Drawing on in-depth case studies across England, this book argues that governance and population health are inextricably linked. Using original research, it shows how these links can be illustrated at a local level through commissioning practice related to health and wellbeing. Exploring the impact of governance on decision- making, Governance, commissioning and public health analyses how principles, such as social justice, and governance arrangements, including standards and targets, influence local strategies and priorities for public health investment. In developing ‘public health governance’ as a critical concept, the study demonstrates the complexity of the governance landscape for public health and the leadership qualities required to negotiate it. This book is essential reading for students, academics, practitioners and policy-makers with an interest in governance and decision-making for public health.
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
Governance is a multidimensional and somewhat slippery concept, associated with a set of principles, such as accountability and equity; arrangements for the exercise of legitimate authority through regulation, standards and targets; and processes for ensuring accountability and managing risk within organisations. ‘Modes’ of decision-making include market mechanisms, networks and hierarchies, although these co-exist in practice. This chapter considers dimensions of governance and their relevance for population health and local commissioning. Drawing on study data from interviews and focus groups, it discusses stewardship of population health, accountability arrangements, partnership working and approaches to corporate governance. ‘Good governance’ involves commitment to promoting population health and health equity across national strategies and local practice and needs to be reflected through governance arrangements, including those for audit and performance management. Governance for population health involves understanding the impact of different dimensions of governance and negotiating complex governance arrangements across partnerships, networks and sectors.
This chapter considers the history of NHS commissioning in England, the Labour government initiative for World Class Commissioning (2007-10) and the extent to which a public health-led model of commissioning is reflected in practice. Health needs assessment of a local population is described in detail as the first stage in a commissioning cycle and cornerstone of a public health-led approach to commissioning. Drawing on interview data from the study, the chapter discusses how ‘commissioning for health and wellbeing’ is understood and put into practice, and summarises GP involvement in the commissioning process. It reviews local approaches for tackling health inequalities and discusses enablers and barriers to implementation. It concludes by identifying lessons from the research for public health in local government following the major reforms in public health commissioning implemented by the Coalition government in 2013.
National governments adopt a range of methods for assuring standards and monitoring performance, including regulatory frameworks, targets and arrangements for audit and scrutiny. Performance management of public services through a complex system of targets and assurance frameworks was a characteristic feature of the former Labour government, largely dismantled by the Coalition government in favour of a greater role for self-assessment. This chapter reviews public health-related standards, regulation and monitoring arrangements at the time of the study, with an emphasis on targets and the extent to which they were aligned across different agencies or reflected local priorities. It assesses the impact of performance management on decision-making, drawing on evidence from the study. In practice, short-term demands displaced a longer-term public health perspective and targets for acute care predominated. It concludes by discussing relevance of the research to public health commissioning following implementation of the 2012 Health and Social Care Act.
This chapter assesses the impact on performance of financial and other incentives, locating debates in a theoretical economic framework, and considers characteristics of ‘incentive contracts’. At the time of the study, incentives for increased activity, performance, partnership working and quality improvement were in place. The chapter reviews their impact and how commissioners exploited reward schemes and contractual flexibilities for promoting health and wellbeing. It discusses incentives for quality improvement in primary care, rewards for GP involvement in commissioning and incentives for delivering specific preventive services. Benefits and drawbacks of incentives are discussed, drawing on study data. Incentives were often piecemeal and uncoordinated and a transactional approach risked undermining local engagement. However, they encouraged the provision of evidence-based preventive services. The chapter demonstrates the importance of considering perverse incentives, potential effects across a whole system, and factors involved in developing incentive contracts.
Concern over the scale of preventable morbidity is compounded by its differential distribution across the population. Economic arguments for prevention have become more prominent and this chapter considers the policy context, influences on priority-setting and enablers and barriers for prioritising prevention in practice. It reviews public health intelligence and assesses a range of decision-support methods, including economic evaluation and return on investment for prevention. The chapter shows that methods for priority-setting were not always suited to addressing equity or longer-term public health investment; data were often inadequate; and modelling skills were in short supply. While disinvestment was increasingly considered a prerequisite for public health investment, this was difficult to achieve. Commissioners made relatively little use of decision-support methods. With economic pressures facing local authorities, prioritisation frameworks will be required to make difficult rationing decisions more transparent: implications of the study for prioritising public health investment are discussed.
Participation by the public and accountability to the public are principles of governance. This chapter discusses participatory governance and considers policies for patient and public involvement in health. Drawing on the study, it illustrates views on public involvement in commissioning and scrutiny, describing a range of initiatives and how they worked in practice. Involvement in commissioning preventive services proved difficult to achieve and the capacity of the Voluntary and Community Sector to influence partnerships was limited. The chapter reviews changes arising from the creation of Healthwatch England and local Healthwatch, following the 2012 Health and Social Care Act. While growing professionalisation of the third sector and the appointment of local Healthwatch as core members of Health and Wellbeing Boards will increase influence, there may be implications for wider engagement and accountability. With reductions in public spending, effective ways of involving the public in commissioning decisions is increasingly important.
Policy commitments for improving health and addressing inequalities are unlikely to prove successful unless reflected through governance arrangements and decision-making processes at national, regional and local levels. Governance for public health is inseparable from wider debates over governance and ‘deficits’ in public health can also indicate governance deficits. This chapter summarises the impact of different dimensions of governance on prevention and the importance of achieving coherence across them. A ‘whole system’ approach illustrates the extent to which modes of governance (such as markets and partnerships) or incentives at different levels may reflect conflicting goals. Relocating public health responsibility to local authorities is largely welcomed. However, local decision-making does not exist in isolation from the national context or from enduring questions of public health ethics. Using the governance framework described in the book can help identify whether governance principles and the arrangements which reflect them are being brought together for effective ‘public health governance’.
Health systems everywhere are experiencing rapid change in response to new threats to health, including from lifestyle diseases, risks of pandemic flu, and the global effects of climate change but health inequalities continue to widen. Such developments have profound implications for the future direction of public health policy and practice.
The public health system in England offers a wide-ranging, provocative and accessible assessment of challenges confronting a public health system, exploring how its parameters have shifted and what the origins of dilemmas in public health practice are. The book will therefore appeal to public health professionals and students of health policy, potentially engaging them in political and social advocacy.