APPENDIX 33
Memorandum by the King's Fund (PH 67)
SUMMARY
It is disappointing that the National Plan does
not announce any further convergence of Health Improvement Programmes
(HImPs) and local authority-led Community Plans.
We recommend that the lead role in relation
to HImPs should either be shared between health authorities and
local authorities, or rotate between them.
It is important that HImPs should continue to
select local priorities in conjunction with national ones, and
that local priorities are not downgraded.
The ambiguities surrounding the HAD must be
clearly resolved if it is to succeed in spreading good practice.
It is a fundamental question whether the HAD
should remain within the Department of Health or be funded by
more than one Department and work across Government under the
aegis of the Cabinet Office.
If PCGs and PCTs are to fulfil their potential
they will need:
— Greater shared clarity of purpose.
— Co-ordinated support in the development
of public health/skills.
— Timely, reliable information for
planning purposes and assistance in its interpretation.
— Intermediate measures of local achievement.
— A balanced approach to performance
management.
The Committee should urge the Government to
publish the report of the Calman inquiry. It may provide the basis
of a coherent new framework for the public health function.
The role of the Minister for Public Health and
the role of the Director of Public Health cannot be addressed
without also considering the public health role at the regional
level.
We recommend that health authorities retain
a strong strategic role in public health. This role should be
delivered in close partnership with local authorities, as put
forward in The New NHS: Modern Dependable and Saving Lives: Our
Healthier Nation.
We urge the Select Committee to seek clarification
from the Government as to its plans for the long-term future of
Health Authorities. Where these involve legislation they should
be presented as a Green Paper for public consultation.
The Committee might consider how the inequalities
targets are to be arrived at, how they will be linked to resources,
and what plans will be developed to ensure that the targets are
realised.
The Committee should also consider how those
most in need of paid employment could be helped into work in the
NHS and its partner organisations, as the investment programme
is rolled out.
Evidence from The King's Fund to the Health
Select Committee
1. INTRODUCTION
1.1 This submission focuses on the NHS Plan,
which was published in July 2000 following a swift but intensive
period of consultation. We note how the Plan deals with public
health issues and the opportunities it presents for improving
policy and practice in relation to the twin goals of health improvement
and reducing health inequalities. We consider gaps in the Plan's
provisions for public health and questions raised by its approach.
2. PUBLIC HEALTH
RELATED INNOVATIONS
IN THE
NHS PLAN
2.1 The Plan is primarily concerned with
health care and with "modernising" the NHS. It describes
how substantial new investment will be deployed, following the
announcement that NHS funding is to increase by one third in real
terms over five years, with the longer term aim of bringing it
up to the EU average. Most of the new money is to be spent on
NHS facilities and staff. Chapter 13 deals with improving health
and inequalities, where the most specific innovations are:
— New national health inequalities
targets "to narrow the health gap in childhood and throughout
life between socio-economic groups and between the most deprived
areas in the rest of the country". To be developed in consultation
with stakeholder groups and experts. To be delivered by combination
of health and other government policies.
— A new healthy poverty index combining
data about health status, access to health services, opportunities
for good health—eg through diet, exercise and safe environment.
— New funding formula to have reducing
inequalities as a key criterion when distributing resources to
different parts of the country.
— 200 new Personal Medical Services
(PMS) schemes (for salaried GPs and other NHS personnel) in disadvantaged
communities by 2004.
— By 2003 a free translation and interpretation
service available everywhere via NHS direct.
— Extra £500 million for Sure
Start.
— New Children's Fund worth £450
million.
— Comprehensive smoking cessation programme,
with nicotine therapy on prescription.
— Free fruit in schools for children
up to six years old.
— Local Strategic Partnerships developed
with help of NHS, with a view to integrating health action zones
with other action zones (education and employment).
— By 2002 single integrated public
health groups formed across NHS regional offices and government
offices of the regions. Accountable through the DPH to CEOs of
health and government at regional level.
— By 2002 a new Healthy Communities
Collaborative to spread best practice, following formula of Cancer
and Primary Care collaboratives.
— By 2003 a new leadership programme
for health visitors and community nurses to develop their capacity
to work directly with local communities.
2.2 Innovations set out in other Chapters
that may be relevant to public health include:
— The ninth "core principle"
set out at the front of the Plan says: "The NHS will help
keep people healthy and work to reduce health inequalities . .
. The NHS will work with other public services to intervene not
just after but before ill health occurs. It will work with others
to reduce health inequalities." (p 5)
— New "Care Trusts", to increase
integration of health and social services, able to commission
primary and community health care as well as social care for older
people and other client groups. (7. 9/10)
— A major expansion of PMS, to cover
a third of GPs by 2002 (8.8)
— New powers for local government to
scrutinise the NHS locally, with health authority CEO required
to attend all-party scrutiny committee of local authority at least
twice a year if requested. (10.26)
— Each health authority required to
establish an independent local advisory forum chosen from residents
to provide a "sounding board" for determining priorities
and policies, including the health improvement programme (HImP).
(10.28)
— Breast cancer screening extended
to women aged 65-70. Possible new screening programmes for colorectal
and prostate cancer, and eventually for ovarian cancer "as
and when research demonstrates cost-effectiveness (14.5/6).
— 1,000 new primary care mental health
workers and 500 more community mental health staff (14.29).
3. ISSUES ARISING
3.1 Many of the proposals summarised above
are relevant to the six subjects of the Select Committee's inquiry:
— the inter-operation of Health Action
Zones (HAZs), Health Improvement Programmes (HImPs), Community
Plans and other area-based initiatives;
— the role of the Health Development
Agency (HDA);
— the role of Primary Care Groups (PCGs)
and Primary Care Trusts (PCTs);
— the role and status of the Minister
for Public Health;
— the role of the Director of Public
Health; and
— the extent to which current public
health policy is reducing health inequalities.
4. LOCAL PARTNERSHIPS:
HIMPS,
HAZS ETC
4.1 Local and regional partnerships. The
emphasis in the Plan on local strategic partnerships, together
with the introduction of integrated public health groups at regional
level is to be welcomed. We offer some comments specifically on
HImPs and HAZs.
4.2 We recommend that the lead role in relation
to HImPs should either be shared between health authorities and
local authorities, or rotate between them.
4.3 It is important that HImPs should continue
to select local priorities in conjunction with national ones,
and that the development of National Service Frameworks does not
relegate local priorities. Local variations in health needs justify
differentiation and autonomy to select priorities.
4.4 If HImPs are to be more than a theoretical
framework, they must be demonstrably capable of influencing the
allocation of resources by both health and local authorities.
[67]
4.5 It is disappointing that the National
Plan does not announce any further convergence of Health Improvement
Programmes and local authority-led Community Plans. Nor does it
address the need to invest in the development of partnership working,
with training and capacity-building programmes.
4.6 We would question the overall impact
of the Plan on the development of local partnerships. For example,
although local accountability of the NHS is badly needed, and
we welcome the new powers of scrutiny of health authorities by
local authorities, this may hinder partnership working unless
carefully implemented. We are also concerned about the impact
the new Care Trusts may have on partnership working at local level,
if local authorities are replaced as local commissioners and/or
providers of social care services.
4.7 It surely makes sense to "join
up" Health Action Zones with other action zones and we welcome
the proposal to achieve this via Local Strategic Partnerships
(paragraph 13.24), but it is not clear whether the lessons from
the HAZs' first years have been learned. There has been a great
deal of early enthusiasm for cross-sectoral working and for innovation,
but most HAZs have under spent their budgets spectacularly, because
they have been unable to get enough "action" going fast
enough to justify the release of funds. Experience suggests that
more time and energy needs to go into the development of partnerships
and communities—not as part of an exotic experiment, but
as an essential part of day-to-day "mainstream" working—to
create a firm foundation for creative innovation at local levels.
4.8 We welcome the involvement of the NHS
in delivering the Government's National Strategy for Neighbourhood
Renewal. The fact remains that, despite the plethora of partnerships
and inter-sectoral local initiatives to which the NHS Plan refers—"local
communities are poorly represented within NHS decision-making
structures" (paragraph 2.34)—a point we strongly endorse.
5. THE ROLE
OF THE
HEALTH DEVELOPMENT
AGENCY
5.1 The Health Development Agency is barely
mentioned in the Plan. Its role remains unclear, its budget has
been severely reduced and it is apparently not due to receive
any of the new money. It is hard to see how good practice can
be identified or spread unless the ambiguities surrounding the
HDA are clearly resolved.
5.2 It is a fundamental question whether
the HDA should remain within the Department of Health or be funded
by more than one Department and work across Government under the
aegis of the Cabinet Office.
5.3 The HDA has stated its intention to
play a developmental role, and we note that it has established
a network of regional posts for that purpose. It is encouraging
that a number of these posts are situated in government regional
offices and regional development agencies. Public health capacity
needs to build in to local government, and we welcome the decision
to make the London regional appointment to the GLA, which has
cross-sectoral strategic competence.
5.4 It is not yet clear how the HDA, through
its regional as well as national activities, will make use of
and contribute to the effective working of the new public health
observatories. This needs careful consideration.
6. THE ROLE
OF PRIMARY
CARE GROUPS/TRUSTS
6.1 Contribution to the Health Improvement
Programme: It is widely anticipated that the PCG contribution
to HImPs will be greater in the second year than in the first.
The majority—60 per cent—of PCGs in an Audit Commission
study, [68]
had formed their own HImP sub-committees, which should help to
co-ordinate responses to future HImPs. However, they perceive
a risk of their own aspirations being eclipsed by top-down national
priorities.
6.2 Health Authority Support: PCGs give
low assessments of health authority support received to underpin
this work. In contrast, health authority representatives rate
fairly highly their own capacity to support PCGs in health needs
assessment and health improvement. "Capacity" may indicate
no more than that information and expertise are present in the
health authority; the capacity to share such resources effectively
with PCGs may be less developed.
6.3 PCGs need more detailed and PCG-specific
data than are available. One in three PCGs in the Audit Commission's
study said that the only available planning data were based on
boundaries different from those of PCGs.
6.4 PCGs and health authorities have different
expectations of what they can expect of each other. It is unclear
how much public health support is required but PCGs are concerned
that there may not be enough to meet their needs. [69]
Health authorities need to share understanding about what resources
are available for PCGs.
6.5 Levels of health needs assessment activity
reported by PCGs to the Kings Fund[70]
were surprisingly high (for organisations less than a year old
and with heavy work programmes). However, it is not clear what
such activity consists of. Total purchasing pilots, which preceded
PCGs, showed wide variation between projects in terms of what
they regarded as needs assessment. [71]
Given the reported limitations of PCG's information systems for
this purpose, the quality of needs analysis of primary care data
is unlikely to be high.
6.6 Few PCGs are yet embracing a perspective
on health which encompasses the broader determinants of health
as well as clinical factors. As PCGs merge and become PCTs, as
health authorities relinquish much of their commissioning role,
and as community and mental health services are reconfigured,
there is a risk that the associated organisational change will
eclipse health improvement. It will require determination and
persistence on the part of all agencies to ensure that the population's
health, rather than the organisation of health care, remains a
central focus of the new NHS.
6.7 If PCGs and PCTs are to fulfil their
potential in this area they will need:
— Greater shared clarity of purpose.
— Co-ordinated support in the development
of public health/skills.
— Timely, reliable information for
planning purposes and assistance in its interpretation.
— Intermediate measures of local achievement.
— A balanced approach to performance
management.
7. LEADERSHIP:
THE ROLE
AND STATUS
OF THE
MINISTER FOR
PUBLIC HEALTH
AND THE
ROLE OF
THE DIRECTOR
OF PUBLIC
HEALTH
7.1 On the subject of national leadership
in public health, the downgrading of the post of minister for
public health was, in our view, regrettable. It not only sends
out the wrong message about the importance of public health, it
must affect the degree of influence which the office-holder can
exert across government.
7.2 The National Plan says nothing about
the need to have effective links between the (more or less) autonomous
four countries within the UK, or how the Government plans to ensure
uniformly high standards of public health. This may present an
issue for the future.
7.3 The organisation of public health has
been under review and hence a matter for speculation for too long.
The report on the inquiry of the former CMO, Sir Kenneth Calman,
into the public health function has been completed but not released.
After more than a year, the Calman Report is still "with
Ministers".
7.4 Rather than revisiting the same structural
issues which were the subject of the Calman inquiry, the Committee
should urge the Government to publish the Report of that Inquiry.
It may provide the basis of a coherent new framework for the public
health function.
7.5 It is difficult to address questions
about the role of the Minister for Public Health and the role
of the Director of Public Health without also considering the
public health role at the regional level. This topic was dealt
with by the Calman inquiry. According to the National Plan, Regional
DsPH are expected to co-ordinate new regional public health groups
across the NHS regional offices and government offices of the
regions. This will inevitably highlight, once again, the difficulties
caused by the continuing lack of coterminosity between regions
in the health and non-health sectors.
7.6 In England, the developing relationship
between NHS bodies and the new Greater London Authority would,
we believe, repay evaluation. This could inform any arrangements
made for future devolution to English regions.
7.7 At the local level health authorities
are undergoing another wave of major change. As Primary Care Trusts
and Care Trusts increasingly take over leadership of health care,
a number of questions urgently need answers. Will what remains
of health authorities be capable of providing a strong lead in
achieving public health goals? What are the implications of ceding
this role either to regional health authorities or to Primary
Care Trusts and Care Trusts? Is there a case for giving local
authorities the lead? The National Plan does not address these
issues.
7.8 It is a matter of concern that there
is insufficient public health expertise to provide the necessary
public health advice to every PCT. There are, in any case, sound
reasons to retain an adequate "critical mass" of public
health expertise within health authorities who can then provide
the support to PCTs. Registered populations take no account of
mobility or homelessness; ONS data are based on resident, not
registered populations; the populations of PCTs are too small
to yield reliable epidemiological data, except for the most common
conditions. More broadly, PCTs do not have responsibility or influence
over the major health determinants: employment, regeneration,
housing, transport, education and the environment. These justify
a major role for local authorities.
7.9 We recommend that health authorities
retain a strong strategic role in public health. This role should
be delivered in close partnership with local authorities, as put
forward in The New NHS: Modern Dependable and Saving Lives:
Our Healthier Nation.
7.10 We urge the Select Committee to seek
clarification from the Government as to its plans for the long-term
future of Health Authorities. Where these involve legislation
they should be presented as a Green Paper for public consultation.
7.11 There needs to be more public debate,
before any reconfiguration of health authorities (and in advance
of any devolution to the English regions) about the respective
health functions at PCT, health authority and regional levels.
8. IMPACT OF
CURRENT PUBLIC
HEALTH POLICIES
ON HEALTH
INEQUALITIES
8.1 The introduction of a new set of national
inequalities targets is to be welcomed. Combined with the new
health poverty index, it provides an opportunity to give higher
priority to tackling inequalities and to monitoring progress on
this front. It is important that the targets are meaningful and
realistic, and that sufficient resources are invested in measures
to achieve them. It is also vital that the targets are matched
by effective partnerships and operational plans for achieving
them.
8.2 The Committee might consider how the
inequalities targets are to be arrived at, how they will be linked
to resources, and what plans will be developed to ensure that
the targets are realised. Overarching national target should be
underpinned by a framework of intermediate targets, (on education,
jobs, environment, and income, for example) for which different
departments would bear responsibility.
8.3 Identifying and spreading good practice.
The Plan announces the establishment of a "Healthy Communities
Collaborative" based on the Primary Care and Cancer collaboratives.
It does not acknowledge that "good practice" in improving
health and reducing health inequalities is a more complex matter
than "good practice" in health care. This involves multiple
partners and success can be hard to measure because effects are
often indirect and usually long-term. An effective collaborative
for healthy communities depends on community development which
should be established through a phased process to allow time to
gather evidence and build on good practice. [72]
8.4 Employment opportunities. The
scale of investment in the NHS is vast. There is every indication
that the implementation of the Plan will provide extensive new
job opportunities, both in the NHS and in construction and supply.
There is strong evidence that employment is an important determinant
of physical and mental health. The NHS is already one of the largest
employers in the country and often the main source of jobs in
disadvantaged areas that have suffered industrial decline
8.5 The Committee might consider how those
most in need of paid employment could be helped into work in the
NHS and its partner organisations, as the investment programme
is rolled out.
October 2000
67 Arora S, Davies A, Thompson S (1999) Developing
Health Improvement Programmes: Lessons from the First Year
London. King's Fund. Back
68
Audit Commission (2000) The PCG Agenda: Early Progress of
Primary Care Groups in "The New NHS" London. The Audit
Commission. Back
69
Levenson R, Johnson L (1999) Improving Health at Local Level:
the Role of Primary Care London. King's Fund. Back
70
Wilkin D, Gillam S, Leese B (Eds). (1999-2000) National Tracker
Survey of Primary Care Groups and Trusts. NPCRDC/King's Fund. Back
71
Mays N, Goodwin N, Killoran A, Malbon G (1998) Total Purchasing:
A Step Towards Primary Care Groups London. King's Fund. Back
72
Gowman N. (2000) Establishing a Healthy Communities Collaborative;
Preliminary Thoughts from the King's Fund London. King's Fund. Back
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