What does the Public Health Outcomes Framework reveal about the DH’s vision?
Public health is no longer the sole responsibility of one single organisation. Government reform through the Health and Social Care Act outlines how local authorities, the NHS, clinical commissioning groups (CCGs) and, more importantly, Public Health England (PHE) have now been tasked with improving the health of the nation. So how will it work?
PHE is the new, integrated and professional health system designed by the Government to be more effective and to give clear accountability for the improvement and protection of health within the community. The main function of PHE – along with its partners in the health service and in wider society – is to deliver support and enable improvements in health and wellbeing and to design and maintain systems to protect the population against existing and future threats to public health. The new body brings together experts from a range of organisations, such as the Health Protection Agency, under one umbrella and gives local authorities and CCGs control over the public health budget – believed to be in the region of around £5.2bn – to improve regional requirements.
Public Health Outcomes Framework
For the first time public health will be measured against a devised framework allowing councils and the Government to track improvements and to take action where systems are failing. From April next year, councils will be given access to a ring-fenced budget to tackle public health inequalities in the local population and meet Government targets. Councils who make the most improvements against desired outcomes will be rewarded with a cash incentive.
Former Health Secretary Andrew Lansley said that the decision to move the public health budget away from Whitehall to local authorities was “absolutely right”. He said: “We are giving local councils the money, the power, the right expertise and information to build healthier communities. Every area of the country is different so councils will be able to decide what the most important public health concern is for them and spend the money appropriately.”
A public health outcomes framework for England, 2013–2016 sets the context for the revised system from local to national level with one simple vision: “to improve and protect the nation’s health and wellbeing, and improve the health of the poorest fastest”.
It builds on the white paper Healthy Lives, Healthy People – published at the same time that PHE was established in December 2010 – and reveals that outcomes will be measured by a broad range of 66 indicators chosen by experts and grouped into four domains. The framework has two high-level targets: increasing healthy life expectancy, and reducing differences in life expectancy and healthy life expectancy between communities.
The Department of Health said the main outcomes “reflect the focus we wish to take, not only on how long we live – our life expectancy – but on how well we live – our healthy life expectancy, at all stages of the life course.”
Domains, objectives and indicators
The domains, which each have individual objectives, are:
- Domain 1: Improving the wider determinants of health
- Domain 2: Health improvement
- Domain 3: Health protection
- Domain 4: Healthcare public health and preventing premature mortality.
The framework makes it clear that although responsibilities have been moved away from central Government to local authorities, the NHS will still “remain critical to protecting and improving the population’s health” and “NHS clinical contribution is therefore central” to driving improvements.
In order to do this, the framework aligns with the Adult and Social Care Framework and the NHS Outcomes Framework through a series of shared or complementary indicators. The DH says that it intends to create an alignment with the outcomes framework through a series of set shared indicators that straddle domain 4 of its framework and the first domain in the NHS alternative. The shared indicators will be on premature mortality from specific areas of cancer, cardiovascular disease and liver disease.
The first domain in the public health framework has the objective to make “improvements against wider factors that affect health and wellbeing and health inequalities”. There are 19 indicators included, ranging from children in poverty to employment for those with long-term health conditions, including those with a learning difficulty/disability or mental illness and people with a mental illness or disability in settled accommodation.
Yet it is possibly in the other three domains where the pharmaceutical industry can exert greater influence and offer support. The objective of Domain 2 is to ensure “people are helped to live healthy lifestyles, make healthy choices and reduce health inequalities.” The 24 indicators here include a number that are relevant to pharma. These range from successful completion of drug treatment to cancer screening coverage and recorded diabetes- and alcohol-related admissions to hospital.
Improvements in these indicators will, in the main, be led locally by clinical commissioning groups through schemes devised or introduced to drive standards of public health.
Domain 3 has just seven indicators – although the framework says these are “critical” to protect the public’s health. Its target is to ensure “the population’s health is protected from major incidents and other threats, while reducing health inequalities.” Indicators that focus on Chlamydia diagnosis, vaccination coverage for the population, people presenting with HIV at a late stage of infection and treatment completion for tuberculosis are of clear significance for the pharmaceutical industry.
Domain 4 aims to reduce the “numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities.” Several indicators stand out as far as Key Account Managers should be concerned. Indicators including mortality from causes considered preventable, mortality from all cardiovascular diseases, and mortality from cancer, liver disease and respiratory disease call out for pharma’s expertise in creating innovative pathways of care, and of course its products.
The DH makes it clear in the framework that it is the responsibility of all healthcare providers to deliver improvements in indicators in this domain.
As well as driving standards of public health, the framework also supports health improvement and protection at all stages and across the life course of the population, especially in the early years. A further purpose is to provide a mechanism for transparency and accountability across the public health system. “As governance and accountability for Public Health England, local government and the NHS differ from each other, so will their relationship to demonstrating performance towards improving public health outcomes,” the document says.
Crucially, it will be for local authorities, in partnership with health and wellbeing boards, to demonstrate improvements in public health outcomes through progress against the indicators included in the framework that best reflect local needs, included in Joint Strategic Needs Assessments (JSNAs) and reflected in Joint Health and Wellbeing Strategies (JHWSs), to achieve cash incentives. Here, the DH expects specific progress against measures in the framework being “built into” JSNAs and JHWSs. These documents should be easily obtainable and accessible for KAMs, allowing an insight into local priorities which can then be targeted.
Although the framework has been planned for a three year period until 2016, the DH has confirmed that it will be refreshed annually “as data improves, technical capability across the public health system develops” and as it maintains an “aligned approach” across the NHS and local authorities.
Indicators will also be developed in order to create a complete set of baselines to support local service planning within the coming weeks by public health observatories, local authorities, the NHS and the Department of Health.
The DH accepts that “public health is such that the improvements in these outcomes will take years – sometimes even decades – to see marked changes”. But with budgets already in place to help tackle regional issues, pharma is perfectly placed to assist in driving public health outcomes in the short, medium and long term.