HC 1048-III Health CommitteeWritten evidence from the UK Commissioning Public Health Network (PH 110)

Summary

Health Services Public Health (PH) is that branch of the discipline that deals with the health needs of the population and the strategic development, planning and delivery of healthcare to services. This includes the monitoring of the quality of the services that are provided.

Health Services PH is not properly considered in this legislation. This needs to be corrected. Public health should have a lead role in commissioning and this should be put on a statutory footing.

Many public health specialists are clinicians with considerable experience in health service public health. These individuals are the only clinicians who have the training and the skills to provide a both a medical and population perspective.

Public Health England should not be part of the Department of Health, but should be part of the NHS.

We believe that fragmenting the specialist PH workforce between many organisations will reduce the effectiveness of that workforce and would be a retrograde step.

PH observatories, and cancer registries, are an integral and important part of the public health infrastructure and should be commissioned as such.

We believe that the proposals as currently constituted risk driving down quality and increasing health inequalities.

Background Information about the UK Commissioning Public Health Network (UKCPHN)

1. The UKCPHN is a professional network of senior public health doctors and other specialists working for the NHS either in primary care trust commissioning or specialised commissioning teams.

2. The group was first established in 2002 and now has 230+ members. These members are drawn from all 10 England specialised commissioning teams and the majority of PCTs in England. As such the membership represents a significant proportion of public health specialists actively working in commissioning.

The Creation of Public Health England (PHE) within the DH

3. The specialist PH workforce consists of consultants in public health that have been trained in PH and have demonstrated that they have achieved a sufficiently high level of expertise. They work in all three domains of PH, health protection, health improvement, and health services, often undertaking roles in more than one area.

4. The UKCPHN remains of the view that Public Health England should not be a part of the Department of Health. There is a need for an organisation that can employ PH specialists, and this should remain part of the NHS. This is to ensure that we have the ability to speak freely, analysing the health of the population and not being fettered by being part of government.

5. In addition, many public health specialists are of the view that Public Health England should employ all PH specialists, thus preventing the fragmentation that we perceive to be one of the greatest risks of these proposals.

6. Those specialists that have concerns about Public Health England being the sole employer of public health specialists within the NHS have reservations because, unless Public Health England is an integral part of the NHS structure, health service public health in particular will merely be reduced to a technical function rather than providing a leadership function as a core member of the commissioning multi-disciplinary team. This will be to the detriment of the NHS given that public health specialists have training in most aspects of commissioning and are the only specialty / professional group trained in some aspects of commissioning.

7. It is therefore essential that any new structure both prevents the fragmentation of the specialty and does not reduce health service public health to a merely technical and distant function from health service commissioning.

Arrangements for PH Involvement in the Commissioning of NHS Services

8. The role of PH in commissioning is both strategic and operational. There is nothing in this Bill that takes cognisance of this, or that even hints at the realisation that managing change to improve quality and value for money is a complex and highly skilled task. Whilst many, including GPs, have a remit for evidence-based medicine, analysis of and advocacy for evidence based policies and practices are a core function of Public Health consultants as specialists in population health.

9. Health services public health has a unique configuration of skills that are relevant to commissioning. These include:

Assessing, reviewing, interpreting and presenting scientific evidence in a comprehensible manner.

Engaging and leading clinicians as trusted partners in improving service quality and patient outcomes.

Understanding the complete care pathway and ensuring that decisions are implemented and monitored.

Maintaining independence and objectivity so that funding decisions are based on evidence and need.

The ability to work across multiple clinical areas.

Clinical knowledge (for many).

Leadership.

10. This combination of skills, superimposed on previous clinical experience and a sound understanding of how the NHS and its partners work, give us the ability to deliver cost effective, population based and patient oriented outcomes. Our role as “expert population advocates” enables us to harness the expertise of others and to coalesce it to the benefit of the public. Our unique role as advocates for the entire population needs to be recognised and utilised. The need for a population perspective in commissioning health care is not clear in the Bill. Setting priorities for health care investment depends on an understanding of the needs of the population, understanding of the relative and absolute benefits to be obtained from proposed investments, the ability to assimilate and explain evidence, and the ability to take and push through difficult decisions. This cannot be done for each individual patient. It must be done collectively for a defined population, where the individual members of the population are not identified and cannot, therefore, influence the decision-making process with essentially irrelevant issues (eg the social status of a particular individual).

11. Many clinical services are complex and each defined clinical area will have its own set of issues, depending on the disease and the associated medicines and technological interventions, and these issues will need addressing separately so as to meet the patient and population needs. Public health has a major contribution to make to this in the annual commissioning cycle. This is not delivered in isolated parts but through a well-coordinated commissioning team, combining the expertise of public health with that of finance, information and experienced commissioning managers. Remove any one of those parts and it will become considerably more difficult to manage the risks inherent in health services commissioning and to deliver the end result of a well specified and good value contract with the associated good relationship with local providers.

12. Care pathways should be designed as a seamless whole, from prevention, through primary, secondary and tertiary care where necessary and, ultimately, end of life care. The proposals fragment the responsibility for these different aspects and this will make the designing of care pathways far more difficult. It will also make it harder to move resources from one sector to another eg if the primary prevention for a particular condition sits with public health in the Local Authority, and secondary care is commissioned by GP Consortia, will it be possible to move resources out of hospital and into the Local Authority? We should be striving for a joined up commissioning process, not a fragmented one.

13. Commissioning across the health needs of a population is complex and in order to acquire such high level skills GPs will have to invest significant time and effort. It may be neither necessary nor appropriate for GPs to have to acquire the high level skills required to commission operationally at this level. They will, however, need to have access to professionals with these skills, and have partners that can help them to make the best value commissioning decisions.

14. The key elements of successful commissioning include:

Having good understanding and oversight of the entire healthcare programme.

Making difficult choices on the allocation of resources based on the scientific evidence of the value of interventions.

Setting priorities based on magnitude of need, and patient and population oriented outcomes.

Working and improving the care pathway for patients to focus on outcomes, reduce unnecessary interventions and include treatment threshold decisions.

Explaining to the public and patient groups about the needs of one patient being balanced against the needs of all the others (opportunity costs).

Agreeing specifications and standards for services that clearly identify the clinical, quality and productivity outcomes that are important for patients and the NHS, and monitoring services to ensure delivery of these outcomes.

Developing and managing relationships with providers including clinicians.

Ensuring implementation of robust commissioning decisions.

Auditing the entire process in a commissioning cycle.

15. As the paradigm of control moves to a more local level, public health is best placed to work in partnership with GPs to make the best value decisions. Our ability to analyse health services information from a population perspective, combined with deep clinical knowledge, will enable effective commissioning decisions. We work closely with secondary care clinicians through acute commissioning units, and in secondary and tertiary care, to ensure best quality clinical outcomes.

16. We are different to non-clinical managers in our ability to bridge the gap between clinical practice and a bird’s eye view of healthcare needs.

17. We are ready and willing to work closely with GPs to enable them to focus on their whole practice population and the health care needs of that population.

18. We fully endorse the recommendations in paragraphs 36, 37 and 41 of the previous health select committee report relating to the need for more clinical skills in commissioning. Indeed these proposals constitute the only mechanism so far suggested that would provide consortia with health service public health expertise supported by medicines management. Board level presence is of particular importance because this branch of public health practice is central to the priority setting process that enables health care resources to be allocated in an equitable way. Consortia will be responsible for the allocation of the majority of the NHS budget and we would echo the opinion of the committee that reductions in health inequality can only be achieved with appropriate public health input into acute sector commissioning. Further, the skills of health service public health professionals will provide consortia with robust assessments of new treatments and medicines. In this way consortia can mitigate the significant risk of financial volatility that can result from the introduction of high cost interventions and medicines without an evaluation of their value to the NHS and appropriate placement within an overall clinical management programme.

19. Finally, we are concerned that there is no realisation of the difficulty of implementing and monitoring commissioning decisions. The fact that a Consortium has decided something does not make it happen. There is then a major piece of work to be undertaken to ensure understanding and acceptance of the policy at all levels. PH consultants are well placed to undertake this task and to ensure successful implementation of treatment policies.

Arrangements for Commissioning Public Health Services

20. Optimising population health must be a key consideration for any health service. Authoritative specialist public health advice and guidance should be delivered from a single NHS organisation, with any necessary joint appointments (which already exist between LAs and PCTs) being maintained or created, but with contracts of employment for public health specialists being held in the NHS. This will maximise the influence of the small specialist PH workforce and have the biggest impact on the health of the population while retaining flexibility of deployment. Individual specialists could then be seconded into other organisations.

21. All health services, from Primary Care through to tertiary referral hospitals, have a fundamental role in improving the public health, preventing disease and reducing health inequalities. PH involvement with Commissioning Consortia can only help to keep the public health focus in primary care.

The Future of PH Observatories

22. Public Health Observatories are a hugely useful resource for commissioning population health care. They must be preserved and would be best placed with the total public health family in one organisation. They must also include cancer registries, without which we shall be unable to monitor the effects of changes on cancer outcomes.

The Structure and Purpose of the PH Outcomes Framework

23. We regret that the outcomes for public health are being considered separately from the NHS and Social Care outcomes. We believe that, once again, it endangers the development of integrated care pathways and systems across organisations. We would suggest that a common Outcomes Framework should be developed.

The Future of the PH Workforce

24. There is a real danger that PH will fragment into three completely distinct sub-specialties, with the director of public health and a small team being responsible for health promotion/health improvement within the LA, some PH consultants working with GP consortia with a brief for commissioning and yet others at the NHS Commissioning Board and yet others in Public Health England working within the Department of Health. It also increases the disconnection between public health and providers making it more difficult to engender change in the provider sector.

25. The fragmentation runs the risk that there will be no continuity of thinking. It also risks de-skilling an already under-resourced and over-stretched workforce, and it could lead to real problems in designing adequate training programmes for the next generation of PH consultants.

26. Obtaining value for money in the commissioning of services will not be assisted by the fragmentation of the commissioning function. It is unlikely that consortia will have greater ability to control the hospitals than PCTs have had. Indeed, it seems not unlikely that the major power in the system will reside with the Foundation Trusts.

27. The training of the next generation of PH professionals is a cause for major concern. It is still very unclear where they will be based, how the training will be organised and what the implications are. It is imperative that:

Training is seen as an integral part of the public health function.

Clinical Governance of the training function is assured.

All locations where PH trainees might potentially be placed understand the ways in which the training works and what they will be expected to provide.

We are still in a position to train in the skills needed for commissioning.

June 2011

Prepared 28th November 2011