HC 1048-III Health CommitteeWritten evidence from S Peckham, A Hann, A Wallace, S Gillam, S Kendall, K Nanchahal and R Rogers (PH 20)

White Paper: Consultation Question – Role of GPs and GP Practices in Public Health

This is a response to the Committee’s request for submissions on the proposed public health changes in England outlined in the White Paper. This submission focuses on the implications for primary care and addresses key questions raised by the White Paper “Healthy Lives, Healthy People”, and subsequent consultation on commissioning for public health. Our focus here is specifically on how the proposals affect the delivery of public health in general practice and primary care. The response has been prepared by a research team currently undertaking research on public health in general practice funded by NIHR. The research team would be happy to discuss any aspects of our response and contact details are given below.

The Role of General Practice in Public Health

GPs and their practice teams have a crucial role in promoting health and preventing disease. Every consultation is an opportunity to detect early-warning signs that prevent illness and disease. The Royal College of General Practitioners agree GPs should be pro-active in carrying out public health activities and interventions, and it expects GPs to possess a wide range of skills related to ill-health prevention and public health. However, research continues to find that the relationship between public health and general practice in England focuses primarily on secondary prevention (Boyce et al 2010), and many GPs state they lack the skills needed to delivery effective health promotion. For example, GPs currently more frequently respond to requests for support in smoking cessation, rather than proactively engage their patients. Therefore, there is an enormous potential for general practice to take a more pro-active role in ill-health prevention and public health. National Institute for Clinical Excellence (NICE) public health guidance advises primary care professionals, such as GPs, to opportunistically and pro-actively carry out activities such as brief interventions. The White Paper on public health acknowledges this role, stating that GPs “have huge opportunities to provide advice, brief interventions and referrals to targeted services.”

It is important that GPs and the wider primary health care team stay involved in public health, and to encourage an even greater level of participation. However, we are concerned by several aspects of the government’s proposals. This response lays out some challenges we see in accomplishing this goal given the restructuring of the public health service, but also includes some suggestions for how to enhance GP involvement in public health planning and delivery.

Fragmentation of Funding and Commissioning:

The first potential problem is that public health will be fragmented on two levels – on the level of funding and commissioning, and on the level of delivery. In terms of funding, the splitting of public health resources across GP consortia, local authorities and Public Health England/NHSCB is a key concern. It is not clear what level of resources local authorities will have to spend locally nor what mechanisms will be available nationally to contract local public health activities in general practice. Grouping commissioning of similar services together can have great advantages, if there is enough funding behind it to make the services worthwhile. For example, drug, alcohol and mental health services will all be commissioned via local authorities. These important public health challenges are often overlapping and are best dealt with by joint services, which may include GPs in shared-care arrangements if locally appropriate. However for just that reason they are often expensive to deliver in the short term and will require a large financial contribution that the local authorities may or may not have. These services are a good example of how by commissioning similar public health services by one body (in this case, local authorities), there can be streamlining of service delivery and inclusion of GPs where beneficial, but this grouping together will only be effective if there is enough funding to support these joint endeavours.

Recommendation 1: Assign commissioning responsibilities so that services that are best delivered together can be grouped, and provide commissioning bodies with enough funding to support these joint services

There is also the question of when a service is commissioned nationally, how will GPs be incorporated when necessary? For example, public health for under-5s, which include pre-established programs and services that fall outside the NHS, will be contracted centrally by the NHSCB, yet GPs play a huge role in the care of under5s and work collaboratively with local health visiting teams and other community staff. The commissioning consultation makes it clear that the NHS (presumably mostly GPs) will still be responsible for the treatment of under-5s, but for this age group so much of routine care is based in prevention and health promotion. It is reasonable to try to standardize under-5 care by commissioning it at the national level, but it is not clear how the necessary linkages will be made between GPs and community services when it comes to the care of under-5s. Encouraging and maintaining these linkages and essential to keeping GPs involved and to providing well-coordinated and high quality care. The organisation of commissioning for under-5s needs to be re-examined to ensure continuity and good local co-ordination.

Recommendation 2: Either commission services locally or ensure that GPs are connected up with other services that are commissioned and delivered nationally

The last concern regarding fragmentation of commissioning is in situations where individual aspects of one public health service are commissioned by different groups. This is the case for screening, immunizations and sexual health services, where commissioning is split. In each case, part of the service will be provided by GPs as part of the GP contract (cervical cancer screening, childhood and elderly vaccinations, and contraception services, respectively), but other, similar services are not (ie additional cancer screening, booster vaccinations, and STI screening and treatment). Those services that are not part of the GP contract may be commissioned to other community providers (as part of the “any willing provider” model), which could lead to a situation where similar services that can be most effectively provided side by side (most obviously, contraception and STI services) may be available from different providers because they are commissioned by different groups. This runs the risk of confusing patients and making GPs feel that they cannot provide adequate public health services to their patients.

Recommendation 3: Keep commissioning of all aspects of one service under one roof. This applies specifically to sexual health, vaccination, and screening services

Fragmentation of Delivery

Beyond the potential problems that arise when commissioning of similar services is done by different bodies, there is a more general likelihood of fragmentation of delivery of public health services due to the “any willing provider” model. While the idea behind this approach to commissioning is to increase quality of care via a wider field of competition, and while it is possible that this increased competition will drive out poor providers and reduce the total number of providers, there is still a risk that the overall effect of this policy will be that public health-related care is divided over a larger number of providers. The effect on GPs may be twofold. The first is simply that services that were once provided by GPs will be provided elsewhere (this will be especially true given the suggestions of future “flexibility” of the GP contract when it comes to public health measures). The second effect, which will likely be the more common one, is that patients will have to seek out many geographically separated providers for services such as STI treatment, cancer screening, and nutrition advice. This may be confusing and frustrating to patients as well as GPs. Good communication between local authorities, the local Health and Wellbeing Board, and all local GPs will be necessary to minimize this confusion. GPs must be kept aware of which providers are providing which services so they can properly advise their patients on where to seek care. Additionally, GPs must be able to keep track of what care their patients have received from other providers. Coordinating with other providers and keeping detailed record of their patients’ care, particularly when it comes to routine screening and immunization, are key roles of the GP. It will be crucial to build in a way for all commissioners and providers of public health services to share their knowledge and records with GPs so that GPs can continue to do their jobs effectively.

The “any willing provider” model also calls into question the future role of entire categories of providers already working in public health, including health visitors, midwives and school nurses. Investment in health visiting is discussed in the white paper and is welcomed, but other key members of the local primary health care team who deliver public health are not mentioned. For example, the crucial role of School Nurses is not mentioned in the documents and it is not clear where this service will need to focus its attention or how it will be integrated into the rest of public health delivery. More clarity is needed about how essential local public health services will be worked into future commissioning, otherwise there could be a lack of co-ordination between local authorities and GP consortia for many key public health services, or worse, a loss of the currently-existing services all together.

Recommendation 4: Develop an information-sharing system such that GPs are always aware of where their patients can seek various public health services, and streamline the sharing of health records between providers, where appropriate

Recommendation 5: Make clear how services from existing groups of primary care-based public health providers (midwives, school nurses, etc) will be commissioned and what their roles will be

GP-led Public Health Delivery

We should not just see GPs as public health coordinators; we should ensure that GPs stay involved in public health on the delivery side as well. The three current methods for payment for public health activities within the GP contract are core standard tasks expected in normal practice (advice, information etc), aspects of the Quality and Outcomes Framework (QOF), and Local Enhanced Services (LES) elements of the contract. LESs have been particularly effective in involving GPs in locally-driven public health efforts. To date, LESs have been used in many areas to support a wide range of evidence-based public health activities, such as identifying CVD risk and providing long-acting contraceptives, and in 2009-10 they accounted for some £370 million (Marks et al 2011). Having the option of LESs in the contract has provided a way for GPs to reduce preventable morbidity, and it could continue to do so in the future. This option would be especially helpful in the context of a more diverse provider landscape. However, many of the activities currently funded through LESs, such as health check programmes, sexual health services falling outside the core GP contract, smoking cessation, prevention and treatment of alcohol misuse, falls prevention, and mental health promotion will now be commissioned through the public health budget of local authorities, and the GP contract will in future be done by the NHSCB. Will there be a mechanism for local authorities to engage with contracting processes and negotiate agreements that allow for local delivery of services that go beyond what is included in the nationally-based GP contract? Maintaining some mechanism for GPs to provide services that address local needs but are not included in the contract or in QOF may be an effective way to keep GPs involved in delivery of public health, and to keep our communities healthier.

Recommendation 6: Retain a mechanism for local adaptations to the GP contract, either LES or something similar

Changes to QOF

Experience from LESs suggests that while financial incentives are effective in changing practice, outcomes-based contracts rather than activity-related incentives could encourage a more proactive approach. Similarly, a key criticism of much of general practice (when it comes to public health) is that it focuses either on secondary prevention or simply information and advice. While both of these activities are useful, other interventions can be more effective. All of these considerations and criticisms are of particular importance when it comes to QOF. QOF is a key driver of GP practice, and could be another way to increase GP involvement in public health. A main proposal in the White Paper is that NICE adjust QOF to ensure that 15% is devoted to “evidence-based public health and primary prevention indicators.” Currently QOF has two indicators that it designates as “primary prevention”, and otherwise it focuses mainly on secondary prevention and uses proxy or process outcomes. Findings of a research study examining QOF and public health suggest that QOF has led to more systemisation of public health activity with a secondary and medical focus (Dixon et al 2010). The upcoming changes that NICE and QOF enact, and whether they truly make the focus on primary prevention and actual outcomes, will to a large extent dictate how much GPs are involved in improving the health of their patient population.

Recommendation 7: Take due notice of the potential for general practice to deliver public health when adjusting QOF to make sure the focus is truly on primary prevention and outcomes

GPs and the Public Health Outcomes Framework

Conversely, whereas the QOF is an incentive program for GPs that can be adjusted to insert public health, the Public Health Outcomes Framework (PHOF) is a public health incentive program that could be used to bring more GPs into the delivery of public health. As it currently stands, the PHOF indicates the few places that responsibility for achieving indicators is shared with the NHS – just eight indicators in the entire list refer to the NHS, and most of them are around reducing premature death in people with chronic diseases rather than disease prevention or health promotion. It is not clear what this shared responsibility refers to – provision of funding or delivery/planning of services. Looking at the entire list of public health indicators it is clear that GPs, and therefore the NHS, can be instrumental in delivering many services beyond the ones singled out - in services relating to sexual health or smoking cessation, to name just two areas. When local authorities and local health and wellbeing boards are considering how to best respond to these indicators (which they will be driven to due by the “health premium” payments), they should keep GP services in mind for many indicators beyond those with designated NHS involvement. Hopefully the GP presence on the health and well-being boards will help to keep GP services on the table. Additionally, the boards may find that GPs are particularly well-primed to the idea of indicators, having now been working with QOF for six+ years. While these two sets of indicators are very different in character (though they will hopefully become less so, as discussed above), GPs may be comfortable with the idea of indicators and may have ideas for how to incorporate this new set into their practices.

Recommendation 8: Include GPs services in the discussion of how to best deliver on the public health outcomes framework

GP Consortia

GP consortia will be represented on health and well-being boards and will be involved in local decisions about public health resource allocation, which is an important piece of maintaining GP involvement in public health. However, the most dominant role of the GP consortia will be in commissioning, which provides a new set of challenges as well as opportunities for improvement in public health and ill-health prevention. Research on Practice Based Commissioning (PBC) found that GPs focused more on preventing “unnecessary” hospital admissions then on primary prevention (Thorlby and Curry 2007). Analyses of private primary care similarly found GPs used traditional models of general practice and did not address key public health problems (Coulter 2006; Kai and Drinkwater 2003, Peckham 2007: 43). However, this is not a reason to take public health out of GP commissioning responsibilities. In fact, researchers have suggested GP budgets for commissioning health services be aligned with budgets for commissioning public health (Smith and Thorlby 2010), which is similar to what may happen with the new expanded responsibilities of GP consortia. By giving GPs responsibility for standard health services commissioning as well as some public health services, they may be forced to think more broadly about their communities. In order to integrate ill-health prevention into general practice, it is essential that future contract negotiations and consortia commissioning responsibilities discuss and assign responsibility for primary and secondary prevention. More specifically, GPs should have responsibility for commissioning those public health activities that most closely relate to the ones they provide themselves via the GP contract (like contraception services and cervical cancer screening). Aligning these responsibilities puts GPs’ already existing knowledge of service provision to work, and helps to ensure that patients have access to the most streamlined pathways for these services (as well as the best quality ones).

We welcome the emphasis on GP Consortia being responsible for the well-being of their whole community. However, systems developed within PCTs for supporting GPs with epidemiological analyses are likely to be disrupted with changes to public health departments. New relationships, systems and processes will need to be developed to provide what is critical support for the new commissioning bodies. Additionally, this will have to be done at a time when new organisational structures for public health also need to be developed and new relationships forged. While consortia provide an opportunity for GPs to take a broader community focus it is not clear whether the scale of change and focus on other aspects of commissioning and organisational change will allow this to occur. To best support GP Consortia in their public health responsibilities during this tumultuous time, local epidemiological responsibilities should be maintained and transferred to local authorities, who will then provide information to GP consortia.

Recommendation 9: GP consortia should commission those activities that are most similar to the ones in the GP contract, for better streamlining of care

Recommendation 10: Local health monitoring and epidemiological services should be kept intact and active during the transition to GP consortia and should maintain an open stream of communication with the consortia

Research

One final measure that will benefit everyone from GP consortia to the NHSCB in their commissioning of public health activities is good sharing of existing evidence and increasing the evidence base related to GP delivery of public health. Our research group is currently engaged in a scoping study of the role of GPs in health promotion and disease prevention, with particular focus on service organization and delivery. Our initial literature search has shown that the number of studies on this topic is large and growing daily, but it is difficult to define the topic precisely, and therefore it is challenging to access all relevant information. To combat this challenge it is essential that this large body of literature be thoroughly explored, then shared and put to good use in commissioning and shaping practices. At the same time, it is clear that quality studies on the best methods for delivery of health improvement services are lacking. General practitioners, other primary care providers, public health officials and academics need to work together to improve this evidence base.

Recommendation 11: Fund additional research on how GPs can deliver public health interventions, and create improved mechanisms for sharing research and effective practices

June 2011

Additional References

Boyce T, Peckham S, Hann A and Trenholm S (2010) A pro-active approach. Health Promotion and Ill-health prevention Kings Fund: London

Coulter A (2006). Engaging Patients in Their Healthcare. Oxford: Picker Institute Europe.

Dixon A, Khachatryan A, Wallace A, Peckham S, Boyce T and Gillam S (2011) The Quality and Outcomes Framework (QOF): does it reduce health inequalities? NIHR SDO Programme.

Kai J and Drinkwater C (eds) (2004) Primary Care in Urban Disadvantaged Communities. Oxford: Radcliffe Medical Press

Marks L, Cave S, Wallace A, Mason A, Hunter D J, Mason J M and Peckham S (2011) Incentivizing preventive services in primary care: perspectives on Local Enhanced Services Journal of Public Health pp. 1–9 Published online 1 November 2011 in advance of publication doi:10.1093/pubmed/fdr016

Peckham, S (2007), “The New General Practice Contract and Reform of Primary Care in the United Kingdom”. Healthcare Policy, vol 2, no 4, pp 34–48.

Smith J, Thorlby R (2010). Giving GPs budgets for commissioning: what needs to be done? London: The Nuffield Trust. Available at: http://www.kingsfund.org.uk/publications/giving_gps_budgets.html (accessed 10 August 2010).

Thorlby R, Curry N (2007). Practice-based Commissioning. London: The King’s Fund.

Prepared 28th November 2011