Preface: these are Dr Brambleby’s personal views, to stimulate thought and debate, and not necessarily those of NHS Croydon or Croydon Council.
Where will public health sit in the new system?
PB: “Everywhere, I hope! Public health is a way of thinking and a set of tools, not just a group of specialist practitioners. Anyone who takes an interest in populations and not just the person in front of them is by definition a public health practitioner. Or anyone who thinks in terms of health improvement as opposed to healthcare, or in sustainable solutions rather than temporary fixes, or in working with others not just the health professions: they are all in public health.
“That kind of thinking already exists in general practice and local authorities. It even exists in many acute trusts where, for instance, an enlightened diabetologist might take an interest in the diabetic health of the whole catchment population, not just the patients referred to the hospital. Doctors like that make it their business to get out into primary care to sort out standards. They take on the local fast food outlets for reduction in unhealthy fats, and get involved with the local football club’s outreach programme, and so on.
“These people exist in a number of specialities – I’ve seen them in rheumatology, neurology and respiratory medicine - and they are truly inspirational.
“So when it comes to the current crop of directors of public health and their teams, and the public health specialists in academic departments and government departments, the trick will be to seize this opportunity to inculcate the public health way of thinking into the new GP arrangements, hospitals and local authorities, wherever they end up sitting. And not too much sitting either: they should be exemplars of a healthy, active lifestyle!”
What can we learn from successes in public health commissioning under the old system?
PB: “If we can learn from our mistakes as well as our successes, then we will be wise indeed! The NHS is not good at sharing bad practice (in a developmental way): perhaps it should do so more often. We always put on the best possible gloss when the regulators come calling, and we miss a lot of shared learning that way.
“This question goes to the heart of what commissioning is all about or, to risk a cliché, ‘what is the mission at the heart of commissioning’? I believe we should be commissioning for health improvement, not healthcare activity. The gloriously mis-named “payment by results” incentivised activity (and ignored results) so public health commissioning was always going to be up against it.
“I declare a personal bias, but I do think that the health programme budgeting approach, twinned with marginal analysis, offers a ray of hope and is an ideal framework for the future. There is now a substantial alignment between the 20 chapters of the International Classification of Diseases, the PCT annual financial returns published on the Department of Health website, the outcomes data from the National Centre for Health Outcomes Development, the spend and activity data available down to named practice level on NHS Comparators website and the PCT ‘spend and outcome profiles’ issued by the Association of Public Health Observatories.
“It is now possible to ask powerful questions which pull together the agenda of public health, commissioning, finance, patients and clinicians. They are these: “How much does my PCT spend in the major health programmes? What good does that investment do? How do we compare with others? What might we do differently with our given programme budgets next year?” That’s a considerable success. All we need to do is follow through”.
Why did world-class commissioning and GP practice-based commissioning fail?
PB: “This is a loaded question, albeit backed up by testimony and evidence. The findings of the Health Select Committee inquiry into commissioning, published on 30 March 2010, included this quote: “Ridiculous though the term is, much of the World Class Commissioning initiative is unexceptional.” And this on practice-based commissioning: “Commissioners continue to be passive, when to do their work efficiently they must insist on quality and challenge the inefficiencies of providers, particularly unevidenced variations in clinical practice.”
“In my view, the values and competencies set out for world class commissioning were a significant step forward. Where it fell down was on the assurance framework. This was excessively bureaucratic. It diverted PCTs into submitting written evidence of mind-numbing complexity, which were unintelligible to the lay public (and most of the provider side of the NHS). There are 11 competencies, each broken to three sub-categories, and four possible scores – making 132 permutations. No-one can carry that around in their head, so it is of little practical daily use to the commissioner on the ground either.
’World-class commissioning enriched a lot of management consultants and impoverished the service’
“Paradoxically, it stifled a lot of innovation by its sheer complexity and rigidity. World-class commissioning enriched a lot of management consultants and impoverished the service.
“This was a shame really, because we now risk throwing the baby out with bathwater. Much of the syllabus it set should roll forward to the new practice-based commissioners who must now learn their craft. When it comes to assurance, all that commissioners need to ask themselves is: “Am I any good? How do I know? What will I do better today?” Providers might want to chant that mantra too.”
What role do choice and competition have in public health?
PB: “This is a tricky one. It is taken as axiomatic that choice and competition are essential to drive up quality and drive down costs, and that customers are king. But in my limited (and largely unscientific) experience, users of health services don’t want the stress or hassle of choosing (except in florid cases) but want their nearest GP or hospital to provide a good service with a good outcome.
“Healthcare is not a straightforward market, and the usual rules of choice and competition don’t always apply. The demand-supply relationship is complicated by the troublesome concept of ‘need’ (where need is ability to benefit – a measurable change in health status resulting from an intervention). The patient’s presenting complaint (“Doctor I can’t sleep, have a pain, have found a lump, etc”) has to be translated into a need for a specific service by the clinician acting as agent and interpreter - or sometimes, can be met by simple reassurance.
“In fact, I often find patients ask another question altogether, which is: “What are my chances, doctor?” That takes us into the realm of published outcomes, by hospital, team and clinician, and to patient-reported outcomes. That’s what should influence choice.
“As for competition – I’m ambivalent. It is nice to know there is an alternative when a provider is being inflexible, obstructive or over-charging, but the majority of healthcare is best done as a collaboration. Inter-dependent clinicians in primary and secondary care should co-operate to shape patient pathways to meet local needs within a given budget. Clinical governance and scrutiny of outcomes should cover the whole pathway, with collective as well as personal accountabilities. That requires collaboration, not competition.
“Continuity helps too, because change takes time. And it really jars to read ‘commercial in confidence’ stamped all over documents that relate to public funds on public services.
“Both choice and competition come at a cost. Generally they require, or result in, spare capacity. That is waste we can ill afford.”
How will commissioning of public health interact with GP-led commissioning consortia?
PB: “This is the big challenge for public health departments in PCTs and SHAs (and public health observatories too). They cannot expect to be at the table as of right – they will have to make themselves indispensable.
“Those who have already established their visibility and credibility will find this easy – others will have to prove themselves, and they had better get on with it. The future is approaching fast, and the future is not what it used to be! In fact, the future is here already – it is just distributed unevenly.
“But the synergies and opportunities are huge. One of those opportunities will be to build bridges into the local councils. We could, and should, drop the pharmaco-medical model where a better one exists. We could de-medicalise a lot of healthcare and change patient expectations, for example in management of sadness, anxiety, chronic pain, and dying, and we should put effort into housing, recreation, jobs, transport, walking and cycling, allotment gardening, creative arts, and education.
“Healthy living centres and polysystems could lead on this. Imagine having Citizen’s Advice Bureaux adjacent to GP surgeries so the older patients or pregnant mums can get a wealth check alongside a health check.”
Local government is going to lose 25% of its funding under the new Budget. How will this affect public health?
PB: “Arguably, there could be a bigger adverse impact on public health from taking money out of councils than taking it out of the NHS. It depends where the inefficiencies are, and where the money can be extracted at least adverse impact.
“Councils are in the business of promoting enterprise, learning, culture, outdoor spaces, exercise, built environment, transport, policing, social services, alcohol licensing, drains, and so on – all of which are determinants of how well and how long the citizens will live.
“Contrast this with the NHS role in care and repair, where nearly half our expenditure is locked in to the last year of life. But here’s a proposition. It’s not what we cut from our local authorities or the NHS matters, but what we spend. This gets more and more true the bigger the deficit. So in this scenario, the challenge is how to spend our 75% to better effect, not how to cut 25%.
“At that level of change, it might be worth re-thinking our contract with the public entirely rather than trimming existing budgets and former ways of working to that which is merely affordable. Necessity, on this scale, will be the mother of all inventions. Take for instance libraries. Libraries are important to public health for a host of reasons, but must they be expensive book repositories, plus or minus a few internet stations? Why not have a computer terminal or two at every health centre and order books (if that’s what you want) delivered like Amazon does, through the post?
“And so on. Has your local council set out its priorities or “vision”? If so, see how those map onto deployment of resources (we are back to programme budgeting here) and look at spending what it has at its disposal to better effect, against those objectives.”
Do you think GPs really want to ration care?
PB: “They already do! It’s just a question of how. Rationing is used as a pejorative term but it began as a positive concept – a means of fair shares to the maximum number of beneficiaries when resources were scarce. A ration book in the post-war years of austerity was a list of your entitlements, not what you couldn’t have.
“So I would rephrase this question thus: “Do GPs recognise the opportunity cost of what they do, and do they want to take responsibility for it?” For that to happen, they need regular feedback on their activity, their outcomes and their expenditure – all adjusted for the need of the practice population. They also need to know how they compare against the PCT or other norms, or better still, against comparable practices.
“Here again there is a role for ‘programme budgeting’ as a framework – telling coherent stories about, say, the respiratory programme, where a combination of smoking cessation performance, use of diagnostics, pattern of prescribing and admissions to hospital, compared with peers, might point to a better spread of activities and use of resources. Who does it best?
“And that is rationing. No-one else is better placed (certainly not the PCT, hospital or government) to assess need, decide on the appropriate response, commit the resources and assess the quality of the outcome. GPs can and do ration care. Public health can and do help at every point in that process.”
The new system fundamentally accepts that some clinical commissioners will make a healthcare pound go further than others – a “postcode lottery”. How will this affect public health?
PB: “It is not a lottery. In fact, a lottery is about the only thing we haven’t tried yet in healthcare. Lots of schools now do it to select their pupils, so watch this space! In a lottery, the participants have a small and entirely random chance of winning. We are talking here about a systematic and certain chance of getting a ‘yes’ or ‘no’.
“But is variation bad? If there are innovators who are successful in making the pound go further, let them open up a gap - but let them share the learning, so the rest can catch up.
“And if there is genuine engagement at local level, and needs or priorities vary between localities, then variation can be justifiable and even be a positive indicator of a locally sensitive, locally responsive system. If there is to be no variation at all, we might as well have central diktat and do away with commissioning altogether.
“We will never eliminate inequality. Think about it. We will never have every baby born at the same birth weight, and everybody dying at the same age, and everybody having diabetes or never having diabetes. It is ridiculous. We all have different inherent life trajectories, embedded in our genes.
“The challenge is to allow each individual to realise their best span of quality of life and length of life. It is the avoidable inequalities in health and unjustifiable variations in delivery of care that matter.
“And to conclude on the pound-stretcher point, it is an ethical imperative for clinicians to pursue efficiency, because the price of their inefficiency is paid by the public, and the currency in which the public pay is avoidable distress, disability and dying before their time.”