To all Chief Executive of Strategic Health Authorities
15 September 2005
Dear colleague
Following the document entitled: ‘Commissioning a Patient-Led NHS’ and the subsequent communication from John Bacon, we are contacting you to highlight our concerns over the potential risks and opportunities relating to public health in the proposed reorganisation.
Commissioning a Patient-Led NHS sets out a requirement to achieve the ‘right configuration for commissioning and the right people in the right places’. It reiterates a commitment for Primary Care Trusts to ‘improve health and reduce health inequalities’ for local populations, states that NHS Foundation Trusts will have a duty to contribute to health improvement in local communities, while Strategic Health Authorities will focus on the performance management of the NHS local public health function.
We are keen that as you approach the development of your response to ‘Commissioning a Patient-Led NHS’ you realise the potential opportunities for utilising public health to maximise existing partnerships around issues such as health improvement and health protection as well as the potential to reduce the long term burden of health through the implementation of Choosing Health.
John Bacon outlined the importance of economies of scale, while reflecting on the realities of delivering such proposals in such a short time scale. We would support taking the opportunity to review coterminosity with local authorities, where the population and local political structures are appropriate, and we particularly want to highlight the potential for joint appointments and teams across organisations. Such models have been successful in areas such as London where coterminous PCTs and Local Authorities have enabled close working relationships and the potential to share common infrastructures across organisations with inherent cost-savings.
As you are aware, much of the delivery of Choosing Health relies upon close working between local authorities and health services around areas such as education, transport, leisure, housing and regeneration strategies. In addition, threats such as flu pandemics require close partnerships between organisations both during planning and implementation of response strategies.
By ensuring that that a PCT retains a core public health team there will be a capability to build on local government relationships and extend to these voluntary and private sector engagement. Although there is undoubtedly a period of change and reorganisation approaching we feel that the critical public health functions around community development, emergency planning and infectious disease control must be maintained, to ensure that should we experience similar catastrophic events as those recently experienced in New Orleans, that we are resilient and responsive.
We are writing to remind you that many in the public health field are of the view that the most sensible basis for the organisation of the public health function is through the appointment of a Director of Public Health to the population of a management unit of a local authority. There is evidence that in districts where this has been a stable model of organisation for some time, they have been able to make sustained progress in addressing health inequalities. There are three reasons for this:
- Local government is itself an important contributor to the public health agenda
- Local government areas tend to be the source of local identities and civic cultures
- Many very important public health activities, such as community development and emergency planning need the stability that changeable NHS boundaries do not give
The Department’s document did however indicate that in some cases a PCT might cover a group of unitary authorities. Where this is the case we believe that a separate Director of Public Health should be appointed for each of those authority areas. This will assist you in meeting the requirements in the subsequent letter from John Bacon, that where this option is chosen you should identify how you will maintain effective working with local authorities. The key responsibility for partnership working could appropriately be placed upon the Directors of Public Health appointed to the different local authority areas.
Conversely, the document also indicated that a large local authority may be divided into several PCTs. We are not convinced that there is any unitary local authority for which this would be sensible, and it may well be that the letter had county councils in mind. If however you are minded to take a large city council and divide it into multiple PCTs we would strongly urge that they should share a DPH.
Sometimes the adoption of this approach will lead to public health departments serving large populations and sometimes smaller populations. Within public health, as within the rest of the structure, it will be necessary, as the Bacon letter emphasises, to find ways to overcome the problems of any chosen model. Small PCTs will need to share support functions and work together on strategic commissioning, although it is important that this is done through coherent structures rather than amorphous networks. Large PCTs will need to devolve internally to relate to practices and to local authorities. Similarly, small public health departments will need to work together to deliver the public health input to strategic commissioning; large departments will need to look at how to deliver public health advice to practices and neighbourhoods.
We are aware of various examples of good practice and we are also aware of some interesting ideas for new models of organisation, including the idea of Public Health Trusts and the idea of Directors of Public Health as corporations sole. The issue of the input of public health into Foundation Trusts also arises. We are currently working on a document drawing these strands together which we hope to send it to you shortly.
We appreciate that this is a complex challenge and there are no simple solutions which will be appropriate across all of England, however we think there a huge opportunities to develop and reform local health services to work in a positive relationships with local government and agencies. We hope that you will find these observations useful in your deliberations and would be more than happy to engage in more detailed discussions around your local situation if you feel this would be helpful.
Yours sincerely
Dr Peter Tiplady
Chairman
Committee for Public Health Medicine and Community Health