Contact: Denise Holden ext. 7338

e-mail: [email protected]

1. Summary and Purpose

1.1. The aim of this report is to provide Members with information about the issues brought to the attention of the Committee and the action taken as a result of this referral. The report sets out the inquiries received, the source of this inquiry, action taken and recommendations for further action. Where appropriate comments have been included and copies of briefings or other information attached.

1.2. The approach adopted provides the route through which Patient and Public Involvement Forums(due to be established in 1 December) and other partner organisations (Hampshire district councils, NHS bodies, voluntary and independent sector providers and organisations that are representative of social care service users and carers) can raise issues with the Committee.

1.3. Where inquiries raised with the Committee are already subject to monitoring or other performance management activities the action taken will be focused on the local resolution of inquiries through appropriate sign-posting to the agency best placed to respond.

1.4. Where an issue cannot be satisfactorily resolved between the parties concerned then options for further action can be considered by the Committee.

1.5. The recommendations included in this report support Aim 5 of the Corporate Strategy (Improving Services) through the overview and scrutiny of health services in the Hampshire County Council area.

2. Recommendations for Action

2.1. Chiropody Services: the Committee considers the scope for undertaking an in-depth review of access to foot care for people with diabetes.

2.2. Diagnostic and Treatment Centres: the Committee continues to follow the introduction of the new centres and the impact that they have on local services to ensure that these services are accountable to local people.

2.3. Patient and Public Involvement:

· The Committee continues to press for further information about the membership of the forums across Hampshire.

2.4. Redevelopment of Queen Alexandra Hospital and services in south east Hampshire: This issue is included as a standing item on the Committees agenda

· The Committee notes the letter to the Chairman of the House of Commons Health Select Committee

· The response from the House of Commons Health Select Committee is circulated to Members when received

2.5. Delayed Discharges: Regular reports are provided to the Committee by the Director of Social Services on progress with placing patients

Section 100 D - Local Government Act 1972 - background papers

The following documents disclose facts or matters on which this report, or an important part of it, is based and has been relied upon to a material extent in the preparation of this report.

NB the list excludes:

1. Published works

2. Documents which disclose exempt or confidential information as defined in the Act.

File Location

None

Hampshire County Council: Health Review Committee 30 March

Inquiries Received and Action Taken

Hampshire County Council Annexe A

Health Review Committee

Independent Sector Treatment Centres: follow-up

Independent Sector Treatment Centres

These centres have significant potential to improve waiting times and choice for local people and the response received did provide some helpful information about the way in which this national programme is being taken forward. The Committee is keen to understand the implications of ISTCs for health services in our area and there are some issues raised in our letter of 16 October that could usefully be clarified to inform the Committee.

In particular the response from the Strategic Health Authority appears to concentrate on the Havant ISTC, not the others which we understand will provide services for people in our area. It would be helpful therefore if you could provide the Committee with additional information on the following

· Planning Assumptions: We asked for confirmation that current and planned capacity in the NHS was being fully utilised and that the planned schemes were affordable to the local health economy.

· Benefits for Local People: The only reference is to the Havant ISTC, not the others. If the contract is binding how can the PCTs respond to changing needs in their population.

· Links with Lift: It was helpful to have confirmation that there will be robust links with LIFT. Members will continue to take an interest in this and would appreciate your comments on what the options will be for continuing the ISTC after the life of the 5 year contract.

· Staffing: Members were not clear what was meant by the term `additionality'. The inference seems to be that these staff will be provided on a long term basis from overseas.. What are the circumstances in which NHS staff will be `allowed' to work with ISTCs. How will a `drift' be prevented.

· Evaluation: If PCT local delivery plans are expected to assess and integrate capacity with other providers does this mean that ISTCs will have priority for the duration of the contract?

· Health Scrutiny: We would appreciate confirmation that the SHA will indeed seek to ensure that the full intent of this section of the OSC guidance will be included in any contracts. Similarly it would be helpful to have your thoughts on the way in which the ISTCs would relate to Patient and Public Involvement Forums.

· Complaints and PALs: Although there is confirmation that patients complaints will be dealt with there is no reference to this being in the framework of the NHS complaints procedure and it would be helpful to have confirmation that this will be the case.

Considering the point raised about PALs services it would be useful to have confirmation from the PCTs concerned about the way they will deal with patients that may come from beyond their boundaries.

· Clinical Governance and audit arrangements. CHAI only visits every three years. How will the quality of care provided be evaluated between these visits.

Hampshire County Council Annexe B

Health Review Committee

Independent Treatment Centres: SHA response

Planning Assumptions:

Southampton ISTC has been project managed by the whole system orthopaedic group, which is a cross PCT and acute Trust group. It is working towards achieving maximum efficiency and quality within the local traditional providers, but still requires additional capacity in order to meet the goals laid down in the NHS Plan. The ISTC will allow us to close this capacity gap. Affordability is strictly governed by the new activity having a net cost to the PCT equivalent to NHS national tariff.

Benefits for Local People:

Orthopaedics is recognised nationally as a speciality at highest risk of not achieving the 6 month waiting targets and the proposed Southampton ISTC would provide elective orthopaedic capacity to help support achievement of this target. The contract is binding for the 5 years in terms of the minimum activity that will use the ISTC. Negotiation with the provider allows for expansion of the service if required and if value for money is provided.

Links with LIFT:

There is an expectation that over the life of the contract the price will reduce towards NHS tariff. This means that at the end of the 5 year contract, PCTs can decide whether to continue to utilise the ISTC or purchase capacity elsewhere.

Staffing:

NHS staff can work in the ISTC as part of a structured secondment with the agreement of their employing Trust. The Southampton gap is dependent on all staff being recruited from outside the NHS and this has been reinforced at every opportunity. The Government have inserted a clause that forbids staff from the NHS working in the ISTC if they have been employed by NHS within the previous 6 months (whether this is enforceable remains to be seen).

Evaluation:

We envisage having a range of providers in line with the choice agenda. The ISTC contract will state that a minimum value of activity must be generated each month and it will be for the PCTs to ensure they maintain value for money by utilising the service. There is a degree of flexibility allowing substitution of similar cases to help achieve this.

Health Scrutiny:

ISTC providers are expected to assist local commissioners in their dealings with local Overview and Scrutiny Committees. They are formally contracted to provide the NHS with information required by the OSC, where able to do so (i.e. not information which is commercial in confidence etc).

Complaints and PALs:

The ISTC is in every sense part of the NHS and so its terms and conditions will follow that of the NHS. In addition, there are robust performance indicators (PI) and quarterly joint service reviews which can call for investigations of the PI's, if they are not attained. Patients from beyond the boundary of the sponsoring PCT will not have direct access to the ISTC, unless part of a brokering arrangement if there is spare capacity.

Clinical Governance and Audit Arrangements:

The National Care Standards Commission will have to grant each facility a licence prior to opening to allow them to operate. Quality of Care will be monitored by the Pi's (see above) and the contract management unit to ensure the facility is providing the service that PCTs have purchased.

Hampshire County Council Annexe C

Health Review Committee

Services in South East Hampshire: Letter to House of Commons Health Select Committee

Future of Royal Naval Hospital Haslar, Gosport

I am writing to ask if you are able to take any action in relation to discussions between the Ministry of Defence (MOD) and the Department of Health regarding the future of the Royal Naval Hospital Haslar. The MOD has recently reaffirmed its intention to move from the Haslar site in 2007. Without agreement regarding the transfer of the Hospital and its services to the NHS this will mean the loss of an excellent facility for both local people and the armed forces. It is difficult to see how such an action would be in the interests of either the public, the NHS or the MOD.

You may recall that there has been extensive public support for the retention of Haslar Hospital as a resource for local people. This resulted in the matter being raised in the House of Commons; the last adjournment debate took place in October 2002, initiated by the Gosport MP Mr Peter Viggers.

The Haslar site is owned by the Ministry of Defence and the Hospital is a listed building. The MOD first indicated its intention to withdraw from the site in 1998 prompting a massive public outcry. The Portsmouth and South East Hampshire Health Authority undertook a full public consultation exercise at that time to determine the health services required on the Gosport peninsula. The outcome of this process identified Haslar as the preferred site for providing the NHS services needed by the local population. This was subject to agreement with the MOD regarding the transfer of part of the site to the NHS. Despite repeated attempts by the local PCT and Hampshire and the Isle of Wight Strategic Health Authority to secure this transfer, no agreement has been reached. Incredibly, the MOD announced in the press recently that it intends to raise the charges to the NHS for the use of Haslar from £1.3 million to £9million per annum, an increase of over 700%!

Plans are progressing for the redevelopment of the Queen Alexandra Hospital Cosham, via a PFI programme. This is intended to provide acute medical care, major trauma and other specialist services.

The anticipated completion of the PFI contract has however already incurred slippage due to planning difficulties. There is a very real concern that, should the MOD persist with its plans, Haslar may shut before the new acute hospital is completed. This would be catastrophic for local people.

In addition both Gosport and Fareham Borough Councils have highlighted concerns that the basis on which the original planning assumptions were predicated does not take account of new housing developments in the area or other demographic changes. These will inevitably result in new demands for health services in this area, which a facility such as Haslar Hospital would be well placed to meet.

Haslar Hospital currently provides a wide range of services including elective surgery, out-patient clinics, diagnostics, an accident treatment centre and recently opened orthopaedic treatment centre. Investment in the Hospital by both the NHS and the military has been significant and resulted in a `state of the art' facility providing an enviable quality of equipment and service. Whilst the redeveloped Queen Alexandra Hospital will provide much of the acute care for local people in the future the scope for Haslar to provide intermediate and elective care is considerable, particularly as technology extends the range of procedures that can safely be provided in this way.

Having visited the site there is no doubt that it is an excellent asset for local people. Patients, health professionals, local government and the public have indicated their support for the retention of the Hospital in the strongest possible terms. Fareham and Gosport PCT is currently working with local people and organisations to review the health needs of the population and clarify options for delivering the full range of services promised to people living on the Gosport peninsula. The lack of agreement on the transfer of the site to the NHS and the recent action by the MOD to significantly increase the charge it makes to the NHS is effectively removing Haslar Hospital from this discussion. We do not consider this to be in the interests of the local health community or an appropriate use of public finance.

It seems incomprehensible that this Hospital, funded from the public purse to such an excellent level of provision, is to be lost to the population of Southeast Hampshire. Given the other changes that are happening to health services in this area we believe this matter needs to be dealt with speedily. There is a genuine commitment from all interested parties locally to resolve this problem in a way that will bring benefits for all concerned. I am therefore writing on behalf of Hampshire County Council Health Review Committee to ask if you are able to provide any support in securing the future of the Royal Naval Hospital Haslar to the best local and financial effect.

Hampshire County Council Annexe D

Health Review Committee

Report on Delayed Transfer of Care

Contact: Lynn Waight Ext: 7265

1.0 Introduction

1.1 Reasons: This report supports Aim 1 of the corporate strategy (Maximising Life Opportunities) by contributing to the Older People Service Plan and the Older People Commissioning Strategy.

1.2 The Delayed Discharges (Community Care) Act was implemented in full on 5 January this year, following a three month shadow period. This piece of legislation requires acute hospital trusts to invoice social services departments at the rate of £100 or £120 per day for every delay in an acute hospital bed that can be attributed to a broad range of social care reasons as laid down by the Department of Health. Both elective and emergency patients are included.

1.3 It was stated in the Guidance that the object of the legislation is not to
financially penalise and to establish perverse incentives, but to force health
and social care partners to work together to improve whole system working.

2.0 Process

2.1 The shadow period did not accurately reflect authentic activity, but was an
extremely busy time for all concerned. Nevertheless, implementation has
been effected smoothly and the reimbursement process is gradually
embedding into discharge practice.

2.2 The HCC-led Pan County Reimbursement Group has continued to meet and has a final meeting planned for mid-March. This group has been a forum for good practice and also provides local support where necessary. A representative from the Strategic Health Authority sits on the Group and has made a steady and helpful contribution to its function.

3.0 Operations

3.1 The five main acute sites with which HCC SSD conduct daily business have differing local strengths and weaknesses that have been highlighted since implementation.

3.2 Frimley Park NHS Trust have a very well developed patient education and choice policy which has proved helpful to the SSD team, for example by ensuring realistic patient expectations from (and sometimes before) point of admission. Circumstances at Frimley are good and partners are confident and equal in their working relationships.

3.3 Jointly funded beds (HCC/North Hampshire PCT) currently used for block interim placements and which have been successful in limiting fining liability, will no longer be available from 1 April and all three health and social care partners are working together to find and agree alternatives.

3.4 Winchester & Eastleigh Health Care Trust have approached the legislation with particular enthusiasm and the development of a demanding data base system. However, this has not prevented the HCC team from continuing to challenge and negotiate, with support where necessary. The departure of two key senior managers from this acute trust could affect future joint working.

3.5 Long standing SSD accommodation problems within the Southampton University Hospital Trust have been resolved with a short term solution which is on schedule to be in place by the beginning of next month. Mid and long term options are being discussed and provide an opportunity for all staff (health and two social services' departments) working on discharge to be located together. Historically this relationship has been low key and recent work has raised its profile to positive effect.

3.6 Portsmouth Hospitals Trust (two sites) continues to be an example of where there has been very good working relationships that have survived the bureaucratic and divisive challenges of the reimbursement regime.

4.0 Information

4.1 The systems for information collation both nationally and locally are adjusting
to the different needs of the new ways of working.

4.2 There was an assumption that once the Department of Health `sitrep' definitions were realigned in late November, all acute social care delays would be automatically `reimbursable' - this is not the case and has been the root of some confusion, both on acute sites and also at the Strategic Health Authority. A joint (i.e. equal responsibility given to each partner) information system would eliminate the majority of problems, and discussions have begun regarding this, although it would be a long term action which could be driven by S.A.P (National Service Framework requirement - Single Assessment Process).

4.3 Several weekly reports are produced of the overall County perspective. The information is duly analysed by SSD HQ and disseminated to relevant managers. At the time of writing, week ending 30.01.04 shows 29 acute social care delays (of which 20 delays were reimbursable) and 166 whole system delays. Whole system figures include social care, health and jointly attributable delays and have not reduced in ratio to the social care reductions.

4.4 The average expenditure per week on fines for the first five weeks of reimbursement has been £6,600 per week. If we look back to January 2003 and use a similar trend pattern, the average spend on fines per week would have been £45,000. This once again demonstrates the very significant reductions achieved in social care delays over the last year.

4.5 Since the first week it has been a general trend that the reimbursable delays will be approximately two thirds of the total acute social care sitreppable delays. Until a formal review of whole systems delays takes place, it is not easy to analyse the remainder.

4.6 Summaries of whole systems delays continue to be sent out a week in arrears by the Department of Health; a more responsive method is needed to be able to address problems.

4.7 The County spreadsheet has been adjusted both in codes and content and now contains reimbursement information as well as sitrep information. It needs further work, but will be fit for purpose by the middle of next month.

5.0 Future

5.1 There have been several highlights from the shadow period and the first six weeks of the new regime as follows:

5.1.1 Some health partners genuinely wish to use the legislation to improve
discharge procedures for patients/clients. Others wish to use it to bolster
funding deficiencies in their economies. It is difficult to meet both intentions
with an equal response.

5.1.2 HCC staff have worked hard to reduced social care delays. They work in a pressurised and difficult environment on a daily basis - their continued effort is vital to maintaining this reduced level of delays.

5.1.3 Whole systems delays continue to affect Hampshire residents and there needs to be a shift in national focus so that improvements on these figures are driven from the centre.

5.1.4 HCC service users' interests need to be kept at the forefront of the process and every effort should be made to ensure that person-centred care is delivered both during and after a hospital visit.

6.0 Recommendation: To be noted.

Hampshire County Council Annexe E

Health Review Committee

Up-date on access to NHS dental services

Introduction

This paper follows that of 9 September 2003, and provides an update on access to NHS dentistry in Hampshire and the Isle of Wight and developments within the last six months, including measures being taken to improve the situation, both in the coming year, and with a view to future changes in contracting for dental care from April 2005.

Primary Care Trusts' dental action plans

Hampshire and Isle of Wight PCTs have arrangements in place to ensure that those needing urgent dental treatment can receive it, usually within 24 hours. It has however been much more difficult in some PCTs to provide routine access to dental care as fewer dentists have been accepting new NHS patients in their areas, as explained, with the background, in the September Board paper., However, contrary to reports in the media alleging an overall large fall in the number of NHS dentists, the number of dentists with NHS contracts in Hampshire and the Isle of Wight has actually increased over the last year and in December 2003 was 795.

Recognising that Hampshire and the Isle of Wight is one of the most challenged areas for dental access, the Department of Health Dental Access Support Team visited the Strategic Health Authority (SHA) in October to discuss with PCTs' Dental Management Leads the report compiled by the SHA, from PCT feedback, on the most difficult problems, action in hand, and scope for additional funding to improve access.

Isle of Wight, Fareham and Gosport, and New Forest PCTs have been recognised by the

Department of Health as being among the 16 PCTs with the greatest dental access challenges, and accordingly the Dental Access Support Team (DAST) is now working with these PCTs to develop specific action plans, on the basis of which additional funding can be made available. Four dental facilitators will be funded by the DAST, to work with the 16 PCTs. For the "South West" sector, this full-time post will cover West Gloucestershire PCT and the three identified Hampshire and Isle of Wight PCTs, and will be hosted by Hampshire and Isle of Wight Strategic Health Authority.

National funding to improve NHS dental access, quality and choice

Funding has been made available nationally in three tranches:

_ £35m to be used for capital grants to independent dental contractors, in accordance with Incentive Scheme Directions 2003

_ £15m which can be used for the same purposes as the £35m as well as paying salaries or buying sessions, or for use in the salaried services

_ £5m modernisation capital for the salaried services where previous such funding has not been received, e.g. through Personal Dental Service (PDS) pilots

These funds have been allocated to SHAs on a "fair shares" weighted capitation basis, and Hampshire and Isle of Wight SHA has been allocated £1.148m from the first tranche, and 492,000 from the second. The allocation for salaried service modernisation is £164,000. All funding is for the year 2004/5.

In preparation for the funding allocation process, PCTs were asked to update the earlier Reports they prepared for the Autumn 2003 meeting with the Department of Health Team, since the availability of NHS dentistry can change considerably in a short period of time. The SHA group convened to consider the allocation of funding comprised the Deputy Director of Finance, the Primary Care Performance Manager, the Dental Lead, the two Dental Practice Advisers who cover HIOW PCTs, and the Lead PCT Chief Executive for dentistry.

Recognising that three PCTs had been identified as having particular access problems, it

was concluded, following recent developments, that the next most challenged PCTs in

descending order were East Hampshire, Southampton, Eastleigh and Test Valley South, Portsmouth, Mid Hampshire, North Hampshire, and Blackwater Valley and Hart. The funding to be received by Isle of Wight, Fareham and Gosport, and New Forest PCTs from the DAST would be in addition to their allocation from HIOW access funding.

Some funding had already been made available by the Department of Health and used to maintain dental access where otherwise a severe loss would result, and it was considered that these commitments should be deducted from the overall SHA allocation. Existing access problems and PCTs' action to address these and potential problems were taken into account during the allocation process, as was the interdependence of PCTs' access arrangements and the volatility of the situation. It was thus thought prudent to set aside some contingency funds. Accordingly, the SHA has advised the Department of Health that a total of £120,000 should be allocated to each PCT, with the remaining £140,000 held as a contingency sum for use later in the year.

The salaried service capital funding was allocated to the three services (of five) in

Hampshire and Isle of Wight which had not previously received modernisation funding via PDS pilot schemes. On a capital allocation basis therefore Blackwater Valley and Hart PDS was allocated £26,000, Portsmouth and South East Hampshire CDS £77,000 and North and Mid Hampshire CDS (including Eastleigh) £61,000

Progress towards local commissioning of NHS dentistry in April 2005

Primary Care Trusts have been arranging meetings with the dental practitioners in their

area to introduce members of the PCT Board, identify specific contacts with whom dentists can liaise, and to discuss the initial information from the Department of Health on the forthcoming arrangements for local dental contracting.

At the end of February 2004, the document "Framework Proposals for primary dental

services in England from 2005" was issued by the Department of Health and is now going to all dentists for consultation. The earlier discussions in HIOW between PCTs and local dentists have already resulted in approximately 20 requests from dental practices in the PCTs with the greatest access problems, to participate in early piloting of the new contract arrangements in advance of 2005, and several of these have already begun the implementation process. This would seem to augur well for future dental contracting and associated longer-term improvements in NHS dental access in Hampshire and the Isle of Wight

Hampshire County Council Annexe F

Health Review Committee

Securing Good Health for the Whole Population: DHN briefing

This summary of the `Wanless' Report has been prepared by the Democratic Health Network. Full details of the report can be found on http://www.hm-treasury.gov.uk/consultations_and_legislation/wanless/consult_wanless04_final.cfm

Introduction

In 2002 Sir Derek Wanless was commissioned by the Treasury to examine the future demands on the NHS and to recommend ways of improving public health and reduce health inequalities. His first report, Securing Our Future Health: Taking a Long-Term View assessed the resources necessary to provide health services on a par with other developed nations. In this first report, it underlined the significant differences in the cost of providing health services to a "fully engaged" population (in which individuals are actively engaged in improving, protecting and promoting their health) and a population in which large sections of the population are not "fully engaged" (such is the case in the UK evidenced by relatively high rates of smoking, obesity, binge drinking and other harmful behaviours). Clearly, unless more was done to promote good health and prevent ill-health, more and more of the UK's resources would be spent on "running to keep up" with demand for health services.

On 25 February, the government published the second and final report produced by Sir Derek Wanless. Securing Good Health for the Whole Population sets out the agenda for improving public health and reducing health inequalities. It also focuses on the need for a sound evidence base to health promotion and public health so that we can be confident that such interventions are cost effectiveness.

Findings

The key findings are summarised below:

· Efforts over the past three decades to improve the nation's health and transform the NHS from a "national sickness service" into a body which promotes good health and prevents ill-health have failed. Despite action at national and local level, rising rates of obesity, failure to reduce smoking rates significantly, high levels of teenage pregnancy and sexually-transmitted diseases, and poor nutrition have contributed to high rates of illness and premature death. The report acknowledges that there have been public health successes: notably protection against infectious diseases, and the compliance by the vast majority of car users in relation to seatbelt wearing.

· The report focuses on how individuals can be supported, by central government, local government, the media, businesses, society at large, their families and the voluntary and community sector, in becoming fully engaged to make healthier choices. But this must be done within a coherent framework of action, strongly supported by evidence of what interventions and actions are effective. The report also identifies the strong correlation between socio-economic inequalities and health inequalities and recognises the urgent need for them to be addressed.

· The evidence base for identifying effective public health interventions must be improved at national and local level. The report suggests that this is due to the low priority given to public health intervention research which makes it difficult to secure funding to determine what works in relation to public health. There is also a need for economic evaluation of public health interventions, in much the same way as the National Institute for Clinical Excellence evaluates the effectiveness of clinical interventions.

· Health data, essential for monitoring the health of the population and for monitoring the effects of health interventions, is often poor and unreliable.

· National targets relating to public health and health inequality are often inconsistent and narrowly focused on behaviours rather than addressing "upstream issues" (such as improving educational attainment and reducing poverty) which, by reducing socio-economic inequalities may have a greater long-term effect on health inequalities.

· Government needs to work closely with local government, health organisations and community and voluntary groups to set national and local objectives for all major determinants of health. These objectives will need to be reviewed on a regular basis to establish what progress is being made.

· The report acknowledges that there is a significant problem with public health capacity. For example, each PCT is required to have a Director of Public Health which means that the existing resource is being spread more thinly. The prospects for making best use of resources are good in those areas that have made joint appointments in public health between the PCT and the local authority but we still need evidence that such joint arrangement deliver benefits and cost effectiveness.

· The NHS should support its employees to make healthy choices since there is a strong business case for reducing staff absence due to illnesses or accidents.

Recommendations

The report makes 21 specific recommendations, all of which are summarised below. It also recommends that all new public health policies are considered against a "checklist" to ensure that they are evidence-based, represent best value and take into account that, ultimately, the choice is up to the individual. The 21 recommendations are as follows:

· the Treasury should develop a framework to guide ministers on what economic policies might promote better public health

· the government should draw up consistent national objectives for public health, with a three or seven year deadline, including targets for specific population groups

· PCTs, local authorities and other local agencies should develop local targets, based on national targets, but taking into account local health profiles

· all public health interventions need to be evaluated for cost effectiveness

· it should be the responsibility of the Secretary of State for Health to ensure that the cabinet assesses the health impact of all major government policies

· national service frameworks should include details on the cost-effectiveness of different interventions, particularly in relation to ways of improving patients' lifestyles

· performance indicators for the NHS should be based on the benefits of interventions rather than the number of operations carried out, with the emphasis on prevention of ill-health

· the Department of Health's (DH) review of health quangos (currently underway) should ensure that there are no gaps or overlaps between the responsibilities of the various public health bodies

· the DH review should also look at how such bodies engage at a local level with PCTs

· the effectiveness of a national public health strategy should be regularly monitored

· pilot schemes need to be established to assess the benefits of electronic patient records to detail and monitor the health risks of individual patients

· there needs to be more cooperation between academics and public health professional to improve public health research

· the government's forthcoming White Paper on public health should tackle the barriers to obtaining public health data posed by patient confidentiality

· we need more investigation into how to improve public understanding of health information, especially for those people with poor literacy

· the forthcoming consultation on the White Paper on public health should address the balance between an individual's right to choose his or her lifestyle and the impact this has on the wider society

· the government should set up a web site and a national telephone help line to give advice on healthy living

· there should be an annual report on the state of the nation's health

· there should be an assessment of public awareness of public health advice and the level of support for controversial policies to tackle behaviour which is harmful to health

· the Commission for Healthcare Audit and Inspection should draw up performance indicators to assess the public health work of PCTs and strategic health authorities

· there is a need for a public health workforce strategy which would address the role of specialist public health practitioners and the wider health workforce

· the NHS should do more to improve the mental and physical well-being of its workforce.

Comments

By and large the report has been welcomed as a "wake up call" for the government, the NHS, public agencies and individuals that urgent action needs to be taken to reduce ill-health and premature death caused by unhealthy behaviours. The DHN welcomes the report's recommendation that there needs to be a national strategy for public health to support individuals to make healthy decisions. We also welcome the recognition that public health interventions need to based on sound evidence and regularly monitored in order to ensure that they are working.

There are, however, real concerns about the remit of the report. Many commentators, such as the Consumers' Association, have expressed disappointment with the lack of concrete proposals in the report. The widely discussed "fat tax" (extra taxes on foods that are high in fat and sugar) is not mentioned in the report. Neither is there a recommendation on the banning of advertising "junk foods" aimed at children. The report does not recommend any curbs on businesses as a way of improving health, even though many public health experts have urged the government to take such steps.

The report has also been criticised for ignoring sexual health, even though the UK has far higher levels of sexually transmitted diseases and unwanted pregnancies than most other developed countries.

In our view, the most significant flaw in the report is the emphasis on individual personal behaviour and choices, without any consideration of the way these choices are constrained by socio-economic circumstances. This report, which was widely trailed as a landmark report in the history of public health, has many positive recommendations but it is flawed by the lack of understanding of how socio-economic factors limit an individual's choice in making healthy choices.