House of Commons - Health

Select Committee on Health Second Report

Public Health in Primary Care

66. An individual's first contact with healthcare and advice is usually through their own GP or another member of the primary care team. Primary care has a long tradition of authority and trust built up between the primary care team and the community, such that GPs, for example, are authoritative figures to deliver public health messages. As Chris Town, Chief Executive of Peterborough Primary Care Trust and representative of the NHS Confederation, told us, GPs "are seen as very influential people locally. They are listened to".[84] Moreover, in one year, 70% of patients consult their GP, and over seven years this rises to 97%, so the primary care team does interface with the great majority of the population on a fairly regular basis.[85] In addition, health visitors have a statutory responsibility for all children under five and thus come into frequent contact with their families. Community pharmacists are also in frequent contact with the public and their advisory role is being strengthened. In fact, what might be termed public health activity already forms part of the day to day job of the primary care team. Immunisation and screening programmes are an important element of preventing ill health, as is chronic disease management, and health needs assessments, if carried out properly, could allow the information held by practices to be used to identify and target at risk groups.

67. The role, or potential role, for primary care in public health is a fraught issue, with experts divided over how much of a public health responsibility primary care should, or can, take on. However, the Government has repeatedly placed great emphasis on both improving public health and developing primary care as a leading part of the health service, and it would therefore seem logical to assume an involvement of primary care in public health. We believe it will be vital to establish what public health responsibilities can be taken on at each level of the healthcare system and by other organisations.

68. The introduction of Primary Care Groups and Trusts (PCG/Ts) has major implications for the role of primary care in public health. The first of the three objectives of PCG/Ts is to improve the health of their populations and address inequalities. This would appear to put public health at the top of their agenda. However, as we shall see, there are serious concerns about the capacity of PCG/Ts and primary care itself to fully develop its public health role.

THE ROLE OF THE GP

69. As we have noted above, GPs come into frequent contact with members of the public and they are generally highly-regarded. This places them in a central position for the dissemination of health advice and they would seem to be a main plank of the public health function. However, on our visits we were often told that GPs do not become involved in local public health projects. Indeed, GPs themselves may not even know their local DPH.[86] We received evidence describing how GPs perceive health authority public health physicians to be caught up with the management structures of the NHS, and therefore not offering impartial advice, and moreover, remote from the 'real world' of care.[87] (We return to the links between primary care and health authorities below.)

70. GPs' wider public health role often takes a back seat to the other functions they must carry out - most notably, recently, their involvement in PCG/Ts. In addition, they are under considerable time pressures, as their very short average patient consultation times (a little over seven minutes) attest.[88] GPs are also, in general, not used to or trained in taking a public health perspective. They work with the concept of individualised care, and to make the shift to a population overview would require a great deal of support.[89] We recommend that the national Public Health Workforce Development Plan and Public Health Skills Audit (mentioned in the Department of Health's evidence) assesses whether primary care actually has the capacity to take on public health responsibilities. We discuss the implications of lack of capacity in public health further at paragraph 104.

71. A further problem arises from the fact that GPs are not rewarded financially for making time to carry out public health work. Dr Archard of the RCGP described the problems he had experienced in taking up more public health work:

"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 bêtes 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."[90]

If GPs are to be more involved in wider public health work, particularly of a community development kind, the Government must find some way of creating a career and pay structure which enables them to do this and allows them sufficient time and provides sufficient incentives to facilitate their involvement.

72. In the short term, however, one way around imposing more responsibilities on GPs in terms of public health would be to use other members of the primary care team more effectively.

HEALTH VISITORS AND COMMUNITY NURSES

73. Health visitors and other public health nurses seem to us to be the key to delivering public health through the primary care team. These workers are involved with communities at the closest possible level, and as the health visiting service is universal, they have a population focus not shared by other practitioners.

74. In 1998, the Independent Inquiry into Inequalities in Health recommended that "a high priority is given to policies aimed at improving health and reducing inequalities in women of childbearing age, expectant mothers and young children".[91] Health visiting represents a rarity among public health interventions, in that there is firm research evidence to confirm its beneficial effects. Evidence exists from the USA and Canada to show that the benefits derived from a programme of home visits to women who are expecting a baby and then in the first two years of the life of the baby, are "uncontroversial", according to Sir Donald Acheson.[92] This evidence should be capitalised upon to back a government focus on developing the health visiting workforce and other professions working with children.

75. It is worth remembering the role of midwives in this respect, who also work across sectors, visiting mothers and babies at home and providing a flexible antenatal and postnatal service which includes giving health advice, offering tests and screening, and supporting the psychological health of mothers. Midwives are often passed over by public health strategists because they are usually employed and managed by the acute sector, which is not at the forefront of the public health agenda, but in fact they have an important public health role and we believe they should be given the support they need, especially in terms of recruitment. Midwives work with the social model of health, and are not just interested in medical outcomes. However, in this work - such as providing emotional and social support for women in pregnancy, which has been shown to be linked to shorter labours, less analgesia and operative delivery and other positive outcomes - midwives are undermined by staffing and funding shortages, and a prioritisation of short-term medical outcomes.

76. Health visitors currently limit their work to mothers and the under fives, but we believe there is scope for the development of their role. We believe health visitors should work with the elderly or other needy groups, so as to broaden their skills base to encompass other activities. We would also like to see a role for health visitors as the key public health resource for all community health care professionals. We are concerned that health visitors are not sufficiently empowered in terms of resources and capacity to carry out wider public health functions beyond their statutory duties. We also think that there is scope for greater integration and co-ordination between health visitors, school and community nurses. We recommend that the role of the health visitor is reviewed and clarified. We would like to see it developed as a holistic, public health function.

77. The Government is keen to activate health visitors and allied professions in community nursing, and is working on a "programme to strengthen the health contribution of nurses, midwives and health visitors, including a specific national development programme for health visitors and school nurses".[93] We welcome this commitment. However, the nursing professions as a whole are experiencing a crisis in recruitment, and community nursing and health visiting are no exception. In our inquiry into Future NHS Staffing Requirements, the CPHVA provided evidence of falling numbers of health visitors and increasing age in the workforce: the average age of community practitioners and health visitors then was 46 years old.[94]

COMMUNITY PHARMACY

78. Pharmacists represent a resource of expertise and training which could be better utilised to deliver the public health agenda. Community pharmacists come into contact with a large proportion of the well and ill population on a fairly regular basis, they can be spoken to without an appointment and represent a non-threatening source of advice for the public. Pharmacists are also highly skilled individuals whose training focuses increasingly on social issues such as communication with customers and interaction with the healthcare team. However, they are currently largely restricted to dispensing medicines and giving a small amount of health advice. As such, they represent an under used resource.[95] A small number of pharmacists are already playing a much more active role in community health but they are not incentivised so to do.

79. To do any of these things, however, would require a strong lead from above, and importantly, a reorganisation of the remuneration system for pharmacists. According to evidence we received, "the current system rewards pharmacists for keeping patients on long-term medication rather than helping them in other ways".[96] Community pharmacists are health professionals who currently rely for much of their income on the sale of non-clinical goods to ensure that they remain profitable; to shift their focus to public health issues, they would have to be compensated for restructuring premises to create more appropriate public and private spaces for giving advice, for extra training for staff in public health skills, for, perhaps, additional IT and media facilities for supplying information, for additional time spent on planning and delivering public health outreach programmes and for any lost earnings from the commercial sales side which public health interventions may to some extent replace.[97]

80. Pharmacists could be used more systematically to deliver public health interventions such as health advice and life style information, a range of health tests, advice on medicine management, and could even engage proactively with the community by offering an outreach advice service to particular interest groups and acting as a referral point through to other appropriate health care services. The pharmacy itself could potentially be developed to act as a resource centre or an access point to other services, including non-health services.

81. The DHSS in Northern Ireland has recently engaged in a consultative procedure with the Central Pharmaceutical Advisory Committee to consider the potential expansion of the community pharmacist's role. We were told of an example of a pharmacy acting as a sort of one stop shop in Northern Ireland. We support this model of community pharmacy. We recommend that the Government takes steps to create incentives for community pharmacists to play a more active role in public health. We welcome the idea that a pharmacy could act as a more general health resource centre, thus better utilising the very considerable expertise of pharmacists.

PRIMARY CARE DATA

82. There is a great deal of potential for public health in the data sets which GPs hold on their practice populations. If these life-long health records could be easily accessed and used, the potential to link socio-economic factors with health and to target at risk groups of the population would be great. However, most of the data is not easily accessible, because of the problems posed by patient confidentiality and the relative computer illiteracy of many practices. Amongst those practices which do have IT systems in use, the diversity of incompatible systems is such that comparison of data is very difficult. Installing computer systems to manage data is also very expensive for practices in terms of money and staff time. Dr Archard of the RCGP described the problems:

"There are numerous practices which have huge and accurate databases of health data regarding their patients. This is used by these practices to develop their services and to practice high quality clinical care. There are a large number of practices, though, that are comparatively computer illiterate and do not have electronically recorded health data. Add to this that there are so many different computer systems and that these systems are used differently by different practices, it can be seen that rarely can one practice merge their information with another.... It is regrettable that IM&T [Information Management and Technology] was not managed pro-actively more than ten years ago so that a good database would by now have existed. That being said, there are numerous practices with written data, but the problem is extracting this data from notes. To properly resource practice computing is expensive; the latest upgrade in our surgery cost our partnership, even after any available grants, over £20,000. This is a large personal expense for a small practice to bear among its partners, and we are aware that, no doubt, to remain at the forefront of this technology we will probably have to spend a similar amount in three years time. Meanwhile our possibly more financially sensible colleagues would not dream of spending their own money on this sort of venture - and who can blame them? ... Only when a properly resourced IM&T structure for Primary Care which crosses the boundaries of general practice and community care is introduced will an effective health database be possible."[98]

83. A primary care IM&T structure would ideally take account of not only the GP's records, but also those of the rest of the primary care team. Ms Jackson of the CPHVA told us how the qualitative information collected by health visitors and community nurses is kept separately from the information collected by the GP. Linking this information together would provide a fuller picture of the context of a population's health profile.[99] If the information resources of primary care are to be exploited, a properly resourced information management and technology structure will have to be implemented.

PRIMARY CARE GROUPS AND TRUSTS

84. Many witnesses have been very positive about the potential public health role of PCG/Ts, which provide the structure for health professionals to have a community or population focus. Dr Archard described how "PCGs are allowing GPs to become more involved with their communities, allowing them to move towards a community focus rather than an individual practice focus. It has been quite remarkable, the change in attitude from a competitive attitude to a co-operative attitude with the introduction of PCGs".[100] However, improvements are needed if PCTs are realistically to take on public health responsibilities.

85. The NHS Alliance has described how PCG/Ts have four public health functions:

Improving health and reducing inequalities through HImPs
Developing partnerships and community involvement jointly with the local authority
Informing the commissioning of services (best practice, best value and evidence)
Clinical governance - development and use of better information systems for disease surveillance and quality control of service delivery.

The Alliance is concerned that the latter two functions - which are more specialist - are currently being more fully developed, at the expense of the first two - more holistic - functions. We heard how PCG/Ts will be unable to engage meaningfully with the population health agenda because their efforts are focused on health care issues and public health medicine rather than community development, given the priorities set by Government. A study conducted by the London School of Economics demonstrated that many PCGs see tackling health inequalities as a minor part of their responsibilities.[101] The Government must performance manage public health responsibilities to ensure that PCG/Ts do take up their new responsibilities meaningfully. It must also ensure that the relevant training and support is provided to all PCG/Ts to enable them to do this.

86. PCGs depend on the engagement of GPs to influence primary care - however, we have received evidence that GPs are disengaging with the PCG/T process first because they do not have the capacity to take on the extra work it imposes, second because often they are not trained to carry out those functions, and third because some GPs feel their independence is threatened by the activity of PCG/Ts. Some way must be found of better supporting or remunerating primary care workers taking part in the PCG/T process.

87. PCG/Ts must be aware of their limits as far as public health is concerned. Some diseases require surveillance at a bigger population level than the PCT and many other public health functions require a wider population perspective, and there must be collaboration with health authorities to determine clearly where the responsibilities of each structure lie as far as planning is concerned. (For links between primary care and health authorities, see below paragraph 92).

88. We also believe it is essential that public health leadership by PCG/Ts should not lead to the loss of public health work closer to the ground. A number of witnesses have expressed the worry that PCTs will be just as remote as health authorities have been, and that the good local work which has been facilitated by PCGs will be lost in the expansion to PCTs.[102] Although PCTs will be able to bring the relevant players together, there will still be a need for public health work closer in to communities. We feel it is important that local initiatives should be encouraged. PCG/Ts also need to find ways of involving local communities in ways beyond the tokenistic appointment of lay members to boards. Such an example of community involvement exists in Newcastle West PCG, where through the support of the PCG, a local group Community Action on Health has been set up as an independent project with charitable status. Local people are elected to be community representatives on the PCG board, with the support of Health Development Workers.[103] In Walsall, the Council has developed a unique system of local neighbourhood committees as a form of localised self governance. These committees have subsequently become involved with the activities of the Walsall HAZ, an example of how regeneration policy and health policy can come together at the community level.[104] By creating community groups with a broad remit, it is much more likely that communities can become involved with statutory structures such as health. We discuss community development below at paragraph 113.

89. The relationship of PCG/Ts with local government is often a problematic issue. Local government is concerned that, without its representation on the PCT Board, it will become an NHS management structure which is aloof from (and unaccountable to) the population it serves. At present PCG/Ts are only required to have a representative from Social Services on the board, who is primarily there to represent the interface between social services and health. We recommend that PCG/Ts should be required to have an additional designated officer from the local authority with a broader remit for public health. If PCG/Ts are significantly to influence health, they must have access to those local government services which affect the social determinants of health. PCG/Ts also need to be given more information about how local government works, so that they can begin to use it more effectively.

90. PCG/Ts will also have to find some meaningful way of collaborating with the Director of Public Health, and of contributing to the HImP. The DoH's evidence states that PCG/Ts "will help to shape the Health Improvement Programme".[105] This will only happen if it is integrated into formalised planning structures. It has also been suggested to us that PCG 'HImP-lets' - small PCT-based health improvement plans - are useful in that they allow PCGs to really engage with the subtleties of very localised problems which might otherwise be skated over by a plan at a higher level.[106]

91. There is the final problem that PCG/Ts will only be able to engage with a limited population if they focus on GP-registered populations. Registered populations take no account of homelessness and mobility, and often it is amongst the most deprived that these phenomena will obtain. PCG/Ts must develop services to reach such people. Moreover, PCG/T populations will not be geographically regular or coterminous with other agencies, given that people choose their GP. These are problems for health authorities to work out - their strategic overview should allow them to fill the gaps between PCTs and is another good reason why health authorities need to continue their involvement in public health.

RELATIONS BETWEEN PRIMARY CARE AND HEALTH AUTHORITIES

92. One thing which stands between primary care and public health is the past relationship between primary care and the public health departments of health authorities. Primary care has often felt that the health authority departments are distant and (in the words of the RCN) "remote from the real world".[107] There is a fundamental difference of perspective and culture between the two functions, and we believe health authorities will have to work hard to improve their communications with primary care, perhaps through secondments or work-shadowing, to improve mutual understanding of the different ways of working.

93. It appears that many health authority functions, including a great deal of public health work, are being devolved to PCTs. The situation is very unclear, however, because health authorities still have statutory responsibility for public health, yet the responsibility of PCG/Ts for improving health seems to throw responsibility their way too. The Government needs to clarify exactly what the respective public health roles of the different tiers of the health system will be.

94. We also believe it is crucial that devolving public health expertise to primary care does not dissipate the public health resources which already exist in health authority departments.[108] Some strategic population health issues will need to be dealt with at a larger level than the PCT, and health authorities will still have responsibility for taking an overview of PCTs and allocating resources according to need, so it is important that the health authority does not lose its body of expertise because of fragmentation to PCTs.[109] According to the evidence of the DoH, each PCT Executive Committee will have to include a specialist public health professional "to ensure the provision of appropriate and strategic public health advice to the chairman and members".[110] However, given that health authority departments are already struggling with public health capacity, this requirement might dissipate their resources entirely.[111] There are simply not enough public health experts to go around all the PCTs, never mind the health authorities as well. The public health experts on PCT boards also run the risk of being professionally isolated.[112] A better solution to the problem of supplying public health advice to PCTs, which will certainly be needed, might be in the form of managed public health networks, with which PCTs and indeed Local Authorities could contract for public health support[113]. Public health teams are multi-disciplinary, and fragmenting teams into individuals attached to PCTs would mean that each PCT only had a very narrow and specialised resource, unless this individual was firmly connected into some kind of network or centre of expertise, from which they could draw on other public health disciplines than their own.[114] It may be that, with PCTs becoming the predominant purchasers, health authorities could focus on public health almost exclusively and house such centres of expertise on a hub and spoke model. It may well be that no one national solution will cater for the different local situations of different areas, but guidance and an exploration of this area is vital. We recommend that the Government conducts a review of the best way of providing public health support to the variety of local agencies which require or will require it.

95. There are a number of ways in which primary care could contribute more to the wider public health vision. The primary care team could become a fulcrum for interagency work, physically providing a base for various combinations of 'one-stop shop' or healthy living centre or at least creating an information link to other statutory services. Formalised links and defined referral pathways to local government departments such as housing, leisure (such as through the exercise on prescription scheme) and schools, to name a few, would link the medical health care team more effectively to the social determinants of health and the statutory powers who may affect such determinants. On a wider canvas, health visitors and nurses could lead primary care involvement with community interventions and development. The establishment of PCTs should allow Primary Care to take a broader population perspective. Given that PCGs and PCTs have as one of their three key functions "to improve the health and address inequalities of their community" a way must be found to make public health a viable reality for primary care.[115]

84 Q359. Back

85 Kessel N and Shepherd M Original Papers (c. 1962) The health and attitudes of people who seldom consult a doctor, cited in Perspectives in Public Health, ed Griffiths and Hunter "Primary Care Perspectives", David Colin-Thome, pp.179-191, p.181. Back

86 Q452. Back

87 Ev., p.118; Ev., p.212. Back

88 P.Venning et al, BMJ, 2000, 1320: 1048-53; suggest that average GP consultation times are currently 7.3 minutes; nurse consultation times are nearly 12 minutes. Back

89 Q502. Back

90 Q456. Back

91 Independent Inquiry into Inequalities in Health, p.120. Back

92 Q146. Back

93 Ev., p.12. Back

94 Third Report from the Health Committee, Session 1998-99, Future NHS Staffing Requirements, HC 38-II, p.251. Back

95 Ev., pp.450-53. Back