Select Committee on Health Written Evidence


Memorandum submitted by Milton Keynes Council (PCT 15)

EXECUTIVE SUMMARY

  Milton Keynes Council believes that the reform of PCTs should be along clear lines of principle. Milton Keynes Council enjoys a robust partnership with the PCT and co-terminous boundaries and the benefits derived from this arrangement have been cited in the paper. We believe that the important principles that relate to securing public health services to make PCTs fit for purpose include:

    —  As the core purpose of the DoH and this service transformation is to improve health and tackle inequalities, it is important that reconfigured services maximise influence of resource allocation in both the NHS and local government.

    —  It is essential that there is effective public health input at each level of commissioning (Practice Based, PCT, supra-PCT, Local Government).

    —  As public health goals are at the core of the purpose for PCTs, it is essential that the corporate leadership of the PCT includes visible, high level public health expertise.

    —  The NHS should be able play its full part in the negotiation and delivery of Local Area Agreements and maximize the benefits of co-terminosity with local government.

    —  To be effective commissioners and to provide effective support to practice based commissioners, PCTs will need access to a range of public health skills.

    —  PCTs will need to be able to discharge their range of mandatory public health duties and responsibilities.

    —  A restructured NHS should be able to support teaching and training of public health specialists and practitioners and support constructive links with academic public health teams.

    —  Public health services should be provided in ways that maximize efficiency and value-for-money.

    —  It is unlikely that there is a "one-size-fits-all" model that will be right in every area. New organisational structures should be tailored to the circumstances of local areas and reflect variations in the structure of local government.

    —  New organisational structures should build on arrangements that work.

INTRODUCTION

  1.  Milton Keynes Council welcomes the opportunity to submit a brief memorandum on the Government's proposed changes to Primary Care Trusts (PCTs). The information which we have submitted reflects the views of both the Milton Keynes PCT and the Local Strategic Partnership (LSP). We have set out a principled vision of how we believe that PCT reform would best serve communities across England, grounded in evidence of effective partnership work in the Milton Keynes area.

BACKGROUND

  2.  The purpose of restructuring is to make the NHS and health care system fit for purpose ie able to implement The NHS Improvement Plan, Choosing Health and Creating a Patient Led NHS. Together, these documents describe how the Department of Health intends to deliver its overall aim for 2005 to 2008 as set out in the 2004 Spending Review Public Service Agreements, which is to:

    "transform the health and social care system so that it produces faster, fairer services that deliver better health and tackle health inequalities."[3]

  3.  Implementation of these plans and realisation of the DoH's aim will require substantial organisational change for both commissioners and providers of health and social care services. In particular, it is intended that:

Provision

    —  a health and social care market should be created in which an increased number and type of provider will participate—ie there will be plurality of provision. This is intended to enable patients to choose where, when and how they receive care from among a greater variety of public, private and voluntary sector organizations.

Commissioning

    —  Primary Care Trusts (PCTs) should become more powerful commissioners that can manage a new health and social care market so that the public have dependable access to a full range of high quality responsive health services and that the health and social care system as a whole delivers improvements in health and reductions in health inequalities to the population as a whole.

  4.  As the overall purpose of the system transformation is to produce faster, fairer services that deliver better health and tackle health inequalities, if the organisations created are to be fit for purpose, it is important they are designed from the outset with a view to maximizing their impact on health and inequalities.

  It is with these issues in mind that we have set out our principles and proposals below.

PRINCIPLES FOR THE REFORM OF PCTS

  5.  Milton Keynes Council believes that there are a number of important principles that relate to securing public health services to make PCTs fit for purpose include:

    (i)    The majority of public funds that are likely to contribute to improving health and tackling inequalities are channelled through the NHS and local government. As the core purpose of the DH and this service transformation is to improve health and tackle inequalities, it is important that reconfigured services maximise influence of resource allocation in both the NHS and local government.

    (ii)    Services will be commissioned at a variety of levels and by a variety of bodies including:

  (a)  Practices and groups of practices—through practice based commissioning.

  (b)  PCTs.

  (c)  Supra-PCT bodies for specialized commissioning.

  (d)  Local government—sometimes acting alone and sometimes jointly with the NHS.

      It is essential that there is a strong public health input at each level of commissioning if the maximum improvements in health and health inequalities are to be achieved.

    (iii)    As public health goals are at the core of the purpose for PCTs, it is essential that the corporate leadership of the PCT includes visible, high level public health expertise.

    (iv)    Efficient provision of health services, and the design of relevant multi-agency care pathways is greatly facilitated if the agencies involved are responsible for the same population. In practice, this means maximizing the opportunities and benefits of co-terminosity between PCTs and local government.

    (v)    In future, Local Area Agreements will become an increasingly important vehicle for the planning, delivery, local target setting and accountability of local public services. The NHS will be expected to play its full part. NHS restructuring must allow the NHS to participate effectively.

    (vi)    If they are to be effective commissioners and to provide effective support to practice based commissioning, PCTs will need access a range of public health skills that include:

      —  Strategic planning for health and inequalities.

      —  Access to and interpretation of the evidence base.

      —  Needs assessment.

      —  Data analysis and information management.

      —  Service evaluation.

      —  Priority setting.

      —  Change management—including clinical credibility and clinician challenge.

      —  Partnership and multi-sectoral/multi-agency working.

    (vii)    As well as generic commissioning skills, PCTs will need access to specialist advice to commission specialised public health services (many of which will contribute to demand management) including:

      —  Screening services.

      —  Vaccination and immunization services.

      —  Sexual health and teenage pregnancy services.

      —  Dental public health services.

      —  Health promotion and health improvement services.

      —  Addiction services (includes substance misuse, alcohol, tobacco).

      —  Prison health services.

  (NB  This paper focuses on the commissioning aspects of specialist public health and does not address the options and implications for the organization and continued delivery of the provider aspects of these specialist public health services).

    (viii)    PCTs also have a range of mandatory public health duties and responsibilities, which they will need the skills to fulfil. These include:

      —  Emergency planning—including planning for pandemic flu; chemical, biological, radiological and nuclear terrorism (eg "dirty bombs").

      —  Child protection/safe-guarding.

      —  Local authority "proper officer" functions.

      —  24/7 public health/health protection out-of-hours emergency cover.

      —  provision of expert advice from Joint Health Advisory Cells—when called by police in emergencies.

      —  Production of an annual report on the health of the population.

      —  Statutory consultation responses as part of Integrated Pollution Prevention Control (IPPC).

—  Port Health duties (where relevant).

    (ix)    The ability to teach and train is essential for the sustainability of health care in the UK. A restructured health service should ensure that it is able to support the teaching and training of public health specialists and practitioners.

    (x)    Similarly, it is important that a restructured health service is able to support constructive links between service and academic public health teams.

    (xi)    Public health services should be provided in ways that maximize efficiency and value-for-money. For some public health services this is likely to mean organization at a supra-PCT level eg literature review and analysis of the evidence base; support to specialised commissioning. Other services require detailed local knowledge and will need to be provided locally eg multi-agency working with local government, clinician challenge, aspects of health protection and emergency planning.

    (xii)    The characteristics of local health economies and the structures of local governments vary substantially across the country and within the Thames Valley. It is unlikely that there is a "one-size-fits-all" model that will be right in every area. New organisational structures should be tailored to the circumstances of local areas and reflect variations in the structure of local government.

    (xiii)    New organisational structures should build on arrangements that work ie they should aim to consolidate rather than destroy successful arrangements and change and strengthen recognised organizational weaknesses.

THE BENEFITS OF CO-TERMINOUS ARRANGEMENTSTHE MILTON KEYNES EXAMPLE

  6.  Milton Keynes is a former New Town, with one of the fastest rates of population growth in the UK. As a major city and growth centre in the South Midlands, it has specific needs which need to be addressed. The city has adopted a consensual, partnership approach to growth and service delivery, which encompasses all of the major public sector providers, including the PCT. The city enjoys a clear strategy through to 2034, set out in its Community Strategy.

  7.  Milton Keynes firmly believes that the interests of its citizens are best served by the creation of an integrated commissioning model and the retention of a PCT which closely matches the local authority. It is fundamentally important that commissioning services are reconfigured in order to maximise the resource allocation in both the NHS and local government. Through co-terminous arrangements, it will be possible for local authorities, such as Milton Keynes, to continue to maximise benefits of joint working arrangements and tackle health inequalities. The creation of Local Area Agreements (LAAs) will further refine opportunities for local target setting and local service redesign.

  8.  Milton Keynes Council and the PCT, for example, currently have co-terminous boundaries, which has enormous benefits for the city. The city prides itself on its reputation for innovative delivery patterns and original thinking. This applies to the health economy just as much as to other local government initiatives. The local authority and PCT have aligned their plans, budgets, commissioning and agendas over a number of years, delivering an integrated approach to public health. Milton Keynes has also pioneered the joint appointment of a Director of Public Health, recognising the importance of partnership working between the PCT and the local authority.

  9.  All partners in Milton Keynes represented on the Local Strategic Partnership[4] see health and health inequalities as a key issue, and health services as an integral part of the city. Application of the principles set out in this paper—reinforced by the experience of recent years—lead them to believe strongly that the best interests of this rapidly growing city and its people—both present and future—will be best served by a PCT that is co-teriminous with the Unitary Authority.

  10.  Many other parts of the country have come to similar conclusions about the relationship between unitary authorities and new PCT boundaries. Appendix 2 sets out a list where SHA proposals are that unitary authority and PCT boundaries should remain co-terminous. The Thames Valley Strategic Health Authority has submitted three proposals to the Department of Health : two would combine Milton Keynes with Mid and South Buckinghamshire PCTs and so lose many of the benefits of co-terminosity; the third would keep the PCT and UA co-terminous. We believe, in the interests of the people of Milton Keynes are best served by this last option.

11.  CONCLUSION

  In conclusion, it is the view of the major statutory stakeholders in Milton Keynes, that the development of new structures and guidelines for PCTs should be grounded in a number of core principles. In particular, we believe that PCTs should aim to maximise resources and benefits through joint-working arrangements with local authorities and this can only really be properly achieved through the adoption or retention of co-terminous boundaries, including at a unitary council level.

Milton Keynes Council

November 2005








3   HM Treasury. 2004 Spending Review. Public Service Agreement 2005-08. p 15 July 2004. Back

4   Not printed. Back


 
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