Select Committee on Health Minutes of Evidence



A Discussion Paper


  1.1  Ther are a number of reasons to review the future organisation of public health in Greater Manchester.

    —  The need envisaged in the National Plan for entities larger than the current health authorities for a number of key strategic tasks.

    —  The creation of Primary Care Trusts with an important role in the development of the health of their populations.

    —  The devolution of important strategic public health functions to local authorities with their new duty to promote public health. "Modernising Local Government" also states that all functions will be reorganised co-terminously with local authority boundaries as opportunities permit.

  1.2  This paper suggest how public health might reorganise to fulfil its functions within the new structures.


  2.1  Work in public health has to be carried out at a number of population levels: neighbourhood, PCG/PCT, borough, hospital catchment and at county level. New powers to delegate health authority functions to NHS bodies or to local authorities create the potential for statutory authority to exist at these different population levels.

  2.2  It is our view that the most coherent way of addressing these different population levels is by organising public health predominately at the borough level and at the county level. This is not to neglect the other three levels. The reasons for this view were expressed in our response to "Fit for the Future".


  3.1  The functions of public health can be broadly described in three areas: health policy which promotes health in communities ie Our Healthier Nation; health protection; and health care development and management. A number of functions need to take place at a strategic (health authority level) and local (borough or PCT) level.

  3.2  A Greater Manchester Health Authority will be mainly a strategic body focusing on the functions set out in Leadership for Health and the NHS Plan but will undertake some other functions that are best organised at this level. The public health strategic role will include stimulating policy to improve health; contributing to performance management within the NHS; and providing specialist advice to policy makers in organisations inside and outside the health service.

  3.3  The role of public health at borough level is implementation of the public health functions outlined above (para 3.1), for example the National Service Frameworks. Health improvement can be promoted at borough level through input in the PCT or CT, acute trust or local authority.


  4.1  Several different organisational models may achieve these public health functions. We feel this will best be met by establishing a Greater Manchester Health Authority with each borough having either a borough-wide Primary Care Trust or Care Trust with substantial devolved health improvement functions or a statutory delegation of those functions to a section 31 partnership or a formal sub-committee of the health authority.


  5.1  In this paper we consider the need for specialist public health practitioners (public health doctors and public health specialists). We have not yet considered other groups involved in improving public health for example health promotion specialists, human ecologists or environmental health officers. We have as yet only considered public health nursing in the context of communicable diseases control and not in its wider role in community development, school nursing or health visiting. The strategic direction of these other professional groups will need further consideration.

  5.2  It is this current resource of specialist public health practitioners which we would initially deploy at Greater Manchester and borough level. We need to undertake a detailed piece of work looking at current skills, future requirement and career aspirations of the current practitioners. We believe there will be a need for public health capacity building within organisations and more public health practitioners will be needed in the future.


  6.1  We see managed public health networks as being the future organisation of public health practitioners across Greater Manchester. Public health networks will involve practitioners at borough or PCT level, county level and academic institutions. Networks will ensure that there are sufficient mixes of skilled staff to input at the level of borough and county. We do not wish to see fragmentation of public health staff and professional isolation. We propose a Greater Manchester Public Health Network but envisage that local networks will develop across practitioners working in boroughs for example working in PCTs, acute trusts and local authorities. The organisation of these local networks will depend on the organisational structures agreed below the Greater Manchester level. It will be important that these networks include other people with expertise that can work with public health such as health economies and social scientists.

  6.2  The Greater Manchester Zonal Public Health Observatory and public health academic institutions will be key components of this network. Links with academic departments can support education and training; research and development; and enhancement of specialist expertise. Service public health practitioners should be able to contribute to both undergraduate and postgraduate education and the members of academic department should be able to contribute to the training of public health practitioners. The nature of the proposed organisation outlined in this paper has the potential of allowing joint posts particularly in those areas where there is local academic expertise. The most obvious academic links are with public health departments but links should not be confined to such departments, for example other departments may include geography.

  6.3  There is a need for the Greater Manchester Health Authority to take a lead role in research and development. The responsibility for research and development needs to be linked to the public health agenda, for example health inequalities. A public health presence within the Health Authority will be required for these responsibilities.

  6.4  All public health practitioners need ready access to strong information and library services at their place of work. The Greater Manchester Health Authority and/or the Public Health Observatory will be key in ensuring access to public health intelligence. The information links will also provide communication channels for the Greater Manchester Public Health Network of public health practitioners.


  7.1  A public health practitioner needs to have the formal personal professional responsibility of analysing the health of the borough and reporting upon it. If a borough-wide PCT or CT has taken on the extended role of leading the health improvement process it will need to reflect that in its structure. It will be logical for the lead public health practitioner to be a member of the Board and the Executive Committee.

  7.2  The formal organisational base for this public health work should be a single borough-based unit constituted either as a section 31 partnership or as a part of a borough-based PCT or CT. However there will not be borough-wide PCTs or CTs in all ten boroughs and even where there are they may not wish to expand their role in this way. The arrangements in Boroughs where there are not PCTs or CTs will need further consideration.

  7.3  We believe more detailed work needs to be undertaken on staffing levels but as a preliminary guide an independent report by Secta/Dearden Consulting in Salford and Trafford Health Authority has suggested the existing Primary Care Trust which serves half the Borough requires on public health consultant w.t.e. The report also states that "access to a wide range of skills, not often held by a single individual, needs to be secured".


  8.1  There will be a Director of Public Health with public health practitioners responsible for priority areas. The priority areas need to be chosen on the basis of priorities included in Saving Lives: Our Healthier Nation and the areas covered by the National Service Frameworks. There may be other issues, which may be partly easier to deal with at the Greater Manchester level because of the way other bodies are organised; these may include transport; ambulance services and prisons.

  8.2  There will be some health care commissioning at a Greater Manchester level that will need the support of public health practitioners. These services include intensive and high dependency care; renal; neuroscience; spinal injury; cystic fibrosis; clinical genetics; and burns.

  8.3  Dental public health will be provided through a unit at the Greater Manchester Health Authority although members of the unit will have some geographical responsibilities.

  8.4  If there is more than one health authority in Greater Manchester, there should still be only one strategic public health department, which will provide a Director of Public Health to each health authority and will provide strategic advice to all health authorities.


  9.1  It is our view that there will be a need for a degree of centralisation of the health protection function across Greater Manchester although some functions will remain at PCT or borough level. Work is being undertaken to develop the most appropriate organisational arrangements for health protection in Greater Manchester. Professor Ashton is also leading a group considering the "Future Provision of Health Protection Services in the North West". A Greater Manchester DPH and Consultant in Communicable Disease Control are contributing to this group.

  9.2  Public health responsibilities for HIV/AIDS in Greater Manchester will be discharged through a group working at the Health Authority. This group of officers will also be responsible for working with primary care trusts on other policies relating to sexual health.


  10.1  The National Plan announced the creation of public health departments serving Government Regional Offices, Regional Development Agency and NHSE Regional Office. The National Plan also indicated that in future some of the RO performance management functions could be devolved to health authorities.

  10.2  Work at regional level that could easily be undertaken locally includes work supporting specialist commissioning within the Greater Manchester tertiary care providers and work on NSFs and clinical governance. There will be other areas of work where Region may keep a responsibility but that responsibility will be considerably simplified by the co-ordination at country level—performance management, health protection, and organisational development may well be examples. It may be appropriate therefore for some of the public health resource at Region to be transferred into the new authority, perhaps through the mechanism of joint contracts.


  11.1  This is a discussion document which needs further consideration by all public health practitioners in Greater Manchester. There are issues, which will need further work, for example employing authorities and service level agreements to achieve a public health network. Further discussions will be needed with the Consultants in Communicable Disease Control and the public health nurses they work with on the future direction of health protection services. The strategic direction and levels of leadership for other groups promoting public health, for example health promotion specialists need to be considered.

  11.2  Detailed work now needs to be undertaken to map the key public health resources in Greater Manchester and to estimate the future workforce requirements.


  1.  The Chief Executives of the Greater Manchester Health Authorities agree to the way forward outlined in this paper.

  A further paper will be submitted when more detailed work and discussion has taken place.

  2.  Directors of Public Health, given the above agreement of Chief Executives, work collaboratively to create a Greater Manchester Public Health Network.

  3.  Each Health Authority:

    (a)  Identifies for each borough whether the focus of public health activity locally will be:

      (i)  A borough-wide Care Trust or Primary Care Trust with an expanded health improvement role or

      (ii)  A section 31 partnership

      And puts the appropriate arrangements in place locally.

    (b)  Identifies the strategic lead public health practitioner for each borough.

  4.  Note the Regional Office lead on the future provision of health protection services and that Greater Manchester proposals for health protection services are being developed.

October 2000

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