Improving the public health/primary care partnership: a perspective from NHS Hounslow

Why this matters to me

It is still not clear how the public health workforce will work with future clinical commissioning groups. Is it enough we are told that ‘Public Health England will ‘ensure appropriate population advice is available to the NHS’? Should we wait until we are invited? Should we wait until we are told what to do? The public health workforce should aspire to be central to population health, from prevention to care pathways through to establishing outcomes and evaluation measures, and to exert influence beyond the joint strategic needs assessment. In Hounslow, public health is currently an integral part of the workforce in both the local authority and the emerging clinical commissioning group, providing an example of the so-called ‘public health core offer’. This is an example of public health working in new ways, building effective and lasting partnerships across primary care, social care and all public health boundaries.

Abstract

The purpose of this article is to set out the importance of the public health role for clinical commissioning groups as they develop their role as commissioners and work to improve health and reduce inequalities. The article describes the experience of Public Health Hounslow that supports the local authority (Local Borough of Hounslow) and the emerging Hounslow Clinical Commissioning Group (HCCG). I review the roles of public health and primary care within the context of the current NHS reforms, and set out the rationale for the best ways to facilitate public health/primary care partnerships.

Common purpose between public health and primary care

Winslow's definition of public health is one of the most commonly cited

the science and art of disease prevention, prolonging life, and promoting health and well-being through organised community effort for the sanitation of the environment, the control of communicable infections, the organisation of medical and nursing services for the early diagnosis and prevention of disease, the education of the individual in personal health and the development of the social machinery to assure everyone a standard of living adequate for the maintenance or improvement of health.¹

We highlight the first line because it explains why primary care and public health need to be in partnership – both are concerned with the ‘science and art of disease prevention…’. Primary care practitioners contribute to this science and art through personal care and medical care, whereas public health contributes through ‘organised community effort…’.

More recent definitions of public health have restated Winslow's emphasis on health protection, promotion and prevention, and collective social activities to improve health.^2,3 Childress⁴ offers a definition that emphasises knowledge management, ‘the collection and use of epidemiological data, population surveillance, and other forms of empirical quantitative assessment’ to illuminate the ‘multidimensional nature of the determinants of health’.

The need to harness public health and primary care contributions to health has been internationally acknowledged ever since the World Health Organisation's 1978 conference in Alma Ata.⁵ But this is often easier in theory than in practice because partnership working requires creative interaction – shared endeavours in which each discipline contributes to a programme of work that is beyond what either could achieve on its own.

This article outlines the current NHS reforms, and then builds an argument about the best ways to facilitate public health/primary care partnerships using the experience of public health in NHS Hounslow.

NHS policy for public health and primary care

The government's NHS White Paper: Equity and Excellence: Liberating the NHS⁶ outlined NHS reforms that involve general practitioners (GPs) taking over responsibility for commissioning the majority of NHS services in England. By April 2013, GPs will join other health professionals in clinical commissioning groups (CCGs), supported by and accountable to a new independent NHS commissioning board (NHSCB). CCGs will take over the responsibility for commissioning health services, including planned and emergency hospital care, rehabilitation, most community services, mental health and learning disability services. CCGs will also be responsible for engaging with local people to ensure that the services meet their needs.

The changes also see certain public health functions (mental health promotion and prevention, nutrition, physical activity, obesity programmes, substance misuse and tobacco control) being transferred to local authorities, and the setting up of new health and well-being boards (HWBs). Under these plans, public health budgets will transfer to local authorities through ringfenced grants.

Public Health England will be created as an executive agency and will take the lead on the provision of health protection, emergency preparedness and functions as the hub for public health intelligence, bringing together the work of public health observatories and the cancer registries. Nationally, Public Health England will work closely with the NHSCB to provide evidence and intelligence, ensuring effective approaches are in place for the delivery of public health outcomes. A health premium will incentivise improvement against a subset of indicators from the public health outcomes framework due soon. This health premium will be paid to high-performing CCGs and local authorities, and will focus on quality and outcomes rather than financial performance, taking into account reduction in health inequalities.

Locally, directors of public health will be able to advise the local CCGs on public health issues through HWB or through the provision of intelligence and data on population health issues as part of a core public health offer. To ensure joined-up commissioning at a local level, local authorities and CCGs will each have an equal and explicit obligation to prepare the joint strategic needs assessment, and to do so through the HWB.

The reforms also place duties on the NHSCB and CCGs to obtain an appropriate range of clinical advice from the new clinical structure ‘Clinical Senates’ – multidisciplinary representation, which will also include public health.

But how can this work locally?

The updated White Paper; Healthy Lives, Healthy People: Update and Way Forward⁷ was not decisive on how local authorities will provide public health advice to CCGs as part of the core public health offer, or how this will happen in practice. It is not clear what is the exact nature of this ‘offer’.

I identify three ways that the reforms risk reducing the efficacy of the public health functions, weakening its beneficial impact on the health of populations.

CCGs risk losing public health support for healthcare commissioning

Moving public health into local government carries advantages bringing together health improvement with other local authority responsibilities, but the challenge is to make sure that the NHS does not lose out as a result. Since 1974, when public health responsibilities were removed from local authorities and transferred to the NHS, public health has provided knowledge management support for commissioners in primary care trusts (PCTs). In many PCTs, public health worked closely with NHS commissioners to conduct needs assessments, impact assessments of new services and evaluated service outcomes. They have measured disease burden, helped decide local priorities and designed care pathways. As public health moves entirely to the local authority it may become more difficult to nurture and/or continue this relationship.

CCGs risk loss of the health improvement function

As CCGs inherit the core functions currently vested in PCTs to improve population health and address inequalities,⁸ they will need to give due weight to achievement in health improvement, and to prevent health improvement from dropping down the agenda against the usually highly rated clinical outcomes. Public health supported PCTs through the establishment of ‘managed public health networks’⁹ and local strategic partnerships that linked multidisciplinary professional groups across organisational boundaries, for the common goal of health improvement. Although CCGs may aspire to collaborate with community groups, schools and others to improve community health, GPs are often not familiar with health promotion and have limited experience of community development activities.¹⁰ They may not have the time or experience to be successful. By contrast, local authorities naturally prioritise horizontal integration – the domain of social cohesion.

Public health services risk being fragmented across local authorities and CCGs

The updated White Paper gives some public health services to local authorities, such as the promotion and prevention of long-term conditions, nutrition, physical activity, obesity programmes, substance misuse and tobacco control, while maintaining the CCG's lead role in immunisation, screening, HIV treatment and contraception.

In long-term conditions, for example, responsibility is given to the local authority to provide activity data on behavioural and lifestyle campaigns to prevent cancer and long-term conditions, while commissioning medical care is provided by GPs and specialists. How will the two organisations work together? How will they address issues of prevention and chronic disease management, and support self-management and provision of brief interventions in primary and secondary care while services are commissioned by separate bodies?

What are we proposing here?

Strengthening the public health function in primary care through being an integral part of the emerging CCG is an option that we have adopted in NHS Hounslow. Public health specialists are located both within the local authority and HCCG. The purpose for public health is to combine their resources to support commissioners, both with primary care providers and local authorities in new and effective ways that move primary care services closer to the ambitions of Alma Ata:

1. Better understanding of health inequalities. Public health could work with local authority data and social networks to understand the local population in deeper ways than ever before, creating ways to bring to the attention of commissioners the lived reality of vulnerable groups, and from this, identify high-quality services that improve health outcomes for the most disadvantaged. Gillam, in this issue, describes ways that this has been done under the banner of ‘Community Oriented Primary Care’.

2. Coordinated health improvement campaigns. Clustering general practices into locality groups provides the opportunity for them to contribute to health promotion campaigns that are led by public health and local authorities. General practices can lend their waiting room walls and authority to reach patients, while the work of mounting the campaigns is done by others. This could also help to support relationships between GPs for a range of other purposes, including peer-to-peer review and the university-linked localities proposal described in this issue.

3. Integrated health and social care commissioning. Public health can help develop whole system pathways of care that includes prevention programmes to ensure early diagnosis and improve outcomes, especially for long-term conditions.

4. Better horizontal integration. Local authorities support a range of networks and community groups who could help support local communities for health that includes primary care functions. Public health could link the work of school nurses and primary care staff, with obvious benefits for childhood immunisation uptake rates, identification of family distress at an early stage and support for mental health tier one universal services.

Conclusion

The new NHS reforms have major technical, organisational and professional implications for the way both primary care and public health will operate in the future. There is great opportunity for public health to consider the balance of their responsibilities in terms of prevention, health improvement and public health intelligence to work in partnership with local authorities and emerging CCGs to improve local population health. Public health interest in this partnership should stem from their interest to improve health and social outcomes and to reduce inequalities. Primary care interest should be in respect of their new responsibilities and the benefit of maintaining public health involvement in NHS commissioning and their access to public health advice at no cost. A public health/primary care partnership will ensure public health services are not fragmented and bring further integration of service provision closer to the vision described at Alma Ata.