HC 1048-III Health CommitteeWritten evidence from the Royal College of General Practitioners (PH 184)

Please note: this response was drafted before the outcome of the listening exercise and subsequent Government response

Summary

The Health and Social Care Bill brings an immense opportunity for GPs, both as commissioners and providers, to improve public health outcomes. As providers of holistic care, GPs understand the context in which the patient operates and are well placed to take on this role.

Consortia will need to be equipped to take on responsibilities for population health through sharing of best practice; a more sophisticated usage of population health data; and more explicit terms of cooperation with public health staff.

There will need to be tight controls on the types of projects applicable for public health funding, and rigorous oversight from Public Health England.

The Public Health Outcomes Framework will need to be tested and evidence-based to avoid restricting the flexibility of local Health and Wellbeing Boards to plan services according to local needs.

The Health Premium must target incentivised outcomes at those groups which are particularly disadvantaged.

1. The Royal College of General Practitioners is the largest membership organisation in the UK solely for GPs. Founded in 1952, it has over 42,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline. We are an independent professional body with enormous expertise in patient-centred generalist clinical care.

2. The RCGP is at the forefront of developing general practice to address the health needs of the wider population. The College’s curriculum and associated statements, the first of their kind for general practice in the UK, includes the curriculum statement Healthy People: promoting health and preventing disease, and was developed in partnership with the Faculty of Public Health. It sets out how GPs should meet the curriculum requirements of promoting health and preventing disease in a range of settings.

3. The College’s Centre for Commissioning—a virtual service that equips GPs, practices and consortia with the skills, competencies and expertise required to deliver effective healthcare commissioning—is undertaking joint work with the Faculty of Public Health and has produced a memorandum of understanding on how both organisations can work better together. Outcomes from this memorandum include College Members working with their public health colleagues to develop support materials for a variety of settings.

4. The work of the RCGP Research and Surveillance Centre (RSC), currently funded by the Health Protection Agency, is regarded as leading the world in this area—it has data and baselines extending back for 50 years—this is unparalleled. RSC data is even recognised by media and public in respect of flu outbreaks and there is great confidence in this data. The unit and its work are relatively cheap and cannot be easily displaced (it is possible to collect routinely obtained data from general practice quite easily, but without the baselines and context, it is relatively meaningless).

General Comment

5. The College holds the belief that GPs and their practices can play a key role in many aspects of the public health agenda. The advent of clinical commissioning brings with it opportunities for new models of care and means that GPs can play an even wider part in improving the health of the nation.

6. GPs, on the whole, are enthusiastic to take on increased public health responsibilities. To be able to realise their full potential and achieve the best outcomes for patients they will need the right tools: the appropriate skills and knowledge, supported by the right information and usage of data.

7. The RCGP welcomes the attention given to public health issues in the White Paper Healthy Lives, Healthy People and its subsidiary consultation papers. However, it is regrettable that public health has been dealt with separately to the wider health reforms and we believe this has missed opportunities for greater integration.

8. In relation to the wider health reforms, we are reassured that things are moving in the right direction; the emphasis on preserving the principles of the NHS and keeping it free at the point of need; freeing the NHS from political interference; clinical commissioning of local services; and the real focus on reducing health inequalities are to be welcomed. However, we still have a number of outstanding concerns about the potential risks and unexpected consequences of the proposals. We need the Government to reassure us that GPs will be given the freedom and autonomy to lead the decision-making and design of future integrated health systems drawing on the support of other health, social care and third sector services. We support clinician-led commissioning but continue to believe that GPs are best placed to lead this process.

Specific Questions

Arrangements for public health involvement in the commissioning of NHS services.

Arrangements for commissioning public health services.

Consortia Level

9. We welcome the proposal that commissioning consortia will have responsibility for the whole population in their area and that Public Health England, the NHS Commissioning Board and local Health and Wellbeing Boards will be expected to coordinate with consortia in planning and implementing public health strategies.

10. We welcome the Prime Minister’s recent announcement that Monitor will have a responsibility to integrate services and believe this has to be enshrined in the Health and Social Care Bill.

11. We are concerned that, in some cases, consortia and local authorities will be non-coterminous, with the potential for overlapping boundaries, making cooperation unnecessarily complicated. This could result in these consortia being required to commission in line with the strategies of multiple Health and Wellbeing Boards and multiple Joint Strategic Needs Assessments. If the public health needs of the population are to be truly addressed, the Government must look at aligning consortia with local authority boundaries.

12. As well as this, the proposed abolition of practice boundaries and resultant greater flexibility for patients to choose their GP practice, is likely to result in practices having a number of patients outside of the territorial area of their consortium, making it even harder for them to commit resources to community-level initiatives. The decision to abolish practice boundaries, with potentially huge implications for patient safety, home visiting and practice stability, must be reconsidered.

13. Effective accountabilities for Public Health England, Local Authorities and Health and Wellbeing Boards need to be in place in order for the right cooperation to take place. This must be supported by the Health Premium and outcomes frameworks that are targeted and incentivising in the right way.

14. For public health expertise to be properly embedded in commissioning, there will need to be more explicit terms of cooperation between consortia and public health staff. A major concern for GPs and GP commissioners is the removal of public health staff into local authorities which could reduce rather than facilitate the capacity for public health intelligence to inform NHS planning and commissioning. Our members have commented that they make considerable use of public health epidemiological and data assessment skills, and envisage these becoming more useful under GP commissioning, particularly for analysis of sociodemographic variations in outputs of service.

15. Crucial to the maintenance and success of the commissioning relationships between local authorities and the NHS will be the assembly, analysis and sharing of examples of best practice as well as the availability of public health information. Consortia must be enabled to use this data in more sophisticated ways than is currently possible.

16. In terms of data, there is a wealth of information already kept in general practice and this is an untapped resource. Computer systems that can be inter-linked across organisational boundaries could facilitate the collation and utilisation of this data, which would make a real impact in improving population health.

Practice Level

17. Many GPs see their role as at the front line of meeting the public health needs of their populations and are enthusiastic about taking this forward.

18. However, some are sceptical of their potential to manage population health needs and feel that there is a tension between health promotion at a population level and their primary role of meeting individual patients’ needs and that this may, in fact, in some cases damage the relationship with an individual patient. Recurrent challenges to patients about lifestyle can be seen as personal criticism and undermining of the struggles individuals face to overcome unhealthy habits. There needs to be a culture shift and GPs will increasingly need to look at patients from a preventative perspective in order to combat this.

19. More emphasis needs to be put on GPs’ day to day role in public health. Public Health England would be well advised to develop coherent and persuasive evidence for the efficacy and level of specific interventions, to ensure ‘buy-in’ from clinicians and the effective use of their time and skills.

20. The proposal to hold GP practices to account for public health outcomes, including 15% of the QOF allocation, is welcomed but will place and additional training and education burden on GPs. Adequate training provision will have to be in place to ensure that GPs fully understand Joint Strategic Needs Assessments and the roles of other public health professionals. The case for enhanced training of GPs, which the College and others have been pressing for some time, is also now stronger than ever.

21. Ultimately, GPs and public health professionals need to understand each other’s roles. To facilitate this, opportunities for GP training placements in public health should be increased as they are currently limited.

The future role of local government in public health (including arrangements for the appointment of Directors of Public Health; and the role of Health and Wellbeing Boards, Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies)

22. It is crucial that consortia are closely engaged with the Health and Wellbeing Boards to encourage alignment between healthcare and public health commissioning.

23. Much will depend on the willingness and ability of the members of local Health and Wellbeing Boards to cooperate and coordinate activities—costs of backfill and appropriate contracts are always necessary for full engagement by health professionals.

24. A further financial challenge is the fact that each consortium may need to work with the Health and Wellbeing Boards, Directors of Public Health and HealthWatch organisations of more than one local authority, and vice versa. It is essential that these interactions are supported by adequate funding to allow them to flourish. They also need to be constructed in a way which is not overly bureaucratic as a failure to do so will work against the fundamental aims of “Liberating the NHS”.

25. Given the shared responsibility of all healthcare professionals for public health issues, it is desirable to have as close co-operation as possible on workforce planning. It is therefore entirely sensible for Public Health England to have a role within Health Education England, and similarly for local authorities, presumably through local Directors of Public Health, to have a role in local provider skills networks.

The creation of Public Health England within the Department of Health: How the Government is responding to the Marmot Review on health inequalities

26. We endorse the suggestion from the Faculty of Public Health that Public Health England should have a degree of independence either as a special health authority or as an executive agency.

27. The report of the Marmot review identified a variety of social and economic causes for health inequalities that do not appear to be properly acknowledged in the Government’s proposals for public health.

The future of the Public Health Observatories

28. As has been stated earlier, GPs already use information about care services to support and advise their patients; and this is a vital part of primary care which can be enhanced by more accurate data and by information technology solutions. It is anticipated that a far greater volume and quality of information from all health and social care sources will be a vital tool to aid GP commissioners. This must also include access to public health information, as currently produced by Primary Care Trusts and the regional public health observatories: these datasets need to be retained if the public health function moves into local authorities.

The structure and purpose of the Public Health Outcomes Framework

29. It is of upmost importance that public health responsibilities do not become divorced from healthcare, since the primary care team has so many opportunities to influence public health. The purpose of the outcomes framework must be to prevent this separation. Equally important, the framework should be structured so that its objectives are effective and measurable.

30. To realise this dual challenge, outcomes should apply equally to the partners involved and also have enough evidence base behind them to ensure that appropriate interventions can be designed and monitored.

31. This is important because it is essential, especially given the current restricted financial situation, that those public health initiatives that can be shown to be most effective are resourced and that perverse incentives and outcomes are avoided.

Arrangements for funding public health services (including the Health Premium)

32. It is important that any outcomes incentivised through the Health Premium must be clearly measurable and genuinely responsive to specified public health activities. They must also aim at maximal health gain in those areas where the greatest improvement is needed and must not be designed to disempower challenged communities if it is solely outcomes based.

33. It will therefore be important to target incentivised outcomes at those groups which are particularly disadvantaged. There is great value in the use of regular health checks for people with learning disabilities. Incentives like this can have an immediately positive effect on inequalities.

The future of the public health workforce (including the regulation of public health professionals);

34. Success of the proposed reforms will be dependent on the engagement and hard work of public health professionals, and care should be taken that their status and working conditions are not unduly impacted in moving them into local authorities.

35. The future of the professionals is perceived as highly uncertain and some loss of high quality medics is already occurring. The lack of clarity about future employment routes for senior medics in the public health profession is causing great concern.

36. It will be of the upmost importance that the functions of the Health Protection Agency (HPA) and the National Treatment Agency for Substance Misuse, when transferred to the Department of Health, retain their independence. If an outbreak of flu or measles happens quickly, it is currently unclear as to who, under the proposed reforms, would be responsible for the management of the situation.

37. The funding of the RCGP Research and Surveillance Centre (RSC) must continue to be provided through the Department of Health (following the abolition of its current funder, the HPA) if major virus outbreaks are to be monitored effectively. In the flu outbreaks of recent years, the centre’s twice weekly reporting and surveillance of influenza-like illness and other respiratory diseases has become increasingly important.

The abolition of the Health Protection Agency and the National Treatment Agency for Substance Misuse

The public health role of the Secretary of State

38. The proposed new powers for the Secretary of State to protect the population’s health are welcomed but must clarify the degree of intended involvement in both strategic and operational Public Health functions.

June 2011

Prepared 28th November 2011