Memorandum by the NHS Alliance (WP 101)
1. The NHS Alliance represents the frontline
of the NHS. It is the voice of clinicians, managers and lay people
working in primary care and of Primary Care Trusts (PCTs). Most
PCTs are currently members and 98% belong to NHS Alliance Networks
which includes a Public Health Network led by professor Sian Griffiths.
2. The NHS Alliance welcomes the White Paper
and commends the government on its publication. We believe that
to achieve the goals aspired to will require sustained commitment
to improving health, keeping this as a mainstream policy thread
at national level across government departments and at local level
through Local Strategic Partnerships.
3. Are the proposals appropriate, will they
be effective, are they Value for Money?
The proposals sensibly build on existing policy
initiatives such as Every Child Matters in a number of areas.
This is to be welcomed but there is a need to ensure that policy,
targets and performance management criteria all pull in the same
direction.
(i) This is a particular issue with
regard to the Quality and Outcome Framework for the new GP Contract.
This framework is made up of a number of points, which have monetary
value, that are awarded on the basis of delivering specified outcomes.
There are for example 72 points for asthma management and 105
points for hypertension management. The Alliance is concerned
that there are only 41 points allocated for mental illness. This
represents around 5% of the total points which is in contrast
with the fact that GPs are estimated to spend 30% of their time
dealing with mental health problems. In addition the 41 points
are made up of 23 points for reviewing patients with severe long
term mental problems, 11 points for lithium monitoring and seven
points for production of a register of patients with severe long
term problems. This does not reflect the bulk of mental health
problems that GPs deal with, which are largely related to stress,
anxiety and depression. This means that there are no incentives
for GPs to look at how they might strengthen and support individuals
through promoting self-esteem and through encouraging wider participation
by referral to exercise programmes and arts on prescription programmes.
Research evidence increasingly suggest that mental health is a
key determinant of good health outcomes and that people who are
stressed, anxious and depressed find it harder to make healthy
choices. We recommend that the Department of Health needs to
review the Quality and Outcome Framework to look at how it might
more effectively incentivise mental health promotion.
(ii) The Alliance also has concerns
about how best use can be made from the introduction of practice
based commissioning from 1 April 2005. The Alliance view expressed
in our evidence to the Choosing Health consultation was that commissioning
for health needed to be separated from commissioning for sickness
and that it should be a joint responsibility of PCTs and local
authorities. There is an opportunity to develop co-terminosity
between local authority local areas structures and locals clusters
of practices so that practices in partnership with local authorities
and the local community can develop locally appropriate ways of
improving the health of the local community and of managing demand
for expensive hospital care. This approach would be consistent
with the White Paper recommendations on the development of local
area agreements. We recommend that the Department of Health
should be asked to explore how practice based commissioning could
be developed into an effective model for improving the health
of the local community and for addressing inequalities in health.
(iii) The Alliance is concerned about
the total number of proposals in the White Paper. We hope that
the delivery plan will outline clear priorities. We also hope
that PCTs will be encouraged to build on the good work that is
already going on across the country rather than necessarily introduce
a whole new set of intiatives.
4. Is the infrastructure sufficient?
(i) The Alliance welcomes the introduction
of Spearhead PCTs and coterminous local authorities in the areas
of greatest social disadvantage. These areas because they have
the poorest health also have the greatest demand for existing
services and therefore the least capacity to focus on health improvement.
They will therefore need more infrastructure support in order
to improve the health of the local population. We would welcome
clarification of the sort of support that they can expect.
(ii) The Alliance believes that public
health capacity needs to be strengthened both by increasing the
specialist public health function and by developing new roles
and raising the awareness of all frontline staff to the importance
of public health and health improvement. In particular we believe
that more opportunity should be provided for GPs and community
nurses to develop competence in public health. These practitioners
working with PCT Directors of Public Health could then provide
a local support function for practice based commissioning for
health.
(iii) Health trainers provide an excellent
opportunity for PCTs to explore how unemployed people in disadvantaged
local communities can be provided with training and employment
opportunities so that they can act as health link workers between
the local community and frontline staff. We believe that this
initiative needs to take account of the many other people already
working in community development and of the many examples of good
practice. This is not necessarily a new cohort of people to be
employed by the NHS, they could instead be employed by the voluntary
and community sector. As the White Paper rightly points out the
voluntary and community sector are often much better than the
statutory sector at engaging with groups of people who face most
difficulties or who do not access traditional sources of advice
on health.
(iv) We welcome the proposals for increasing
skills in the community and for improving leadership for health.
We would wish to be reassured that training in these areas will
be available to local authority staff and to staff in the voluntary
and community sector and that resources will be made available
to all staff who have a key role to play in local partnership
working.
(v) We also welcome the establishment
of an Innovations Fund and the plans to develop good practice.
This is consistent with the NHS Alliance approach which has aimed
to foster a "can do" approach in Primary Care Trusts
through the publication and dissemination of "CANDO!"
which disseminates examples of good practice being delivered by
PCTs.
(vi) We welcome the plan to employ more
school nurses and to develop more healthy schools and extended
schools. We hope that the work of the nurses will be integrated
with GP practices and with other primary health and social care
professionals and with the existing good work going on in Sure
Start programmes.
February 2005
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