APPENDIX 5
Memorandum by Oxfordshire NHS Health Authority
(PH 8)
SUMMARY
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.
BACKGROUND
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.
KEY MESSAGES
FROM THE
PUBLIC HEALTH
REVIEW:
The review is still in process but some early
messages include:
1. RELATIONSHIP
WITH LOCAL
GOVERNMENT
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.
2. PRIMARY CARE
TRUSTS AND
PUBLIC HEALTH
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.
3. FUTURE ROLE
OF HEALTH
AUTHORITY AND
THE IMPACT
FOR THE
ORGANISATION OF
PUBLIC HEALTH
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:
HIMPS /COMMUNITY
PLANS
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 ROLE
OF THE
HEALTH DEVELOPMENT
AGENCY
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.
THE ROLE
AND STATUS
OF THE
MINISTER OF
PUBLIC HEALTH
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.
THE ROLE
OF THE
DPH
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.
THE EXTENT
TO WHICH
PUBLIC HEALTH
POLICY IS
REDUCING HEALTH
INEQUALITIES
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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