I remember vividly my first big project as a public health trainee. It was a review of orthopaedic services in Gwent, South Wales, where many of the Welsh Valley areas were (and remain) home to significant levels of deprivation and poor physical health. Indeed, the term Inverse Care Law was coined by Dr Julian Tudor Hart whilst studying holistically the care of his own GP population there.
I was expertly mentored by my consultant tutor. We did the usual healthcare public health (HCPH) ‘stuff’ – the disease prevalence, the service provision and cost, the quality, the quantification of the unaccounted patients. We looked at the variability of service provision geographically and, most importantly, in relation to health inequalities. This was traditional HCPH as I knew it – planning for quality, accessible healthcare services proportionate to the population need.
But somehow this didn't really solve many problems – at the time HCPH seemed a much narrower world of possibilities than now. The report we wrote was passed to the Finance Director, who took it to the Board, who decided what services should be commissioned. We weren't invited to the table. How, I mused, would he and his colleagues effectively prioritise investment in one service development over another? Where was the understanding of quality outcomes, the evidence of effectiveness and the disability potentially endured through the absence of an intervention? Who would consider the community infections and connections for these patients?
This was an isolated discussion between ‘health’ and ‘hospitals’. Had we really tried to stem the flow of ill people, reduce the service demand and rebalance the investment in service provision and prevention? For me, healthcare pathways should mean just what they say – a whole journey from primary prevention right through to tertiary level, highly specialist care. Modern PH teams, with all the requisite skill sets combined across different organisations, are now well placed to deliver a new HCPH agenda.
Understanding of HCPH is very variable – but without shared knowledge we are missing opportunities. One definition proposed by Sir Muir Gray for the aim of HCPH, or population healthcare as it is sometimes called, is to ‘maximise value and equity by focusing on populations defined by a common symptom, condition or characteristic.’ If you are new to HCPH you can find more information, examples of HCPH and the most recent HCPH newsletter here. You can also read more about how HCPH links with current PHE work to describe the value of public health interventions more broadly in a previous blog by Kevin Fenton and Brian Ferguson.
The critical factors are that HCPH is a population and complex system approach to care services; has a key commissioning component; and has at its heart a fundamental notion of value. HCPH has sometimes been considered a technical clinical specialty, potentially not relevant as public health now it has transitioned to local authorities. Indeed, during the transition it almost seemed to fall off the public health agenda completely for a time. Now the brevity of its apparent demise is looking much more like a timely and well needed rest before an exciting surge in demand to which PHE is actively responding.
But why is it feeling different?
Firstly, while many of the previous commissioning structures have been fractured in the April 2013 transition, new alignments are bringing new opportunities. Five commissioning ‘types’ now exist – national (NHS England), specialist, CCG, local authority and PHE – but public health practitioners can effectively link all of these together. The HCPH Community of Practice ensures all those involved with HCPH can work together across systems and organisational boundaries.
Secondly, the notion of value is a key determinant of the use of our combined resource for care and prevention services in the current economic context. There’s a focus on specialised services commissioning too - 10% of the whole NHS budget, more than £12 billion each year, is spent on specialised services and PHE is strongly supporting a new review process.
Thirdly, with new NHS Leadership there are strong signals that NHSE’s primary care strategy will change to a more local, community driven system of co-production. With our support, this can align directly with a place and asset based approach to PH for all our communities. You can see what the new NHS England Chief Executive Simon Stevens said at the Annual Conference of Clinical Commissioners last week here.
Now PHE is aligned directly with colleagues in a multitude of external organisations and localities the challenge of making the healthcare pathway a reality has become achievable on a meaningful scale.
Blood borne viral disease such as hepatitis is a good example. Lifestyle behaviours are critical to disease risk and ultimately therefore the need for health and care services. Local authorities, schools, voluntary services, the police are all contributing to the education and harm prevention agenda related to drug taking and sexual practice. Primary care staff in GP surgeries, pharmacies, dental surgeries will be preventing transmission and ensuring effective treatment. Drug and alcohol and sexual health services, commissioned largely by Directors of Public Health, will be seeking to encourage safe use, early diagnosis and early treatment. Microbiologists and their laboratories and infection control specialists (many in PHE) will be providing advice and rapid service response. Hospital services commissioned by Clinical Commissioning Groups and NHS England to provide quality clinical care when people are ill will also have been supported through the actions of their local Public Health Teams and the PHE HCPH and Specialised Commissioning Consultants across the country.
Like most of public health it is the interconnection and complexity in HCPH which offers great opportunities. We can now more easily influence increased investment earlier in the pathway, like the GPs in Reading who have invested directly in interventions to increase exercise as a means of decreasing their service spend on diabetes. Or the weight management project in Rotherham where the town is 18 tonnes lighter in combined weight loss at a fraction of the cost estimated for specialist bariatric surgery and other services related to obesity. We can also support the effective commissioning of existing services, such as through the use of the excellent primary care Commissioning for Value Packs which are jointly produced between PHE’s Knowledge and Intelligence Teams and NHSE. This is not a case of either/or but both – great prevention, great services. The greatest population health wins will be through prevention, but there will always be a need for quality service provision. The trick is working together on a balanced pathway.
Within PHE national leadership for HCPH sits with Professor Kevin Fenton and his team in the Health and Wellbeing Directorate. They work directly with staff from the Operations and Knowledge & Information Directorates based in our Regions and Centres. Of critical importance are the PHE Specialised Commissioning Consultants and the Centre based HCPH Consultants who between them work nationally and locally across NHS, local authorities and primary care. We are developing a governance structure for HCPH within PHE to ensure we maximise all the talents and opportunities across the organisation to support our partners on the current big HCPH issues: Better Care,a new primary care strategy, the financial challenge facing specialised commissioning and more. There is plenty to do and plenty of public health gains we hope to achieve.
But even though you may not be working on the HCPH agenda directly, I challenge you to tell me you are not part of HCPH - everyone can contribute.