My notes from a recent Duncan Society event ‘The future of Public Health in England’Professor John Ashton, Director of Public Health and County Medical Officer – Cumbria and Chair of United Kingdom Public Health Association (UKPHA)
Maggi Morris, Director of Public Health at NHS Central Lancashire
Venue: Quaker (Friends) Meeting House, Liverpool
(NB these are my notes, not a complete transcript and should not be used for navigational purposes)
Neil’s summary: The main message was that we're going back to a similar arrangement to the past. But with modifications which may yet prove successful. Although big society is nothing new, Maggi suggested that this could encourage development of asset based community development (Chicago-style). John was enthusiastic about Health and Wellbeing boards harking back to Chadwicks original idea, which never got off the ground.
I thought an interesting point that John made was that this may be successful even if not all GPs want to be leaders and budget-holders etc. All it needs is a minority of keen and 'progressive' GPs to take on that role and this peer-leadership structure may be respected by the majority of GPs. i.e. it may be a more effective way of engaging GP's than the PCT arrangement (On the other hand they may turn into way-overpaid managers!) Maggi suggested this may be a way of encouraging GPs to focus more on prevention - and highlighted Sokrates course at LJMU that she developed with Mary Lyons - where they were able to support GP's to do PH training with locum provision to give them enough time to do some service reorganisation towards PH.
My interpretation is that spirit of all this is:
let's make the best of a bad job and
with a little luck we may be able to get some extra gains out of this.
JA
Bit of organisational history:
In 60’s and 70’s: 5000-6000 people under medical director in council
This generated silos as people wanted their own space
then same people moved to PCT
Important to include all social and health practitioners within PH
even RSPCA officer can have PH role – also important for health and social
Inbalance in remuneration: Newlands (engineer), £800, Duncan (medical officer) £300, Fresh (nuisances) £150pa
Sanitation – separating human / animal waste from drinking water and food
founding (and organising) principle in development of PH
maybe this needs to change now
What good things could come out of restructure:
John thought that Health Action Zones might be start of board of health.
Chadwick started this, but only lasted a few yrs
Could board of health and wellbeing be what we’ve been aspiring to?
Link between poverty and illhealth – almost a litany – rehearsed almost without meaning
lifecycle approach is good
can’t get rid of poverty, but can minimise impact of poverty
Bismark – took action to increase equality – started welfare benefits
John’s previous TV documentary in Weller St in Dingle, for healthy cities - interview with Kitty – her idea of health‘a nice house, some food for the kids and a bit of money in my pocket’.
Lack of ‘ownership’ of programmes –
noticed refurbishment of social housing every few years as tenants didn’t feel commitment to neighbourhood
Reframe the 5 giants
marmot’s 6
problem is high level of abstraction – but the mood music is welcome
minimum wage moved on to liveable wage
John (UKPHA) calls for fundamental change to energy fee structures to tackle fuel poverty
standard charge – everyone pays
first 1000 most expensive
so poor pay more, relatively
many excess winter death due to keeping one room warm downstairs
need to change to progressive charges
also added benefit of sustainability
Ownership and locus of control – paternalism no longer fit for purpose
need to engage with this discussion – big society etc
Whether a slimmer public sector rolling back the state Tea party style
or transforming to an enabling, supporting, active citizenship,
NHS started as tripartite system, hospitals community and local govnmt
future: GP/hospitals (some PH), PHE – programmes, dPH wellbeing agenda (local govnt)
i.e. PHE sitting between GP and local government
dPH and wellbeing board may have to take a semaphore stance –
pulled in two directions – one arm up - accountable to minister, one arm sideways – accountable to local government.
local board of H&W – representation of GPs
local authority sponsors
postmodern formula, fragmenting and trying to bring together again.
interdepartmental parliamentary committee at top – but how effective can this be?
Maggi Morris
Civic society inversely proportional to inequality
immunisation discussion – responsibility and control will be within health and wellbeing board
COPC – community orientated primary care – comprehensive engagement
GPs resistant to this idea at the mo. due to case load and business model
Sokrates programme (LJMU) started to get GPs onto the programme with locum cover, to enable them to reorganise their services to improve prevention
Smokefree Liverpool, Manchester and other boroughs bottom-up approach – experts came in when necessary
Q&A
NC – Maggi made an interesting point about immunisation decisions being made locally? I’ve done a bit of an analysis of the PH white paper and for every statement about localisation there is another statement on centralisation. The policy states it’s aim is localisation but do you think this is likely to happen?
JA – similar to comments on dPH being pulled in two directions – there are conflicts
described arrangement as in three columns and two (or three) rows
columns (accountability from minister): Public Health England, Health and Wellbeing Boards, and GP consortia
rows cross-cutting work locally – mainly through H&W board, cross-cutting in government, will there be some regional working as well (not called regional though!)
Question – return of old system?
JA - likely to see return of regional hospital board – health commissioning board – subnational or supralocal
JA - GPs become deskilled in cities – because they can just send them up the road to the consultant no change since Acheson
partly what Darzi reportt about
Question – at a mental health meeting there were concerns for champions for community engagement
4 GP seriously interested in mental health – only one of which attended meeting
patchy interest of GPs?
JA – JSNA will have to be delivered by consortia – held to account by H&W board
White paper: ‘GP consortia and LA equal and explicit obligation to prepare JSNA through H&W board’
at the moment the biggest variation in service is in general practice
but these changes may be transformed if GPs take leadership from their peers who are keen to develop leadership
needs can’t be met in ‘hospital style’ approach which we have at the moment
need radically different – primary care approach
MM – Asset Based community Development (ABCD) – in US,
often in impoverished neighbourhoods
idea of developing resilience
Marmot – and white paper – communities that lack aspiration are hit hardest
and lower life expectancy etc
JA – economic decline of West relatively – rebalancing of global power
even more important that social institutions are strong
insist on value for money from public service
MM - Margaret Mead – “history is not a pendulum – it’s a helix”
MM – should publish GP wages and all add-ons
A couple of interesting references:
Local Government Association 'The Health of the Public'
King's Fund, Chris Ham's blog 'Ten Questions to ask about the Health and Social Care Bill'
