Big story: power to the people?

03 October 2018

Five years after local authorities in England took on responsibility for commissioning public health services, journalist Juliette Astrup asks how councils are reaching out to their communities to shape the local health agenda.

Last summer, North Yorkshire County Council (NYCC) launched a public consultation to find out what residents and partner organisations thought the future of public health provision in the area should look like.

At its core were three simple questions:

  • What do you see as the priorities for public health in North Yorkshire between now and 2025?
  • What role can you or your organisation play to improve public health in North Yorkshire?
  • What are the barriers and opportunities to this work?

The survey was launched by Dr Lincoln Sargeant, director of public health at the council, as part of the development of his annual report, with the aim of feeding the responses into a ‘collective approach and vision for public health in North Yorkshire’.

He explains: ‘It is five years since North Yorkshire County Council took over public health responsibilities from the NHS. This makes it a good time to look at the progress we have made so far across the county and look at where we want to be in 2025’ (NYCC, 2018).

In all, 52 responses to the online survey were received, revealing that priority areas for children were obesity, school readiness and mental health; for adults, mental health, general wellbeing and access to services and healthy lifestyles ranked highest; and for older people, healthy ageing, social isolation and loneliness were the biggest concerns to emerge.

Consulting on public health

Though few in number, the responses are an important part of a much broader process, explains Kathryn Ingold, a public health consultant at NYCC. It involves consultation with county and borough council executives, councillors, the North Yorkshire health and wellbeing board, leaders from NHS trusts and clinical commissioning groups (CCGs), as well as feedback from NHS England, Public Health England and the voluntary, community and faith sectors in North Yorkshire.

‘We need to understand public concerns,’ says Kathryn. ‘We have considered priorities identified by the public, alongside data measuring the health of our population and interviews with professional stakeholders.’

She adds: ‘It has influenced the public health agenda locally. We commission lifestyle services, have a “healthy weight, healthy lives” strategy which is delivering a multipronged approach to reducing obesity, have a healthy ageing programme, and are delivering work to improve school readiness – the consultation provides evidence that we need to continue to deliver against these agendas.

‘And the consultation exercise has influenced the recommendations which will focus on reducing health inequalities, improving public mental health and embedding public health action.’

While some public health services are mandated, such as the National Child Measurement Programme, or the five universal health-visiting checks, many others are down to local decision-makers.

In North Yorkshire, local authorities carry out joint strategic needs assessments, drilling down into the health data at ward or even street level, and consult widely before defining their key public health priorities. The local authority’s health and wellbeing board – which includes GPs and other non-elected members – is responsible for their sign-off.

Taking a population perspective is at the heart of public health, and a natural part of the role of local government, as the Department of Health guidance (2011) points out. It follows that many local authorities are applying a consultative approach to public health (see England in consultation, below).

Balancing act

But as local authority budgets shrink under intense pressure, and public health services are cut, how well placed are the general public to decide where the precious public health pounds are spent? How are their voices tempered by other legitimate concerns?

A Local Government Association spokesperson says: ‘Bringing the analytical rigour of public health professionals to bear on the information and insight councils have about their local populations is essential.

‘Conducting residents’ surveys provides an opportunity for councils to understand what communities think and offers valuable insight. Councils will use evidence from residents’ surveys and various data sources to capture the needs in their communities.

‘While residents’ surveys are an important tool, councils must also ensure they fulfil their statutory responsibilities, and that under-represented groups and potentially controversial areas of public health are not ignored.’

Honest and upfront?

Ruth du Plessis, chair of the Doctors in Unite public health specialists committee, is a former nurse and health visitor and now a public health specialist who has worked with local authorities in Greater Manchester, Cheshire and Merseyside. She says consulting with local communities on public health priorities is ‘absolutely the right thing to do – as long as it’s done well’.

‘Getting a sense of what the public’s priorities are and what people value can really help policy-makers make the argument for keeping a budget protected when it’s under threat – there’s a real positive around that,’ she says.

‘Consultation also gets people talking, understanding and engaging in public health, which can only be a good thing,’ she adds.

‘But you have got to be honest about what you’re consulting on – about what services are mandated, what the public can actually influence and what they can’t. Otherwise you run the risk of generating an expectation that can’t be met, resulting in people feeling they weren’t listened to.

‘There needs to be openness and honesty when there are difficult decisions and about the impact that it is going to have. If it’s about making cuts, then be upfront – people want honesty. For example, when cuts are wrongly badged as a “new service” or a “reconstituted service” rather than a reduced service, then they can feel misled or let down.’

England in consultation

Northumberland: the council and CCG launched a survey in August to ask residents if the draft health and wellbeing strategy set out by the Health and Wellbeing Board ‘focuses on the right key health, care and wellbeing issues for the people of Northumberland’ (Northumberland County Council, 2018).

Somerset: the county council carried out a consultation to inform its joint ‘Improving Lives’ strategy, which will steer the decisions of members of the Somerset Health and Wellbeing Board over the next decade (Lawrence, 2018).

Leicester: the city council used research agency Ipsos MORI to conduct its health and wellbeing survey to help plan health services and develop future public health priorities in the area (Leicester City Council, 2018).

West Sussex: the county council holds a two-yearly ‘What Matters to You?’ survey with questions about what it should prioritise across its services, including public health (West Sussex County Council, 2018).

New opportunities

Commissioning of public health services moving into local authority hands in England has undoubtedly come at a time of intense pressure on budgets and widespread cuts to services, but it also brings benefits, says Ruth.

It offers opportunities for council departments to work collaboratively and take a more holistic approach to public health issues, for example, or focus more sharply on primary prevention than under the NHS, which leans towards secondary prevention. ‘Local councils represent local people, so you could also argue there will be a higher level of engagement,’ she adds.

‘But at the same time, you’re seeing homelessness on the rise, social mobility in decline, life expectancy flatlining, inequality going up all the time – all the indicators showing things are going the wrong way.

‘There has been a lot of anxiety that public health is not protected under local authorities and, although the budget is ring-fenced, that the director of public health sits a couple of tiers down in the executive and doesn’t have the same level of control over the budget that they did in the NHS.’

So how much say can people actually have? Is public consultation really meaningful?

‘It’s not about new money – it’s about having system leadership in place so something can be prioritised,’ adds Ruth. ‘It can be meaningful in that way.

‘It also creates the space for innovation and creative thinking. As local people understand local issues and engagement encourages looking at things from a different perspective and generating different ways of doing things.

‘It’s an opportunity to think radically – but we need to make sure we’re in tune with where people are at.

Public health commissioning in the rest of the UK

Health is a devolved matter in Scotland, Wales and Northern Ireland.

Scotland: Scotland’s NHS is run by 14 health boards responsible for the protection and improvement of their population’s health as well as the delivery of frontline healthcare services. Public health in Scotland is undergoing reform currently, in line with the recommendations of the 2015 Review of public health in Scotland. Specific commitments including agreeing national public health priorities, establishing a new national public health body and developing local joint public health partnerships.

Wales: The Welsh NHS is run by seven health boards – a similar model to Scotland – responsible for protecting and improving the health of their population: everything from planning, providing hospital care and community nursing to contracting GPs and arranging specialist treatment. In many cases, health services will be planned and provided by the same health board, but in other instances, provision will be by independent NHS contractors, other health boards, the Welsh Health Specialised Services Committee, or non-NHS organisations.

Northern Ireland: The Health and Social Care Board (HSCB) is responsible for commissioning services, resource management, performance management and service improvement. It works to identify and meet the needs of the Northern Ireland population through its five local commissioning groups that cover the same geographical areas as the health and social care trusts.

In addition, the Public Health Agency (PHA) has the key functions of improving health and wellbeing and health protection. It also provides professional input to the commissioning process. The PHA is jointly responsible with the HSCB for the development of a fully integrated commissioning plan for health and social care.



Department of Health. (2011) Public health in local government: factsheets. See: (accessed 11 September 2018).

Lawrence C. (2018) Improving lives: have your say on our county’s health and wellbeing priorities. See: (accessed 11 September 2018).

Leicester City Council. (2018) Leicester health and wellbeing survey 2018: information and FAQs. See: (accessed 11 September 2018).

Northumberland County Council. (2018) Have your say on health and care in Northumberland. See: (accessed 11 September 2018).

North Yorkshire County Council. (2018) Public health report looks back to the future. See: (accessed 11 September 2018).

West Sussex County Council. (2018) What matters to you 2018. See: (accessed 11 September 2018).

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