Memorandum by The NHS Alliance (PH 81)
PUBLIC HEALTH FUNCTIONS OF PRIMARY CARE GROUPS
AND TRUSTS
BACKGROUND
1. The public health function within a PCG/Ts
needs to include the following elements:
1.1 Improving health and reducing inequalities
through HimPs.
1.2 Developing partnerships and community
involvement jointly with the local authority.
1.3 Informing the commissioning of services
(best practice, best value and evidence).
1.4 Clinical governance—development
and use of better information systems for disease surveillance
and quality control of service delivery.
2. This is a very broad range of functions
which can be divided into two components:
2.1 A community focused public health function
which needs to deliver reductions in inequalities and improvements
in health through partnership and community involvement (1.1 and
1.2 above).
2.2 A narrower specialist public health
function which encompasses 1.3 and 1.4 above.
3. The NHS Alliance is concerned about the
current emphasis on the narrow specialist function at the expense
of the broader function. The move to PCTs and their need to develop
robust and effective commissioning and governance structures is
likely to increase this emphasis which the Alliance feels has
the following significant disadvantages.
3.1 It will foster a medical rather than
a social model of health care, at a time when there needs to be
a more effective balance between the two models.
3.2 It will become increasingly absorbed
in secondary care commissioning and performance management at
the expense of a broader approach.
3.3 It will not place enough weight on developing
local community involvement.
3.4 It will not place enough weight on building
public health capacity within the PCG/T, in particular in developing
the role of non-medical public health specialists, health visitors
and school nurses.
3.5 It will not devote sufficient time to
ensuring that primary care teams and practitioners incorporate
public health perspectives within their daily work.
3.6 It will not have sufficient time to
devote to effective inter-agency working, which is essential if
inequalities in health are to be effectively addressed.
4. The alternative approach is to develop
the PCG/T public health function as a generic locally based resource
in partnership with Local Authorities who have a lead responsibility
for community plans and neighbourhood renewal. The Alliance believes
that this approach will result in less discussion of what should
happen and more real change, which engages with the needs of front
line professionals and the communities they serve. This is particularly
true of PCG/Ts serving disadvantaged communities and the remainder
of this paper describes an approach adopted by Newcastle West
PCG.
PUBLIC INVOLVEMENT
5. Newcastle West PCG has actively supported
community involvement since it first became a locality commissioning
group in 1994. This has resulted in the formation of Community
Action on Health, which is an independent project with charitable
status. The committee is composed of local people elected annually
from nominations from community groups. Two members of the committee
have been elected to be community representatives with a shared
vote on the PCG Board and they are supported by 1.5WTE Health
Development Workers.
6. Community Action on Health has the following
functions:
6.1 Support to local people and community
groups who wish to raise issues or concerns and/or to lobby for
the development of new services to meet community needs.
6.2 Maintaining and managing a network of
over 90 community groups and projects who all have an interest
in health issues.
6.3 Support to a number of high priority
projects which have recently included the West End Youth Enquiry
Service, A Community Care Information Project and the Black Mental
Health Forum.
6.4 Advocating for the community voice at
a number of forums and meetings.
6.5 Running an Annual Community Conference
which provides an opportunity:
— for local people and groups to get
together to talk about their health issues, and about what action
can be taken, that will make a difference;
— for professionals to listen to the
community's voice;
— to increase the community's sense
of confidence and power to act; and
— to be an opportunity for groups to
make useful links with each other.
7. The Annual conference is always workshop
based around priority areas and the task of the workshops is to
identify action points. For example a workshop on Drugs and Alcohol—a
health issue for the wider community identified the following
action points:
— put more resources into community
based organisations;
— develop education for everybody,
including parents, done sooner at school, even down to nursery
age;
— use the experience and knowledge
of users and ex-user, like "Choose Life" does, at service
and policy level;
— train staff to offer an appropriate,
non-stigmatising service; and
— train GPs to ease the strain on secondary
services.
8. This model successfully developed within
one PCG has now been rolled out across the other two PCGs in Newcastle
and there is also a post which has a city-wide co-ordination function.
9. Recommendation. Public involvement should
go beyond the token appointment of lay members to PCG/T Boards.
There need to be mechanisms for developing local community networks
who nominate accountable representatives. The networks and their
nominees should be supported with resources, preferably through
a dedicated organisation accountable to the local community. This
will enable PCG/Ts to truly engage with the communities they are
designed to serve. Public involvement at all levels of the organisation
should also be promoted as part of best practice with lay representation
on the Executive Committee of PCTs.
PUBLIC HEALTH
10. Newcastle West PCG has a Public Health
Sub-Group which is accountable to the PCG Board. This group is
chaired by an academic GP who is a co-opted Board member. The
group has the following membership:
— Public Health Nurse for the PCG;
— Health Promotion Specialist;
— Member of Community Action on Health;
— Health Visitor who is the PCG Board
Representative;
— Senior Nurse Communicable Disease
Control;
— Senior Non-Medical Public Health
Specialist from the Health Authority;
— LA Regeneration Manager;
— PCG Public Health/Regeneration Manager;
and
— Specialist Health Visitor for Refugees
and Asylum seekers from the Health Authority.
11. The Public Health Sub-Group has the
following responsibilities.
11.1 Developing effective links with local
initiatives such as Sure Start, New Deal for Communities, Regeneration
Partnerships and HAZ. This is the specific remit of the PCG Public
Health/Regeneration manager who is jointly funded by the PCG and
the Local Authority.
11.2 Developing public health capacity in
the PCG by increasing the skills and competencies of primary care
nurses. This work is led by the PCG Public Health Nurse.
11.3 Developing and delivering new local
initiatives that meet HimP priorities. Work within other PCGs
has demonstrated that locality strategies (HimPlets) are more
likely to produce robust and sustainable change that can then
be rolled out to other areas.
11.4 Working with Community Action on Health
to ensure that priorities identified by the local community are
addressed.
11.5 Addressing new and emerging priorities
such as the needs of refugees and asylum seekers.
This is a large remit which does not include
commissioning of services and clinical Governance. These functions
are the responsibility of other PCG Committees.
12. Examples of work that has been developed
in these areas includes:
12.1 A HAZ National Employment Pilot in
partnership with Newcastle College, Employment Services and the
three Newcastle PCGs. This project is identifying training placements
in general practice for full time New Deal trainees who will be
trained to NVQ Level 2 in Customer Services or Admin by Newcastle
College;
12.2 Employment of two specialist nurses,
one for Child and Adolescent Mental Health to work with GPs, Health
Visitors and School Nurses and the other for Young People and
Substance Misuse who is responsible for developing locality initiatives
to address these problems;
12.3 Development of a very successful community
based coronary rehabilitation programme which is run from a Healthy
Living Centre (the West End health Resource Centre) and has increased
uptake of coronary rehabilitation from 15 per cent to 85 per cent.
This programme is now being rolled out across two other PCGs;
and
12.4 Development of a PMS Pilot Project
for Refugees and Asylum seekers.
13. The Alliance is aware of other similar
work going on around the country in Southampton, Birmingham, Nottingham,
London and Mid-Devon. The success of this work appears to have
two key components.
13.1 The willingness of PCG/Ts to engage
effectively with their local communities and with Local Authorities
and other partners so that sometimes sterile HimP Strategy documents
can be converted into effective locality based services which
make a real difference to people's lives.
13.2 The ability of PCG/Ts, or individuals
within them, to make the best of the opportunities available to
gamer additional resources to support community involvement and
local innovation.
14. Recommendation. Resources should be
invested in the delivery of HimPs at the level of localities and
PCG/Ts. These resources should be used to release people within
the local system so that they can use their creativity and local
networks to develop robust and sustainable services which meet
needs identified by the local community. There should also be
more structured opportunities for shared learning and mutual support.
Access to these resources should be dependent on being able to
demonstrate high levels of community participation and partnership
with the Local Authority.
Philip Crowley, Community
Action on Health, Newcastle upon Tyne
Professor Chris Drinkwater,
Public Health Lead, Newcastle West PCG, for the NHS Alliance.
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