Select Committee on Health Appendices to the Minutes of Evidence





  Government policy, as expressed in the White Paper Saving Lives: Our Healthier Nation, is focused on health improvement. Leadership for Health makes clear that the future strategic role of the Health Authority will be as a public health organisation. This role, however, must be played in partnership with Local Authorities, which have a duty to bring about improvements in the well being of the citizens they serve. The role of other partners, including Primary Care Trusts, will also be crucial. The Government has made a commitment through the Modernisation Fund to strengthen the capacity of the public health function in all these sectors in order to deliver health improvement. There is widespread agreement that the NHS, local government and other partners need to work together to tackle the root causes of ill health.

  As part of the work to define its future roles and responsibilities, Avon Health Authority established a Working Group in January 2000 to consider the future of the public health function in the Avon area. This Working Group has taken the form of a "select committee" made up of experts representing the range of Avon organisations concerned with improving public health (Appendix 1). The Working Group's terms of reference were agreed as follows:

    —  to develop a shared vision of the public health function at the three levels (communities[1], Primary Care Trusts, Health Authority) of practice in the Avon area in terms of activity, workforce and networking;

    —  to achieve this by an analysis of the current position and estimating the future needs within the wider Avon health community, the Health Authority, Local Authorities and voluntary sector, and with particular regard to the emergence of Primary Care Trusts;

    —  to estimate the education and training implications of this analysis; and

    —  to make realisable recommendations to the programme director[2] on a project plan for achieving change within the wider organisational change process.

  In February 2000, the Working Group invited written evidence from a wide range of interested parties in the Avon health community, and verbal evidence from a small sample of interested parties representing different levels of public health activity. The tight timescale for the overall process of organisational change meant that evidence needed to be received by the first week in March 2000.


  Written evidence was received from 28 local individuals and organisations concerned with public health in the Avon area, and oral submissions were taken from six individuals representing the different levels of communities, Primary Care Groups, Local Authorities, the Health Authority and the Regional Office of the NHS Executive (Appendix 2).


  There was widespread consensus among witnesses and within the Working Group on the principles which define public health work:

    —  goals which involve population health improvement;

    —  strategies which cover the broad range of what determines health in a population; and

    —  active interventions involving communities themselves and many disciplines in several organisations.

  With the Government's modernisation agenda and re-organisation throughout the public sector, the challenges and opportunities lie in making the new linkages work.

  Our vision is the establishment of a strong and mutually supportive network involving communities and public health specialists and practitioners working in a collaborative partnership to improve the health of the population (Figure 1).


  Currently, the public health resource in the Avon area includes:

    —  the Public Health Directorate at the Health Authority;

    —  Health Promotion Service Avon currently based in the North Bristol NHS Trust;

    —  Trust community staff, in particular health visitors;

    —  other Trust based staff including those responsible for clinical governance;

    —  primary care practitioners including GPs and practice nurses; and

    —  Local Authority staff including health and environmental services, community development and regeneration workers.

  Within the Public Health Directorate, there are currently 6.4 wte consultants in public health (and one vacancy), 3.5 wte public health specialists/managers, one part-time consultant in dental public health and a varying number of public health trainees and other staff. Directorate staff are responsible for programmes of work in priority areas (eg cancer, coronary heart disease, mental health) which includes monitoring the health of the population, devising strategies for improving health and tackling health inequalities, as well as geographic/PCG responsibilities. Recently the Directorate has developed a Public Health Network based on four Local Authority area multi-disciplinary Public Health Forums.

  Health Promotion Service Avon represents a significant part of the Avon public health workforce. It employs approximately 50 people and its work includes:

    —  strategy development and implementation, in conjunction with Avon Health Authority and partner agencies for inequalities, accidents, smoking, mental health etc;

    —  running health promotion programmes focused on priority topics such as smoking and sexual health;

    —  working on community health development in areas and communities of high health need; and

    —  providing training, education and publicity materials, co-ordination of programmes and support for health promoters from the NHS, Local Authority and voluntary sectors.

  The strong and consistent message from witnesses to the Working Group was the need for the focus of public health activity to be much more "out there" with practitioners and communities while, at the same time, maintaining central "critical mass", the quality of public health specialist practice and key central functions (eg strategic leadership, infection control, training). Similarly, those who commented on Health Promotion Service Avon (HPSA) felt its focus of activity needed to be more "out there" in PCTs while maintaining economies of scale and specialisms. Existing public health specialists were also reported to be working to capacity, mainly on Avon-wide priority programmes. At the same time, witnesses identified a substantial public health development and support agenda at PCT and community levels. In order to balance these competing demands, we recommend that:

    —  the Public Health Directorate be maintained as a central public health resource based at the Health Authority for the entire Avon health community;

    —  all public health specialists from the Public Health Directorate be outposted to PCTs for an average of 0.2 wte each. With 10 or more public health specialists (medical and non-medical) in the Directorate, plus trainees, this would represent a contribution on average of a team input of over 0.4 wte public health specialist to each of the five prospective Avon PCTs;

    —  further work should be undertaken to identify how best to integrate public health and information support to PCTs;

    —  the management of HPSA should be transferred to one PCT to provide a service on behalf of all PCTs/communities, with operational staff outposted to PCTs;

    —  planning should commence for the new role of PCT public health lead, to be developed and funded from new resources (Appendix 3); and

    —  the PCT public health lead should co-ordinate a public health team drawing on health and Local Authority practitioners, outposted public health specialists and health promotion specialists and the PCT information analyst(s).

  Given the existing demands on public health capacity, it is recognised that implementing these changes will require hard choices to be made within both the Public Health Directorate and HPSA to free up resource for outposting to PCTs. It is likely that the development of a PCT public health lead role will depend upon interim arrangements with outposted specialists from the Public Health Directorate. Planning the PCT public health lead role will need to draw upon the contributions both of the Public Health Directorate and all those involved in PCT development.

  The ways in which the PCT public health lead will co-ordinate and provide public health leadership for a multi-disciplinary and inter-agency team will need further exploration. It is anticipated that the teams may evolve out of the public health forums currently being established in each local authority area.

  Table 1 below summarises the implications of the Working Group's recommendations for the structures, processes and outputs for public health in Avon.


Health Authority Primary Care Trust/Local Authority/NHS Trust Primary Care Team/Community
StructuresPublic Health Directorate:
—Public health specialists
—Clinical governance support
—Control of Infection Unit
Public health resources:
Public health network central co-ordination and support.
Public health lead role established.
Outposted public health and health specialists.
HSPA managed by one PCT on behalf of all, with resource centres in all four LA areas and health promotion specialists outposted.

Public health team/forum:

—Outposted specialist team
—Local Authority specialists (environmental health, community development)
—Other specialist (public health nurses, information)
—Primary care (health visitors, GPs)
—Voluntary organisations
Public health team/forum support to wider group of practitioners and the community.
ProcessesStrategic leadership.
Performance management.
Health service appraisal and care programmes.
Equity audit and health needs assessment.
Specialist commissioning.
Education and training.
Public health network.
Service level agreement between Health Authority and PCT.
Link between PCT and Health Authority leads.
Public health team/forum for collaborative.
Service level agreement between HPSA host PCT and other PCTs.
Support to Partnership Board.
Support to PCT decision making.
Support for NHS Trust service development.
Health need assessment.
Development of relationships with local Authorities.
Action to:
—reduce inequalities
—prevent disease (screening, health promotion and primary prevention)
—ensure community participation and development (eg Surestart)
OutputsHealth Improvement Programme.
Standard setting and performance monitoring, National Service Frameworks, Joint Investment Plans, Public Health Intelligence and Annual Health Report.
Strategies and plans (eg Health Improvement Programme).
Support for change management.
Joint Health Report with Local Authority.
Local health profiles.
Local health priorities.
Support for change management.


  Strengthening public health capacity at the PCT and community level will require sustained development of public health education and training. There is currently a high quality regional training scheme for public health specialists; there is no similar comprehensive framework for the education and training of public health practitioners, and no clear framework for the new role of PCT public health lead. There are, however, a number of education and training opportunities which have been identified in a recent NHS Executive scoping study of public health education and training opportunities in the region. The Public Health Directorate has initiated a Public Health Network across the Avon area, and Public Health Forums in each Local Authority area, in order to address the continuing professional development needs of practitioners involved in public health activity (Annex 4). In order to build on this foundation, the Working Group recommends that:

    —  a new Public Health Education and Training Working Group be established involving a range of stakeholders including practitioner representatives PCGs/PCTs, NHS Trusts, academic partners and the Avon, Gloucestershire and Northern Wiltshire Education Purchasing Consortium;

    —  the Working Group should lead the development of a public health education and training strategy for the Avon health community; and

    —  the education and training strategy be based on available national evidence and a systematic scoping assessment of local public health education and training need.


  The advent of PCTs and the wider process of organisational change in the Avon health community requires a relatively rapid process of change. By July 2000, PCGs will decide whether to start formal consultation about an April 2001 target date for PCT status. As consultations are likely to take place over Summer 2000, it will be advisable to have guidance and plans for public health in PCTs (and therefore across the Avon health community) in development by this time. The Working Group recommends that between April and July 2000:

    —  public health development plans for each prospective PCT are drafted in partnership between the Public Health Directorate, Geographical "clusters" (ie the Health Authority's Geographical Directorates and PCGs), Health Promotion Service Avon and the appropriate Local Authority;

    —  the role of, development process for and funding arrangements for the PCT public health lead are clarified including interim arrangements involving the Public Health Directorate and longer term arrangements for training and developing individuals to take on this new role;

    —  service level agreements are drafted between the Public Health and Geographical Directorates/PCTs for public health specialist support/outposting to PCTs;

    —  a project management process is agreed for the transfer of HPSA management to one PCT, and the development of a service level agreement between the host PCT and other PCTs; and

    —  the HPSA Service Manager should be invited to attend the Public Health Directorate management team and a Directorate link person identified for HPSA.

April 2000

1   Communities may be defined in either geographical terms or as communities of interest. Back

2   The Health Authority's chief executive is acting as programme director for the wider organisational change process in the Avon health community. Back

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Prepared 28 March 2001