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.
— Data analysis and information
management.
— 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:
— 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
ARRANGEMENTS—THE
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
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