Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by Oxfordshire NHS Health Authority (PH 8)


  A review of the public health function is currently being undertaken and this provides the basis for our evidence. Initial findings can be grouped under three headings.

1.   Relationship with local government

  There is clear recognition of the major contribution of local government to the public health agenda, although the nature of the relationship between the sectors sometimes lacks clarity. Coterminosity between Primary Care Trusts and local government is a national issue and we would encourage a flexible development of networks, based on coterminosity wherever possible since improving the public's health must be predicated on multisectoral joint working. We believe there is a need for better understanding of agendas and improved communication. A potential way forward is to have more formal joint working, including opportunities within the Public Health Department, and encouraging better and more direct communication.

2.   Primary Care Trusts and public health

  Further thinking about the nature of Public Health in PCTs is needed, but we do not believe there can be a single national organisational solution. We support the development of managed national public health networks. We would favour joint accountability to local government and primary care for defined local populations, with links to both decision making processes. We would not wish public health departments to be an independent agency, and emphasise that public health practice, whilst important in primary care, is also necessary at other population levels. Which in our case country wide, and also supra district level with respect to specialist services, teaching, training and research.

3.   Future role of the Health Authority and the impact for the organisation of public health

  Future development would be facilitated by:

    —  a clear population boundary;

    —  a managed public health network;

    —  clear links to primary care, but cognisant of local authority responsibilities;

    —  enhanced cross-agency working, ie the HIMP with community plans and local strategic partnerships; and

    —  maintaining the DPH role within the health Authority setting.

  To avoid fragmentation of public health resources, we would encourage the creation of a managed public health network which:

    —  engages all relevant organisations;

    —  identifies appropriate population bases with which to work;

    —  identifies and supports public health skills within all organisations;

    —  ensures appropriate opportunities for training and the development of all staff;

    —  monitors the health of the population, particularly inequalities in health;

    —  maintains the specialist skills; and

    —  ensures the HIMP process works effectively, reporting to both health and local authorities.


  Oxfordshire Health Authority has responsibility for the population of the people of Oxfordshire and for the health services served by the six PCGs who have accountability to the Health Authority. The population of Oxfordshire is around 600,000 people, of whom one third live in Oxford City and Banbury, with the rest living in a predominantly rural environment around market towns.

  The population statistics show that the country's health is better than average, due both to the affluence of the population but also to the high quality of care from the hospitals, and from general practice, many of whose clinicians are involved in teaching and training and research. There are however significant pockets of health inequalities and financial problems within the Trusts.

  The county is made up of a county council with five district councils. There is no clear coterminosity between local government and primary care. Within this complex environment the public health team are trying to find effective and efficient ways of working.

  A full review of the public health function across the county is currently being carried out. Views have been sought from our key partners in Trusts, local government, the CHC, academic departments, primary care and within the health authority. The purpose of the review has been to map all the existing public health capacity within the county, to identify strengths, weaknesses and gaps which need to be filled and to consider the most appropriate arrangements for future working within the county. The review builds on previous studies by the Public Health Resource Unit, particularly on relationships with local government and with primary care.


  The review is still in process but some early messages include:


  There is clear recognition of the major contribution of local government to the public health agenda. There are however some questions, given the size of their own agencies about the internal priority given to health by local authorities (LAs). In addition, the nature of the relationship between local government and public health practitioners within the health sector—within primary care as well as with the Health Authority department is not always clear.

  However, local initiatives between LAs and PCGs are blossoming across the county and involvement in local Health Improvement Programmes (HIMPs) has been very positive. Despite, or even perhaps because of, this there is a feeling that communications with the HA could be improved and better understanding of the relative agendas could be achieved. This could be helped by greater of engagement of council senior officers across the county. More joint working including opportunities within the Public Health Department and direct communication might help get clearer messages throughout local government.


  The current arrangement is that there is an identified public health specialist, information analyst and health promotion specialist for each PCG. This model of a central team of public health specialists at the health authority supporting the emerging PCTs has held the ring for the time being and the review suggests there is no overt dissatisfaction. However, there is recognition that more specialist public health help will be required at a local level, particularly with information, use of data and use of evidence. The general view is that the PCTs have not yet been focussed on public health issues, given the demands of structural change within the organisations and lack of clear organisational responsibilities until PCTs are established. The intention for the county in the future is that the PCTs will work together to keep a county wide perspective for commissioning and also for utilisation of many of the skills within the public health department. This will create inevitable tensions between central support and local needs as PCTs develop their own agendas. However it is difficult to see how the existing public health resource can be stretched further to address the increased demands. Consideration needs to be given to new ways of working.

  The initiatives already taken, such as the GP learning sets, have been appreciated and ideas such as:

    —  closer working between public health specialists and PCTs;

    —  GP/PCT Development of staff skills in public health;

    —  explicit agreements for levels of support from the public health department;

    —  secondment/training opportunities for primary care staff in the public health department; and

    —  greater involvement of health visitors in needs assessment for the local HIMP.

  These could all contribute to the desired cultural change of integration of public health—ie population perspectives into primary care practice. These models could also be developed with local authorities.

  More work needs to be done to recognise the public health skills within community nursing, particularly health visitors and school nurses, and to use the resources of the specialist health promotion team more effectively, to address the population needs of PCTs.

  In particular, targeting work towards socially excluded groups—including those living in rural isolation—needs to be considered and developed. Health visitors interviewed expressed their wish to clearer leadership and also time and recognition of their public health role as well as closer working with the public health specialists at the health authority.


  The public health department is structuring its work around the 10 core elements described by the standards committee of the Faculty of Public Health Medicine (attached).

  This is enabling:

    —  individuals to set their objectives;

    —  the department to be clear how it contributes to the countywide health agenda;

    —  systems of governance to be established; and

    —  clearer expectations of the department to be established.

  There are tensions for the Public Health role which is increasingly involved in both performance management, and with providing advice and services, as well as teaching and research.

  However, the need to work more closely with primary care at a community level as the PCTs begin to drive the agenda raises the dilemma of how the county's public health specialists should work, including addressing the need to work more effectively with local government.

  Whilst there is a need to work with colleagues in primary care, local government and the community, there is also a significant public health "maintenance agenda" currently falling statutorily to the HA.

  In addition to this there is a responsibility for work with populations larger than the county for specialist services via specialist commissioning.

  When the evidence was submitted we had not yet been able to consider the impact of the National Plan to be published later that month. We have used the national consultation process to make our view clear that we would wish to use Our Healthier Nation as a vehicle to promote the public's health. We believe the promotion of community development to address the issues highlighted in the National Strategy for Neighbourhood Renewal from the Social Exclusion Agenda should form part of the public health agenda at a local level as well as promoting multiagency working across the county as promulgated within our HIMP.

  We do not subscribe to the view that we should only focus on medical interventions in prevention.

  However, we are concerned that the focus of health authorities is increasingly towards performance management. We would not see the public health team as spending a majority of its time on indicators around waiting lists or performance of individual clinicians. We believe that the trust that employs the clinical staff must take a role here, and our role will be to interpret the impact of their performance on the health of the county's population. In this way we would provide professional advice and be involved as appropriate.

  One of the challenges we face is creating new ways of working at the same time as delivering on the maintenance agenda. We would wish to explore different models of accountability for populations which reflect closer working with primary care trusts and with local government.

  We recognise we need a clear population boundary, and for us that would be Oxfordshire. We would encourage any changes which promote greater co-terminosity.

  Our observation that local government and primary care are forging new and exciting links which benefit local communities lead us to suggest a new model is required for public health departments. As yet we have to firm up a view on this, but our preference would be to remain linked to the decision making processes within primary care rather than become solely an advisory agency. We would favour joint accountability to local government and primary care for defined populations. We are attracted to the idea of a managed public health network, which would allow all public health practitioners to "buy in" to the network at the appropriate level of population. We will be discussing this model and its implications throughout the consultation and formulation of recommendations from the review. We would be happy to present this in more detail to the Select Committee once the work is completed.

  Regarding other points under consideration by the review:


  We would wish to see closer working between local government and the health sector and believe that the HIMP should represent a cross cutting theme throughout the community plans which are produced—so that there is a coming together of the various planning documents rather than the current separation. We welcome the new local authority legislation with its responsibilities for economic and environmental factors impacting on health and would support further development of health impact assessment—not as major pieces of work but as general considerations across local government policies. We have no direct experience of being a HAZ although we are linked to a rural network and would urge that greater consideration be given to rural deprivation.


  The Health Development Agency is still finding its new role. We would wish to emphasise the need for clarity about the arrangements for elements of its previous role—giving health advice and running campaigns— and how links will be maintained with public health. For example, submissions for the extension of health promoting schools are being sought directly from PCG Chairs—an arrangement which could bypass local public health/health promotion specialists who have experience and expertise. Programmes for preventing teenage pregnancy and for smoking cessation are managed directly from DOH. There is a risk that all these parallel programmes are only co-ordinated at a local level—and greater central co-ordination is important. The role, if any, of the Health Development Agency in this and in supporting staff in the field needs to be clarified particularly since this is presumably part of their standards brief.

  We would not wish to see slavish adherence to the idea that all action must be evidence based when evidence from randomised controlled trials may not be appropriate and other qualitative community based evaluation may also be valuable. The Health Development Agency could have an important role here.


  There needs to be discussion about the relationship of MPH with the work of the social exclusion unit, the level of seniority of the role and the best arrangement for public health leadership.


  We believe that the Director of Public Health has a central role to play in the development and leadership of a managed public health network. The role is probably most effectively discharged at the level of a health authority—which is acting as a central hub within a hub and spoke model across our county—co-ordinating and facilitating rather than hierarchical—and linking to other counties.


  We would support local targets for reduction in inequalities. This could be central to the HIMP process and it could be the responsibility of the HIMP process to ensure the monitoring of these targets—for which all sectors would have a formal responsibility. We have begun to develop such an approach in the county but the relevance of the targets vis-a"-vis other targets such as waiting lists will need support from central government and involvement of local government, the private sector and others. We would want to see the importance of the HIMP emphasised by the Department of Health and more weight given to its potential to reduce health inequalities.

  The time given for the evidence to be submitted has made it difficult to involve all partners in the way we would have wished. However, we would be happy to present the findings of the public health review, which will have been discussed by the autumn.

Sian Griffiths

Director of Public Health for Oxfordshire

June 2000

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