health and social care act 2012 essay

Essay on Health and Social Care Act of 2012

Government policy formulation is always triggered by some aspects, which are aimed to improve service delivery to users within an economy. Provision of healthcare facilities is sensitive, and practitioners in the field should exhibit a high level of professionalism for the achievement of sustainability in the sector (Adams, 2007). For instance, social issues within a population can prompt the government to formulate strategies to handle the problem. Circumstances such as disease outbreak within a population can influence the formulation of specific policies as it relates to healthcare (Williams, 2002). The study focuses on evaluating an existing government policy and its relevance to service users. Equally, the paper will seek to gain an understanding of the services that are provided by specific legislation or policy. A thorough discussion of the policy is important to provide insight into the phenomenon. The research will also seek to discuss the decision making process of the policy and possible impacts that are associated (Field and Brown, 2019). To meet the objectives set, the study will use the Health and Social Care Act of 2012 in the United Kingdom to explore the concept (Care Quality Commission, 2012). In essence, the report aims to discuss the Health and Social act of 2012 in its bid to establish facts that revolve around policy formulation.

The legislation was adopted as a way of driving the economy to sustainability by providing healthcare facilities. The need for sustainability in the field of healthcare necessitated the formulation of a framework that addresses issues that arise. The main aim is to improve the population health of a particular nation (Williams, 2002). The implementation of the framework saw the development of the National Health Service commissioning board and other groups with similar capabilities. For instance, the act stipulates the role of practitioners in various facilities in facilitating equity. There is a need to show equality in the provision of services to patients within a country. Upon its inception, the act was meant to instil excellence in the healthcare sector through the National Health Service (Field and Brown, 2019). The act stipulates what is required of each stakeholder in the provision o healthcare facilities in the United Kingdom. In essence, the act was established to ensure sustainability through the National Health Service (Walshe, 2012). The act was established to reduce the high level of inequality that was notable in the provision of services. For instance, minority groups are at a high risk of receiving poor services in the country. Both equality and excellence were required in the sector, which prompted many parliamentarians to rally behind the implementation of the act.

The Health and social care Act of 2012 was established to support equity in the healthcare sector, and at the same time, spearhead improved performance. The act mentions the responsibilities of various stakeholders in the industry. The first part concentrates on what the Secretary of State on health is obliged to do to promote sustainability (Williams, 2002). According to the act, the secretary of state should be held accountable on matters relating to the provision of standardized healthcare. Part one of the act saw the creation of the National Health Service commissioning board and the abolition of strategic health operations. The second phase of the act dealt with some provisions, including the abolition of the Health Protection Agency (HPA). Equally, functions of the HPA were transferred to the secretary of state for health. Biological substances and radiation protection was a provision introduced in the second part. The repealing of the AIDS control Act of 1987 was done in part two, including the duties that all bodies providing healthcare facilities are obliged to follow. The act underwent many transformations with subsequent parts covering important aspects in healthcare such as adult and child care facilities.

The impact of the implementation of the Health and Social Care Act of 2012 can be felt within the healthcare system of the country. For instance, the fact that the act supports equality in the provision of services has reduced disparities that were notable initially. Racial prejudice is still notable in the provision of healthcare facilities, even though the law discourages the same. The act asserts that all people are equal and should be treated fairly when receiving services, despite one’s skill color, culture and other factors (Sadek and Sadek, 2004). Equally, the legislation has been at the forefront of championing excellence within healthcare facilities. As such, the quality of service provision has improved over time, indicating how important it has been in shaping reforms within the healthcare sector. Every practitioner’s role is well outlined in the policy to enhance professionalism and improved service provision. Such provisions make healthcare employees committed to achieving high service delivery to people (Adams, 2007). The act is instrumental in controlling and offering guidance in a case where there is a conflict of interest, especially among clinical practitioners. Such conflicts affect one’s performance leading to poor service delivery in the healthcare sector. In essence, the health and social care act of 2012 is a legal framework that serves to ensure sustainability in Medicare provision.

Some policies were formulated as a way of controlling the behavior of workers in the Medicare industry. For instance, the act states what is required of the secretary of state to health as far as the provision of standardized healthcare facilities is concerned (Howieson, 2012). Such regulations are important at places of work with a view of promoting population health. Equally, the act included provisions to abolish the Health Protection Agency, which was replaced by a National Health Service board. The board has been efficient in ensuring that people in the country receive standardized Medicare services in an equal manner. In the Health and Social Care act, policies on child care and adult care devilment are handled (Field and Brown, 2019). The act served as a way of addressing significant issues in the health care sector that has derailed the achievement of a desirable level of population health. Policies that govern the distribution of resources for the provision of services are inclusive in the health and social care act of 2012. The policies have proved helpful in promoting equality, excellence and coverage of the healthcare facilities.

The Health and Social Care Act of 2012 has affected many people in the United Kingdom as service users in the Medicare field. For instance, service users have the privilege of receiving equal treatment as far as healthcare is concerned (Sadek and Sadek, 2004). Prejudice against a population that needs medicine is detrimental to improved universal healthcare. The government understands the importance of a healthy population and therefore, the need to excel in service provision. The health and social care act of 2012 rejuvenated society’s trust in the government to improve the delivery of healthcare services. With a list of guidelines and tasks of what one should perform at work, users experience convenience and efficient. In essence, users are benefitting from the strategies that were put in place through the act (Glover-Thomas, 2013). The act provides an opportunity for controlled drug pricing, which has promoted consumer welfare. Lack of such policing within the community exposes individuals to exploitation by unscrupulous business people. Equally, users are advantaged by the fact that there are better and improved hospital facilities.

Commission groups established within the society help detect any possible dangers that might risk the wellness of a population. In the event, the government can formulate plans to ensure that the problem is curtailed early enough. The groups inquire and research on issues that can otherwise risk the health of the population. In essence, the health and social care act of 2012 works to ensure that the population is safe and healthy (Sadek and Sadek, 2004). The legislation has powerful guidelines that shape the manner, which the sector is run. Implementation of the act in the United Kingdom has contributed to excellence in delivering quality services (Nazarko, 2004). Users are enjoying the experience as they are handled professionally and with deserved respect. The idea of introducing penalties for violations of set ethical standards has ensured that users receive quality services.

The Health and social care act helps deliver services to individuals within the United Kingdom. For instance, it allows for assessment of the population to determine its vulnerability to disease. Some diseases can be dangerous and fatal to a population, which necessitates the introduction of procedures to test any disease or condition that may be impending. Failure to conduct such assessments puts the whole population health at risk (Nazarko, 2004). Healthcare services are a basic need, and any slight chance to overlook the sector can lead to fatalities within the population. The health department in the UK is well structured and organized due to the act, which has provided crucial principles on the handling of matters pertaining to healthcare. For instance, the act outlines duties for each body in the healthcare sector (Speed and Gabe, 2013). Such restrictions put facilities on toes to provide the best of care to both children and adults. It is through the legislation that the government controls the exploitation of its citizens by poor service provision in healthcare facilities (Kew and Stredwick, 2008). The policies in place coordinate the running of operations in the healthcare sector to the extent of achieving sustainability. The health and social care act of 2012 is crucial to the population health in the United Kingdom.

Besides assessment of the health status of a population, the act has ensured that people are treated in an equal manner despite their color, originality or ethnic community. Inequalities in the healthcare sector have existed for decades within the country, and there is a need to address the matter by implementing legislation that prohibits any kind of discrimination (Kew and Stredwick, 2008). Prejudice in a healthcare facility can make worsen a patient’s condition, which necessitates for equality in such a context. Other services provided courtesy of implementation of the act include advising clients on the best of habits that promote good health among the population. An informed population is in a better position of preventing a possible outbreak compared to when one lacks information (Pownall, 2013). As such, the health and social care act of 2012 is a law that was put in place to handle inequalities and improve the quality of service provision (Kew and Stredwick, 2008). Equally, the staff employed by the National Health Service work hard to sensitize the community on matters that pertain to healthcare.

The decision-making process of policy formulation is based on some aspects, including the health of the population itself (Nazarko, 2004). In cases where the population health is poor, there is a need to put more effort to restore the desired condition. Financial considerations should be made when devising policies geared towards the promotion of population health in the United Kingdom. Bodies that take part healthcare provision should be tasked with the obligation of promoting good practices (Adams, 2007). Decisions that determine the distribution of resources should be made collectively after engaging various stakeholders in the field.

To sum it up, population health is n important aspect, which affects the economic performance of a country. The paper focuses on the decision-making process that is involved in the formulation of policies. Some policies are set up as a result of a particular incident, while others are not. The study applied the health and social care act of 2012 as an example to illustrate government policies and how they impact operations, especially in the healthcare sector. The act was established primarily to enhance equality and propel excellence in the healthcare sector. The act outlines distinctly roles that each stakeholder must oblige to do for mutual understanding. Equally, the act has promoted good practices within the healthcare sector that have improved the provision of holistic care. In essence, the report is focused on evaluating the Health and Social care act of 2012 and its impact on the provision of standardized services. It is always crucial to devise strategic measures that can promote the welfare of people, especially for healthcare.

Adams, R. ed., 2007.  Foundations of health and social care . Macmillan International Higher Education.

Care Quality Commission, 2012.  The state of health care and adult social care in England in 2011/12  (Vol. 763). The Stationery Office.

Field, R. and Brown, K., 2019.  Effective leadership, management and supervision in health and social care . Learning Matters.

Glover-Thomas, N., 2013. The Health and Social Care Act 2012: The emergence of equal treatment for mental health care or another false dawn?.  Medical law international ,  13 (4), pp.279-297.

Howieson, W.B., 2012. Mission command: a leadership philosophy for the Health and Social Care Act 2012?.  International Journal of Clinical Leadership ,  17 (4).

Kew, J. and Stredwick, J., 2008.  Business environment: managing in a strategic context . Kogan Page Publishers.

Nazarko, L., 2004.  Managing a quality service . Heinemann.

Pownall, H., 2013. Neoliberalism, austerity and the Health and Social Care Act 2012: The Coalition Government’s Programme for the NHS and its implications for the public sector workforce.  Industrial Law Journal ,  42 (4), pp.422-433.

Sadek, E. and Sadek, J., 2004.  Good practice in nursery management . Nelson Thornes.

Speed, E. and Gabe, J., 2013. The Health and Social Care Act for England 2012: the extension of ‘new professionalism’.  Critical Social Policy ,  33 (3), pp.564-574.

Walshe, K., 2012. The consequences of abandoning the health and social care bill.

Williams, R.S., 2002.  Managing employee performance: Design and implementation in organizations . Cengage Learning EMEA.

Cite this page

Similar essay samples.

• Essay on Identify 3 Models of Psychopathology. Critically Examine Thei...
• Embracing the CRT
• Essay on Importance of Developing Critical Thinking Skills for Effecti...
• Essay on Social Media and Teenagers’ Emotional Well-Being
• Is leadership a transformational process or is it a form of control?
• Essay on Security Mechanism

Cookies on GOV.UK

We use some essential cookies to make this website work.

We’d like to set additional cookies to understand how you use GOV.UK, remember your settings and improve government services.

We also use cookies set by other sites to help us deliver content from their services.

You have accepted additional cookies. You can change your cookie settings at any time.

You have rejected additional cookies. You can change your cookie settings at any time.

• Health and social care

Health and Social Care Act 2012: fact sheets

A series of fact sheets explaining aspects of the Health and Social Care Act 2012.

Applies to England

Overview of the health and social care act fact sheet.

PDF , 130 KB , 2 pages

Health and care structures fact sheet

PDF , 159 KB , 3 pages

Scrutiny and improvements fact sheet

PDF , 157 KB , 2 pages

Clinically-led commissioning fact sheet

PDF , 149 KB , 2 pages

Provider regulation fact sheet

PDF , 138 KB , 2 pages

Greater voice for patients fact sheet

PDF , 159 KB , 2 pages

New focus for public health fact sheet

PDF , 161 KB , 2 pages

Greater accountability locally and nationally fact sheet

PDF , 152 KB , 2 pages

Streamlined arm's length bodies fact sheet

PDF , 141 KB , 2 pages

Support worker regulation fact sheet

PDF , 122 KB , 2 pages

Tackling inequalities fact sheet

Promoting better-integration of health and care services fact sheet.

PDF , 160 KB , 2 pages

Choice and competition fact sheet

PDF , 133 KB , 2 pages

Role of the secretary of state fact sheet

PDF , 147 KB , 2 pages

Reconfiguration of services fact sheet

PDF , 120 KB , 1 page

Establishing new national bodies fact sheet

Embedding research as a core function of the health service fact sheet.

PDF , 156 KB , 2 pages

Education and training fact sheet

PDF , 151 KB , 2 pages

Case for change fact sheet

PDF , 125 KB , 1 page

These fact sheets explain particular topics associated with the act, including key themes. They include case studies of the policy in action and answers to frequently asked questions about the topic.

The fact sheets were first published in October 2011 and have since been updated to reflect the changes made during the act’s passage through Parliament.

Related content

Is this page useful.

• Yes this page is useful
• No this page is not useful

Help us improve GOV.UK

Don’t include personal or financial information like your National Insurance number or credit card details.

To help us improve GOV.UK, we’d like to know more about your visit today. Please fill in this survey .

• Research article
• Open access
• Published: 17 February 2017

Commissioning for health improvement following the 2012 health and social care reforms in England: what has changed?

• E. W. Gadsby 1 ,
• S. Peckham 1 ,
• A. Coleman 2 ,
• D. Bramwell 2 ,
• N. Perkins 2 &
• L. M. Jenkins 1  

BMC Public Health volume  17 , Article number:  211 ( 2017 ) Cite this article

9586 Accesses

20 Citations

28 Altmetric

Metrics details

The wide-ranging program of reforms brought about by the Health and Social Care Act (2012) in England fundamentally changed the operation of the public health system, moving responsibility for the commissioning and delivery of services from the National Health Service to locally elected councils and a new national public health agency. This paper explores the ways in which the reforms have altered public health commissioning.

We conducted multi-methods research over 33 months, incorporating national surveys of Directors of Public Health and local council elected members at two time-points, and in-depth case studies in five purposively selected geographical areas.

Public health commissioning responsibilities have changed and become more fragmented, being split amongst a range of different organisations, most of which were newly created in 2013. There is much change in the way public health commissioning is done, in who is doing it, and in what is commissioned, since the reforms. There is wider consultation on decisions in the local council setting than in the NHS, and elected members now have a strong influence on public health prioritisation. There is more (and different) scrutiny being applied to public health contracts, and most councils have embarked on wide-ranging changes to the health improvement services they commission. Public health money is being used in different ways as councils are adapting to increasing financial constraint.

Conclusions

Our findings suggest that, while some of the intended opportunities to improve population health and create a more joined-up system with clearer leadership have been achieved, fragmentation, dispersed decision-making and uncertainties regarding funding remain significant challenges. There have been profound changes in commissioning processes, with consequences for what health improvement services are ultimately commissioned. Time (and further research) will tell if any of these changes lead to improved population health outcomes and reduced health inequalities, but many of the opportunities brought about by the reforms are threatened by the continued flux in the system.

Peer Review reports

The UK government elected in 2010 embarked on a wide-ranging program of reforms to the health and social care systems in England. The Health and Social Care Act (2012) formed the centrepiece of the reforms, introducing extensive changes to the organisation, structure and delivery of health services. As part of these changes, key public health functions were transferred from the National Health Service (NHS) to local government councils. This transfer included specialist public health staff and the budget for commissioning a range of public health services, including sexual health services, public health nursing, drug and alcohol treatment, smoking cessation and weight management services. In addition, a national public health agency (Public Health England, PHE) was established, as the national leadership body for public health to provide national campaigns and co-ordinate health protection, and as an active partner in local initiatives where appropriate [ 1 ].

During the reforms, the government highlighted a number of issues that lay behind inadequate population health outcomes. It felt the system was fragmented, lacked integration and synergies across services and had overlapping responsibilities [ 2 , 3 ]. It also felt the system disempowered public health professionals, insufficiently valuing their skills [ 3 ]. Crucially, the government argued that there was an insufficient focus on the root causes of ill health, and pointed to a lack of accountability with regards to outcomes. Issues faced in England chimed with cross-cutting themes that emerged from a review of public health in Europe, notably: the importance of inter-sectoral working, the existence of wide inequalities between and within countries in Europe, and the knowledge gaps around what public health policies and interventions are being implemented where, and which are most effective [ 4 ].

In 2012, a new European health policy framework was developed, to support action across government and society to improve the health and well-being of populations, reduce health inequalities, strengthen public health and ensure people-centred health systems [ 5 ]. It was in this context that the UK government set out, in the English reforms, to clarify responsibilities and accountabilities, empower people and communities, and focus on the evidence of what works. They wanted a greater emphasis, at all levels, on disease prevention, and a more joined up approach, with clearer leadership. In addition, the need to achieve better results with less money was an undercurrent to the entire health and social care reforms, driven by the government’s aim to reduce their budget deficit.

Prior to the reforms in England, Primary Care Trusts (PCTs) were the NHS bodies responsible for commissioning – strategic planning and purchasing - most health services, including for public health [ 6 ]. Until 2011, PCTs also directly managed the vast majority of NHS community health services, such as district nursing, health visiting and children’s services. In 2013, PCTs were abolished and replaced by a new NHS commissioning architecture, locally led by Clinical Commissioning Groups (CCGs), and nationally led by a new independent NHS commissioning board (NHS England) [ 7 ].

Within PCTs, public health specialists tended to provide a lead role in developing strategies for meeting local health needs, and specialist clinical and public health advice to inform PCT commissioning. Whilst public health was (and remains) an inter-organisational function, with much close working between PCTs and local councils, funding remained predominantly from NHS sources, with most decisions about services and expenditure taken within an executive decision-making framework by Directors of Public Health supported by PCT Boards [ 6 , 8 ].

Public health services are now funded by a public health budget, separate from the budget managed through NHS England for healthcare. This budget is decided by the Department of Health (DoH), and managed by PHE. PHE funds public health activity either through allocations to upper-tier and unitary councils, by commissioning services via NHS England, or by commissioning or providing services itself. Most locally delivered public health activities are now commissioned or provided by local councils. The structure of local government in England is complex: there are 27 areas where services are split between upper-tier county councils (taking responsibility for social care, education, transportation and strategic planning), and smaller district councils (covering e.g. housing, leisure, environmental health and planning), and there are 125 unitary councils that provide the full range of services. All of these councils are run by elected councillors, usually affiliated to a political party, who represent and engage their local population, make key decisions, contribute to policy/strategy review and development, and conduct overview and scrutiny roles. Councils have the freedom to innovate and to make changes locally, under the ‘general power of competence’, introduced by the Localism Act 2011 [ 9 ]. There are important differences, then, in the context in which local public health commissioning is now done.

The Health and Social Care Act also introduced Health and Wellbeing Boards (HWBs) as statutory sub-committees of local councils. These boards were intended to bring together the key NHS, public health and social care leaders in each local council area to work together to co-ordinate commissioning of their services. They are thus an important part of the new health commissioning landscape [ 10 ].

A House of Commons Health Committee inquiry on public health post-2013, launched October 2015, is starting to raise some important issues related to the structures, organisation, funding and delivery of public health following the reforms [ 11 ]. However, to date, little academic attention has been paid to the impact of the reforms on public health commissioning in England. This article examines key changes to the public health system following the reforms, and explores the broad function of commissioning for health improvement within the new system. It highlights some important changes in the way public health commissioning is now undertaken, in who is doing it, and in what is commissioned. It draws on findings from a 3-year research study funded by the DoH, which examined the impact of structural changes on the functioning of the public health system, and on the approaches taken to improving the public’s health. The article critically examines these findings in the context of the intentions of the reforms to create a more joined-up system with clearer leadership and greater opportunities to improve population health.

The PHOENIX study was a 3-year research project to examine the impact of structural reforms on the functioning of the public health system in England. It was an exploratory study that took place from the time of transition (April 2013), and so could explore the ways in which the planning, organisation, commissioning and delivery of health improvement services were changing over time as the new structures bedded in. One of its objectives was to examine approaches taken to commissioning within the new system, using obesity as a focal topic.

The study incorporated multiple methods. In a scoping review [ 12 ], we analysed policy documents and responses to the reforms from key stakeholders [ 13 ], developed a picture of how the new structures were developing, and collated demographic and other data on all 152 upper-tier and unitary local councils in England. This review identified the key themes to follow up on in the next phase of the research. It also enabled the purposive selection of local councils for later case study research, conducted from March 2014 to September 2015, in five areas. The areas were purposively selected for maximum variation across a a range of characteristics related to the councils and the populations they serve (including council type, size, urban or rural location, varied socio-demographic and economic circumstances, obesity prevalence and different political control) in order to provide a diverse range of cases. The five areas (described in Table  1 ) encompassed 13 different councils, including unitary, upper-tier and a sample of lower-tier (district) councils, some of which had a variety of different sharing arrangements. This enabled an examination of multiple perspectives and inter- and intra-organisational relationships.

Within the case study areas, 103 semi-structured interviews were conducted (see Table  1 ) with 36 council public health staff; 18 elected members; 25 council non-public health staff; 13 provider organisation staff; six CCG staff and three other staff at regional levels. Three members of the research team were allocated across the case study sites to enable each researcher to develop a deep understanding of and good relationships within each area. Fifteen meetings were observed and documentary evidence was collated to enrich our understanding of the case study areas. A further five interviews were conducted with key informants outside of the case study areas, particularly to explore national and regional level issues and relationships with/within PHE.

In the autumn of 2015, a web-based questionnaire was sent to all Directors of Public Health (DsPH), and to councillors in all 152 upper-tier and unitary councils who had a public health brief. Usable responses were received from 49% of DsPH and 32% of elected members. The questionnaire was broadly a repeat of a survey conducted the previous year (not reported in this paper). The distribution of responses from local councils was highly representative overall. Data was analysed using SPSS.

Qualitative data was analysed on a case and theme-based approach, using NVIVO 10. Multi-investigator, multi-site and multi-method triangulation was used in an ongoing and iterative process of bringing together and interrogating the data. Reflexive, narrative accounts of each case study area were shared with the research team, which was made up of experts in public health, local government, ethnography, and public policy. Rich interpretations of emergent themes across the cases were developed collaboratively, paying particular attention to roles and relationships, power/autonomy, and decision-making processes. Analysis drew on a number of integrative theoretical frameworks, employing concepts and ideas drawn from a number of different paradigms [ 14 , 15 ]. Ongoing analysis of the data allowed shifts in focus according to the interplay between theory, concepts and data, enabling sensitivity to the constantly changing field of study.

Ethical approval was granted by the university research ethics committee, and research governance approvals were obtained for each case study site.

Throughout analysis, commissioning was considered as one of the broad aspects of public health activity. As a theme, it included identifying needs, reviewing service provision, deciding priorities, procuring services, and managing performance. Our research set out to examine the context for commissioning, the people/organisations involved in commissioning activities, the processes involved, and any evidence of things changing.

The context for commissioning

The transfer of public health staff and resources into local councils from PCTs was far from straightforward, and often accompanied other system reorganisations. For instance, in one of our case study areas, staff in a PCT were separated into a council public health team, one of three CCGs, or into a provider trust. One children’s public health commissioner who was formerly in the children’s joint commissioning team in the PCT with commissioning responsibilities for the whole of the 0–19 pathway, was transferred to a council team. Her former commissioning responsibilities were split amongst different organisations, and she was now responsible only for certain elements of the healthy child programme. She explained the resulting confusion:

“… It has caused fragmentation of the system and certainly for the 0–19 pathway or services for children, you know, the health services for children. It has meant that different parts of the system are now responsible for commissioning different elements of it …, which is challenging” (senior public health commissioner, council, site B).

This also had implications for the sharing of information between health and council commissioners, which this officer described as being “much more difficult for us now”.

Some public health staff chose to join PHE or NHS England, and some became part of new commissioning support organisations. There was much confusion over where staff should be transferred to (sometimes depending on the proportion of their time spent on service commissioning versus service provision), and around the organisation of budgets. There were instances where this tested relationships between councils and CCGs.

Local councils received their public health staff, resources and duties at a time of unprecedented cuts to their budgets [ 16 ]. These cuts precipitated ongoing restructures within councils which sought to streamline their organisations and reduce staffing costs. The positioning of public health teams within councils varied. Our survey found that 26% ( N  = 73) of the public health teams were distinct public health directorates; 52% were sections of another directorate; and 22% had other arrangements, including merged, distributed and mixed models. DsPH also had different levels of access to key council decision-making bodies (53% of DsPH respondents were members of the council’s most senior corporate management team), and different line-management structures (47% said that they were managerially responsible to the council’s chief executive; 53% were managed by a range of other directorate heads). Consequently, DsPH were not always in the best place for strategic influence in the council.

Commissioning processes and people involved

Decision-making within councils was found to be very different to that within PCTs. Decisions about how to spend money were subject to a greater range of decision makers and wider consultation, both across the council and amongst the public, than before. Elected members are the key decision makers within councils; the role of officers, including those in public health, is to support them. Elected members, therefore, were influencing the priorities and actions of the public health team, sometimes overtly and sometimes more subtly. 92% of elected members responding to our survey ( N  = 38) said they felt always able (45%) or quite often able (47%) to influence the priorities of the public health team. In our case studies, we saw how this influence might operate more subtly, perhaps according to the ideologies and interests of the elected member, or the politics of the council. For instance, in one Conservative-led council, the elected member explained that he would have a very difficult job persuading his cabinet to significantly increase spending on smoking cessation: “They’re not particularly interested in it, they think … ‘oh well if people smoke themselves silly, let them smoke themselves silly’” (elected member, council, site A).

Compared with the NHS, local councils take different approaches to prioritisation and commissioning, influenced in part by over 15 years of implementing ‘Best Value’ Footnote 1 . The processes of commissioning (and new procurement laws) within a council have had to be learned by incoming public health staff. At the same time, public health staff have tried to educate councillors in public health commissioning.

Several commissioning officers who had worked within councils prior to the reforms (e.g. in adult or children’s social care directorates) and who moved, following the reforms, into the public health teams, talked about differences they observed in how commissioning was done. One, referring to her incoming public health colleagues, explained:

“We were faced with a lot of ignorance about commissioning - local authority style commissioning and business processes - amongst our colleagues… I was shocked actually by the lack of understanding of what we had been doing or what we did [as local authority commissioners]” (commissioner, council, site B) .

Another talked about the differences between commissioning in PCTs and commissioning in the councils. She explained that “public health has commissioning responsibilities now in a way that they didn’t in the old PCT”. She described commissioning in the former PCTs as comparatively less ‘robust’, with less accountability, and less scrutiny of performance and outcomes data:

“ there’s much stronger scrutiny in local government and that’s all areas of business and it’s something that we’ve had to really work with our providers in NHS specifically around understanding” (commissioner, council, site A) .

From the point of view of providers, however, the sometimes rather narrow outcomes-based scrutiny that services were now subjected to was not always appropriate for complex public health interventions. For instance, the provider of a range of obesity prevention services in one of our case study areas complained that the focus on outcomes in terms of body mass index reductions belied the fact that most of their time and resources were spent on engaging communities and developing relationships with schools and others. The outcomes of this type of activity, however, are impossible to measure.

Having a distinct public health grant for the first time enabled DsPH to take a different approach – a more strategic approach - to the allocation of the public health budget. A public health officer in one of our sites described how, in the PCT, they were sometimes left ‘scrabbling’ around for funds, when public health priorities and PCT priorities were not always well matched. However, with a ring-fenced budget, they were able to plan how best to match spending against their local priorities. The leader of a council in site A explained how they were prepared to completely shake up the way in which the public health grant was spent: “ We’ve got to start at reviewing; is that delivering to the right priorities or not? Is it value for money or not? And what should we stop doing and what should we start doing? ” Indeed, this process of whole-scale service reviews for specific areas (such as obesity) was demanded by councillors in all of our case study areas. For public health officers, this sometimes gave them the freedom to pursue quite different approaches.

Decision-making across the local system following the reforms was intended to be more co-ordinated. However, with commissioning responsibilities now fragmented between NHS England, PHE, local councils and CCGs, our research found that co-ordination was proving to be difficult. Moreover, the lack of clarity about responsibilities sometimes led to delays in the commissioning of services, and/or tensions in the relationships between organisations. Commissioning across an obesity pathway, for instance, involves councils (for broad obesity prevention and non-intensive weight management services), CCGs (for specialist obesity services) and NHS England (bariatric services) [ 17 , 18 ]. Across England, we know that there are significant gaps in this pathway, with a particular lack of specialist obesity services [ 19 , 20 ]. Following the reforms, there was a great deal of confusion about whose responsibility it was to commission these services.

It is clear that, as with many public health interventions, if weight management and obesity prevention services are to achieve their objectives, primary and community care providers play a vital role. The presence, absence, type and success of health improvement services commissioned by councils have important implications for NHS work. However, there is now a greater disconnect between public health officers and NHS commissioners. In response to our survey, 48% of DsPH ( N  = 69) said they felt ‘less able’ to influence local CCGs than before the reforms. In our case study sites, we found that evidence of meaningful engagement between public health teams and CCGs was limited. This HWB chair felt that CCGs had become disengaged from public health:

“ I think we’ve got to persuade the CCG that, in particular, public health is everybody’s business, it’s not just the local authority’s business. … they see public health as a separate entity at the moment, and not part of an integrated health economy” (Chair HWB, council, site C) .

HWBs were meant to be the mechanism for co-ordinating commissioning across NHS, social care and public health at the strategic level. Our survey found that amongst DsPH ( N  = 65), 48% felt the HWB was ‘definitely’ instrumental in identifying the main health and wellbeing priorities, and 45% felt it had ‘definitely’ strengthened relationships between commissioning organisations. However, less than 5% felt that the HWB was ‘definitely’ making difficult decisions, and only 28% felt that it had ‘definitely’ begun to address the wider determinants of health. A further complication with co-ordinating across the system and addressing wider determinants is that in two-tier councils, many of the functions that public health are expected to work across are based in multiple lower-tier district councils. Public health officers must therefore build relationships with a greater number of different organisations, all with their own priorities and ideas. In addition, these district councils often have a limited voice on HWBs. It is perhaps partly for this reason that some HWBs were not seen to be significantly engaging with the public health agenda. As this HWB chair explained:

“We have a very strong focus on integration, Better Care Fund – all that side of things. I’m conscious sometimes of an element of criticism … there’s always a challenge to say, ‘Are you actually thinking enough about long term determinants and all the sort of public health agenda’ …” (Chair HWB, council, site A).

What has changed?

Our research suggested that, as a result of the reforms, public health commissioning was changing on a number of levels. Firstly, money was being used in different ways. One indication of this was the way in which the ring-fenced public health budget was being used to invest in other departments in the majority of councils (see Fig.  1 ). Given the huge cuts councils were having to make, most DsPH felt that, now the public health budget was contained within the council, it was expected to contribute to the overall savings they needed to make. Many seemed reconciled that the budget would now be used to fund other services – in many cases, services that would have been cut (e.g. children’s centres) had public health funding not been available. And in our case studies, public health officers talked about the opportunities this sometimes presented, in terms of embedding public health activities and objectives within other council services and providing more joined-up ways of thinking and working.

Use of public health budget to invest in other council departments in previous 12 months

Secondly, there were many changes being made to the commissioning of health improvement services (see Fig.  2 ). The move to local government prompted public health commissioners to look at services and contracts anew. In addition, councils tended towards shorter contracts and more frequent retendering of services than the NHS. All our respondents had started the process of retendering within 2 years. But we also saw the majority of responding authorities ( N  = 64–67) having set up new services (73%), changed provider of existing services (90%), re-designed existing services (94%) and de-commissioned services (69%). In our case study areas we saw that extensive commissioning changes were sometimes occurring as a result of changes in local area arrangements, for instance, where several areas (former PCTs) were brought together into one (council). Other commissioning changes, however, were as a result of service reviews that were very critical of service outcomes.

Changes made by councils to services commissioned under public health budget in last 12 months

Our surveys asked for more information about changes that were being made to obesity commissioning. DsPH commented that they were wanting to move away from ineffective schemes, increase their focus on children, use new providers and create a more integrated pathway. All these changes were resulting in insecurity in the provider landscape.

Finally, there were changes to the size and profile of the public health teams responsible for commissioning health improvement services. DsPH were asked whether there had been changes in the last 12 months to the size and composition of their public health team. 28% ( N  = 72) reported that they had fewer public health specialists. 15% reported they had more business managers/commissioning support staff, and 22% ( N  = 54) said they had more ‘other’ staff (not falling into the DPH, specialist, analyst or commissioning support categories). In our case study sites, public health officers talked of the need to address skill gaps within their team in response to working in the new environment. In one of our sites, for instance, the public health commissioning team (made up of non-public health specialists) had been significantly bolstered. The team of public health specialists had been correspondingly reduced.

It was not easy to tell, at this juncture, whether these observed changes in commissioning had resulted in a significantly different set of activities being commissioned. However, there were early signs of some general shifts occurring. In three of our case study areas, we observed a shift towards the commissioning of more holistic ‘healthy lifestyle’ services, bringing together weight management, smoking cessation, alcohol reduction, sexual health services, and so on. In two of our councils, we saw a shift (at least in rhetoric) towards ‘whole council’ approaches, for instance, where they were seeking to address a broader range of factors influencing obesity, particularly by working across council departments. We witnessed a greater recognition of public health objectives and expected outcomes in a wider range of council services as a result of public health investment. And we saw public health staff working hard to influence the wider workforce. Particularly during the transition phase, as public health were settling into their new homes, a number of programmes including learning events, information sharing, and engagement events were targeted at elected members and non-public health officers across the council.

The reforms expressed a clear intention to simplify and streamline a previously complex, fragmented system. The transfer of public health responsibilities into local councils was to ensure that public health outcomes were embedded across a council’s functions. The creation of HWBs was to ensure strategic direction across organisations.

The functions of the now extinct PCTs were spread across CCGs, councils and provider organisations, creating a more complex organisational picture than before the reforms, with more complex accountability and governance structures. Moreover, there was continued upheaval in the system, with elements such as CCGs and public health teams merging, the PHE regional tier ‘downsizing’, and local councils constantly restructuring as they tried to cope with substantial budget cuts. Fragmentation is a problem common to many health systems, and is a condition related to the tendency within health care planning to focus and act on the parts without adequately appreciating their relation to the evolving whole [ 21 ]. There is a constant challenge to create a system focused on relationships across the whole – whole people, whole systems, whole communities. It is often these relationships across the whole that suffer in the context of financial restraint and continual change [ 22 ].

The move of public health into local councils in England created a new working environment for commissioners, public health practitioners and providers. Our findings have demonstrated how, in this new environment, existing public health capacity has been both freed and stifled. Public health professionals have the opportunity to take on a more significant role in shaping local places, but will need to find a balance between ‘service’ public health and academic ‘social medicine’ [ 23 ].

The considerable literature on decentralisation suggests that the transfer of authority and resources to local government might offer significant opportunities to improve access to health and other care services, to provide services that are better aligned to needs and local preferences, and to allow for increased flexibility and transparency [ 24 – 26 ]. However, the reforms in England simply moved public health responsibilities at the local level from executive decision-making bodies (PCTs) to democratically governed councils. Whilst PCTs had the same ‘local’ focus as councils, they were historically more directly accountable to central government, and, with a few exceptions, were poor at developing local ‘bottom-up’ methods for making NHS services more user-responsive [ 27 ]. Councils, on the other hand, have been subject to a longer experience of competitive tendering and service commissioning than the NHS [ 28 ], and tend to have a more structured approach for community engagement and user-involvement embedded in their organisational culture [ 29 ]. As a result, there appears to have been a shift in how public health commissioning is performed, from a more specialist-led investment approach to a more ‘business’-orientated approach adopted by many local councils, using best value frameworks.

In the new environment, there seems to be more opportunity for variation across the country in what activity is commissioned, and in who provides it (as well as how, where and to whom). The Localism Agenda [ 9 ] gives councils more freedom to innovate, to both drive down costs and meet local needs [ 30 ]. Considerable discretion was afforded to individual councils to interpret the full and detailed scope of their new functions and services [ 31 ]. This was important, given the independence of councils as democratic organisations, but it means that public health decision-making is now less amenable to central government control.

In the absence of strong central control, it is important to question the extent to which local problems can be solved locally without risking geographical inequity of services which underpin basic human rights [ 32 , 33 ]. For the next couple of years, the annual public health budget devolved to local government in England will be around £3.3 billion (reducing by an average of 3.9% every year in real terms until 2020) [ 34 ]. Prior to the reforms, this budget would have been spent by PCTs, who were accountable for that spend to the DoH, via regional NHS authorities (now abolished) who were mainly concerned with overall NHS expenditure and financial sustainability of NHS healthcare services. Following the reforms, whilst the public health outcomes framework gives a clear sense of outcomes the DoH expects to see, the accountability for spending money is much weaker. Beyond a basic report to the Department on how the budget has been spent, there is very little role for formal state-driven accountability. In a way most uncharacteristic of the NHS, PHE has emphasised that it is there to support local councils, not performance manage them. Instead, there is a reliance on sector-led improvement, whereby councils review and support each other’s performance [ 35 ]. In addition, public health commissioning is coming under much closer scrutiny from elected members within the local council. Our research supported the idea that we can expect to see increasing variation in services, but it is far from clear what impact this will have on variations in outcomes.

Public health officers moving from the NHS to local councils have sometimes struggled to adjust to this different relationship with central government. From the point of view of commissioners, the lack of guidance and clarity from Government was often found to be unhelpful. In particular, public health officers expressed the need for more timely information, for instance, regarding responsibilities for commissioning across the fragmented system, or how the in-year budget cuts would be implemented [ 36 ]. In the absence of detailed information, public health teams were sometimes forced to make commissioning decisions based more on expediency than on need. In the new system, the DoH is defined as the ‘system leader’, improving people’s health and wellbeing through its stewardship of the public health system [ 37 ]. The concept of health stewardship implies a broad over-arching responsibility over the functioning of the system as a whole and, ultimately, over the health of the population [ 38 ]. However, we suggest that central government in England has yet to resolve some important stewardship issues, particularly around its role in securing resources, balancing competing interests and demands, and assuring delivery in the context of localism and the move of public health into local government. Moreover, there was little in our research to suggest that PHE have sufficient capacity, or have yet developed the strong relationships required, to provide meaningful support to local partners in the delivery of their vision.

Public health officers have also had to adjust to different roles and relationships relative to other actors at local level. Directors of public health were previously key decision makers on the executive boards of PCTs. Whilst they were often the first to be pushed back if cuts were required or budgets exceeded, DsPH had clear authority with regards to public health prioritisation. Following the reforms, they are expert advisers to elected members. Leadership for public health is more dispersed; decision-making is now more complex, and arguably subject to greater political ideology and personal interest. There may also be unforeseen consequences arising from the outcomes-based scrutiny of complex public health interventions, and from increased insecurity within the provider landscape. Many public health interventions require a long time-frame in which to bring about significant population health improvements. This doesn’t sit well with the short-termism of contemporary politics. As local councils struggle to cope with tighter budgets, public health officers may find it harder to convince their elected members of the added value of some of the public health services they commission.

Our research has highlighted the huge amount of change occurring in the commissioning (and decommissioning) of health improvement services in England. Whilst it will be important for the wider health system that key public health services are protected and improved (for instance, in smoking cessation, weight management and sexual health services), the public health specialists will need to capitalise on bringing about positive change through closer integration with the strategy and activity of the council. Commissioning for health improvement requires commissioners to focus on the modifiable determinants of health, taking a pro-active approach to improving individuals’ life chances and reducing social inequalities, rather than waiting until people are already ill and commissioning reactively. Local councils, due to their wider scope and responsibilities, are better placed than the NHS with its largely clinical orientation, to address a broad range of determinants, such as lifestyles, community, local economy and activities [ 30 ]. Our research, like the many case studies highlighted in a range of Local Government Association reports [ 39 – 42 ] has identified a range of positive examples where stronger and more direct public health involvement and influence across councils has brought about new opportunities. In their new ‘home’, and with the right support from their council, public health officers can be afforded the freedom to approach public health challenges in new ways. Local councils are also more adept than NHS organisations at broader level consultation and community engagement, which might afford new opportunities in line with the Ottawa Charter recommendations for public participation and empowerment [ 43 ].

The NHS continues to have a vital part to play in population health improvement, and the reforms hoped to bring about improved synergies between public health, NHS and social care. However, with public health moving ‘arms-length’ to the NHS, both health services commissioners and providers are becoming more remote to the local public health systems. Moreover, the vital co-ordination role of HWBs is not always working well locally [ 10 ]. Some health improvement services could, as a result, end up being disconnected from each other and from wider support. Similarly, services that are crucial to the achievement of health service objectives (such as reducing premature mortality from the major causes of death), but which are commissioned or provided by the council (e.g. weight management, smoking cessation and alcohol services), are at risk of being cut or changed. Our research has highlighted that there is much change in the way public health commissioning is done, who is doing it, and what is commissioned. Time (and further research) will tell if these changes are to result in improved outcomes and reduced inequalities. However, until there is a strong sense of shared ownership across local systems, and ‘whole system’ commissioning at local level, any opportunities afforded by the reforms to the public health system might be outweighed by the challenges of fragmentation and budget cuts.

We found that the system created by the reforms was confused, continually changing, and - from the point of view of commissioning - more fragmented than before. In some ways, the move of public health into councils has brought about some of the opportunities associated with decentralisation – in particular, allowing for increased flexibility. However, most public health commissioners were essentially moved from one local organisation (NHS), to another (council), so the comparisons with decentralisation are limited. In this new local environment, former public health capacity has been at the same time freed and stifled. Public health commissioning is being more strongly influenced by a new set of decision-makers in the form of democratically elected councillors, with their own local knowledge, ideologies, and experiences. Meanwhile, many councils are bringing a more business-oriented approach to bear on public health commissioning, with greater scrutiny of outcomes in relation to spend. This is challenging the public health specialists and provider organisations, and changing the shape of health improvement services. Whilst we can expect to see increasing change and variation in services across England, it is far from clear what impact this will have on outcomes and on variations in outcomes.

The Duty of Best Value makes clear that councils should consider overall value – including social value – when considering service provision. Under the general Duty of Best Value, local authorities should “make arrangements to secure continuous improvement in the way in which its functions are exercised, having regard to a combination of economy, efficiency and effectiveness” https://www.gov.uk/government/publications/best-value-statutory-guidance--4.

Abbreviations

Clinical Commissioning Group

Department of Health

Directors of Public Health

Health and Wellbeing Board

National Health Service

Primary care trust

Public Health England

Department of Health. Local government’s new public health functions. 2011. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216710/dh_131905.pdf . Accessed 18 July 2016.

Department of Health. New focus for public health - the health and social care act 2012. Factsheet B4. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138263/B4.-Factsheet-New-focus-for-public-health-250412.pdf . Accessed 18 July 2016.

Department of Health. Healthy lives, healthy people: our strategy for public health in England. London: Her Majesty’s Stationery Office; 2010.

Google Scholar  

Rechel B, McKee M, editors. Facets of public health in Europe. European Observatory on Health Systems and Policy Series. 2014.

World Health Organisation. Health 2020: The European policy for health and well-being. 2016. http://www.euro.who.int/en/health-topics/health-policy/health-2020-the-european-policy-for-health-and-well-being . Accessed 18 July 2016.

Marks L, Cave S, Hunter D, Mason J, Peckham S, Wallace A. Governance for health and wellbeing in the English NHS. J Health Serv Res Policy. 2011;16 suppl 1:14–21.

Article   PubMed   Google Scholar  

Department of Health. Equity and excellence: Liberating the NHS (cm 7881). London: Her Majesty’s Stationery Office; 2010.

Marks L, Cave S, Hunter DJ. Public health governance: views of key stakeholders. Public Health. 2010;124(1):55–9.

Article   CAS   PubMed   Google Scholar  

Department for Communities and Local Government. A plain English guide to the Localism Act. London: DCLG Publications; 2011.

Coleman A, Checkland K, Segar J, McDermott I, Harrison S, Peckham S. Joining it up? Health and Wellbeing Boards in English Local Governance: Evidence from clinical commissioning groups and shadow health and wellbeing boards. Local Gov Stud. 2014;40(4):560–80.

Article   Google Scholar  

UK Parliament. Public health post-2013 inquiry launch. 2015. http://www.parliament.uk/business/committees/committees-a-z/commons-select/health-committee/news-parliament-20151/public-health-post-2013-inquiry-15-16/ . Accessed 18 July 2016.

Gadsby EW, Peckham S, Coleman A, et al. PHOENIX: Public health and obesity in England - the new infrastructure examined. First interim report: The scoping review. 2014. http://blogs.lshtm.ac.uk/prucomm/2016/07/15/phoenix-public-health-and-obesity-in-england-the-new-infrastructure-examined-2/ . Accessed 18 July 2016.

Riches N, Coleman A, Gadsby EW, Peckham S. The role of local authorities in health issues: A policy document analysis. London: PRUComm: Policy Research Unit on Commissioning and the Healthcare System; 2014. https://www.kent.ac.uk/chss/docs/CLG-report.pdf . Accessed 18 July 2016.

Turnbull S. Bricolage as an alternative approach to human resource development theory building. Hum Resour Dev Rev. 2002;1(1):111–28.

Bryant C, Jary D, editors. Giddens’s theory of structuration: a critical approach. London: Routledge; 1991.

The Centre for Local Economic Strategies. Austerity uncovered: Final report prepared by the centre for local economic strategies, presented to TUC. December 2014. https://www.tuc.org.uk/sites/default/files/TUC%20Final%20Report%20Dec'14_1.pdf . Accessed 18 July 2016.

Department of Health. Developing a specification for lifestyle weight management services. Best practice guidance for tier 2 services. London: Department of Health; 2013.

NICE. Obesity: Identification, assessment and management. Guidelines CG189. 2014.

Public Health England. National mapping of weight management services. Provision of tier 2 and tier 3 services in England. London: Public Health England; 2015.

Hughes C. The rewards and challenges of setting up a tier 3 adult weight management service in primary care. Br J Obes. 2015;1(1):1–40.

Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med. 2009;7(2):100–3.

Article   PubMed   PubMed Central   Google Scholar  

Pavolini E, Guillén A, editors. Health care systems in Europe under austerity: Institutional reforms and performance. UK: Palgrave Macmillan; 2013.

Gorsky M, Lock K, Hogarth S. Public health and England local government: historical perspectives on the impact of ‘returning home’. J Public Health. 2014;36(4):546–51.

Mosca I. Is decentralisation the real solution? A three country study. Health Policy. 2006;77(1):113–20.

Robalino DA, Picazo OF, Voetberg A. Does fiscal decentralization improve health outcomes? - evidence from a cross-country analysis. Policy, Research working paper; no. WPS 2565. Washington, DC: World Bank; 2001. http://documents.worldbank.org/curated/en/832091468739534469/Does-fiscal-decentralization-improve-health-outcomes-evidence-from-a-cross-country-analysis .

Peckham S, Exworthy M, Powell M, Greener I. Decentralisation, centralisation and devolution in publicly funded health services: Decentralisation as an organisational model for health care in England. Report for the national co-ordinating centre for NHS service delivery and organisation R & D (NCCSDO). UK: NCCSDO; 2005.

Dowling B, Sheaff R, Pickard S. Governance structures and accountability in primary care. Public Money Manage. 2008;28(4):215–22.

Bovaird T. The ins and outs of outsourcing and insourcing: What have we learnt from the past 30 years? Public Money Manage. 2016;36(1):67–74.

Schehrer S, Sexton S. Involving users in commissioning local services. York: Joseph Rowntree Foundation; 2010.

Royal Society for Public Health. The RSPH guide to commissioning for health improvement. 2014.

Peckham S, Gadsby EW, Coleman A, et al. PHOENIX: Public health and obesity in England - the new infrastructure examined. Final report. 2016. http://blogs.lshtm.ac.uk/prucomm/2016/07/15/phoenix-public-health-and-obesity-in-england-the-new-infrastructure-examined-2/ . Accessed 18 July 2016.

Pugh M. Centralism versus localism? Democracy versus efficiency? The perennial challenges of Scottish local government organisation. History and Policy. 2014.

Collins C, Green A. Decentralization and primary health care: Some negative implications in developing countries. Int J Health Serv. 1994;24(3):459–75.

Public health grants to be cut by £160m over next two years. Public Finance. 12 Feb 2016. http://www.publicfinance.co.uk/news/2016/02/public-health-grants-be-cut-ps160m-over-next-two-years . Accessed 18 July 2016.

Buck D. Why we need to strengthen local authorities’ accountability for public health outcomes. The King’s Fund. 30 January 2013. http://www.kingsfund.org.uk/blog/2013/01/why-we-need-strengthen-local-authorities-accountability-public-health-outcomes . Accessed 18 July 2016.

Department of Health. Local authority public health grant allocations 2015/16. Government response to public consultation on in-year savings and equality and health inequality analysis. London: Department of Health; 2015.

Department of Health. How is the Department of Health changing? 2013. http://webarchive.nationalarchives.gov.uk/20130805112926/http://healthandcare.dh.gov.uk/dh-change/ . Accessed 18 July 2016.

World Health Organisation. The World Health Report 2000. Health systems: improving performance. Geneva: WHO; 2000.

Local Government Association, Public Health England. Public health transformation nine months on: bedding in and reaching out. London: LGA; 2014.

Local Government Association. Public health transformation twenty months on: Adding value to tackle local health needs. London: LGA; 2015.

Local Government Association. Sexual health commissioning in local government. London: LGA; 2015.

Local Government Association. Healthy weight, healthy futures: Local government action to tackle childhood obesity. London: LGA; 2016.

World Health Organisation. The Ottawa charter for health promotion: First international conference on health promotion, Ottawa, 21 November. 1986.

Download references

Acknowledgements

We are grateful to our case study sites for allowing us to spend so much time with them and for being so open in discussing their work. We are also grateful to the survey and interview respondents for giving up their valuable time to respond to our questions. The project’s stakeholder group have provided valuable guidance and support throughout the research.

This research on which this article is based was funded by the UK Department of Health. The views expressed are those of the researchers and not necessarily those of the Department of Health.

Availability of data and materials

Data will not be shared due to the difficulties of ensuring anonymity of sites and individuals.

Authors’ contributions

SP managed the research on which this article is based. EG, AC, DB, NP and LJ carried out the research. LJ conducted the analysis of the surveys. EG, AC, DB, NP and SP were involved in analysing the case study data. EG drafted the manuscript. EG, SP, AC, DB, NP and LJ helped to interpret the data and edit the manuscripts. EG, SP, AC, DB, NP and LJ approved the final version of the manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Approval was sought and granted from the University of Kent’s School of Social Policy, Sociology and Social Research Ethics Board (SRCEA No. 112), and research governance approval was obtained for each case study site in respect of NHS interviewees from the Health Research Authority (15 July 2015/182754). Written, signed consent was obtained from the heads (leaders and/or chief executives) of all local councils within the case study areas and every individual interviewed within the study.

Author information

Authors and affiliations.

Centre for Health Services Studies, University of Kent, Canterbury, UK

E. W. Gadsby, S. Peckham & L. M. Jenkins

Centre for Primary Care, University of Manchester, Manchester, UK

A. Coleman, D. Bramwell & N. Perkins

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to E. W. Gadsby .

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Gadsby, E.W., Peckham, S., Coleman, A. et al. Commissioning for health improvement following the 2012 health and social care reforms in England: what has changed?. BMC Public Health 17 , 211 (2017). https://doi.org/10.1186/s12889-017-4122-1

Download citation

Received : 20 July 2016

Accepted : 09 February 2017

Published : 17 February 2017

DOI : https://doi.org/10.1186/s12889-017-4122-1

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Health sector reform
• Public health commissioning
• Health improvement
• Local government

BMC Public Health

ISSN: 1471-2458

• Submission enquiries: [email protected]
• General enquiries: [email protected]

• Share on Twitter
• Share on LinkedIn
• Share on Facebook
• Share on WhatsApp
• Share by email
• Link Copy link

Structural changes from Health and Social Care Act (2012)

The Health and Social Care Act 2012 came substantively into force on 1 April 2013, bringing about a wide range of structural changes that would impact on the NHS, public health and adult social care.

Strategic health authorities (SHAs) and primary care trusts (PCTs) were abolished, with responsibility for NHS commissioning passing to NHS England at a national level and clinical commissioning groups (CCGs) at a local level. Local authorities took over control of health improvement functions and Public Health England was established as a national body to oversee health improvement and health protection.

Clinical commissioning groups (CCGs)

211 CCGs were established to replace 152 PCTs and commission urgent and emergency care, elective hospital care, community services, mental health services and maternity services. CCGs would be made of GP practices, but to ensure that a broad range of healthcare perspectives are taken into account, they would seek advice from a range of other healthcare professionals.

NHS England was established to oversee the operation of CCGs and allocate funding to them.

CCGs would control the majority of the overall NHS budget, with specialised services commissioned by NHS England, and health improvement services commissioned by local authorities. Clinical senates were established to provide strategic advice to CCGs, health and wellbeing boards and NHS England on commissioning and decision making on healthcare for local populations. 12 senates were established in England, comprised of a core Clinical Senate Council (a small steering group) and a Clinical Assembly or Forum (a multi-professional group providing support and expertise to the Council). Members include health and care professionals and experts, voluntary sector and patient representative groups. 19 commissioning support units (CSUs) were set up to provide commissioning support services to CCGs, acute trusts, local government and NHS England. These would provide services such as contract management, information governance, financial management, human resources, IT and communications.

Monitor took on its new functions as the sector regulator for the NHS with functions that included:

• running a system of licensing of providers of NHS services
• setting and enforcing requirements to secure continued provision of NHS services
• regulating prices for NHS services through a national tariff, in conjunction with the NHS Commissioning Board
• securing continuity of NHS services provided by companies through a process of 'special administration' and establishing funding mechanisms, to enable trust special administrators to secure continued access to NHS services
• establishing funding mechanisms.

The Cooperation and Competition Panel, which investigated breaches of competition law, became part of Monitor which was given concurrent powers with the Office of Fair Trading with regard to NHS merger decisions.

Public Health England

Public Health England (PHE) was created as an executive agency of the Department of Health. It was given operational independence, but ministers would set its strategic objectives and its functions would be conferred directly on the secretary of state for health by the Health and Social Care Act 2012.

PHE brought together a range of public health functions previously carried out by the Health Protection Agency, the National Treatment Agency, public health observatories, cancer registries and strategic health authorities. It would be responsible for discharging the secretary of state's duty to protect the health of the public, through securing the improvement of the public's health and improving population health through the provision of sustainable health and care services. It would also have a role in ensuring that the capacity and capability of the public health system was maintained, including through supporting local government with their public health duties.

Health and wellbeing boards

Health and wellbeing boards were established by the Health and Social Care Act 2012, to facilitate joint working across health and social care organisations. The boards would also be responsible for producing joint strategic needs assessments and joint health and wellbeing strategies. The Act specified a number of statutory members, including the director of adult social services and director of public health. Additionally, the Act placed a duty on health and wellbeing boards to encourage integration between health and social care commissioners for the benefit of the health and wellbeing of the local population.

Healthwatch England

Healthwatch England was established to act as an independent consumer champion for health and social care service users and to support the local Healthwatch network. It would be responsible for representing the public's views to national bodies, such as NHS England, Monitor, the Care and Quality Commission and the Secretary of State for Health. Its main functions would include supporting local Healthwatch organisations, collecting and collating national information, and charting trends to discern issues of concern and nationally championing these issues for service users and patients. Local Healthwatch organisations were established in every local authority area to take over the work of previous local information networks (LINks). They would provide advice, promote choice and signpost individuals, carers and community groups. They would also have the ability to influence local commissioning decisions, through their statutory seats on health and wellbeing boards.

Part of their remit would be to gather information on local people's experiences of health and social care and feed that data into Healthwatch England, which would use the information to influence national policy. They were also given powers to enter and view services. Some local Healthwatch organisations would also be commissioned by their local authority to provide NHS complaints advocacy services.

The National Institute for Clinical Excellence (NICE)

The National Institute for Clinical Excellence (NICE) was given responsibility for developing guidance and quality standards for social care, using its evidence-based model. This was intended to promote better integration between health services, care services and public health. NICE confirmed that it intended to develop quality standards on the following areas related to social care:

• challenging behaviour in people with learning disability
• managing medicines in care homes
• mental health problems in people with learning disability
• social care of older people with multiple long-term conditions
• transition between health and social care
• transition from children's to adults' services.

Health and Social Care Act 2012.

Campbell F. Get in on the act - Health and Social Care Act 2012. Local Government Association; 2012.

NHS England. Understanding the new NHS. NHS England; 2014.

Ellison J. Public Health England remit letter. Department of Health; 2014.

Healthwatch. What we do. Healthwatch; 2019.

Healthwatch. Healthwatch marks network launch across five events in England simultaneously. Healthwatch; 2013.

East Sussex Strategic Partnership. Overview of local Healthwatch functions. East Sussex Strategic Partnership; 2013.

NHS England. Further Commissioning Support Unit (CSU) managing directors announced by the Board Authority. NHS England; 2012.

NHS Commissioning Board. Developing commissioning support - towards service excellence. NHS Commissioning Board; 2012.

NHS Commissioning Board. Clinical Senates update. NHS Commissioning Board; 2013.

National Institute for Health and Care Excellence. Social care. National Institute for Health and Care Excellence; 2019.

BMA. NHS structures and integration. BMA; 2019.

Share this page:

• About this website
• About the Health Foundation
• Accessibility
• Terms and conditions
• Copyright statement
• Privacy policy and cookies

Hear from us

Receive the latest news and updates from the Health Foundation

Copyright The Health Foundation 2024.

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Peckham S, Falconer J, Gillam S, et al. The organisation and delivery of health improvement in general practice and primary care: a scoping study. Southampton (UK): NIHR Journals Library; 2015 Jun. (Health Services and Delivery Research, No. 3.29.)

The organisation and delivery of health improvement in general practice and primary care: a scoping study.

Chapter 7 impact of changes in the health and social care act 2012 and public health white paper.

• Introduction

The coalition government (2010–15) policies since 2010 highlighted the potential for greater GP involvement in public health. The changes to the structure of the NHS and to public health oversight introduced in April 2013 were designed to strengthen local public health, although the extent to which this will support and increase GP involvement is not clear. The combined implications of the government’s proposals for public health in England set out in Healthy Lives, Healthy People 37 (and subsequent consultation papers) and the changes contained in the Health and Social Care Act 2012 21 on the structure and delivery of public health in England have been enormous. In this chapter we discuss those implications which have a direct impact on the public health role of general practice. In the White Paper and other public statements, the government outlined an increased role for GPs and general practices in public health. GPs and their practice teams have a crucial role in promoting health and preventing disease. Each year there are over 300 million consultations with primary care professionals – the majority with GPs but increasingly with practice nurses and other practice-based healthcare staff – with every consultation an opportunity to detect early warning signs that prevent illness and disease. 18 This was recognised by the coalition government of 2010–15 in its White Paper on public health arguing that GPs ‘have huge opportunities to provide advice, brief interventions and referral to targeted services through the millions of contacts they have with patients each year’ (p. 61). 35 In addition, since January 2012 there has been a call to NHS professionals to ‘Make every contact count’ 449 in a campaign to improve public health via every contact between a NHS professional and the public. As well as all aspects of primary and secondary prevention, there has also been an effort to incorporate the guidance into wider aspects of public health such as homelessness. 450 Furthermore, in 2011 the DH published the Health Visiting Implementation Plan , 98 which proposed an increase in the health visitor workforce by 4500 new health visitors by 2015, with the concomitant emphasis on public health outcomes for children and families at all levels.

However, how these roles are developed, supported and sustained within the new public health and commissioning structures of the NHS in England is still not clear. The development of CCGs, new public health commissioning and delivery roles for LAs, and an expanded national public health role through PHE as well as a public health commissioning role for NHS England create a new and potentially more complex commissioning and service delivery environment for many public health activities in primary care. 36 , 98 , 451 There are particular concerns about the fragmentation of public health functions and service delivery agencies, the distribution of resources between responsible agencies and how proposals for commissioning and organising public health will provide a cohesive and co-ordinated public health system with a clear general practice role. The aim of this chapter is to set the context of this review within the recent changes to commissioning and public health introduced in April 2013. The chapter provides a critical analysis of the organisational changes and policy implications of the Health and Social Care Act 2012 21 as they relate to the organisation and delivery of public health within general practice.

• The changes

Until April 2013 public health was delivered through a number of different mechanisms:

• DH – setting policy and funding a number of health intelligence programmes including the observatories and cancer registries
• government offices
• National Treatment Agency for Substance Misuse – drug treatment monitoring
• strategic health authorities – strategic oversight and performance of each region
• PCTs – commissioning of programmes to deliver health service outcomes/joint commissioning with LAs
• provider trusts – delivery of public health programmes, for example community services
• LAs – a number of different services provided by local government that have an impact on the public’s health such as environmental health, leisure, planning, housing
• Health Protection Agency – health protection services.

Following the Health and Social Care Act 2012, 21 most of these organisations either were abolished or have taken on significantly different responsibilities. In addition, new commissioning and public health organisations have been established. The key strategic changes are as follows:

• Strategic health authorities were abolished at the end of March 2013.
• PCTs were abolished at the end of March 2013.
• PHE was established in April 2013, encompassing the National Treatment Agency and Health Protection Agency, and is responsible for a number of health intelligence functions including the cancer registries and regional observatories, and former government office functions.
• Ring-fenced budgets for public health have been allocated to LAs: unitary authorities and upper-tier authorities (i.e. county councils, not district councils). Directors of public health are employed within these authorities and are joint appointments between PHE and the appointing LA.
• CCGs are now responsible for the commissioning of secondary and community-based health care.
• NHS England (a national commissioning organisation) is accountable for CCGs and oversees the commissioning of specialised services and primary care services (GMS contract).
• A range of provider organisations (‘any qualified provider’) including foundation trusts, charities, independent sector and social enterprise.

In Healthy Lives, Healthy People , 37 the government proposed key changes to the provision of public health. The two key changes involved the establishment of PHE in April 2013 and the transfer of local NHS public health responsibilities to LAs. PHE is responsible for funding and ensuring the provision of a wide range of services such as health protection, emergency preparedness, recovery from drug dependency, sexual health, immunisation programmes, alcohol prevention, obesity, smoking cessation, nutrition, health checks, screening, child health promotion (including those led by health visiting, school nursing and general practice), some elements of the GP contract (including parts of the QOF such as those relating to immunisation), contraception and dental public health. It does not have direct commissioning responsibility but will grant funding to LAs and it will need to work through NHS England to commission services, such as screening services, and the relevant elements of the GP contract.

The 2010–15 coalition government announced its intention in The Coalition: Our Programme for Government 35 that the DH would strengthen the role and incentives for GPs and GP practices on preventative services, both as primary care professionals and as commissioners. There was a recognition that primary care professionals, GPs and GP practices play a critical role in both primary and secondary care prevention. Key areas highlighted by the government were practitioners’ opportunities to provide advice, brief interventions and referral to targeted services through the millions of contacts they have with patients each year. 37

Healthy Lives, Healthy People 37 (para. 451) sets out specific ways by which the DH intends to strengthen the public health role of GPs. These involve a mix of support and incentives:

• PHE and the NHS Commissioning Board will work together to support and encourage CCGs to maximise their impact on improving population health and reducing health inequalities. This includes looking specifically at equitable access to services and outcomes.
• Information on achievement by practices will be available publicly, supporting people to choose their GP practice based on performance. By increasing transparency about how effective different GP practices are in giving public health advice, PHE will enable local communities to challenge GPs to enhance their performance.
• Incentives and drivers for GP-led activity will be designed with public health concerns in mind, for example in terms of prevention-related measures in the QOF. To increase the incentives for GP practices to improve the health of their patients, the DH has proposed that a sum at least equivalent to 15% of the current value of the QOF should be devoted to evidence-based public health and primary prevention indicators from 2013. The funding for this element of the QOF will be within the PHE budget. However, in 2013/14 this has not translated into many additional or different indicators.
• PHE will strengthen the focus on public health issues in the education and training of GPs, nurses and health visitors as part of the DH’s development of a workforce strategy.

These changes have had a significant impact on general practice and its public health role. In particular, five changes potentially increased both GPs’ needs for public health knowledge and practices’ need to increase their provision of health promotion and disease prevention services. The changes also provide significant challenges.

• The now abolished PCTs were responsible for the GMS contract and supporting local practices. The PCT also provided public health support to local practices and delivered some health promotion services such as specialist smoke-stop and sexual health services for young people. In many areas, PCTs developed additional prevention services in collaboration with practices funded through LES within the GMS contract. It is not clear how the new system will continue such support.
• With the abolition of PCTs, newly created LA Health and Wellbeing Boards (HWBs) now have to make decisions about public health priorities for their geographical area. GP representatives from CCGs sit on these boards, and they will probably be expected to contribute to the understanding of what the local health demands are, as well as the ways that general practice and other primary care services can improve health outcomes in these areas.
• General practitioner-led CCGs have taken over the commissioning role of PCTs. This could include some public health commissioning, although the details of which will depend on what NHS England chooses to ‘pass down’ to them. Commissioning public health services will require knowledge of how and where these services are best delivered.

There is a new Commissioning Outcomes Framework which will be used by NHS England to assess CCG performance. The aim of the framework is to allow NHS England to identify the contribution of CCGs to achieving the priorities for health improvement in the NHS Outcomes.

• The QOF will be adjusted so that 15% is made up of evidence-based public health and primary prevention indicators by 2013. 36 While the substance of these changes remains unclear and no change has yet occurred, GPs should be preparing for a shift towards payments for prevention.
• Although funding for public health will be ‘ring-fenced’, overall budget cuts may increase the focus on prevention rather than expensive treatments, a shift which is likely to extend to general practice. Whereas in the past such pressures within PCTs have tended to squeeze out public health expenditure, the protected LA budget will not be at risk of being shifted towards clinical services.
• General practice and the new commissioning arrangements

The emphasis on CCGs being responsible for the well-being of their whole community and the stronger role of the HWBs was recommended in the NHS Future Forum report 449 and ensured that public health became a shared responsibility across local commissioning organisations. However, the splitting of public health resources across general practice, CCGs, LAs and PHE/NHS England presents new challenges for the organisation and delivery of public health in England. For example, drug, alcohol and mental health services will all be commissioned via LAs. From 2015, LAs will also commission the health visiting services, which may have the effect of separating health visiting from the general practice population. These important public health challenges often overlap and are best dealt with by joint services, which may include GPs and community health professionals in shared-care arrangements if locally appropriate. These services are a good example of how, by commissioning similar public health services by one body (in this case, LAs), there can be streamlining of service delivery and inclusion of GPs where beneficial, but this grouping together will be effective only if there is enough funding to support these joint endeavours.

Commissioning has been split between local and national commissioners. While NHS England has local offices, co-ordination between commissioners is important. It is also be important to ensure that CCGs and GPs more generally are linked to broader public health commissioning arrangements. For example, public health services for children aged under 5 years, which include pre-established programmes and services that fall outside the NHS, are contracted centrally by NHS England, but GPs play a huge role in the care of under-5s and work collaboratively with local health visiting teams and other community staff, who also work closely with LA and third sector organisations – all of which are commissioned by different bodies. It is not clear how the necessary linkages are being made between GPs and community services (and local council services) when it comes to the local organisation and delivery of care and prevention programmes to under-5s.

Some degree of co-ordination will possibly be achieved through CCG representation on HWBs. The boards are seen as key to co-ordinating the local health system:

The joint local leadership of CCGs and local authorities through the health and wellbeing board will be at the heart of this new health and social care system . . . [and] enable greater local democratic legitimacy of commissioning decisions, and provide an opportunity for challenge, discussion, and the involvement of local representatives. p. 115 451

Clinical Commissioning Groups have an avenue, therefore, to be involved in local decisions about public health resource allocation – an important way of maintaining GP involvement in public health. Concerns about CCG access to public health support were raised in discussions with GPs and CCG staff, and also identified in research on the early development of CCGs. 334

However, the most dominant role of the CCG is in commissioning secondary care services, which provides a new set of challenges as well as opportunities for improvement in public health and ill-health prevention. Research on practice-based commissioning found that GPs focused more on preventing ‘unnecessary’ hospital admissions than on primary prevention. 452 Analyses of previous primary care commissioning similarly found GPs used traditional models of general practice and did not address key public health problems. 57 , 76 , 258 , 453 However, this is not a reason to take public health out of GP commissioning responsibilities. In fact, researchers have suggested that GP budgets for commissioning health services be aligned with budgets for commissioning public health. 454 On a more positive note, it is possible that, by giving CCGs responsibility for standard health service commissioning as well as some public health services, they may be forced to think more broadly about their communities. CCGs should have responsibility for, or at least be directly involved in, commissioning those public health activities that most closely relate to the ones they provide themselves via the GP contract (such as contraception services and cervical cancer screening). Aligning these responsibilities puts GPs’ existing knowledge of service provision to work, and helps to ensure that patients have access to the most streamlined pathways for these services (as well as the best-quality ones).

One key area of public health activity is the support for commissioners. Systems developed within PCTs for supporting GPs with epidemiological analyses are likely to have been substantially disrupted with changes to public health departments. New relationships, systems and processes need to be developed to provide what is critical support for the new commissioning bodies. Additionally, this is being done at a time when new organisational structures for public health are being established in LAs, placing further strains on developing relationships.

There is continuing tension around the relationship between general practice commissioning and public health. The evidence from previous approaches to primary care-led commissioning suggests that public health has not been a priority for GP commissioners. 453 The development of primary care groups and, more specifically, PCTs did start to embed a more public health perspective in commissioning, but current changes to both public health and health-care commissioning may simply exacerbate what has often been a troublesome relationship between GP commissioners and public health. 77 , 453

• The General Medical Services contract and public health

Currently many public health activities in primary care are supported by the GMS contract. There are three funding strands:

• core standard tasks – expected in normal practice (advice, information, etc.)
• aspects of the QOF
• Local Enhanced Service elements of the contract.

Where clinical services are closely linked to public health activities such as screening, immunisation, obesity and sexual health services, part of the service is being provided by GPs as part of the GP contract (cervical cancer screening, childhood and elderly vaccinations, and contraception services), but other, similar services are being commissioned by LAs or NHS England (i.e. additional cancer screening, booster vaccinations, sexually transmitted infection screening and treatment, and general screening such as the NHS Health Check). This could lead to a situation where similar services that can be most effectively provided side by side (most obviously, contraception and sexually transmitted infection services) may be available from different providers because they are commissioned by different groups. Greater co-ordination of commissioning and service delivery will be essential. Thought needs to be given to arrangements for lead commissioning with the flexibility such as that available between the NHS and LAs under the 1999 Health Act 455 for partnership funding for the commissioning of all aspects of key prevention services by one commissioner.

Local Enhanced Services have been particularly effective in involving GPs in locally driven public health efforts supporting a wide range of evidence-based public health activities, such as identifying CVD risk and providing long-acting contraceptives, and in 2009/10 they accounted for some £370M. 34 Having the option of LESs in the contract has provided a way for GPs to reduce preventable morbidity, and it could continue to do so in the future. This option would be especially helpful in the context of a more diverse provider landscape. However, many of the activities currently funded through LESs, including sexual health, smoking cessation, prevention and treatment of alcohol misuse, falls prevention and mental health promotion, are now commissioned by LAs, with the GP contract the responsibility of NHS England. LESs are commissioned by the local area teams of NHS England, yet the teams do not have any real levers or necessarily the knowledge needed to do this. This appears to be a key weakness in the new system.

One key element of the contract where it is proposed to incentivise more primary prevention in general practice is through the QOF. In the White Paper the government proposed that NICE adjust QOF to ensure that 15% is devoted to ‘evidence-based public health and primary prevention indicators’ (p. 62). 35 Currently, QOF continues to have only two indicators that it designates as ‘primary prevention’; otherwise it focuses mainly on secondary prevention and uses proxy or process outcomes. QOF has had a major impact on how practices undertake public health and other activities leading to more systemisation of public health activity – particularly through use of protocols and special clinics, but mainly with a secondary and medical focus. 65 , 456 While having some impact on primary and secondary prevention by stimulating GPs to run ill-health prevention clinics for screening and monitoring blood pressure etc., QOF has mainly supported secondary prevention activities. 32 , 65 , 93 To date, the evidence that the QOF has improved health outcomes or promoted a public health approach is very limited. 18 , 65 , 330 However, financial incentives that are effective in changing practice and more outcomes-based contracts, rather than activity-related incentives, could encourage a more proactive approach. 32 The impact of proposed changes by NICE will, to a large extent, dictate how much GPs are involved in improving the health of their patient population, which will, in turn, be affected by the future organisation of public health commissioning and service delivery.

There are, however, concerns about the extent to which NICE’s rigidly evidence-based approach is relevant for the development of many public health interventions and also whether or not such approaches are relevant to primary care itself. 457 – 460 In particular, there are concerns about what the contract encourages in the way of public health activity in general practice. There is an important trade-off here: RCT-based ‘certainties’ around expensive technical interventions versus ‘riskier’ but potentially more impactful interventions such as, for example, brief interventions for smoking, which have low impact but are very low cost and, while having a small impact, affect a large number of people. 460 Similarly, many areas of activity such as community-oriented activities or even welfare advice are not currently rewarded.

• The implications of the fragmentation of public health services

Not only is the commissioning of similar services undertaken by different bodies, but there is also a more general likelihood of fragmentation of delivery of public health services due to the ‘any qualified provider’ model. The idea behind this approach to commissioning is to increase quality of care via a wider field of competition, on the presumption that increased competition will drive out poor providers and reduce the total number of providers. However, there is a risk that the overall effect of this policy will be that public health-related care is divided over a larger number of providers. The effect on GPs may be twofold. The first is simply that services that were once provided by GPs will be provided elsewhere, such as NHS Health Checks. The second effect, which is likely to be the more common one, is that patients will have to seek out many geographically separated providers for services such as sexually transmitted disease treatment, cancer screening and nutrition advice. This may be confusing and frustrating to patients as well as GPs, requiring good communication between different agencies to minimise this confusion. GPs must be kept aware of which providers are providing which services so they can properly advise their patients on where to seek care. Additionally, GPs must be able to keep track of what care their patients have received from other providers. Co-ordinating with other providers and keeping detailed records of their patients’ care, particularly when it comes to routine screening and immunisation, are key roles of the GP. It will be crucial to build in a way for all commissioners and providers of public health services to share their knowledge and records with GPs so that GPs can continue to do their jobs effectively. For example, there has been a long tradition of health visitors being ‘GP attached’, and parents and children within GP practices will lose this direct relationship with their GP services when health visitors are commissioned by the LA to provide a community-based service.

Ultimately, this will lead to postcode variation in provision or a variant of the ‘inverse prevention’ law if commissioning is more effectively supported and undertaken in healthier, wealthier areas (as, historically, has tended to be the case).

The opening up of public health delivery and practice to a more diverse range of providers calls into question the future role of entire categories of providers already working in public health, including health visitors, midwives and school nurses. Investment in health visiting is discussed in the White Paper 37 and is welcome, but other key members of the local primary health care team who deliver public health are not mentioned. For example, the crucial role of school nurses is not mentioned in the documents and it is not clear where this service will need to focus its attention or how it will be integrated into the rest of public health delivery.

One mechanism for prioritising the general practice role in public health is via the Public Health Outcomes Framework. 37 As it currently stands, the Public Health Outcomes Framework indicates the few places where responsibility for achieving indicators is shared with the NHS. Just eight indicators in the entire list refer to the NHS, and most of them are around reducing premature death in people with chronic diseases rather than disease prevention or health promotion. It is not clear what this shared responsibility refers to: provision of funding or delivery/planning of services. Looking at the entire list of public health indicators it is clear that GPs, and therefore the NHS, can be instrumental in delivering many services beyond the ones singled out – in services relating to sexual health or smoking cessation, to name just two areas. When LAs and local HWBs are considering how to best respond to these indicators (which they are driven to do by the ‘health premium’ payments), they should keep GP services in mind for many indicators beyond those with designated NHS involvement. Additionally, the boards may find that GPs are particularly well primed to the idea of indicators, having now been working with the QOF for over 6 years. While these two sets of indicators are very different in character, GPs may be comfortable with the idea of indicators and may have ideas for how to incorporate this new set into their practices.

While HWBs have been given a key co-ordinating role, it is questionable how far they will be able to fulfil all the expectations placed upon them. At the current time there remains considerable ‘fuzziness’ around the exact role of HWBs. The lack of statutory powers given to the boards means that it is only by developing good local relationships that they will be able to fulfil their potential. In recent research on the development of CCGs, the development of a strong ‘co-ownership’ model, where CCGs, LAs and HWBs saw themselves as joint owners of the developing strategy, with all partners being actively involved, was noted in some areas. However, in others, CCGs were developing quite separately from their HWBs, with CCG representatives attending meetings but contributing little. 63 , 334 Marks et al. 63 have highlighted the difficulty of aligning priorities across large geographical areas and where organisations were not coterminous. This may prove a problem again, as many of the 211 CCGs cover smaller populations than their HWB, and the ability to respond to local concerns and problems will be important as HWBs develop. Ultimately, despite HWBs having ‘strategic influence over commissioning decisions across health, public health and social care’ as one of their main roles, 461 there is a danger that, as new local public health systems develop, they may become more fragmented in terms of the relationships between LAs, CCGs and HWBs as well as having to cope with a new national context with PHE and NHS England. This may create additional complexities for local co-ordination by the HWBs and raises important questions about how public health activities in general practice will be incentivised, managed and supported in the future. This uncertainty was of concern to many of the GPs we talked to during the research.

• Current developments

In line with the government’s coalition agreement (of 2010–15) policy focused on the health improvement role of general practice. 35 In addition to proposals to revise the QOF to include more primary prevention criteria, the recent Mandate for the NHS Commissioning Board highlights prevention within the concept of making ‘every contact count’, ‘in focusing the NHS on preventing illness, with staff using every contact they have with people as an opportunity to help people stay in good health – by not smoking, eating healthily, drinking less alcohol, and exercising more’ (p. 8). 462 This approach is now reflected in NICE Public Health Guidance with the publication of the draft revision of physical exercise guidelines (currently out for consultation). The proposed revised guidelines specifically target primary care practitioners proposing that they:

Assess the physical activity levels of all adults in contact with primary care services and identify those who are not currently meeting the UK physical activity guidelines. This could be done: opportunistically during a consultation with a GP or practice nurse (or while people are waiting) as part of a planned session on management of long-term conditions run by a practice nurse as part of a consultation with a pharmacist. p. 8 463

With this guidance, primary care practitioners are being encouraged to identify inactive patients, assess their level of activity and deliver a brief intervention to encourage them to increase levels of activity. Concerns have been raised about whether or not it is appropriate for more and more elements to be placed on GPs and nurses given the limited consultation time in practice. These questions have also been raised in connection with a pilot study that examined adding cancer-screening questions into the NHS Health Check. The pilot study involved a screening survey of 4250 patients with high cardiovascular risk undergoing NHS Health Checks. The study, reported at the October 2012 Society of Academic Primary Care conference in Glasgow, found that the process involved substantial nurse and GP time but led to only four cases being identified. 464

The Royal College of General Practitioners argues that GPs should be proactive in carrying out public health activities and interventions, and it is expected that GPs should possess a wide range of skills related to ill-health prevention and public health. 7 Since 1990, GPs in particular, have been encouraged to carry out more public health activities through changes to their contract and the potential of the primary care public health role was highlighted in the Wanless Report on public health. 3 , 48 However, research continues to find that the relationship between public health and general practice in England focuses primarily on secondary prevention, and many GPs state they lack the skills needed to deliver effective health promotion. 432 The King’s Fund Inquiry on quality in general practice concluded that there is enormous potential for general practice to take a more proactive role in ill-health prevention and public health. 18 , 465 In fact, a key criticism of much of general practice (when it comes to public health) is that it focuses on either secondary prevention or just information and advice. While both of these activities are useful, other interventions can be more effective. All of these considerations and criticisms are of particular importance when it comes to the QOF, which is a key driver of GP practice.

The Public Health White Paper 37 outlines a number of key changes to the organisation and delivery of public health in England. However, while the public health role of general practice has been the subject of much debate over the past few decades, the government does not appear to have grasped how this role can be integrated, developed and supported within the proposed changes. Relying on changes to the QOF is both short-sighted and overly narrow. The fragmentation of the commissioning and delivery of public health is likely to lead to problems of co-ordination. It is not clear how HWBs – responsible for local public health co-ordination – will build integrated approaches with both CCGs and PHE as well as the wide range of local delivery organisations, including general practices. Previous approaches to primary care-led commissioning have not demonstrated that GPs can work closely with LAs or other agencies. 453 A further problem may be the attitude of many GPs themselves, as studies suggest that they are more comfortable managing illness than promoting health. How effective the new proposals will be at engaging GPs and other primary care staff in public health activities is still open to question, as for many GPs there is still a significant amount of distrust. 334

In this chapter we have identified a number of potential problems that may result from current policy developments and organisational changes. While an emphasis on health improvement is welcome, there are a number of potential threats to the ability of primary care, and general practice more specifically, to deliver public health. First, commissioning approaches need to be aligned across the different agencies that will be responsible for aspects of public health. In particular, commissioning agencies need to urgently identify how services from existing groups of primary care-based public health providers (midwives, school nurses, etc.) are commissioned and supported within the new structures. Thought also needs to be given to how health improvement activities that have formerly been funded through GMS, PMS and other local contractual arrangements can be continued, and how local variations in funding and service delivery can be incorporated into the new systems and structures. Developments in health improvement in general practice have benefited from local negotiation and relationships with the public health department in the PCT. Concerns have been raised about the ongoing links between public health and general practice now that LAs have taken on public health responsibilities. While policy is increasingly emphasising public health roles being embedded in primary care practice, many of the current organisational changes are creating potential problems for the commissioning and delivery of many important health improvement activities.

Included under terms of UK Non-commercial Government License .

• Cite this Page Peckham S, Falconer J, Gillam S, et al. The organisation and delivery of health improvement in general practice and primary care: a scoping study. Southampton (UK): NIHR Journals Library; 2015 Jun. (Health Services and Delivery Research, No. 3.29.) Chapter 7, Impact of changes in the Health and Social Care Act 2012 and Public Health White Paper.
• PDF version of this title (2.1M)

In this Page

Other titles in this collection.

• Health Services and Delivery Research

Recent Activity

• Impact of changes in the Health and Social Care Act 2012 and Public Health White... Impact of changes in the Health and Social Care Act 2012 and Public Health White Paper - The organisation and delivery of health improvement in general practice and primary care: a scoping study

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

The Health and Social Care Act 2012: The emergence of equal treatment for mental health care or another false dawn?

Affiliation.

• 1 University of Manchester, UK.
• PMID: 26273147
• PMCID: PMC4523576
• DOI: 10.1177/0968533214521090

Although the National Health Service (NHS) is regarded as a national treasure, it is no longer immune from the colossal financial pressures brought about by global recession. Economic sustainability has largely driven the reform process leading to the Health and Social Care Act (HSCA) 2012, however; other considerations have also played a role in the journey to turn the health and social care service into an institution which is fit for the 21st-century needs. This article examines the impact of the HSCA 2012 on those made vulnerable through mental ill health. It then considers three issues: First, whether parity between mental and physical health can have life beyond political rhetoric; second, what impact driving up efficiency within the NHS will have upon mental health patients; and finally, the extent to which the personalisation agenda can be meaningfully applied within the mental health context.

Keywords: Health and Social Care Act 2012; Mental health; efficiency; parity; personalisation.

To read this content please select one of the options below:

Please note you do not have access to teaching notes, the impact of the health and social care act, 2012 on the health and wellbeing of rough sleepers.

Journal of Integrated Care

ISSN : 1476-9018

Article publication date: 17 October 2016

The purpose of this paper is to explore the impact of the Health and Social Care Act, 2012 on London’s rough sleepers as seen from the perspective of one former homeless service user (currently working as a support worker in a day centre providing outreach and “drop in” facilities for people who are street homeless and other vulnerable adults including female sex workers). The discussion centres on some of the unintended impacts of changes to healthcare commissioning; the new arrangements for patient, public representation; and the enhanced role of local councils.

Design/methodology/approach

This paper is grounded in front line practitioner reflection/opinion and draws on practical experience and observation at Spires, as well as research and government papers published by other service providers. The aspirations of the Health and Social Care Act, 2012 are set out before its practical application are examined from the rough sleeper’s dimension.

Putting clinicians and GPs centre stage in the commissioning and purchasing of healthcare may have some benefits for individual patient choice, but it can also dilute patient public involvement in health and social care with negative effects for vulnerable and excluded groups, including rough sleepers. The terms of reference ascribed to Local Healthwatch Organisations, the official representatives of the people, are narrower than previously and limit their ability to influence official policy. The Act centralises control whilst devolving operational responsibility, especially for public health provision on which rough sleepers often rely. It is suggested that local voluntary organisations and specialist “inclusion” health groups are increasingly being expected to take over responsibility for delivering health and social care and that mainstream collaboration is much reduced rather than enhanced by this fragmentation.

Research limitations/implications

This review is based on the opinion of an “expert by experience” which may not be representative.

Originality/value

This is one of few papers which present a front line service user/practitioner perspective on the impact of clinical commissioning on services for marginalised groups.

• Homelessness
• Third sector
• Patient choice
• Clinical Commissioning Groups (CCGs)
• Community and Voluntary Organizations (CVOs)
• Rough sleepers

Acknowledgements

Thanks to Dr Michelle Cornes, Senior Research Fellow, Social Care Workforce Research Unit, King’s College London for her support with earlier drafts of this paper. The views expressed are those of the author and are not necessarily shared by Spires, whose management accept no responsibility for the sentiments contained herein.

Fuller, J.S. (2016), "The impact of the Health and Social Care Act, 2012 on the health and wellbeing of rough sleepers", Journal of Integrated Care , Vol. 24 No. 5/6, pp. 249-259. https://doi.org/10.1108/JICA-05-2016-0018

Emerald Group Publishing Limited

Copyright © 2016, Emerald Group Publishing Limited

Related articles

We’re listening — tell us what you think, something didn’t work….

Report bugs here

All feedback is valuable

Please share your general feedback

Join us on our journey

Platform update page.

Visit emeraldpublishing.com/platformupdate to discover the latest news and updates

Questions & More Information

Answers to the most commonly asked questions here

The Health and Social Care Act 2012 (c 7) Essay

The Health and Social Care Act 2012 (c 7) is an Act of the Parliament of the United Kingdom. It is the most extended reorganization of the construction of the National Health Service in England to day of the month. [ 1 ] It proposes to get rid of NHS primary attention trusts (PCTs) and Strategic Health Authorities (SHAs). Thereafter. ?60 to ?80 billion of “commissioning”. or wellness attention financess. will be transferred from the abolished PCTs to several hundred “clinical commissioning groups”. partially run by the general practicians (GPs) in England. A new executive bureau of the Department of Health. Public Health England. is planned to be established on 1 April 2013. [ 2 ]

The proposals are chiefly the consequence of policies of the Secretary of State for Health. Andrew Lansley. Writing in the BMJ. Clive Peedell (co-chairman of the NHS Consultants Association and a adviser clinical oncologist) compared the policies with academic analyses of denationalization and found “evidence that denationalization is an inevitable effect of many of the policies contained in the Health and Social Care Bill. ” [ 3 ] Lansley says that claims that the authorities is trying to privatize the NHS are “ludicrous scaremongering”. [ 4 ]

The proposals contained in the Act are some of the alliance government’s most controversial. Although many steps were included in the Conservative Manifesto. [ 5 ] they were non discussed during the 2010 general election run and were non contained in the 11 May 2010 Conservative – Liberal Democrat alliance understanding. [ 1 ] which mentioned the NHS merely to perpetrate to a real-term support addition every twelvemonth. [ 6 ] Within two months of the election a white paper was published. sketching what the Daily Telegraph called the “biggest revolution in the NHS since its foundation”. [ 7 ] The measure was introduced in the House of Commons on 19 January 2011. [ 8 ] [ 9 ] In April 2011 the authorities announced a “listening exercise”. holding the Bill’s legislative advancement until after the May local elections.

The “listening exercise” finished by the terminal of that month. The Bill received Royal Assent on 27 March 2012. The Act’s proposals were non discussed during the 2010 general election run and were non contained in the 20 May 2010 Conservative – Liberal Democrat alliance understanding. [ 1 ] which declared an purpose to “stop the top-down reorganizations of the NHS that have got in the manner of patient care”. [ 7 ] However. within two months a white paper outlined what the Daily Telegraph called the “biggest revolution in the NHS since its foundation”. [ 7 ] The white paper. Equity and Excellence: Emancipating the NHS. [ 10 ] was followed in December 2010 by an execution program in the signifier of Emancipating the New hampshire: legislative model and following stairss. [ 11 ] The measure was introduced into the House of Commons on 19 January 2011 [ 8 ] and received its 2nd reading. a ballot to O.K. the general rules of the Bill. by 321-235. a bulk of 86. on 31 January 2011. [ 12 ]

More about Essay Database

• Essay Database Summary
• Essay Database Accounting
• Essay Database Anthropology
• Essay Database Architecture
• Essay Database Biology
• Essay Database Business
• Essay Database Chemistry
• Essay Database Computer Science
• Essay Database Criminology
• Essay Database Culture and Arts
• Essay Database Economics
• Essay Database English
• Essay Database Geography
• Essay Database History
• Essay Database Human resources
• Essay Database International Studies
• Essay Database Linguistics
• Essay Database Management
• Essay Database Marketing
• Essay Database Mathematics
• Essay Database Medicine
• Essay Database Movies
• Essay Database Music
• Essay Database Physics
• Essay Database Politics
• Essay Database Psychology
• Essay Database Relationships
• Essay Database Religion
• Essay Database Science
• Essay Database Society
• Essay Database Sociology
• Essay Database Technology
• Essay Database Television
• Essay Database Tourism
• Essay Database Women and Gender

Related Posts

• The Canadian versus United States Health Care System Research Paper
• Responsible Parenthood and Reproductive Health Act of 2012 Essay Sample
• Legislation, policies and procedures in relation to health and social care Essay
• Ella's Loss: A Great Life Change Research Paper
• Employment Responsibilities and Rights in Health Social Care and Children
• Unit Cu1517 Introduction to Equality and Inclusion in Health and Social Care.
• Communication in Health and Social Care
• Effectiveness and Quality of the Responses Used to Support Victims of Child Abuse Case Study
• Communication and the Health of Work Case Study
• Health and Social Care Unit 10

How about getting full access immediately?

• Skip to main content
• Skip to navigation

legislation.gov.uk

• Browse Legislation
• New Legislation
• Coronavirus Legislation
• Changes To Legislation

Search Legislation

Health and social care act 2012, you are here:.

• UK Public General Acts
• The health service: overview
• Table of Contents
• Previous: Introduction
• Next: Provision

Print Options

What version.

• Latest available (Revised)
• Original (As enacted)

Advanced Features

• Show Explanatory Notes for Sections

Opening Options

• Open whole Act
• Open Act without Schedules
• Open Schedules only

More Resources

• Original: King's Printer Version

This is the original version (as it was originally enacted).

1 Secretary of State’s duty to promote comprehensive health service

For section 1 of the National Health Service Act 2006 (Secretary of State’s duty to promote health service) substitute—

“ 1 Secretary of State’s duty to promote comprehensive health service

(1) The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—

(a) in the physical and mental health of the people of England, and

(b) in the prevention, diagnosis and treatment of physical and mental illness.

(2) For that purpose, the Secretary of State must exercise the functions conferred by this Act so as to secure that services are provided in accordance with this Act.

(3) The Secretary of State retains ministerial responsibility to Parliament for the provision of the health service in England.

(4) The services provided as part of the health service in England must be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed. ”

Back to top

Options/Help

Print the whole act.

• PDF The Whole Act
• Web page The Whole Act

Print The Whole Part

• PDF The Whole Part
• Web page The Whole Part

Print The Whole Cross Heading

• PDF The Whole Cross Heading
• Web page The Whole Cross Heading

Print This Section only

• PDF This Section only
• Web page This Section only

You have chosen to open The Whole Act

The Whole Act you have selected contains over 200 provisions and might take some time to download. You may also experience some issues with your browser, such as an alert box that a script is taking a long time to run.

Would you like to continue?

• Continue to open

You have chosen to open The Whole Act as a PDF

The Whole Act you have selected contains over 200 provisions and might take some time to download.

You have chosen to open The Whole Act without Schedules

The Whole Act without Schedules you have selected contains over 200 provisions and might take some time to download. You may also experience some issues with your browser, such as an alert box that a script is taking a long time to run.

You have chosen to open The Whole Act without Schedules as a PDF

The Whole Act without Schedules you have selected contains over 200 provisions and might take some time to download.

You have chosen to open the Whole Act

You have chosen to open the whole act without schedules, you have chosen to open schedules only.

The Schedules you have selected contains over 200 provisions and might take some time to download. You may also experience some issues with your browser, such as an alert box that a script is taking a long time to run.

Legislation is available in different versions:

Latest Available (revised): The latest available updated version of the legislation incorporating changes made by subsequent legislation and applied by our editorial team. Changes we have not yet applied to the text, can be found in the ‘Changes to Legislation’ area.

Original (As Enacted or Made): The original version of the legislation as it stood when it was enacted or made. No changes have been applied to the text.

See additional information alongside the content

Show Explanatory Notes for Sections: Displays relevant parts of the explanatory notes interweaved within the legislation content.

Different options to open legislation in order to view more content on screen at once

Explanatory Notes

Text created by the government department responsible for the subject matter of the Act to explain what the Act sets out to achieve and to make the Act accessible to readers who are not legally qualified. Explanatory Notes were introduced in 1999 and accompany all Public Acts except Appropriation, Consolidated Fund, Finance and Consolidation Acts.

Access essential accompanying documents and information for this legislation item from this tab. Dependent on the legislation item being viewed this may include:

• the original print PDF of the as enacted version that was used for the print copy
• lists of changes made by and/or affecting this legislation item
• confers power and blanket amendment details
• all formats of all associated documents
• correction slips
• links to related legislation and further information resources

Use this menu to access essential accompanying documents and information for this legislation item. Dependent on the legislation item being viewed this may include:

Click 'View More' or select 'More Resources' tab for additional information including:

• New site design
• Accessibility
• Privacy Notice