1.  INTRODUCTION

  1.1.  The Association of Directors of Adult Social Services (ADASS) represents Directors of Adult Social Services in Local Authorities in England. As well as having statutory responsibilities for the commissioning and provision of Social Care, ADASS members often also share a number of responsibilities for the provision and/or commissioning of housing, leisure, library, culture arts and community services within their Councils.

  1.2.  The Association is able to bring together tremendous breadth, depth and accumulated experience on all issues covering managerial policy and professional activities of Adult Social Care departments and cross cutting issues with Children's Services departments and NHS organisations.

  1.3.  Our members are jointly responsible through the activities of their departments for the well-being, protection and care of thousands of vulnerable people and for the promotion of that well-being and protection through the use of direct services as well as the co-ordination of, and liaison with the NHS, voluntary agencies, private companies and other public authorities.

  1.4.  Our members have leadership responsibilities in Local Authorities to promote local access to services and to drive partnership working to deliver better outcomes for local populations. They participate in the planning of the full range of Council Services and influence Health Service planning through formal and informal Local Strategic Partnership arrangements.

2.  BACKGROUND

  2.1.  Despite increased national prosperity, wider opportunity and increasing life expectancy for all, the gap in life expectancy between and within local authority areas and infant mortality between different social groups remains a major challenge. The shared priority for healthy communities and reducing health inequalities agreed between central and local government makes tackling health inequalities a priority for local authorities, and is included as part of the comprehensive performance assessment. It is recognised that reducing health inequalities requires National and Local leadership and action.

  2.2.  Data in respect of the gaps in life expectancy and infant mortality between different social groups is increasingly well known. Understanding cause and taking action to prevent gives a significant challenge. A Public Health perspective suggests that the reasons for health inequality arise from the following:

—  inequalities in opportunity—poverty, family, education, employment and environment etc.

—  inequalities in lifestyle choices—smoking, physical activity, food, drugs, alcohol and sexual activity

—  inequalities in access to services for those who are already ill or have accrued risk factors for disease( health inequality)

  Actions to address inequalities will need to address all three dimensions of root cause.

  2.3.  The identification of Spearhead Areas (Local Authorities with the worst health and deprivation) with additional support and funding has been welcomed. It is also recognised that health inequalities often arise in communities and families from other disadvantaged groups. They are not confined to Spearhead Areas. Those most at risk are often in touch with Social Care Services within all Local Authority Boundaries.

  2.4.  The importance of Health and Social Care partnerships has been affirmed in many recent publications. (E.g. Our Health, Our Care, Our Say- Department of Health Jan 2006—The Future of Health and Adult Social Care: A Partnership Approach for Wellbeing). These documents provide a unifying vision for integrated health and adult social care. They also recognise Local Authorities' local leadership role for health and wellbeing, advocating partnerships working in localities between Councils and Primary Care Trusts (PCTs) building on Local Area Agreements and Local Strategic Partnerships as key mechanisms for joint planning and delivery.

  2.5.  The importance of developing such plans in the context of a shared understanding of local need has also been recognised in the Local Government and Public Involvement in Health Act (2007). This places a duty on upper-tier Local Authorities and PCTs to undertake a Joint Strategic Needs Assessment (JSNA) of their population(s). The legislation places the accountability for producing the JSNA with the three key Directors: the Directors of Adult Social Services, of Children's Services and of Public Health. Guidance recently published states that the JSNA should inform Local Area Agreements and the forthcoming Sustainable Community Strategy. Both these strategies will be central to local areas commissioning responses and action to address health inequalities.

  2.6.  The JSNA will require Local Authorities (LA) and Primary Care Trusts ( PCTs) to engage with local communities and provide evidence of effectiveness of intervention. These will be core requirements which are welcomed by our members. Recognition of the engagement with individuals and communities as " primary partners" is seen as a significant factor which will address inequality in the longer term. This approach has been highlighted in the Department of Health document "Choosing Health" which is underpinned by the core principles: Choice, Personalisation and Working Together.

3.  ROLE OF THE DIRECTOR OF ADULT SOCIAL SERVICES

  3.1.  Section 6 of the Local Authority Social Services Act 1970 was amended following the introduction of the Children Act 2004. The amendment requires a local authority with social services responsibility in England to appoint an officer as the Director of Adult Social Services (DASS).

  3.2.  In May 2006 the Department of Health issued Best Practice Guidance on the role of the Director of Adult Social Services. The intention of this guidance is to create, within each Council with social services responsibilities, a post with a strategic responsibility for the planning, commissioning and delivery of social services with all adult client groups.

  3.3.  The DASS has a leading role in delivering the Government's wider vision for social care, including delivering better integration between a range of agencies responsible for supporting people with care needs and promoting wellbeing. The postholder champions the wellbeing of adults in the community and in residential care, provides professional leadership and delivers the cultural change necessary to implement person-centred services and to promote partnership working.

  3.4.  The DASS is responsible for supporting and promoting social inclusion and wellbeing by engaging with mainstream services and other local initiatives to support, build and enable community capacity and reduce inequalities. The DASS role is central in encouraging services to be designed around the needs of individuals, rather than dictated by organisational or professional boundaries- the DASS providers a specific focus on adults and this involves a role in championing the needs of adults that goes beyond the organisational boundaries of adult social care. There is a clear link to close working with PCTs and in particular Directors of Public Health, Commissioners and Providers in joint work to reduce health inequalities.

  In this context, the Association is pleased to submit the evidence below to the Health Select Committee Inquiry into Health Inequalities.

4.  THE INQUIRY- HEALTH INEQUALITIES

4.1.   The Extent to which the NHS can contribute to reducing health inequalities, given that many of the causes of inequalities relate to other policy areas eg taxation, employment, housing, education and local government;

  4.1.1.  ADASS recognises that the NHS has a significant contribution to reducing health inequalities. The contribution is both direct and indirect through influence. The scope of NHS interface is with individuals, with communities, with local areas, with regions and a national level. The role is in leadership and the development of strategy across all sectors but it is recognised that the leadership in respect of inequalities of opportunity( viz. para 2.2) are shared with central government and local strategic partnerships. Shared responsibilities and accountabilities exist to ensure that the wider determinants of health and health promotion are realised within the overall strategies and responses of all government funded services.

  4.1.2.  In relation to inequalities and opportunity, the NHS has a significant if indirect role in reducing poverty, promoting family life, engaging in education, promoting employment and ensuring a sustainable environment. The NHS is a key partner through primary care and public health in relation to the development of local strategies to ensure action is taken in areas of need. The role of the NHS in developing the economic environment of local communities and neighbourhoods is perhaps under developed. The recognition of the NHS as a major employer and procurer of services would enable a closer examination at local levels of the impact of decisions and promotion of opportunity. The role of the NHS in working alongside local government to develop sustainable environments and healthy workforces is also an area for further development.

  4.1.3.  The role of the NHS in developing positive lifestyle choices has received increasing national attention with positive examples of significant progress particularly through the work of Spearhead Areas. The role of Public Health alongside local government in developing local strategy, influencing political decision making at local levels and engaging local overview and scrutiny committees has raised the awareness and given opportunity for impact. The increasing role of Directors of Public Health often through joint appointments with Local Authorities, has influenced local decision making in high risk areas such as smoking cessation, increasing physical activity, drug and alcohol strategies, sexual health and more recently the measures being taken to reduce obesity.

  4.1.4.  There is further scope for more targeted action following the publication of local Joint Strategic Needs Assessments. Current initiatives are often funded through short term targeted funding (eg NRF) and are at risk of "quick fix" thinking in relation to health inequalities. Experience shows that impact is often linked to sustained and long term action. The opportunity for Joint Strategic Needs Assessments to influence commissioning decisions of mainstream services is a welcome opportunity to drive targeted mainstream action to improve public health, primary and secondary care outcomes.

  4.1.5.  The recent change of funding to local government through Area Based Grant would give the opportunity for the Department of Health to provide health improvement funding as part of the Area Based Grant rather than through separate mechanism in the NHS. Alternatively, ring fenced NHS funding for health inequalities could be earmarked alongside the Area Based Grant to ensure maximum impact is achieved through local commissioning decision making and the "pooling" of or " alignment" of budget and activity across the NHS and Local Government.

4.2.   The Distribution and quality of GP Services and their influence on health inequalities, including how the Quality and Outcomes Framework and Practice-based Commissioning might be used to improve the quality and distribution of GP services to reduce health inequalities.

  4.2.1.  The "under doctoring" of poorer areas is highlighted in the State of Healthcare report 2007 and reports there are 18% fewer GPs than in the wealthier areas. The Association recognises that in some local areas there is some accelerated development of practice based commissioners taking a broader population perspective and addressing the preventable healthcare needs of their populations. However, it is suggested that these are in the minority and that progress in practice based commissioning and partnerships with social care, local government and the wider public sector are under developed.

  4.2.2.  Contracts with GPs continue to be focussed around high list sizes and payment for defined interventions. It is the submission of the Association that the initial focus of practice based commissioning has been concerning the interface between primary care and secondary care and has not yet actively pursued the potential for partnership with wider public service. The interface has been promoted via PCTs and public health with little direct contact with practices and practice based staff except on matters of individual need.

  4.2.3.  There is considerable further scope for Practice Based Commissioners/GPs working alongside communities and with local strategic partnerships. The barriers to development of closer partnership arrangements are acknowledged, not least the pressures of single-handed GPs and low staffing ratios within areas of high deprivation. Direct influence on the independent contractor role is also challenging in respect of the GP contract. The considerable national emphasis on waiting time targets and secondary care interface may also have influenced the speed of partnership development for practice based commissioners. The Association would recommend a further review of the financial incentives and accountability arrangements for GPs working in areas of high deprivation with the acceleration of options for directly employed practitioners and /or new incentivisation and support for areas where under- doctoring is a significant feature. Contracts should include a requirement of partnership working to prevent the emergence of gaps in service or duplication of effort.

4.3.   The effectiveness of public health services at reducing inequalities by targeting key causes such as smoking and obesity, including whether some public health interventions may lead to increases in health inequalities; and which interventions are most cost-effective

  4.3.1.  The research base of evidence concerning the impact of public health intervention as a direct cause and effect of health improvement is still under developed. It is suggested that much of the research into inequalities is descriptive of the problem and exact measures to say what works in reducing inequalities remains unclear. The many and various causes and determinants of ill health in communities makes it difficult to apply rigorous research methodology. Continued investment into developing the research base focussed on how to make a difference in health inequalities would be welcomed.

  4.3.2.  The Department of Communities and Local Government (DCLG) have Health Inequalities as part of their 2007 Beacon Scheme. The scope of the criteria for judging local authorities and health communities to be Beacons in tackling and reducing health inequalities include leadership vision and strategy, community and customer engagement and empowerment, actions taken through addressing key determinants, promoting healthy lifestyles and secondary care enhanced public health programmes. Examination is made of the quality of partnerships, the actions taken to address equality and diversity and the measurement of outcomes. Decisions regarding the outcomes of Beacon applications have not yet been made. However, wide dissemination of local government and the DCLG best practice would be helpful in partnership with DH and NHS organisations

4.4.   Whether specific interventions designed to tackle health inequalities such as Sure Start and Health Action Zones, have proved effective and cost-effective;

  4.4.1.  The Association offers no specific evidence on this issue.

4.5.   The success of NHS organisations at co-ordinating activities with other organisations, for example local authorities, education and housing providers, to tackle inequalities; and what incentives can be provided to ensure these organisations improve care

  4.5.1.  NHS organisations have committed considerable energy and activity in the last ten years to work in partnership to address health inequalities. As has already been highlighted, the cause or effects as identified in poverty, unemployment, inadequate housing, poor education attainment are all addressed through key policy directives of all government departments. There is a shared ownership through local government and public service partners to address these matters and the vehicles of Local Strategic Partnerships, and latterly Local Area Agreements have been key delivery arrangements. The effectiveness of the NHS has been affected by the complexity of local arrangements including co terminosity (or its absence), and county arrangement where two tier authorities exist. It is the Associations submission that the recent merger of PCTs has considerably eased joint working on a wide range of issues. Previously the relatively small size of PCTs made it difficult to influence the larger populations of local authority decision making.

  4.5.2.  Public services are incentivised through strong performance management frameworks and the move to cross government and cross service collaboration through Local Area Agreements supported by the new public service agreements and performance framework. Development of shared performance targets is a considerable incentive in improving and prioritising the reduction of health inequalities. However, as submitted elsewhere in this memorandum, the emphasis in recent years to short term funding and quick fixes are a barrier to the long term interventions required to tackle health inequalities in the most intransigent areas. A single funding source for local strategic partnerships pooled and shared in relation to prioritisation of the key issues to address would be welcomed. As reported in section 4.1.5 the possibility of combining a DH funding stream alongside the DCLG area Based Grant would be a positive approach across all local government not just the Spearhead Areas.

4.6.   The effectiveness of the Department of Health in co-ordinating policy with other government departments, in order to meet its Public Service Agreement targets for reducing inequalities

  4.6.1.  The engagement of the Department of Health in the development of the Local Area Agreement and the performance framework has been beneficial in supporting local areas to address the reduction of inequalities within their programmes and priorities. The Association welcomes the dual function of Directors of Public Health at Government Regional Office and Strategic Health Authority levels and particularly welcomes the strengthening of social care within regional offices in the near future. A shared cross government initiative to highlight best practice areas for reducing health inequalities would be welcomed.

4.7.   Whether the Government is likely to meet its Public Service Agreement targets in respect of health inequalities

  4.7.1.  The Association shares the concerns outlined in the State of Healthcare report 2007 which highlights the inequalities experienced for those with Mental Health problems and those with Learning Disabilities. The priority focus for the NHS in respect of secondary care waiting time targets continues to disadvantage those with more specialist and on occasion high cost interventions. Whilst the recent announcement to transfer the commissioning of Learning Disability services to local government through Social Services authorities is welcomed, there is a risk that the NHS will reduce further its prioritisation of services and actions to reduce inequality in this high risk group. The role of primary care in reducing mental ill health through health promotion, particularly in disadvantaged communities has struggled to receive the attention warranted. The drive to reinforce the importance of both these disadvantaged groups would be welcomed.

January 2008

REFERENCE DOCUMENTS

  Commissioning Framework to improve Health and Wellbeing http://www.dhn.org.uk/dhn/briefing-detail.jsp?&id=1398&md=0&section=briefing

  Update on Tackling Health Inequalities http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_062903

  The State of Health Care Report 2007 http://www.dhn.org.uk/dhn/briefing-detail.jsp?&id=1678&md=0&section=briefing

  Guidance on the role of the Director of Adult Social Services http://www.dh.gov.uk/en/Consultations/Closedconsultations/DH_4116629

  IDeA Beacon Application Brochure 2007 http://www.beacons.idea.gov.uk

  Our Health Our Care Our Say http://www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Modernisation/Ourhealthourcareoursay/Browsable/DH_4130638

  Guidance on JSNA http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081097

  White Paper: Choosing Health, Making Healthy Choices Easier http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094559