Memorandum submitted by the Faculty of
Public Health of the Royal College of Physicians of the UK and
the Association of Directors of Public Health (PCT 33)
SUMMARY AND
RECOMMENDATIONS
We feel that the momentum flowing from the Choosing
Health White Paper, and some of the pragmatic structural changes
coming from Commissioning a Patient Led NHS, present some
real opportunities to make a progressive change in the future
public health of the country.
These opportunities would be subject to the
following statements.
The Faculty of Public Health and Association
of Directors of Public Health:
(a) Recommend that the Department of Health
clarifies the position of Public Health in the new PCT and SHA
structures. There remains a possibility that the current re-organisation
could reduce the number of Directors of Public Health in England
from a little over 300 to around 150. This risks destabilising
current Public Health teams who are delivering in their communities.
We therefore recommend that there needs to be strong, local Public
Health leadership at all levels of the NHS and local government,
through clearly identified NHS Directors of Public Health.
(b) Recommend that Directors of Public Health
must be accredited public health specialists. We acknowledge that
the target of one DPH per borough is aspirational, and current
limits on the numbers of public health professionals of sufficient
seniority would mean that some local authorities would need to
share a DPH. The Department of Health should urgently progress
plans to review and develop capacity in Public Health through
increasing the numbers of formal training posts for public health.
(c) Recommend that where possible, DsPH
should be maintained and strengthened by using joint appointments
with Local Authorities, ensuring executive-level public health
representation on local authority management teams. The DPH should
continue to be instrumental in setting Local Area Agreements (LAAs)
and work with the wider community through the Local Strategic
Partnership.
(d) Recognise that Commissioning a Patient-led
NHS (CaPLNHS) should lead to stronger service commissioning
arrangements, covering larger areas. These new arrangements should
be strongly supported and in some cases led by Public Health specialists.
(e) Welcome the commitment of the Department
of Health to exclude Public Health expenditure from the £250
million savings plan that this reconfiguration has been set to
deliver.
(f) Are concerned that the significant financial
pressures in many PCTs this year, combined with the need to deliver
management cost savings, will result in money made available through
Choosing Health being used to balance PCT deficits. Changes in
the health of the population need sustained long-term efforts
and for this reason, funds for public health improvement are vulnerable
to PCT savings plans or targets that have to be met in a single
financial year. We therefore recommend that money earmarked for
Choosing Health should be ring-fenced by the Department of Health
and that DsPH should be held accountable for its investment.
(g) Recognise and welcome the opportunities
in CaPLNHS to strengthen local health protection and emergency
planning arrangements. This might be particularly pertinent should
the Health Protection Agency (HPA) start to take on delivery of
some functions, such as immunisation and the control of Tuberculosis.
(h) Regional level Public Health should
be closely linked with regional government offices as the focus
of their health improvement work.
INTRODUCTION
1. The Faculty of Public Health is the Standard
Setting body for specialists in Public Health. We are a joint
Faculty of the three Royal Colleges of Physicians of the United
Kingdom (London, Edinburgh and Glasgow). We are a registered charity,
established in 1972.
2. The aims of the Faculty are:
— To promote, for the public benefit,
the advancement of knowledge in the field of public health.
— To develop public health with a view
to maintaining the highest possible standards of professional
competence and practice, and to act as an authoritative body for
consultation in matters of education or public interest concerning
public health.
3. The Association of Directors of Public
Health (ADsPH) has its origins dating back over 100 years. Its
main function is to represent Directors of Public Health in the
United Kingdom at national level. It is a separate organisation
from the Faculty of Public Health, although most of our members
are also Members or Fellows of the Faculty. Directors of Public
Health provide advice to public bodies across the three domains
of Public Health.
Some more detail about the ADsPH is available
on the tri-fold leaflet.[17]
FACULTY OF
PUBLIC HEALTH
AND ADSPH
RESPONSE TO
THE INQUIRY
4. The terms of reference for the Inquiry
have been covered in detail by other witnesses. We have therefore
focused on the likely changes to Public Health, whilst commenting
on the other terms where appropriate.
5. We would broadly support the submission
to the Inquiry made by the British Medical Association. This submission
comments in detail on some of the other terms of reference that
we do not propose to reiterate.
COMMISSIONING A
PATIENT-LED
NHS
6. The ADsPH drafted an initial response
to Sir Nigel Crisp's letter in September, which is included here
as Annex 1. This was written at a time when Strategic Health Authorities
(SHAs) had not sent in their submissions to the DH on Future PCT
configuration. The picture as of mid-November is a little clearer,
and most areas of the country are now aware of the likely changes
that will go forward to consultation.
RATIONALE BEHIND
THE CHANGES
7. The two main drivers appear to have been
an intention to reduce management costs at PCT and SHA level and
a political commitment towards greater contestability of PCT provider
services.
LIKELY IMPACT
ON COMMISSIONING
OF SERVICES
8. There is currently some uncertainty as
to how Practice-Based Commissioning (PBC), Payment by Results
(PBR) and the changes that will result from CaPLNHS, will fit
together. The Department of Health will need to ensure that these
policies fit neatly together through a period of significant change.
9. One thing that is reasonably clear however,
is that commissioning is likely to occur across wider areas than
are covered by current PCTs. PCTs will remain responsible for
the contracts with providers, GPs will influence the formation
of these contracts, and will guide patients into secondary care
of their choice. PCTs will need to manage demand for secondary
care, and it is likely that Public Health practitioners will play
a leading role in this function.
10. We welcome commissioning arrangements
that will cover larger areas but remain concerned that there is
scope for local inequalities and perverse incentives in the provision
of care under Practice Based Commissioning.
LIKELY IMPACT
ON OTHER
PCT FUNCTIONS, SUCH
AS PUBLIC
HEALTH
11. Annex 2 contains supporting information,
which outlines how public health should work with the new PCTs.[18]
12. The new PCTs have two main functions—commissioning
services for their population and ensuring public health delivery.
The new PCTs are the basic unit of the NHS and have a public health
responsibility. They will have a weighted capitation budget for
their defined population. The PCT DPH will need to have oversight
of the needs of the whole population and provide the overall corporate
leadership within the PCT and across the public health network—ensuring
academic, civil service and local authority and other public health
resources are linked so there is an integrated public health system.
The framework for the PCT DPH to use will be the three domains
of public health—Health Improvement, Health and Social Care
services and Health protection. The PCT DPH will need to satisfy
themselves that these domains are being covered for their responsible
population even if some are commissioned from other providers
eg Sexual Health services and the HPA agreements.
13. Public health delivery under CaPLNHS
will need to include:
13.1 A health Services Commissioning team
to deliver the PCT commissioning process and Practice Based Commissioning.
For critical mass this is likely to be a PCT headquarters function.
This must be supported by a strong public health information team,
something which is weak in many areas of the country, and which
requires further development and investment.
13.2 Health Protection. The DH should ensure
clarity about what the local HPA units provide and what the PCT
needs to also provide (emergency planning) or commission in addition.
Delivery will be at different levels and needs to include screening
and Vaccinations and Immunisation. HPA units should be closely
located or possibly co-located with PCT headquarters to make for
strong and safe joint working arrangements.
13.3 Health Improvement. Agreement is required
about what can be done at PCT level (social marketing and linking
to regional strategies) and what should be done in LSPs. Local
arrangements with joint appointments in unitary authorities and
district/city councils may be the best option. Such posts would
need to input at Chief Officer level and could also lead provider
teams in local authorities (health development/promotion teams).
13.4 Provision of local Health Promotion
services such as smoking cessation, Health Visiting, School Nursing,
provision of health promotion materials. These functions may be
commissioned by rather than provided by the local public health
team.
14. We would envisage this happening at
four tiers
| Tier I: | Public health delivery teams in local authorities.
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| Tier II: | Practice-based commissioning/Local Authority specialist Public Health work overseen by the Local PCT.
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| Tier III: | PCT HQ/County/Unitary Authority work.
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| Tier IV: | Regional Government Office/SHA.
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15. In order to avoid the fragmentation experienced with
the NHS changes under Shifting the Balance of Power, it is important
for PH networks to develop further. Scarce public health resources,
such as dental public health and public health informatics will
need to be shared across PCTs, including academic, local authority,
commissioners and providers. To secure this, DsPH working at the
tier of the LSP will need to be seen as part of the PCT NHS capacity
and thus have Associate Director roles for the NHS whilst carrying
the DPH role for the LA. New resources from Local Authorities
should be enlisted to invest in these new local Public Health
leaders and their teams derived from existing NHS and LA staff.
The PCT would also be the environment to oversee training and
develop R&D capacity, although this could also be supported
at regional level.
16. In rural areas the County is likely to be the level
for the PCT even if there are smaller unitary authorities in the
area eg Peterborough in Cambridgeshire and Peterborough or Luton
in Bedfordshire. The public service model outlined would still
allow the PH leadership in these unitary authorities to be locally
sensitive and linked to a Local Area Agreement. Indeed many of
the Public Health and NHS providers will also be local (including
PBC localities) so much of the joint working should be sustained.
This vision can also apply to lower tier District or City Councils
who contribute via their LSPs to the upper tier LAA.
17. In metropolitan areas such as Manchester and London
the same economies of scale for PCT commissioning can be achieved
while retaining locally sensitive Borough Council joint DSPH and
teams.
Dr Tim Crayford
November 2005
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