Memorandum by the NHS Confederation (WP
74)
INTRODUCTION
1. The NHS Confederation welcomes the new
public health White Paper "Choosing Health" and, in
particular, its emphasis on dealing with the preventable determinants
of ill health eg smoking, obesity.
2. The NHS Confederation is a membership
body that represents over 93% of all statutory NHS organisations,
including Primary Care Trusts (PCTs), across the UK. Our role
is to provide a voice for the management of the NHS and represent
the interests of NHS organisations. We are independent of the
UK Government although we work closely with the Department of
Health and the devolved administrations.
3. Our evidence sets out our general views
on the Public Health White Paper but then concentrates on the
specific questions posed by the Committee.
OVERALL VIEW
4. Health is not purely the province of
health care organisations and it is only by facilitating the use
of a range of different approaches and the expertise of all stakeholders
that the public health agenda can be delivered.
5. The Confederation believes that it is
important to stress that the key delivery vehicle for health improvement
is local partnership; both strategic in terms of the planning
and delivery of services by the wider health and social care community;
and personal between health and other professionals and the individual
or local community.
6. The NHS Confederation endorses a model
which encourages policy and planning around public health to be
joined up at all levels including between government departments
(for example referencing the impact of changes to licensing laws
as part of the overall alcohol strategy) in order to gain maximum
benefit from the work done in local partnerships.
7. The NHS Confederation believes that the
worsening trends in health inequalities have been as a result
of long term health differentials and will require long term solutions
delivered in a stable environment where developments are part
of a consistent programme of action. To this end, it would strongly
urge a cross party approach to public health, enabling the delivery
of this agenda to continue in line with the available evidence
and good practice models irrespective of party political changes.
8. The NHS Confederation also advocates
a balanced approach to the twin health improvement vehicles that
is to say; of technological advance in healthcare; and the building
of health capacity and personal responsibility for health through
health promotional advice, empowerment and support for self care.
It believes that there are sometimes false perceptions of the
relative impacts of each element, whereas, in reality, each is
required in different proportions at different stages in the individual's
health journey, delivered using pathways of care which join the
two together across NHS and other organisational boundaries.
9. Whilst all NHS organisations have a responsibility
to promote health, PCTs were developed specifically with a remit
to lead health improvement within local communities. This responsibility
is of equal importance to other areas of work eg their commissioning
responsibilities and was re-iterated in "Shifting the Balance
of Power" (2001) and strengthened through the development
of public health structures with Board level accountabilities
within each PCT nationally.
10. PCTs are alone amongst NHS organisations
in their responsibilities with regard to health equity auditing
and assessing the health impact of local industrial and other
developments. These responsibilities require a significant depth
of knowledge about the local communities served and their differential
health status and aspirations.
11. The NHS Confederation believes, therefore,
that these requirements mitigate against the enlarging or merging
of PCTs without the development of strong underpinning locality
structures which enable responsiveness to and intelligence of
local issues to be maintained.
IN RESPONSE
TO THE
COMMITTEE'S
QUESTIONS
Question 1—Whether the proposals will enable
the government to achieve its public health goals?
12. The NHS Confederation remains committed
to an absolute ban on smoking in public places. However, it believes
that this will need to be through a staged approach with continued
support from smoking cessation services. In a recent poll of Chief
Executives, smoking was spontaneously raised as one of their top
three overall concerns. We believe that the implementation of
an outright ban would be very challenging in the short term. The
Confederation, therefore, supports the proposals on smoking outlined
in the White Paper, with the proviso that this is a first step
towards a total ban in public places.
13. There is evidence that access to work
and educational attainment are major health determinants and any
proposals which encourage getting individuals into or back into
work are to be welcomed. The Confederation, therefore, supports
the emphasis on work related health, both in general and in the
NHS in particular, and believes that, with occupational health
support as outlined in the White Paper, this is essential to ensuring
healthy futures.
14. The NHS Confederation believes that
there is a genuine problem with the levels of sexual health services
available across the country for all age ranges. We would urge
a more radical approach to the existing under-capacity including
the use of Alternative Personal Medical Services (APMS) and independent
sector procurement where appropriate. We believe that the proposed
48 hour waiting target for specialist Genito-Urinary Medicine
services (GUM) is a step forward and that, if the rapid increase
in sexually transmitted disease is to be halted, there must be
a full review of service to improve access in appropriate settings
and to improve the speed of diagnosis and treatment.
15. The NHS Confederation also supports
the work which will build on the National Alcohol Harm Reduction
Strategy (2004), particularly around auditing access to treatment
services, the programme for improvement for treatment services
and approaches to targeted screening and brief intervention in
primary care.
16. The Confederation supports the use of
Local Strategic Partnerships as vehicles for building community
capacity for health through the development of Local Public Service
Agreement (LPSA) targets which relate to local health inequalities.
By drawing down pooled resources, the partnership can then allocate
these to cross agency, joined up and community based projects.
The proposal for the development of accredited Health Trainers,
drawn from local deprived communities, is similarly welcomed as
a way of building empowered and informed local communities, aware
of the health choices available to them.
17. There is a need to build on models which
focus positively on health, rather than perceiving it as an absence
of illness. Whilst welcoming proactive health checks, we believe
that there is a need to ensure that these do not encourage a continued
focus on ill health. We would therefore suggest that the content
of such checks uses a "wellbeing model" rather than
one which stresses the need to screen for potential ill health.
18. However, these initiatives will not
overcome distortions in community perceptions of risk and the
consequences of risk taking behaviours, particularly in the young.
For example, parents seeking to protect their children by driving
them to school but failing to recognise the risk of low exercise
levels. Developments based on the Canadian SmartRisk model are
therefore also supported by the Confederation as a method of developing
informed personal health choices.
Question 2—Whether the proposals are appropriate,
will be effective and whether they represent value for money?
19. The NHS Confederation believes that
the White Paper proposals are, in the main, appropriate and will
form an effective basis for the achievement of the Public Service
Agreement (PSA) targets to which they relate.
20. Existing evidence shows that the highest
savings in terms of quality of life are achieved where cheap,
positive health advice and support can be used to effect and/or
support change.
21. We therefore particularly welcome the
tobacco control initiatives outlined in the White Paper as representing
long term value for money.
22. Similarly, the use of Pedometers and
the encouragement of young people to exercise through walking
buses and sports initiatives in schools are examples of cost effective
and wholly appropriate proposals.
23. Personal Health guides will also represent
value for money but only when linked to other patient held records
and to the development of the National Care Record and Healthspace
through the National Programme for Information Technology (NPfIT).
24. It is to be hoped that the Health Direct
support line will be part of existing systems (eg NHS Direct)
and will not represent another call centre based service with
a separate infrastructure as has been the case with local GP referral
centres etc.
Question 3—Whether the necessary public
health infrastructure and mechanisms exist to ensure that proposals
will be implemented and goals achieved?
25. The delivery of the White Paper principles
and the related PSA targets will require the commitment of the
whole workforce and not just the specialist public health teams
in PCTs, Strategic Health Authorities, Government Offices and
Local Authorities.
26. There has been a rapid expansion of
specialist public health roles, particularly into primary care
over the past three years but it is important to place these in
the context of the changes in the traditional roles of the wider
non-specialist workforce and to consider the fitness of the existing
vocational programmes to train public health consultants towards
the wider remit of Directors of Public Health.
27. The NHS Confederation does not believe
that increases in overall staffing will be necessary to deliver
the public health agenda. However, there is a need to improve
public health skills across a range of professionals through multi-professional
education programmes so that health improvement takes its place
as core business across the NHS and other statutory partners.
28. Whilst recognising the shortfalls in
specialist public health professionals outlined in the White Paper,
the NHS Confederation also would emphasise the need for strengthening
the effectiveness of public health management programmes. This
will need to be embedded in such a way as to ensure that the skills
of both existing and new specialists, both medical and non-medical,
are fit to support the necessary changes which the White Paper
will bring.
29. It is essential that work continues
through the National Institute of Health and Clinical Excellence
(NIHCE) to ensure that effective and consistent measures of improvement
are available for those initiatives highlighted in the White Paper.
This will enable continuous audit of progress against nationally
agreed standards so that health improvements can be objectively
assessed.
In summary, the NHS Confederation believes that
the White Paper forms a firm basis from which to tackle, through
partnerships and improved education and support arrangements,
the existing inequalities in health.
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