Responsibility for commissioning key public health services including health visiting, school nursing and sexual health could revert to the NHS under long-term plans for the health service’s future.
In a move welcomed by public health nursing organisations, the government has pledged to look again at commissioning arrangements which critics claim are simply “not working” at the moment.
“The NHS will be discussing with government the best way to commission health visitors”
Public health services including health visiting, school nursing, and sexual health are currently commissioned and funded by councils after responsibility transferred from the NHS to local authorities, triggered by the Health and Social Care Act 2012.
Local authorities gained control over budgets for public health services, including school nursing for five to 19 year olds, in April 2013. They then took over the responsibility from the NHS for commissioning for services for all 0 to 19 year-olds, including health visitors, in October 2015.
However, the new long-term plan for the NHS in England now suggests the health service could yet again be given a role in commissioning these key preventative services, because of their direct impact on demand for NHS care.
“As many of these services are closely linked to NHS cases, and in many cases provided by NHS trusts, the government will consider whether there is a stronger role for the NHS in commissioning sexual health services, health visitors and school nurses, and what best future commissioning arrangements might therefore be,” said the NHS Long Term Plan.
“The government will consider whether there is a stronger role for the NHS in commissioning”
NHS Long Term Plan
This about turn will be seen by some as an attempt to prevent further decline in key early intervention services, which have been particularly hard-hit by local authority spending cuts.
Numbers of school nurses and health visitors have nosedived recently and sexual health services have been struggling to cope with demand, with an upsurge in some sexually transmitted infections.
Public health services are currently funded through the local authority public health grant set centrally by the government in Westminster.
However, recent years have seen swingeing cuts to public health budgets, with a further 3.3% –£85m – cut to funding for 2019-20 announced just before Christmas.
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The new budget for 2020-21 onwards is due to be announced by the government in the next spending review in the spring.
The long-term plan implies money for health visiting, school nursing, and sexual health could come from the NHS budget in the future, as the funding and availability of these services “directly affects demand for NHS services”.
Public health nursing organisations gave a cautious welcome to the idea that the NHS would once again have more control over commissioning of such services.
“It is really recognition that there is a problem here that needs to be looked at”
Cheryll Adams, executive director of the Institute of Health Visiting, said she was “absolutely delighted” that the need for change had been recognised, but said it was not yet clear what this might mean in practice.
“What it means is a recognition of a need to look it at it,” she told Nursing Times. “It is not working – all those services are hanging on by a thread – and there is a need to look at the commissioning arrangements for the future.
“Whether it should move to being the NHS commissioning, joint commissioning, stay as it is with other checks and balances in place, I don’t think that has been answered yet. So it is really recognition that there is a problem here that needs to be looked at.”
She maintained the health visiting profession had been caught in a damaging cycle of “feast or famine, investment and disinvestment” over the past 25 years, and it was time services were put on a sustainable footing once and for all.
“I would like to see a commissioning arrangement that works, that is in statute, that can’t be interfered with again in five or 10 years’ time,” she said.
However, she told Nursing Times that investment was urgently needed now to halt the decline in health visiting.
“I think it will happen but the real challenge is: Is it going to happen fast enough for the profession? Because we have got to a serious tipping point,” said Ms Adams.
“While I am optimistic there will be something helpful in the spending review, that finance won’t kick in until next year and there is a need for finance to kick in now,” she warned.
She added: “There is a need for additional training places to be commissioned and new retention policies to support those health visitors who are struggling in unsafe working conditions.”
As a first step, she said it was vital that cuts to the 2019-20 public health budget were scrapped.
“What is particularly unhelpful is the fact the Treasury is now going to take another chunk of money out of the public health budget,” she said.
“So, essentially, if that goes ahead then we’re going to see things getting even worse despite the recognition of how bad they are,” she said. “That policy needs to be turned around.”
“The Treasury needs to allocate the due funds so we can deliver on our service specifications”
Sharon White, chief executive of the School and Public Health Nurses Association, said a move back to the NHS could be beneficial and lead to more joined-up care for children, young people and families.
However, she maintained the move to local authorities had been “painful and fruitful in equal measure”, with increased competition leading to improved practice in some parts of the country.
“The competitive landscape has, in some areas, helped in the development and provision of some excellent forward thinking school nursing practice and improved health outcomes for children and young people,” she said.
Above all she said that whoever commissioned public health nursing must understand its key role in protecting the nation’s health.
“When we were in the NHS our services were often misunderstood, tagged onto huge acute/mental health trusts with competing agendas,” she said.
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“We were perceived as underdog professions at times with funding stripped to meet other pressing targets such as waiting lists,” she told Nursing Times.
She said a move back to the NHS could mean “more seamless service provision”, with better sharing of information. But it was vital to have “strategic leadership with ring-fenced and adequate funding attached to evidence and research-based services”.
“Right now, our view would be that the Treasury needs to allocate the due funds so we can deliver on our service specifications and significantly contribute to the NHS 10-year plan and turn the tide on the abysmal and shameful decline in children and young people’s health outcomes our country is witnessing,” she added.
In a debate on the long-term plan in the House of Commons earlier this week, Labour and Co-operative MP Rachael Maskell warned that health visitors numbers were now in “freefall”, having dropped by 23.5% – or 2,425 health visitors – since October 2015.
Prior to that point, the government’s Health Visitor Implementation Plan, which ran from 2011 to May 2015, had expanded the workforce nationally by almost an extra 4,200 people across England.
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“Health visitors are now working with dangerous caseloads, so when will the secretary of state ensure that we have safe delivery of health visiting services?” she asked.
In response, health and social care secretary Matt Hancock confirmed that the government would be looking at commissioning arrangements.
“The NHS will be discussing with government the best way to commission health visitors,” he told the Commons.
“Health visitors are clearly a health service but, at the moment, they are commissioned by local authorities,” Mr Hancock noted.
“We look forward to working with the NHS and with the Ministry of Housing, Communities and Local Government on how best we can commission health visitors in future, because they are a critical part of maternity services,” he added.
Responding a request for more information from Nursing Times, a Department of Health and Social Care spokeswoman said: “Joined up care is better for patients, which is why we want local government and NHS services to be as closely integrated as possible.
“While there’s lot of good work already happening across the country, in many places services are still too fragmented,” she told Nursing Times.
“As part of our Long Term Plan for the NHS we will work closely with local government and public health teams to identify these barriers and explore potential routes to more effective local integration, including what the best future commissioning arrangements might be.”