Examination of Witnesses (Questions 440
- 459)
THURSDAY 14 DECEMBER 2000
DR IONA
HEATH, CBE, DR
GRAHAM ARCHARD,
PROFESSOR CHRIS
DRINKWATER, CBE, DR
PHILLIP CROWLEY,
MS PAT
JACKSON AND
MS OBI
AMADI
440. Can I explore your views on the location
of the public health function? I am sure you are aware that there
has been much discussion within the inquiry so far in the formal
sessions we have had about whether the current location of public
health within health authorities is the most appropriate location.
Some of us recall the local government involvement with public
health some years ago and the worry I have had is the way in which,
to some extent, the function has been sidelined and become a science
rather than a concern with the practical driving forward. What
generally are your views on the current location? Perhaps at some
point, Dr Crowley, we can explore with you the Newcastle situation
but in general terms what are your views about the current location
and future possible options in relation to the public health function
as such?
(Dr Archard) The view of the College is that the current
positioning of public health services in health authorities does
tend to be distanced from primary care and distanced from those
people at the coal face who are trying to facilitate the agenda.
There is no doubt that if this came closer to the primary care
organisations, primary care groups and care trusts, this would
be seen as a much more main line practice for primary care. One
of the problems of that of course is that some of the sizes of
primary care groups in particular are that small that they could
be seen to be perhaps not being able to represent a global view
or support a global view of public health. Having said that, I
am in a very small PCG, one of the smallest in the country; yet,
we have an area of social deprivation which has a lot of public
health input with great success. It almost needs to be on two
levels: firstly, there needs to be a more global level which is
very much more associated with health improvement plans and then
you have a more local level of public health which will be more
associated with primary care organisations.
(Professor Drinkwater) My view and the Alliance view
on this would be yes, with qualifications. There are some issues
in terms of the location of the function is less important than
how it actually operates. The Alliance view would be that good
public health is very much dependent on the involvement of both
the public and front line health professionals. Health authorities
have not always been as good as they might have been in terms
of engaging with the public and with front line professionals.
There are some issues about that that you very rightly raise.
I think it then comes back to there are different functions at
different levels. Clearly, there is a public health function at
the national level, if you like, which is about regulation and
safety including food safety. That would have to take place at
the national level around regulation. There is a bit below that
which is regional and that might be public health observatories,
epidemiology, comparative data and somebody who is collecting
all of that data and handling all of that data. There is a subregional
bit and I have not called it health authority because I think
it is subregional rather than health authority; infectious disease
control, commissioning, evidence and information. The crucial
bit and the bit that I personally am most interested in is the
bit at the local level, at the PCG/PCT. There are some real opportunities
around the current restructuring, around PCTs and local authorities
and community plans that, if we can get that right, then there
are some opportunities around a real inter-agency way forward,
around delivering locally responsive services that meet the needs
of local communities and really engage at that level with front
line professionals and with the public. That is the critical bit.
There are some concerns that, as the system changes and as we
move to PCTs, if PCTs get caught up in becoming mini-health authorities,
they will still operate a very medical model rather than a social
model and just a concern that we need to invest in that social
model of health at the locality level.
(Ms Jackson) The CPHVA would see public health departments
being too far removed given the situation with health authorities.
We would like to see them coming much closer together with PCGs
and PCTs, essentially to effect communication. Communication should
be two way. We want to move away from science model to a more
social model. The two way communication would facilitate that.
It is using nursing information as health intelligence to inform
those assessment processes because at the moment we feel they
tend to be top down from public health departments.
(Ms Amadi) I would agree.
441. Ms Amadi, I was about to ask your organisation.
I would imagine you have had the experience of working within
a local authority structure, but I have talked to health visitors
who worked pre-1974 in the local authority structure, who felt
far more able to influence the wider public health factors affecting
the lives of the people they were dealing with than they have
been subsequently because of that separation from local government.
Is that an issue that you have given any thought to, on issues
like housing, for example? Within the same organisation that is
responsible for housing provision, some people I have spoken to
felt that the older arrangement made more sense from their point
of view.
(Ms Amadi) Yes, a more similar arrangement where there
are less boundaries and less bureaucratic processes involved would
help the work of community practitioners in terms of fulfilling
public health functions and working with the community, communicating
with the community. It is going to be a much more straightforward
process of effecting change if there are those links.
442. The issue of the future role of DHAs is
an interesting question with PCTs. How do you see the future role
of the DHA, particularly as it relates to public health, if there
are no fundamental changes brought in by the government and we
are not in a position to say what this Committee will be recommending
at this stage obviously, but how do you see the future role of
the DHA operating within the new climate where the PCTs are emerging
and with the concept of care trusts? Any thoughts?
(Dr Heath) From my perspective, they would appear
to be pretty largely doomed.
443. If they are, which is certainly the picture
that I get, does that not open up opportunities to look quite
radically at the future placement of future public health functions?
(Dr Heath) Absolutely.
444. Therefore, what should we do about it?
(Dr Heath) We would concur that the very placement
of public health within health of any nature, directly within
health, perpetuates the notion that public health is a health
care related topic, which I think we would all agree it is not.
Therefore, I share your nostalgia and fond memories of the situation
prior to 1974. I wanted to make a point about the two different
dimensions of public health, one of which is health protection
which can be delivered at all the levels that Chris talked about,
which is to do with the care of populations, which is very largely
outside the health care service; and then there is the issue of
health promotion, much of which has to be delivered to individuals
on the basis of trust and therefore grows naturally out of the
delivery of personal medical services. It is at that point that
public health and primary care services come very close together,
but there is a whole other arena. Now we are in a situation where,
for example, housing managers are delivering a substantial proportion
of the daily care to the chronically mentally ill at a complete
distance from the health care services. If public health were
placed closer to those sort of factors that have such a strong
influence on the health of the most vulnerable, that would be
a very positive move.
445. Dr Crowley, you have a particular example
in Newcastle of what you have tried to achieve. How does that
relate to the future structures, as far as you see them? Having
read in some detail the evidence you have given us, which was
of great interest, would it be fair to say that you have had to
create structures because the current formal arrangements did
not work, or is that an unfair criticism of the background to
what you have done?
(Dr Crowley) We are talking about a very different
context six years ago when we started down the route of creating
links between primary care and the communities that they serve
in an organised fashion. At that time, the structures were only
emerging whereby primary care began to look at things a bit more
collectively. We had a locality commissioning model in Newcastle
alongside fund holding and that created an opportunity for dialogue
across that interface that we were able to develop and nurture.
For me, the new structures of primary care groups and primary
care trusts strengthen the opportunities for alliances between
local communities and front line staff and organised primary care
in that way. My worry however is that the move from primary care
groups to trusts could debilitate the kind of partnership working
that certainly we have developed in Newcastle at PCG level which
is more local clearly than a primary care trust city wide level.
We have been working a lot with the primary care organisations
to ensure that that is addressed in the design of the primary
care trusts with strong locality focuses.
446. Could you be specific about why you see
that change possibly damaging what you have done?
(Dr Crowley) The danger is that the primary care trust
could become a distant bureaucracy at city wide level. While some
communities of interest and identity that we work with are organised
on a city wide basis, many communities have a sense of community
very much more local than that. With the new responsibilities
the primary care trusts will have and the new statutory requirements
about how decisions will be made, the ability to penetrate that
decision making could be weakened in comparison to the kind of
local arrangements we have developed in Newcastle, where primary
care groups have had accountable representation from local communities
on their primary care boards, where we have had annual conferences
with broad ranges of communities and front line staff and primary
care managers and practitioners coming together to prioritise
the public health agenda for their locality. We are keen that
that locality focus is retained and I think the trust proposal
from Newcastle demonstrates the equipment to maintain that.
447. Speculating about the future models and
the possible demise of health authorities, the role of local government,
do you see from your experience any potential for change that
would enhance the work you have been able to do within the structure
that you have created?
(Dr Crowley) I would hope so. The commitment in the
NHS plan and in local government, the Local Government Act, for
local government to take more responsibility for the wellbeing
and health and then scrutiny of health hopefully will bring health
back on the local authority agenda, which in our experience it
has drifted off in those intervening years. Clearly, from a community
perspective, we would be very keen for that to happen because
a lot of the issues that communities will seek to address, public
health issues, will not be addressed without strong partnership
with local government.
Mrs Roe
448. Dr Heath, would you not agree that GPs
and other primary carers already carry out a great deal of the
day to day public health work? Would you tell us whether you think
that the current incentive systems actually discourage them from
doing more?
(Dr Heath) I always have a bit of a semantic problem
in that I cannot conceive of public health being anything more
than the health of all the individuals that make up the population.
Somehow, that sometimes seems to be lost and it takes on an autonomous
existence of its own as public health separated from the individuals.
I think we do an enormous amount. There are problems in that we
are now being set extraordinarily high standards for responsiveness
around personal medical services in terms of access to people
who believe themselves to be sick. Unless we respond properly
and effectively to those, which will always be as working general
practitioners our number one commitment, we will lose the trust
of the patients which enables us to engage them in health promotion
initiatives around taking medication to prevent future disease,
around accepting immunisations, around altering their lifestyles.
Those sorts of things you cannot do if you are not actually providing
a decent service for their self-expressed needs. There will always
be a balance and a tension between those two things. I think we
could do enormously much more if we had closer links with other
agencies in the community and if we had more ready access to public
health expertise. At the moment, we have no way. We now understand
how powerful the socio-economic determents of health are and yet
we continue to practise where we take a history that ignores them.
We ask about smoking but we do not ask routinely about housing
stress. We may ask; we hold a lot of knowledge but we have no
way of recording these things. We have no way using the huge knowledge
base within general practice to inform the delivery of public
health more widely. We know who the most vulnerable people are
from our day to day knowledge because we have more contact than
any other professional group, but it is making that transition,
sharing that information and that knowledge that does not yet
happen.
449. Would you say that primary care trusts
would be better suited to trying to drive up the actual quality
of primary medical care, rather than trying to deliver the public
health agenda too? Do you think primary care is equipped to take
on public health responsibilities?
(Dr Heath) I very much do. What I am trying to argue
is you cannot have one without the other. The two go hand in hand.
They are deeply enmeshed. The structures need to recognise that
more clearly.
(Professor Drinkwater) I wanted to focus a little
on the issue of incentives but also around inequalities in health.
The incentives issue historically, if we go back to the 1990 general
practice contract with health promotion clinics, the Alliance
view on that would be that that was a total disaster in that it
reinforced the inverse care law in the GPs were funded to run
health promotion clinics. It was very easy for GPs in the leafy
suburbs to do that because everyone wanted to come along for a
health check but in the inner cities nobody turned up, so in effect
more money ended up going to the better off practices rather than
the practices that were really struggling in areas of social disadvantage.
There is a major issue in terms of you have to be very thoughtful
about how you put incentives into place, or you may find out that
they are perverse incentives and do not do what you want them
to do. That is one key point. The other point goes back to this
issue of inequalities in health and incentives and what is the
public health function within primary care. If you look at areas
where there are high levels of social disadvantage, inequalities
in health, those are precisely the areas where practices are struggling
because of the demands that are made on them. They have a much
heavier workload and we still have not addressed the issues in
terms of ensuring that resources are equally distributed and that
those practices in areas of inequality get sufficient resources
to meet needs within that area. There are some issues in terms
of you need an enhanced public health function within those areas,
which is about people on the ground, working with local communities,
because I think that is where you have the greatest opportunity
to make a difference and to produce real health gain. It is very,
very important that we do actually address that issue.
Siobhain McDonagh
450. I am new to this Committee and this is
a bit of a bee in my bonnet about GPs. It strikes me that GPs
are removing themselves from the community rather than becoming
more involved in it. Clearly there are notable exceptions and
they really stand out. They tend to be perversely single handed
GPs who become involved in that whole issue of their locality,
the greater needs of their patients, and I looked at your submission
and the three examples you gave of GPs in practices being involved
in public health care. Examples two and three were just brilliant,
except in my constituency I do not ever see any of those examples.
I get to the stage where I beg GP practices to use some of the
information and knowledge they have to encourage the council or
any other public body to do things in a particular way, but I
find it very difficult to do that.
(Dr Archard) There is inevitably going to be a spectrum
of commitment and a spectrum of quality within general practice,
as in any profession. I would probably take issue with your submission
that general practitioners are removing themselves from the community.
I think exactly the contrary is happening, particularly with the
advent of primary care organisations. This has given general practitioner
as well as practices an enormous opportunity, which in my own
primary care group has been grasped by almost every practitioner
within the PCG, to move towards a community focus rather than
an individual practice focus. It has been quite remarkable, the
change around in attitude from a competitive attitude to a cooperative
attitude with the introduction of PCGs. In particularly, although
I do practise in a leafy suburb, there is one area of quite marked
social deprivation in which practitioners have got together with
other agencies and have made an enormous difference to public
health in that area. For example, last week in the schools there
was a fruit week and each child was given five pieces of fruit
a day which had been begged from the local fruit stalls. It was
a remarkable success. Children were eating fruits they had never
seen before. That is the sort of aspect of public health which
has been promoted by primary care groups and trusts no doubt,
but as trusts become larger it is very difficult to keep that
focus with a very small group. This is one school. I would disagree
with you. I do not think that general practitioners are becoming
more removed and I think primary care organisations have done
an awful lot to make them more generous than they were before.
The additional pressures, workload and consultancy rate and so
on within general practice sometimes demands that practitioners
have not been able to give as much time outside practice as they
had previously been able to do.
John Austin
451. Dr Archard and Dr Heath, in the written
evidence the Alliance are saying that because the PCTs will be
heavily involved in developing robust and effective commissioning
in government structures that in itself will mean they will not
put weight on public health capacity and will not have time to
devote to inter-agency working etc., and that the public health
agenda will be lost. Do you share the Alliance's view on that?
(Dr Heath) I think we do share the Alliance's anxieties
that these will be bigger structures; they will be more bureaucratised;
there will be less direct input from people working in the front
line of health or social care directly into this decision making.
There is also a shame in areas like mine. PCGs have been slow
to become established for reasons of demoralisation and work pressure
and people feeling ground down by the circumstances that prevail
now in some deprived inner city areas. It has taken a lot of time
to get the involvement of people in the PCG and it has not had
a chance to run and we have to become a PCT. That feels like a
lost opportunity for development, learning and change that is
very locally based, and that we will be subsumed into a PCT and
back to having a health authority.
Chairman
452. Going back to the Royal College evidence,
I was interested that you stated, "As primary care trusts
are created there is a risk that public health physicians will
become isolated in health authorities." I put a note when
I read it saying, "In my view, they already are." Taking
up Siobhan's point, I had an example a couple of years ago, when
my constituency was reorganised with the kindness of the Boundary
Commission, which put me within two different local authority
and health authority areas. I met some GPs in one part and said
I had been very impressed with the public health people working
in the health authority. They did not even know their names. I
found that astonishing. There was no connection whatsoever between
primary care and public health. I am a bit surprised to see that
you feel they would become isolated, because—
(Dr Heath) Because they have been involved in PCGs,
they have become a little less isolated in the interim. There
is a fear of a return but the whole corporatisation of public
health within health authorities with completely different agendas
from their traditional ones has been very concerning for people
working directly with patients.
(Dr Crowley) You can see the involvement of primary
care and GPs and the local issues at different levels. I would
agree that there is no other service in the list of public services
with the amount of contact with local people that primary care
has. The potential for that contact to be built on is largely
unrealised because of the time issue of delivering what primary
care has to deliver. The possibilities around linking into benefits
maximisation, which we have done a bit of in Newcastle, and many
other services which could link in and create access to are currently
poorly accessed by certain excluded communities is unrealised.
Primary care organisations have allowed some of the time that
is lacking in primary care because of the resources that have
come in to fund people to fulfil roles to then come out of their
practices for a while and create some of these partnerships. Certainly
we have noticed a significant difference.
(Ms Jackson) Coming back to the point of public health
knowledge within general practice, what we would like to see is
integration of information systems within primary care because
there are other workers within primary care setting. Health visitors,
school nurses and other community nurses are out there with the
community, working with them and for them everyday. Currently,
their information is separate from general practice information.
General practice information tends to be fairly quantitative and
can identify an issue; whereas it is the nursing information,
the qualitative information, that can identify why a particular
issue is arising. It is about painting the whole picture within
primary care.
Mr Burns
453. Professor Drinkwater, do you think that
the development of PCTs realistically can be expected to make
a difference to the contribution made by primary care to public
health?
(Professor Drinkwater) It is an enormous opportunity
and if we miss this opportunity we will have failed. The opportunity
is essentially, if we can get it right, around the inter-agency
mix and a more partnership, corporate approach between practices
which will cover a whole range of things. One of the issues in
terms of our own particular patch, Newcastle West PCG, is we run
an out of hours service in that patch. That was a very good way
of getting the GPs together and the GPs beginning to look at what
they collectively were doing and to work much more corporately.
There are lots of opportunities for practices to work more corporately
rather than work in competition with one another. That is an important
thing to hang onto. There are also some key opportunities that
we need to take advantage of around the information systems at
locality level and I would share the CPHVA's concern about records
being dispersed in all sorts of bits of the system. In our patch,
we have a specialist nurse, child and adolescent mental health
service. One of the issues about that is a number of children
are being seen by different agencies without any of the agencies
being aware that they are each seeing them. It is a very wasteful
system. The patients who are subject to that system do not know
who they are seeing, why they are seeing them and so there is
a major opportunity in terms of getting it right at locality level.
I would still argue that locality level probably has to be around
the 100,000, because there are some issues about the size of a
patch that can deliver services where the professionals can work
together and support one another and where you get continuity
within the professionals. There are some issues about where general
practice is at the moment. There are some dangers and threats
to continuity. If you talk to the public and patients, what they
very much want is continuity of care from an individual and there
are some dangers that that bit goes out of the window. There are
some challenges. I would hope it is achievable but it does need
to be resourced at that local level.
454. You said you expect them to work more corporately
together, which is presumably a wish and a hope. Is there not
a potential problem? If it is not worked more corporately together,
there is going to be a danger that PCTs are dealing with such
relatively small numbers of people that you will not get a general
overview of public health trends throughout the country because
of the independence of them all, working in isolation?
(Professor Drinkwater) I do not think that is necessarily
the function of the locality structures. I think the locality
structures are around engaging with the front line professionals
and local people, looking at the national framework and what the
national framework is supporting, but then delivering what needs
to be delivered within that national framework at local level.
All the evidence is that dictats from on high do not work. It
is only when you engage at local level and work within the framework
constructively with the professionals in the community that you
do deliver services that make a difference.
(Dr Heath) I would agree with that. It is a bit about
my health protection and health promotion thing. Your surveillance
is at a different level from where you are trying to achieve change.
One has to have a flexibility at local level to incorporate things
that local people view as priorities, which are not necessarily
going to be national priorities. Then you might be able to deliver
national priorities as well, but you cannot do the one unless
you do the other first.
(Professor Drinkwater) Our best example from Newcastle
West would be about coronary rehabilitation, rehabilitation of
people after heart attacks. When we looked at our patch, we had
a standardised mortality rate which was 235, more than twice the
national average for men under 65. Only 15 per cent of people
after a heart attack were accessing rehabilitation which was based
in the hospital and that was all sorts of issues about access,
perception and fear of hospitals, a whole bundle of issues there,
so we went to the health authority and said, "It ain't working"
and managed to persuade them to fund a community based programme.
Over three years, that has the uptake up to above 80 per cent.
That is because it is locally based and patch based and because
it is engaged with the local community.
455. Is there potentially a conflict between
health authorities and PCTs where they will fall between two stools
and no one will actually take primary responsibility for delivery?
(Professor Drinkwater) Yes. There is a potential conflict
and there are some dangers there. It is a separation out of the
science bit of public health from the public health practice bit.
The science bit is the performance management end, the commissioning
end, where evidence, data, information, having comparative data
from different areas, are going to be very important. That then
needs to be separated out. That is perhaps the subregional or
whatever health authorities become level that that needs to operate
at. At the locality level, it has to be about delivering real
change and real public health practice. Again, I think there are
some examples around personal medical services pilots. In our
own patch, we have just agreed to go ahead with a personal medical
service pilot for refugees and asylum seekers, a very important
group with clear health problems that need to be addressed. There
are some flexibilities within the system where you can begin to
do that at local level, taking advantage of some of the rules
and regulations that already exist.
Mrs Gordon
456. During the course of the inquiry, we have
looked at various community schemes. It was a particular problem
that they could not get GPs involved, however much they tried.
Usually, the reasons given were the workload, too many initiatives,
too many committee meetings for GPs to be involved in. I wondered
if you could give us an idea of what practical measures you think
could be taken to help this perceived problem of being overwhelmed
by the work. Do you think that personal medical services contracts
are part of the answer to this, especially in deprived areas?
Can they make a difference to the public health role of GPs?
(Dr Heath) The great strength and the great problem
for general practice is the broadness of the base of general practice
means that almost every organisation wishes to engage with GPs,
every organisation that is dealing with a particular problem.
To cite some local examples, domestic violence, means of child
protection, local traffic schemes. Everybody would value input
from a GP. I could spend my entire week twice over just attending
very valuable and very important meetings and yet I have 24 hour
responsibility for over 1,500 patients. There is just a point
where these two things are incompatible. I am not sure that any
amount of bureaucratic change is going to change that basic problem.
Every single hospital specialist feels that there is something
they need to tell GPs about their particular things, so that the
range of educational events that one gets invited to—again,
we could attend educational events the entire time, because the
catch phrase is general practice is ideally placed to deliver
my agenda, not necessarily our agenda or our patients' agenda,
but there are a lot of agendas for which general practice is ideally
placed. It is a very difficult balance between the service commitment,
which is essential to get the trust of ordinarily people on which
you can build everything else, and get proper engagement, which
is why PCG's were actually good. That was bringing together GPs
in a small group with other health and social care professionals,
to look at things in a different way and come up with different
approaches. I come back to the fact that that has been cut short
by the development of PCTs.
(Dr Crowley) The experience in the west end of Newcastle
was at a time when clearly general practice was under strain.
Part of the reason it was under strain was it was constantly dealing
with issues to which it did not have the solutions. That became
a key driver for a partnership both with the community and with
other providers of services, in the west end of Newcastle anyway,
where if you like the pay off was to take some of the pressure
off by providing appropriate services for the needs that were
either the hidden agenda in the consultation or in fact expressed
in the consultation but just beyond the capability of primary
care to resolve. One of the initiatives that arose out of that
way of thinking was Families First, which is an initiative where
local people have been trained to provide basic support and signposting
to families who have been identified by primary care as being
under considerable and particular stress at any given time, either
because they have recently moved into the area and are particularly
isolated or under stress for racial harassment or other reasons.
They have been able to go in and provide support to families.
It is an appropriate service for the need. Primary care did not
have the time or maybe the ability to engage with the kind of
social issues that were being raised by families at that time.
That was why primary care became involved before PCGs in the west
end of Newcastle.
(Dr Archard) If I might come back to your point again
about involvement of general practitioners, there is a breed of
general practitioners and indeed others within primary care who
are very keen to take the challenges forward, to try to improve
quality and so on. It comes back again to available time. The
situation arose in my own situation personally in that the only
way I could address the sorts of issues which I felt were important
for general practice was to go part time, which is what I did
five years ago. In so doing, I cut my salary in half with no protection.
I stopped my superannuation by 50 per cent and so on. I am not
remunerated at all for the time I take out, and yet, if I am to
take more time out, my partners become all the more aggrieved
because the amount of work which is left for them to do mounts
and mounts. Therefore, the practitioners who are trying to address
these problems are becoming the bete noires of primary
care. I and a number of my colleagues, quite senior general practitioner
colleagues, have enormous pressures from their partnerships to
get back and do some proper work, rather than get out there and
address the sorts of issues on which we are all very concerned.
I do have a lot of sympathy with that as well, because they are
left with an enormous additional workload, which locums are usually
unable to address, not because of their inability, but because
patients like to see their own doctor or a proper doctor, which
very often they feel a locum is not. Of course they are misplaced
in their thoughts on that but nevertheless that is the way the
public often see them. Consequently, there is enormous pressure.
You either go part time, which is what I have done, in which case
you limit your financial security; you lose your superannuation
and a lot of income; or alternatively you stay where you are or
go back into general practice, feeling quite disillusioned and
burned out as a consequence. You ask what is the way forward.
My feeling is that the way forward is to recognise that there
is a very real career structure which should address the sorts
of problems which you are quoting, so that specific resource can
be put into time so that people can actually address the sorts
of concerns which everybody in this room is worried about.
457. We have heard that in the Newcastle example,
which has made a difference to the way that you work there. What
would make a difference?
(Dr Archard) I think the difference would be a career
structure such that people would have time and recognised positions
to address themselves to these areas. Some people are particularly
good at clinical medicine and some people are—
458. Would having more time mean more bodies?
(Dr Heath) The west end of Newcastle is a fantastic
example of what can be done by extremely committed and energetic
individuals who have achieved an enormous amount, but there are
things about the system that do not make that sort of thing easy.
The achievement is magnificent. It is not going to happen across
the country unless the whole system is incentivised in a different
way. Phillip is absolutely right. If you stand back enough, you
can put in services that will make your life easier, but if you
are just seeing patients at ten minute intervals and wondering
whether you are even going to have time for lunch, to step back,
to make that sort of change, is very difficult for people.
(Professor Drinkwater) I think some of that goes back
to the whole career structure of general practices. One of the
bits that has begun to happen around Newcastle west PCG is a recognition
that you almost need to buy people out of their practices, give
them time out. There are opportunities to do that around the PCT
structure. Equally, I would agree that personal medical services
pilots are another way in which general practice is experimenting
with a different approach.
459. What do you think of them and whether they
can make a difference in public health?
(Dr Heath) That evokes my worries about the universal
provision as opposed to the experimental provision; the whole
fragmentary nature of personal medical services pilots and how
they can be properly evaluated and what system we can have for
taking what is good and universalising it, because the worry is
constant. To come back to health visitors, I cannot waste this
opportunity to say that the whole thing about Sure Start and the
fact that this is in lumps—people get Sure Start in patches,
while the universal service around that is eroded, so people who
are not in Sure Start are getting an ever worse service as case
loads go up and up. I really have a problem about patchy initiatives
that, okay, may do great things for services in a particular area
but do nothing for the population as a whole and leave some of
the most vulnerable people out in the cold. There is a tension
around personal medical services and, if they are genuinely treated
as pilots and one learns from them and takes the best from them
and there is time and resources to evaluate them properly and
disseminate what you find, then yes, but history does not teach
me to be optimistic that we will learn properly from these initiatives.
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