Memorandum by The NHS Confederation (PAH
78)
1. INTRODUCTION
1.1 The NHS Confederation is the membership
body for NHS organisations, representing over 95 per cent of NHS
Trusts, Primary Care Trusts (PCTs), health authorities, health
boards and health and social services boards, and including Primary
Care Groups as affiliate members.
1.2 This evidence is presented in terms
of the English NHS only.
2. CONTEXT
2.1 The NHS Confederation has welcomed the
focus on public health policy by health policy makers through
the Saving Lives white paper and most recently in the NHS Plan.
2.2 It is pleasing to see the NHS Plan (chapter
13) embed work on prevention and tackling health inequalities
within core NHS functions, as well as developing Local Strategic
Partnerships to draw together strands of cross-agency work.
2.3 This evidence concerns:
— the need for clear leadership of
wider health functions;
— recognition of the contributions
that are made to the health of the public by multi-agency and
multi-disciplinary planning and working, and applying effort to
improving the equitable provision of high quality health services;
— the need to establish a performance
management system that can accommodate the local inter-agency
partnership approach to tackling public health issues and strike
a balance between central direction of activity with local discretion
on priorities.
3. KEY POINTS
3.1 Leadership and integration
3.2 There is a pressing need to improve
the integration of planning instruments at local health/government
economy level, drawing in the "action zones"—health,
education and other local varieties—community care plans,
joint investment plans, children's plan, health improvement plans
and others.
3.3 This integrated approach should ensure
that there is systematic consistency between plans, and that each
of the projects can satisfy the question of what impact there
will be on the health of the public.
3.4 This integration of planning should
over time aspire to synchronise planning and resource allocation
cycles between agencies.
3.5 Strong strategic leadership is required
to deliver this—at both local and national level. National
leadership should be concerned with setting a strategic direction
but should not suffocate local initiative by being overly prescriptive,
particularly in terms of specifying how policy should be implemented.
3.6 The competency of local leadership to
draw together all the relevant strands of work and mobilise the
constituency to deliver improved public health is more important
than national nomination of a lead agency.
3.7 From the NHS perspective the Health
Authority has a key strategic role in tackling public health problems,
although the nominated lead agency for a local economy-wide strategic
partnership should be open to discretion based on local circumstances
and skill mix.
3.8 Multi-disciplinary and multi-agency effort
in tackling wider public health issues
3.9 The NHS Confederation is strongly supportive
of moves to broaden the definition of public health professional
and public health specialist, and recognise the value of a multi-disciplinary
workforce.
3.10 In this way we would also like to see
that Director of Public Health posts open to public health specialists
with requisite knowledge and skills and not limited to those with
medical qualifications.
3.11 The entire "NHS family" has
a contribution to make to improving the health of the public.
3.12 The PCG/PCT reforms have seen primary
care services brought under the managed framework of the NHS for
the first time.
3.13 Before the establishment of PCGs and
PCTs, primary care in the NHS had neither the structure to enable
a more forward-looking approach to address wider community health
needs, nor the mechanisms to meaningfully influence strategic
planning. Even though it is reasonable to say that often the GP
surgery has had a good handle on immediate needs of their registered
population, and there are some good examples of primary care in
action in tackling wider public health issues.
3.14 PCGs and PCTs clearly have a part to
play in planning and delivering public health including contribution
to the HiMP development process.
3.15 However it should be recognised as
entirely reasonable for new primary care organisations to concentrate
their main efforts on developing and improving primary (and secondary)
care services and delivering clinical governance.
3.6 The contribution of a well organised
modern health service to overall public health and health outcomes
is often underestimated. There are positive ways through delivery
and commissioning of better organised and higher quality health
services—at both primary and secondary care level—in
which the NHS can make a significant contribution to the health
of the public. At the NHS Plan rightly identifies, public health
will be improved by efforts to implement the National Service
Frameworks for cancer and coronary heart disease, to systematically
engage secondary prevention therapies in public health and to
adopt more integrated approaches to managing chronic diseases.
3.17 Performance management and local autonomy
3.18 Working in a collaborative manner and
developing Local Strategic Partnerships is important. The style
of performance management adopted by the Departments of Health
and other agencies has the potential to fatally undermine effective
partnership working. Heavy-handed performance management has the
potential to stifle local initiative.
3.19 Existing performance management frameworks
are applied on a single-agency basis—NHS & Regional
Office, DETR, SSI and others. This single-agency accountability
approach through distinct performance management frameworks could
impede progress of local partnerships. It may unnecessarily require
constituents of the partnership to put in effort to address the
distinct requirements of their agency, thereby taking energy away
from the core purposes of the partnerships projects.
3.20 The NHS Confederation considers that
the inter-agency approach to delivering the public health agenda
locally should be supported by a single performance management
framework that can accommodate the inter-agency partnership in
tackling public health issues. It should also allow local partnerships
to achieve a balance between central direction of activity against
local discretion on priorities.
November 2000
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