisms of national governments and local commissioners for failing to meet these aspirations. Investing for health involves action to prevent the causes of illness, shifting the focus from immediate, or proximate, causes of ill health (such as lifestyle factors) to the wider social, economic and environmental causes of ill health and health inequity, sometimes referred to as the ‘the causes of the causes’ (Rose, 1992). It also implies public health-informed policy, a longer-term perspective and a shift in investment priorities so that avoidable causes of morbidity and premature mortality can be addressed and health and wellbeing can be maximised. Given the nature of many public health challenges, success also depends on engagement of the public, building on community assets and strengths rather than focusing on deficits (Harrison et al., 2004; Foot and Hopkins, 2010), and encouraging wider policy and structural support for community activities that increase social capital and social cohesion (Putland et al., 2013).
These aspirations are reflected in national and international initiatives to reorient health and social care systems towards prevention and to encourage policy makers to address the social determinants of health and health equity. At an international level, efforts to prioritise prevention have gained prominence over the last forty years through a series of influential reports including the Canadian ‘Lalonde’ report (Lalonde, 1974) with its concept of the ‘health field’; the Declaration of Alma Ata (WHO, 1978), which described health as a social goal; Health for All by the year 2000 (WHO, 1981); and the Ottawa charter for health promotion (WHO, 1986).The latter reflected the breadth of public health action, spanning healthy public policy, community action and the reorientation of health care services towards the prevention of illness and the promotion of health. It also recognised the social determinants of health, emphasising that: ‘the fundamental conditions and resources for health are peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity’. This tradition continues through Health 2020 (WHO 2012a), a European policy framework developed by the World Health Organization (WHO), and its associated European action plan for strengthening public health capacities and services (WHO, 2012b). Health 2020 reaffirms the impact of social (p.2) and economic factors on health and health equity but also emphasises that good health is fundamental for social and economic development: working across government is required to improve health and address health inequalities across the social gradient. These policy documents all make the case for greater priority being afforded to preventing ill health, reducing health inequalities and promoting population health.
The same themes have been reflected, to a greater or lesser extent, in an English policy context, with reports drawing together implications for the NHS and for the wider economy of failing to invest for health and emphasising the importance of addressing inequalities through action on the social determinants of health. Continuity of analysis (if not of policy implementation or of political commitment) can be traced from the materialist approach of the Black Report (1980), through the Acheson report on inequalities in health (Acheson, 1998) with its 39 recommendations across the whole of government, to the Labour government's broad-ranging Tackling health inequalities: a programme for action (Department of Health, 2003a) and the more recent strategic review of health inequalities in England, Fair society, healthy lives (Marmot Review, 2010), with its emphasis on reducing the social gradient in health across the life course.
Arguments based on social justice and fairness have been bolstered by economic arguments and the escalating costs associated with treatment and loss of productivity as a result of preventable morbidity. These themes were reflected in two influential reports commissioned by HM Treasury from Sir Derek Wanless (Wanless, 2002, 2004) where he argued the case for a better resourced and invigorated public health system, focusing attention on the benefits of a healthier population both in terms of reductions in the use of health and social care and in relation to the wider economy. This analysis was influential in increasing the funding allocation for the NHS by the Labour government (1997–2010) and policy documents produced during this period emphasised the importance of shifting the focus towards prevention (Secretary of State for Health, 2004, 2006; Department of Health, 2007a). However, the difficulties involved, even within the relatively narrow confines of the health sector and at a time of funding growth, were not underestimated. For example, the five year plan for the NHS (Secretary of State for Health, 2009) NHS 2010–2015: From good to great. Preventative, people-centred, productive, emphasised that nothing less than a ‘paradigm shift’ would be required. Some years earlier, the White Paper, Our health, our care, our say (Secretary of State for Health, 2006) had asserted that a shift was needed in the ‘gravity of spending’.
(p.3) Despite these repeated policy commitments at national and international levels, it has proved difficult to achieve this hoped-for ‘paradigm shift’ towards prevention or to narrow health inequalities, which are getting wider (Audit Commission, 2010; Marmot Review, 2010). This has been the case within the relatively narrow sphere of health care systems (Marks and Hunter, 2005), in the introduction of policies in other sectors which take account of health impact (Wismar et al., 2007) or in promoting social and economic policies which promote social justice and thereby reduce health inequalities. Many reasons have been suggested for this failure (see, for example, Mackenbach, 2010). Public health challenges, such as obesity (Butland et al., 2007) or health inequalities (Blackman et al., 2012) are inherently complex and involve simultaneous and concerted action across a range of sectors. The complexity of these challenges and their interconnectedness with commercial interests and the wider political and social environment militate against simple solutions: moreover, health inequalities cannot be considered separately from wider social and economic inequalities (Wilkinson and Pickett, 2010). A final reason is the scope and ‘industrial’ scale of interventions required to make a difference at a population level (Bentley, 2008). In practice, the health care sector has a high public and political profile, and its demands overshadow a longer-term public health agenda. Through associating public health systems with health systems, the scope of public health activity may be unintentionally narrowed (although it is possible that the relocation of public health responsibilities to local authorities in England from 2013 may go some way towards redressing this balance).
Questions are also raised over the adequacy of the evidence base for public health interventions, although, to some extent, this is a consequence of the complex nature of public health problems. The public health evidence base has been largely focused on lifestyle-related interventions, which partly accounts for the well-documented phenomenon of ‘lifestyle drift’ (Hunter et al., 2009), where an initial policy emphasis on economic and social determinants swiftly becomes translated into evidence-based, but narrower, interventions designed to change individual lifestyles. This is often associated with a focus on disadvantaged groups rather than on the social gradient in health (Milton et al., 2010). The methodological approach appropriate for evaluating health technologies is not best suited for evaluating complex community-based interventions and a sole emphasis on randomised controlled trials will work against the system-wide action which is often needed.
(p.4) Despite these difficulties, the case has also been made that existing tools and levers are being inconsistently or inadequately applied (Bentley, 2008), and comparative reviews of public health performance and spending demonstrate that ‘local strategies can work’ (Audit Commission, 2010). There is, therefore, an important role for local commissioners.
In the context of the Labour government, a key route through which the ‘shift in gravity’ towards prevention was to be achieved locally was through NHS commissioning organisations. Primary care trusts (PCTs) held the major responsibility at the time for improving health and addressing health inequalities, which included working across local partnerships in recognition of the wider determinants of health. The publication of a Commissioning framework for health and well-being (Department of Health, 2007a) signalled the intention to help commissioners achieve a more strategic orientation towards promoting health and wellbeing, with a stronger focus on commissioning services and interventions across health and local government (para. 1.1) and ‘shifting resources to where investment can have the greatest impact on current and future health and wellbeing needs’ (para. 1.11).This was also intended to reduce future costs of ill health. These aspirations were subsequently reflected in the initiative for world class commissioning (WCC) (2007–10), which specified governance standards and health outcomes, and described the competencies needed by commissioners. It also incorporated a complex performance management framework for NHS commissioners (an aspect often perceived as overly burdensome).
However, shifting the focus of investment of local commissioning organisations towards prevention and addressing health inequalities also proved difficult (House of Commons Health Committee, 2009), despite the inexorable rise in non-communicable diseases, where many of the risk factors can be prevented and where early detection can reduce disability, morbidity and premature mortality. Weaknesses in the skills and capacity of local commissioners were cited as barriers, although this criticism may derive from an underestimate of the resources, incentives and political will required to carry out successful commissioning for public health in the face of competing demands. Short-term gains often prevail over the longer-term benefits of investment in public health for pragmatic and political reasons. Moreover, the public may not be ‘fully engaged’ with a local public health agenda, which has less immediacy than engaging with the quality and accessibility of local health and social care services. This can make cuts in local public health services a relatively easy option for commissioners.
(p.5) But there are also signs of change. All health economies face increased costs due to the rising burden of non-communicable diseases and ageing populations: moral and ethical arguments for investment in prevention are increasingly bolstered by powerful economic arguments. There is a growing evidence base for cost-effective public health interventions (Owen et al., 2012), more emphasis on demonstrating ‘return on investment’ for preventive initiatives in local commissioning organisations (Matrix Insight, 2009a, 2011) and attempts to model the costs of preventable morbidity both for the NHS (Bernstein et al., 2010) and for the wider economy. For example, Butland et al. (2007) estimated costs of NHS treatment for obesity at £4.2 billion in 2007, with costs to the wider economy estimated at £15.8 billion. There is also encouragement for policy makers and local commissioners to develop joined-up strategies for addressing underlying determinants of health across the life course (Marmot Review, 2010) and a renewed emphasis on the social determinants of health and health equity. The relocation of public health into local authorities has the potential to put the ‘public’ back into public health (South et al., 2012) and encourage collective approaches to health improvement. In a context where health care costs are becoming unsustainable but where much ill health is preventable, local commissioning decisions reflect how much emphasis is being given, in practice, to prevention and to investing for health.
The public health governance study
This book draws on one of the public health research projects funded by the former National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO) public health research programme. The research study Public health governance and primary care delivery: A triangulated study (Marks et al., 2011a) assessed the influence of governance structures and incentive arrangements on commissioning for health and wellbeing in the English NHS, as part of a wider programme of NIHR-funded research on ‘incentives, performance and governance’. The study involved a range of research activities, including national and regional focus groups, a national survey of PCTs, and extensive fieldwork in 10 selected case study sites across England. Almost 100 interviews were carried out across PCTs, local authorities, general practices, the voluntary and community sector (VCS) and public involvement organisations (local involvement networks (LINks)), which had been set up in 2008. Each chapter draws on empirical research evidence gathered through the study and more details on the study (p.6) design, including snapshots of the 10 case study sites, can be found in the Appendix.
The book builds on this research to illustrate how principles of governance (and the governance arrangements that are intended to flow from them) influence public health priorities through local decision making. Adopting a broad governance framework, it explores local commissioning practice during a period of concerted political commitment and policy action for improving health and addressing health inequalities, and which coincided with the implementation of WCC. Inevitably, its scope is somewhat limited by a focus on local organisations. The notion of ‘commissioning for health and wellbeing’, with its connotations of local assessment and service provision, sits uneasily with the influence of public policy on health, whether through housing, income distribution, welfare provision or education policy. The effectiveness of commissioners is inevitably affected by this wider political and economic context, and by the strength of government commitments to addressing social determinants of health and health equity through national policy. Improving health and wellbeing clearly reaches far beyond considerations of a commissioning cycle, decisions of any single commissioning organisation, the remit of public health services, or local partnerships. Despite this relatively narrow focus, decisions by commissioning organisations (however configured) remain an important influence and area for study, and illustrate questions of wider policy relevance. How do approaches to governance (separately and taken as a whole) influence population health? To what extent is a concern with public health reflected in governance arrangements, such as regulation, standards, incentives, targets and performance management regimes across different levels of decision making? How are notions of collective responsibility or a stewardship role reflected in local organisations and partnerships?
At a local level, the answers to these questions lie in how commissioning for health and wellbeing is understood and operationalised, the priority attached to a preventive agenda and the matrix of regulations, protocols, targets and incentives within which commissioners make decisions. Through exploring how governance principles and arrangements shape how commissioning for health and wellbeing is understood and prioritised, the study develops ‘public health governance’ as a critical concept.
(p.7) Changing commissioning contexts for public health
There have been major changes in the context and accountability arrangements for commissioning since the study was completed in 2010. At the time of the study (2007–10), 152 PCTs across England controlled about 80% of the NHS budget and were responsible for commissioning primary, secondary and community health services, including preventive health services. Directors of public health (DsPH) were accountable to PCTs (although many were joint appointments across PCTs and local authorities). Partnership working across a local authority area was arranged through non-statutory, multi-agency local strategic partnerships (LSPs), bringing together key partners from the public, private and voluntary sectors. From 2004, the involvement of general practice in NHS commissioning had been encouraged through ‘practice-based commissioning’ (PBC), where general practices were incentivised to work with PCTs to develop commissioning strategies (although with variable success).
Since 2010, there have been major changes in the organisation and commissioning of public health services in England as part of a far-reaching, contested and largely unanticipated reorganisation of the NHS (Timmins, 2012) culminating, after a two-year process, in the Health and Social Care Act 2012. The coalition government's White Paper, Equity and excellence: Liberating the NHS (Secretary of State for Health, 2010a), introduced new, statutory general practice consortia (later renamed clinical commissioning groups [CCGs]) which replaced PCTs as the main commissioning organisations for the NHS. Accountable to a new national body, NHS England, they are responsible for 65% of the NHS budget, commissioning services for planned hospital care, rehabilitative care, urgent and emergency care, most community health services, maternity services, mental health and learning disability services. Some NHS services, including primary care services, dental and ophthalmic services, national public health services such as immunisation and vaccination, and specialised services are commissioned by NHS England. Public health responsibilities of PCTs were shifted from the NHS to democratically elected local authorities, supported by a new and independent executive agency of the Department of Health, Public Health England. Reflecting the situation prior to the 1974 reorganisation of the NHS, local authorities reclaimed the major responsibility for public health commissioning and DsPH and their teams were duly transferred to local authorities from April 2013, when the reforms were implemented. The public health White Paper, Healthy lives, healthy people (Secretary of State for Health, (p.8) 2010b), published four months after Equity and excellence, clarified public health functions and responsibilities of unitary and upper-tier local authorities, the support to be provided by Public Health England, and the role of new health and wellbeing boards (HWBs). The latter were statutory committees of the local authority with core membership to include at least one local authority councillor, the director of adult social services, the director of children's services, a representative of local Healthwatch, the DPH and a member of each CCG, with other members co-opted according to local discretion.
The relocation of responsibility for public health from the NHS to local authorities was widely welcomed as a move towards a social model of health (House of Commons Communities and Local Government [CLG] Committee, 2013) with decisions made in a context of local democratic accountability. The reforms reaffirmed the importance of localism and served to emphasise the public health role of local authorities through their influence on broader determinants of health, such as housing and the environment. They resulted in the transfer from the NHS of a ring-fenced public health grant for commissioning a wide range of public health preventive activities including tobacco control, health checks, alcohol and drug misuse, physical activity, mental health, sexual health and environmental risk (Department of Health, 2011a, 2012d): it was anticipated that these changes in commissioning responsibilities would encourage innovative approaches to improving health and addressing health inequalities. From April 2015, responsibilities for the Healthy Child Programme (health visiting services and the family nurse partnership programme) would also transfer, giving local authorities more influence across the life course. Effectiveness of the reforms would depend not only on how the ring-fenced budget was deployed, but also on the extent to which new public health responsibilities were reflected across local authority directorates. The House of Commons CLG Committee (2013: para. 88) noted that:
Local authorities, if they are to grasp fully the opportunity afforded to them by the return of public health, will need to look beyond those services traditionally considered to be ‘public health’, such as health protection, health promotion and disease prevention, and tackle the causes of the causes of poor health, working with local partners and using all the powers, personnel and services at their disposal.
(p.9) Despite these major changes in organisation and accountability, there were similarities with arrangements prior to 2013. CCGs (211 at the time of writing) built on the organisations developed through PBC and gradually adopted many of the responsibilities of the PCTs they replaced; joint strategic needs assessments (JSNAs), established in 2008 to assess health and wellbeing needs and health inequalities in local populations, were retained but became the responsibility of the new HWBs, along with new joint health and wellbeing strategies. HWBs replaced a mixed array of health and wellbeing partnerships, were placed on a statutory footing and included CCGs as core members.
While WCC was discontinued by the coalition government in 2010, their public health White Paper, Healthy lives, healthy people (Secretary of State for Health, 2010b), continued to emphasise the importance of prevention and addressing health inequalities. The four domains of a new public health outcomes framework (Department of Health, 2012a) provided indicators against which local authorities could assess their performance, but no specific targets were set and the emphasis shifted from the detailed performance management arrangements of the previous government towards local self-assessment. However, a reorientation towards prevention, partnership working and ‘investing to save’ continue to be emphasised in public health strategies.
Whatever the context and accountability arrangements for commissioning, policy makers and public health commissioners face a number of generic questions. How are the needs of the local population to be assessed? How far is a concern with health and health inequalities reflected throughout the commissioning process? To what extent is the public involved in commissioning? How are priorities identified in practice and then reflected in commissioning decisions? What is the influence of policy mandates, the pattern of incentives across a system and governance arrangements, including those for audit and scrutiny? These questions are addressed in the course of the book.
Governance, commissioning and public health: definitions
Each of these key concepts –governance, commissioning and public health –is subject to multiple interpretations, and parameters vary according to the contexts in which they are used. The following section, therefore, briefly outlines these concepts before exploring their mutual relevance. Subsequent chapters explore these themes in more detail, drawing on research evidence gathered through the study.
(p.10) Governance and ‘good governance’
As further described in Chapter Two, governance is open to many different interpretations. While governance arrangements provide a key route for achieving goals and objectives, whether for national government or for local organisations, the term ‘governance’ and its parameters are notoriously elusive (Rhodes, 1996; Davies et al., 2005). Principles of governance, such as accountability or equity, may be uncontentious, but the extent to which these principles are reflected in governance arrangements (such as performance management), the effectiveness of such arrangements and the impact of modes of governance, such as markets or networks, are all open to debate. One of the arguments put forward in this book is that each of the dimensions of governance is relevant for understanding local commissioning practice in relation to health and wellbeing, and that these dimensions can usefully be considered separately, although they operate as a whole. For example, ‘good governance’ has been used to refer to governance based on underlying principles, including accountability, participation and social justice (Weiss, 2000). Governance arrangements provide a means through which such underlying principles may be operationalised via a wide range of ‘steering instruments’, including policies, standards and targets, and through mechanisms for audit, scrutiny and regulation. However, governance arrangements may not reflect underlying principles, there may be a lack of alignment across national, regional and local levels of governance, or specific instruments of governance may exert perverse or unintended consequences and therefore not fulfil their intended purpose.
The importance of understanding how different approaches to governance can affect population health and health equity, and the key importance of social justice as a governance principle have become increasingly recognised. Both are reflected in Health 2020, WHO Europe's health policy framework (WHO, 2012a), which emphasises the importance of collaboration and co-governance for promoting public health in the 21st century (building on underpinning documents on ‘governance for health’ [Kickbusch and Gleicher, 2012] and on the social determinants of health and health equity across the European Region [Marmot, 2013]). Health 2020 is a response to widening health inequalities within countries and across Europe, the growing impact of non-communicable diseases, and the social and economic causes of health and health inequity, as described in the earlier influential report of the WHO Global Commission on Social Determinants of Health (CSDH), Closing the gap in a generation (WHO, 2008). Health 2020 (p.11) emphasises addressing health inequity, that is, ‘differences which are not only unnecessary and avoidable but in addition are considered unfair and unjust’ (Whitehead, 1992), and the unequal distribution of the social determinants of health, such as housing, education and income. This directly relates to governance principles of social justice, the importance attached to health as a human right and the extent to which these principles are reflected in policy making across government.
Population health is, therefore, inextricably linked with the broad spectrum of public policy which influences these determinants and inequalities in health arise from their unequal distribution across the population. An emphasis on equity, combined with a recognition of the influence of public policy on health and the importance of ‘whole of government’ approaches, points to the key influence of governance –in particular, the principles underlying governance –on health. It raises questions over how these principles are reflected in instruments of governance, such as law and policy, and whether these instruments are effectively implemented.
Governance is often associated with hierarchies, networks and markets, although partnership and participatory approaches to governance are of particular relevance for addressing public health challenges, which often involve working across networks of different stakeholders (at national and local levels) and need to build on effective citizen engagement. As discussed in the third book in this series (Hunter and Perkins, 2014) and in Chapter Two, multisectoral working and partnerships also create governance challenges, reflecting the difficulties of working across organisations with different budgets, priorities and accountabilities. Health 2020 reiterates the importance of ‘whole of government’, and multisectoral approaches to improving health, also emphasising that this needs to be accompanied by a ‘whole of society’ approach, encompassing citizen engagement and participation.
Modes of governance are associated with different ‘steering instruments’, including targets, audit arrangements and incentives, and the balance adopted across regulatory and other approaches is influenced by the political context. However, certain steering instruments may not be appropriate when applied to complex systems and can lead to unforeseen consequences. As discussed in Chapter Four, centrally driven targets for reducing health inequalities, in place from 2002 to 2010, were not always prioritised in practice, and the need to demonstrate ‘quick wins’ led to an emphasis on clinical preventive interventions, rather than on the longer-term action required to address social determinants of health (Blackman et al., 2012). Moreover, the relationship between ‘steering instruments’ and modes of governance is complex and it has (p.12) been pointed out (Saltman, 2002) that decentralisation and the adoption of market-style incentives serves to increase the regulatory role of government in health care systems, rather than the reverse.
Commissioning for health and wellbeing
Commissioning is also subject to interpretation, as is the popular phrase ‘commissioning for health and wellbeing’, and these are discussed in turn. ‘Commissioning’ in the health sector has been understood in different ways since the term gained currency during the 1990s and, perhaps not surprisingly, the ramifications of the term remain largely obscure to the general public (House of Commons Health Committee, 2010: para. 1). Although the aim of planning services in relation to need has been in existence as long as the NHS, ‘commissioning’ is largely associated with public sector reforms dating from the 1990s, which promoted the separation of purchasing from the provision of services (otherwise known as the ‘purchaser/provider split’), described in detail elsewhere (see, for example, House of Commons Health Committee 2010, 2011; Glasby, 2012). In England, commissioning activities and arrangements in the NHS reflect political views over the role of markets, choice and competitive tendering as a source of quality. They are, therefore, particularly prone to being reorganised in the context of political change and repeated reorganisations can, in themselves, make it difficult to demonstrate progress. Commissioning arrangements reflect different positions over the role of regulation, the role of a market-based system in health care and the degree of private sector involvement in the delivery of NHS-funded services. They also reflect different views over the balance to be achieved across clinical and managerial influence, the appropriate size and structure of commissioning organisations, and how accountability is to be achieved. In this sense, commissioning arrangements both reflect and embody different modes of governance which, in turn, have an impact on how commissioning for health and wellbeing is understood and implemented locally. In the devolved administrations of Scotland and Wales, for example, England's quasi-market approach has been rejected and the purchaser/provider split dismantled. In Wales, seven local health boards are responsible for both planning and providing hospital, primary and community care, in line with policies set by the Welsh government (Longley et al., 2012), while in Scotland, planning and provision of services is provided through 14 integrated NHS boards, with an emphasis on partnership and integration. Community health (p.13) partnerships (committees of NHS boards) are responsible for primary and community care (Steel and Cylus, 2012).
In England, The NHS plan (Secretary of State for Health, 2000) had identified a lack of national standards, over-centralisation and a ‘lack of clear incentives and levers to improve performance’ (p. 10). Over the decade that followed, commissioning practice was shaped by a wide range of levers, including national standards, contractual flexibilities, policies for patient choice, PBC, the introduction of payment by results (where money was intended to ‘follow the patient’) and the initiative for WCC, intended to focus on health outcomes. These were all supported by a complex system of regulation, targets and incentives which were sometimes interrelated and mutually reinforcing, but often contradictory and ill aligned. Despite the sentiments expressed in the NHS plan, these new arrangements were themselves often criticised as over-centralised.
The substantial demands and transactional costs involved in contracting for health care services have tended to preserve and foster a narrow definition of commissioning as largely comprising purchasing and contract specification. In contrast to this, WCC was intended to promote the commissioning cycle as a whole, commissioning for improved health outcomes, service quality and value for money across a total budget, as opposed to concentrating on one part of that cycle, the transactional phase. WCC set out a continuous cycle of needs assessment, gap analysis, service specification, and the purchasing of services which were then monitored and evaluated, before the cycle was repeated. There were 11 commissioning competencies: commissioners were required to work with community partners, engage with the public and patients, and, as part of ‘prioritising investment’, to develop transparent investment decision-making processes. They were also required to identify and tackle ‘inequalities of health status, access and resource allocation’ (Department of Health, 2007b: 3). In this model, needs assessment was intended as the cornerstone of a commissioning strategy, and, although the reality may often have differed due to other pressures, the commissioning cycle provided an opportunity to address heath inequalities, gaps in services and also recognise the social determinants of health at a local level. This is further discussed in Chapter Three, which considers the commissioning cycle and, in particular, the JSNA, in more detail.
The emphasis in the NHS has largely remained on arrangements for commissioning health care services and on attempts to redress the balance between relatively weak commissioners on the one hand and more powerful provider organisations (NHS Trusts, in England) (p.14) on the other. Commissioning in social care, joint commissioning across health and social services or commissioning related to public health and preventive services have been relatively neglected (Glasby and Dickinson, 2014; Hunter and Perkins, 2014). The initiative for ‘commissioning for health and wellbeing’ through WCC could, therefore, be seen as encouraging a change in emphasis. However, the phrase is also something of a ‘catch-all’, with an interpretation to suit every purpose. Arguably, the entire range of activities carried out by health and social care commissioning organisations (and many outside the health sector) could be included under the broad rubric of ‘commissioning for health and wellbeing’, in the sense of promoting health, recovery, rehabilitation or independence. The phrase can also refer to providing preventive and integrated care organised around individual needs, or reducing the need for hospital admission. It may equally be interpreted as preventing ill health through a range of specific preventive services, such as smoking cessation or the promotion of physical activity.These may be focused on individual lifestyle change or on the creation of an environment which promotes healthier choices. Given the phrase allows for multiple interpretations and emphases, its use can lead to fudging of priorities and even to the neglect of a preventive agenda.
Although often used synonymously with health, ‘wellbeing’ is distinct from health status, and subject to cultural and social construction. Subjective wellbeing has been adopted as a government goal and 10 ‘general wellbeing’ indicators are being developed by the Office for National Statistics for use in attitudinal surveys. Practical and resource guides have also been produced (Michaelson et al., 2012). This reflects similar initiatives in Europe, and elsewhere, to redefine what is meant by societal wellbeing, including factors such as social cohesion, in attempts to move the emphasis away from narrow economic indicators related to economic growth. In the UK, health, employment status and relationship status are among factors most highly associated with wellbeing (Office for National Statistics, 2013). While local commissioners are clearly limited in their capacity to influence the range of national influences on wellbeing, both CCGs and local authorities can play a key role in promoting local health and community wellbeing.
Public health definitions
As discussed in detail in the first book in the series, The public health system in England (Hunter et al., 2010), ‘definitions of public health abound, varying between times and contexts’ (p. 18). Public health (p.15) can refer to the health of populations, the public health function (incorporating health protection, health promotion and heath service improvement), the public health profession or a public health system. The parameters of a public health system are also open to debate depending on the nature of the public health issue under consideration, the workforce and organisations involved in addressing it, and the extent of cross-sectoral action required. For example, a concern with wider social and economic factors may be limited to addressing the health impact of specific social factors, such as housing, or be broad in scope, including impacts on population health of climate change, cultural change or globalisation (McMichael et al., 2006; Hanlon and Carlisle, 2008; Hanlon et al., 2011; Frenk and Moon, 2013). The complex causation of public health threats needs to be reflected in the ways that health systems and public health systems are conceptualised (Hunter et al., 2010; Marks et al., 2011b) and in the range of organisational responses that would be required. Public health problems share the same ambiguity of definition. Verweij and Dawson (2007) point out, for example, that characterising an issue as a public health problem can mean increasing incidence (an epidemiological issue); influenced by socioeconomic or other conditions (a causative issue); or requiring an urgent response, where action is in the public interest (a normative issue). Gaps between the social and economic conditions required for a healthy population and the activities of public health systems (however defined) or public health practitioners mean that debates over the definitions and scope of public health activity are inherently value based and politically contingent.
The definition of public health generally includes a future orientation and the notion of collective action in the public interest. Although many definitions have been put forward (see review in Marks et al., 2011b), the definition adopted by Sir Donald Acheson in 1988 has been widely accepted as reflecting the essence of public health but without narrowing its scope. His definition (following that of Winslow ) described public health as follows: ‘Public health is the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society’ (Acheson, 1988).
The theme of collective action, reflected in Acheson's definition of public health as involving ‘the organised efforts of society’, recognises the role of policy across sectors and implies action on the social determinants of health and of health equity. ‘Organised efforts of society’ also points to the link between public health and governance arrangements.
(p.16) The Acheson definition refers to both the science and the ‘art’ of public health. Notwithstanding a growing evidence base for cost-effective public health interventions (Owen et al., 2012), the ‘art’ of public health recognises the complexity of public health challenges, influenced by political, cultural and commercial factors and, in light of this, the inevitable limitations of an evidence base which is concerned with specific public health interventions. Understanding the social determinants of health and health equity involves analysing corporate interests on patterns of consumption, political commitments to social justice and the distributional aspects of policies related to social determinants of health, such as housing, income and education. The Foresight report on obesity, for example, demonstrated the social, political, environmental and cultural action that would be required to address obesity, a multidimensional and complex public health problem with many interconnected causes (Butland et al., 2007). It meant adopting a system-wide approach, addressing multiple levels of influence simultaneously with a wide range of policy sectors and stakeholders. The uncertainty associated with many public health challenges is reflected in the notion of the ‘precautionary principle’ and the necessity of taking action, given the potential consequences of inaction, even in the absence of conclusive evidence (Martuzzi and Tickner, 2004).
While the scope and function of the public health profession, the public health function and a public health system have been variously defined over time, analysis of the governance implications that follow from the goals of maximising population health, developing local public health systems or addressing health inequalities, remains relatively neglected.
Public health and governance: shared values
Preventing avoidable ill health and promoting wellbeing are core public health values and clearly linked with wider values of social justice and human rights (Saracci, 2007; Gostin, 2008). The action required reaches far beyond public health systems, however broadly defined, to encompass public policy at national and international levels. The obligation to support the ‘right to health’, as part of an international commitment to human rights, is emphasised as a rationale and justification for promoting population health: the interconnectedness of health and of human rights has become increasingly prominent.
Entitlement to health as a human right is reflected in the Universal Declaration of Human Rights (adopted by the United Nations General (p.17) Assembly in 1948), in the 1946 Constitution of WHO, which states that the ‘enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being’ and is further developed in the UN International Covenant on Economic, Social and Cultural Rights (UN General Assembly, 1966: Article 12). This commitment is also reflected in Health 2020. Agreements are associated with government obligations to move towards a ‘progressive realisation’ of the right to health (Yamin, 2008). What this means, in practice, is that policy across government should be informed by this governance principle. This was emphasised in a revised definition of the ‘health in all policies’ approach (originally described by Ståhl et al., 2006), as agreed at the Global Conference on Health Promotion in May 2013. This new definition reiterates connections between health and health equity, public policy and the right to health.
- Health in All Policies [HiAP] is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. A Health in All Policies approach is founded on health-related rights and obligations. It improves accountability of policy makers for health impacts at all levels of policy making. It includes an emphasis on the consequences of public policies on health systems, determinants of health, and wellbeing. (The Helsinki Statement on Health in all Policies, 2013)1
As the above quotation makes clear, the principles of good governance and the aims of achieving the highest attainable level of health and of addressing health inequity are crucially linked. One of the critical identifiers of whether a country exhibits ‘good governance’ is, therefore, the state of the health of its population: a ‘stewardship’ role in relation to population health has been presented as a key responsibility of government (Omaswa and Boufford, 2010).This has been characterised as ‘the careful and responsible management of the wellbeing of the population … the very essence of good government. The health of people is always a national priority: government responsibility for it is continuous and permanent’ (WHO, 2000: viii).
Closely associated with concepts of governance, stewardship is also open to different interpretations, including being entrusted with responsibilities (as in financial stewardship); protection of the public interest by government; or as a form of corporate governance. The (p.18) concept of ‘system stewardship’ has been developed to reflect problems of governance in complex systems and has been defined as ‘policy makers overseeing the ways in which the policy is being adapted, and attempting to steer the system towards certain outcomes’ (Hallsworth, 2011: 8). Perhaps reflecting the complexity of the current arrangements, the Department of Health describes its role as that of ‘system steward’, as ‘the only body with oversight over the whole health and care system’ (Department of Health, 2013c: 25).
National and local health-related organisations often reflect a stewardship role in relation to population health in their mission statements, goals and objectives, although whether health improvement and health equity are prioritised through governance arrangements and commissioning practice is another matter. Unless there is commitment to these principles at national government level, they are unlikely to be prioritised at a local level. What a stewardship role involves in practice also raises ethical and political debates over the balance to be achieved between collective approaches to public health, such as regulation and public health law, and individual responsibility and choice. These issues are revisited in the concluding chapter.
Plan of the book
Public health governance has been defined as ‘the means by which society collectively seeks to assure the conditions under which the population can live with the highest possible level of health and wellbeing’ (Institute of Medicine, 2002, quoted in Bennett et al., 2009). It has often been taken to refer to direct and indirect regulation by governments in the interests of population health. Drawing on different dimensions of governance, the notion of ‘public health governance’ is developed as a critical concept for assessing the extent to which a focus on health and wellbeing is reflected in underlying values informing decision making, priorities for investment, performance management arrangements, and in the use of incentives and contracts. Dimensions of governance are discussed in ChapterTwo, with a particular emphasis on accountability arrangements, partnerships and the stewardship role.
Chapter Three looks in more detail at the commissioning cycle and discusses what is involved in a developing a public health-led approach to commissioning. This includes approaches to health needs assessment through the JSNA and JHWS and the engagement of general practice.
Chapters Four and Five are related, reviewing the influence of governance arrangements and incentives on commissioning for health and wellbeing. Incentives are often contingent on governance (p.19) structures (such as incentives and reward schemes for reaching targets, for example) and modes of governance have implications for the kinds of incentives which are promoted. It has been argued, for example, that the particular mix of regulatory requirements and incentives (in the sense of inducements) is an indicator of the degree of state or market orientation (Saltman, 2002). Chapter Four reviews governance arrangements, including performance management regimes, their influence on decision making and their alignment across different agencies. The coalition government introduced major changes in this area and implications of these changes are discussed. Chapter Five explores links between governance approaches and the use of incentives, drawing on economic perspectives on incentives. It provides an account of incentives and contractual flexibilities used by commissioners to promote preventive services, in particular, local enhanced services (part of the new general medical services [GMS] contract introduced in 2004). Benefits and drawbacks of using incentives for public health services are discussed, drawing on interviews carried out as part of the study.
Chapter Six considers priority setting and issues which arise in attempting to shift the ‘gravity of spend’ in health-related organisations towards prevention. Whether policy is translated into practice depends on local decision-making and prioritisation processes. Different forms of ‘evidence’ come into play, along with different decision support methods and systems for reaching judgements. These include policy evaluation, the public health evidence base, different approaches to economic evaluation, option appraisal and impact assessments (environmental, social, health and health inequality). Drawing on local experience, approaches to prioritising investment and the applicability of current prioritisation methods and tools for longer-term public health investment are reviewed.
Improvements in population health are unlikely to be achieved without the involvement of the public. Participation by the public and accountability to the public are two key underlying principles of governance and, as such, need to be reflected in commissioning arrangements. However, public involvement in commissioning preventive services, as opposed to health and social care services, proved difficult for PCTs to achieve at the time of the study. Chapter Seven explores public involvement in commissioning for health and wellbeing, including the impact of changes arising from the creation of Healthwatch England and local Healthwatch, following implementation of the Health and Social Care Act 2012.
(p.20) The conclusions draw themes together under the broad umbrella of ‘public health governance’ and future directions for commissioning are discussed.