Introduction
The coalition government (2010–15) policies since 2010 highlighted the potential for greater GP involvement in public health. The changes to the structure of the NHS and to public health oversight introduced in April 2013 were designed to strengthen local public health, although the extent to which this will support and increase GP involvement is not clear. The combined implications of the government’s proposals for public health in England set out in Healthy Lives, Healthy People37 (and subsequent consultation papers) and the changes contained in the Health and Social Care Act 201221 on the structure and delivery of public health in England have been enormous. In this chapter we discuss those implications which have a direct impact on the public health role of general practice. In the White Paper and other public statements, the government outlined an increased role for GPs and general practices in public health. GPs and their practice teams have a crucial role in promoting health and preventing disease. Each year there are over 300 million consultations with primary care professionals – the majority with GPs but increasingly with practice nurses and other practice-based healthcare staff – with every consultation an opportunity to detect early warning signs that prevent illness and disease.18 This was recognised by the coalition government of 2010–15 in its White Paper on public health arguing that GPs ‘have huge opportunities to provide advice, brief interventions and referral to targeted services through the millions of contacts they have with patients each year’ (p. 61).35 In addition, since January 2012 there has been a call to NHS professionals to ‘Make every contact count’449 in a campaign to improve public health via every contact between a NHS professional and the public. As well as all aspects of primary and secondary prevention, there has also been an effort to incorporate the guidance into wider aspects of public health such as homelessness.450 Furthermore, in 2011 the DH published the Health Visiting Implementation Plan,98 which proposed an increase in the health visitor workforce by 4500 new health visitors by 2015, with the concomitant emphasis on public health outcomes for children and families at all levels.
However, how these roles are developed, supported and sustained within the new public health and commissioning structures of the NHS in England is still not clear. The development of CCGs, new public health commissioning and delivery roles for LAs, and an expanded national public health role through PHE as well as a public health commissioning role for NHS England create a new and potentially more complex commissioning and service delivery environment for many public health activities in primary care.36,98,451 There are particular concerns about the fragmentation of public health functions and service delivery agencies, the distribution of resources between responsible agencies and how proposals for commissioning and organising public health will provide a cohesive and co-ordinated public health system with a clear general practice role. The aim of this chapter is to set the context of this review within the recent changes to commissioning and public health introduced in April 2013. The chapter provides a critical analysis of the organisational changes and policy implications of the Health and Social Care Act 201221 as they relate to the organisation and delivery of public health within general practice.
The changes
Until April 2013 public health was delivered through a number of different mechanisms:
DH – setting policy and funding a number of health intelligence programmes including the observatories and cancer registries
government offices
National Treatment Agency for Substance Misuse – drug treatment monitoring
strategic health authorities – strategic oversight and performance of each region
PCTs – commissioning of programmes to deliver health service outcomes/joint commissioning with LAs
provider trusts – delivery of public health programmes, for example community services
LAs – a number of different services provided by local government that have an impact on the public’s health such as environmental health, leisure, planning, housing
Health Protection Agency – health protection services.
Following the Health and Social Care Act 2012,21 most of these organisations either were abolished or have taken on significantly different responsibilities. In addition, new commissioning and public health organisations have been established. The key strategic changes are as follows:
Strategic health authorities were abolished at the end of March 2013.
PCTs were abolished at the end of March 2013.
PHE was established in April 2013, encompassing the National Treatment Agency and Health Protection Agency, and is responsible for a number of health intelligence functions including the cancer registries and regional observatories, and former government office functions.
Ring-fenced budgets for public health have been allocated to LAs: unitary authorities and upper-tier authorities (i.e. county councils, not district councils). Directors of public health are employed within these authorities and are joint appointments between PHE and the appointing LA.
CCGs are now responsible for the commissioning of secondary and community-based health care.
NHS England (a national commissioning organisation) is accountable for CCGs and oversees the commissioning of specialised services and primary care services (GMS contract).
A range of provider organisations (‘any qualified provider’) including foundation trusts, charities, independent sector and social enterprise.
In Healthy Lives, Healthy People,37 the government proposed key changes to the provision of public health. The two key changes involved the establishment of PHE in April 2013 and the transfer of local NHS public health responsibilities to LAs. PHE is responsible for funding and ensuring the provision of a wide range of services such as health protection, emergency preparedness, recovery from drug dependency, sexual health, immunisation programmes, alcohol prevention, obesity, smoking cessation, nutrition, health checks, screening, child health promotion (including those led by health visiting, school nursing and general practice), some elements of the GP contract (including parts of the QOF such as those relating to immunisation), contraception and dental public health. It does not have direct commissioning responsibility but will grant funding to LAs and it will need to work through NHS England to commission services, such as screening services, and the relevant elements of the GP contract.
The 2010–15 coalition government announced its intention in The Coalition: Our Programme for Government35 that the DH would strengthen the role and incentives for GPs and GP practices on preventative services, both as primary care professionals and as commissioners. There was a recognition that primary care professionals, GPs and GP practices play a critical role in both primary and secondary care prevention. Key areas highlighted by the government were practitioners’ opportunities to provide advice, brief interventions and referral to targeted services through the millions of contacts they have with patients each year.37
Healthy Lives, Healthy People37 (para. 451) sets out specific ways by which the DH intends to strengthen the public health role of GPs. These involve a mix of support and incentives:
PHE and the NHS Commissioning Board will work together to support and encourage CCGs to maximise their impact on improving population health and reducing health inequalities. This includes looking specifically at equitable access to services and outcomes.
Information on achievement by practices will be available publicly, supporting people to choose their GP practice based on performance. By increasing transparency about how effective different GP practices are in giving public health advice, PHE will enable local communities to challenge GPs to enhance their performance.
Incentives and drivers for GP-led activity will be designed with public health concerns in mind, for example in terms of prevention-related measures in the QOF. To increase the incentives for GP practices to improve the health of their patients, the DH has proposed that a sum at least equivalent to 15% of the current value of the QOF should be devoted to evidence-based public health and primary prevention indicators from 2013. The funding for this element of the QOF will be within the PHE budget. However, in 2013/14 this has not translated into many additional or different indicators.
PHE will strengthen the focus on public health issues in the education and training of GPs, nurses and health visitors as part of the DH’s development of a workforce strategy.
These changes have had a significant impact on general practice and its public health role. In particular, five changes potentially increased both GPs’ needs for public health knowledge and practices’ need to increase their provision of health promotion and disease prevention services. The changes also provide significant challenges.
The now abolished PCTs were responsible for the GMS contract and supporting local practices. The PCT also provided public health support to local practices and delivered some health promotion services such as specialist smoke-stop and sexual health services for young people. In many areas, PCTs developed additional prevention services in collaboration with practices funded through LES within the GMS contract. It is not clear how the new system will continue such support.
With the abolition of PCTs, newly created LA Health and Wellbeing Boards (HWBs) now have to make decisions about public health priorities for their geographical area. GP representatives from CCGs sit on these boards, and they will probably be expected to contribute to the understanding of what the local health demands are, as well as the ways that general practice and other primary care services can improve health outcomes in these areas.
General practitioner-led CCGs have taken over the commissioning role of PCTs. This could include some public health commissioning, although the details of which will depend on what NHS England chooses to ‘pass down’ to them. Commissioning public health services will require knowledge of how and where these services are best delivered.
There is a new Commissioning Outcomes Framework which will be used by NHS England to assess CCG performance. The aim of the framework is to allow NHS England to identify the contribution of CCGs to achieving the priorities for health improvement in the NHS Outcomes.
The QOF will be adjusted so that 15% is made up of evidence-based public health and primary prevention indicators by 2013.
36 While the substance of these changes remains unclear and no change has yet occurred, GPs should be preparing for a shift towards payments for prevention.
Although funding for public health will be ‘ring-fenced’, overall budget cuts may increase the focus on prevention rather than expensive treatments, a shift which is likely to extend to general practice. Whereas in the past such pressures within PCTs have tended to squeeze out public health expenditure, the protected LA budget will not be at risk of being shifted towards clinical services.
General practice and the new commissioning arrangements
The emphasis on CCGs being responsible for the well-being of their whole community and the stronger role of the HWBs was recommended in the NHS Future Forum report449 and ensured that public health became a shared responsibility across local commissioning organisations. However, the splitting of public health resources across general practice, CCGs, LAs and PHE/NHS England presents new challenges for the organisation and delivery of public health in England. For example, drug, alcohol and mental health services will all be commissioned via LAs. From 2015, LAs will also commission the health visiting services, which may have the effect of separating health visiting from the general practice population. These important public health challenges often overlap and are best dealt with by joint services, which may include GPs and community health professionals in shared-care arrangements if locally appropriate. These services are a good example of how, by commissioning similar public health services by one body (in this case, LAs), there can be streamlining of service delivery and inclusion of GPs where beneficial, but this grouping together will be effective only if there is enough funding to support these joint endeavours.
Commissioning has been split between local and national commissioners. While NHS England has local offices, co-ordination between commissioners is important. It is also be important to ensure that CCGs and GPs more generally are linked to broader public health commissioning arrangements. For example, public health services for children aged under 5 years, which include pre-established programmes and services that fall outside the NHS, are contracted centrally by NHS England, but GPs play a huge role in the care of under-5s and work collaboratively with local health visiting teams and other community staff, who also work closely with LA and third sector organisations – all of which are commissioned by different bodies. It is not clear how the necessary linkages are being made between GPs and community services (and local council services) when it comes to the local organisation and delivery of care and prevention programmes to under-5s.
Some degree of co-ordination will possibly be achieved through CCG representation on HWBs. The boards are seen as key to co-ordinating the local health system:
The joint local leadership of CCGs and local authorities through the health and wellbeing board will be at the heart of this new health and social care system . . . [and] enable greater local democratic legitimacy of commissioning decisions, and provide an opportunity for challenge, discussion, and the involvement of local representatives.
p. 115451
Clinical Commissioning Groups have an avenue, therefore, to be involved in local decisions about public health resource allocation – an important way of maintaining GP involvement in public health. Concerns about CCG access to public health support were raised in discussions with GPs and CCG staff, and also identified in research on the early development of CCGs.334
However, the most dominant role of the CCG is in commissioning secondary care services, which provides a new set of challenges as well as opportunities for improvement in public health and ill-health prevention. Research on practice-based commissioning found that GPs focused more on preventing ‘unnecessary’ hospital admissions than on primary prevention.452 Analyses of previous primary care commissioning similarly found GPs used traditional models of general practice and did not address key public health problems.57,76,258,453 However, this is not a reason to take public health out of GP commissioning responsibilities. In fact, researchers have suggested that GP budgets for commissioning health services be aligned with budgets for commissioning public health.454 On a more positive note, it is possible that, by giving CCGs responsibility for standard health service commissioning as well as some public health services, they may be forced to think more broadly about their communities. CCGs should have responsibility for, or at least be directly involved in, commissioning those public health activities that most closely relate to the ones they provide themselves via the GP contract (such as contraception services and cervical cancer screening). Aligning these responsibilities puts GPs’ existing knowledge of service provision to work, and helps to ensure that patients have access to the most streamlined pathways for these services (as well as the best-quality ones).
One key area of public health activity is the support for commissioners. Systems developed within PCTs for supporting GPs with epidemiological analyses are likely to have been substantially disrupted with changes to public health departments. New relationships, systems and processes need to be developed to provide what is critical support for the new commissioning bodies. Additionally, this is being done at a time when new organisational structures for public health are being established in LAs, placing further strains on developing relationships.
There is continuing tension around the relationship between general practice commissioning and public health. The evidence from previous approaches to primary care-led commissioning suggests that public health has not been a priority for GP commissioners.453 The development of primary care groups and, more specifically, PCTs did start to embed a more public health perspective in commissioning, but current changes to both public health and health-care commissioning may simply exacerbate what has often been a troublesome relationship between GP commissioners and public health.77,453
The General Medical Services contract and public health
Currently many public health activities in primary care are supported by the GMS contract. There are three funding strands:
core standard tasks – expected in normal practice (advice, information, etc.)
aspects of the QOF
Local Enhanced Service elements of the contract.
Where clinical services are closely linked to public health activities such as screening, immunisation, obesity and sexual health services, part of the service is being provided by GPs as part of the GP contract (cervical cancer screening, childhood and elderly vaccinations, and contraception services), but other, similar services are being commissioned by LAs or NHS England (i.e. additional cancer screening, booster vaccinations, sexually transmitted infection screening and treatment, and general screening such as the NHS Health Check). This could lead to a situation where similar services that can be most effectively provided side by side (most obviously, contraception and sexually transmitted infection services) may be available from different providers because they are commissioned by different groups. Greater co-ordination of commissioning and service delivery will be essential. Thought needs to be given to arrangements for lead commissioning with the flexibility such as that available between the NHS and LAs under the 1999 Health Act455 for partnership funding for the commissioning of all aspects of key prevention services by one commissioner.
Local Enhanced Services have been particularly effective in involving GPs in locally driven public health efforts supporting a wide range of evidence-based public health activities, such as identifying CVD risk and providing long-acting contraceptives, and in 2009/10 they accounted for some £370M.34 Having the option of LESs in the contract has provided a way for GPs to reduce preventable morbidity, and it could continue to do so in the future. This option would be especially helpful in the context of a more diverse provider landscape. However, many of the activities currently funded through LESs, including sexual health, smoking cessation, prevention and treatment of alcohol misuse, falls prevention and mental health promotion, are now commissioned by LAs, with the GP contract the responsibility of NHS England. LESs are commissioned by the local area teams of NHS England, yet the teams do not have any real levers or necessarily the knowledge needed to do this. This appears to be a key weakness in the new system.
One key element of the contract where it is proposed to incentivise more primary prevention in general practice is through the QOF. In the White Paper the government proposed that NICE adjust QOF to ensure that 15% is devoted to ‘evidence-based public health and primary prevention indicators’ (p. 62).35 Currently, QOF continues to have only two indicators that it designates as ‘primary prevention’; otherwise it focuses mainly on secondary prevention and uses proxy or process outcomes. QOF has had a major impact on how practices undertake public health and other activities leading to more systemisation of public health activity – particularly through use of protocols and special clinics, but mainly with a secondary and medical focus.65,456 While having some impact on primary and secondary prevention by stimulating GPs to run ill-health prevention clinics for screening and monitoring blood pressure etc., QOF has mainly supported secondary prevention activities.32,65,93 To date, the evidence that the QOF has improved health outcomes or promoted a public health approach is very limited.18,65,330 However, financial incentives that are effective in changing practice and more outcomes-based contracts, rather than activity-related incentives, could encourage a more proactive approach.32 The impact of proposed changes by NICE will, to a large extent, dictate how much GPs are involved in improving the health of their patient population, which will, in turn, be affected by the future organisation of public health commissioning and service delivery.
There are, however, concerns about the extent to which NICE’s rigidly evidence-based approach is relevant for the development of many public health interventions and also whether or not such approaches are relevant to primary care itself.457–460 In particular, there are concerns about what the contract encourages in the way of public health activity in general practice. There is an important trade-off here: RCT-based ‘certainties’ around expensive technical interventions versus ‘riskier’ but potentially more impactful interventions such as, for example, brief interventions for smoking, which have low impact but are very low cost and, while having a small impact, affect a large number of people.460 Similarly, many areas of activity such as community-oriented activities or even welfare advice are not currently rewarded.
The implications of the fragmentation of public health services
Not only is the commissioning of similar services undertaken by different bodies, but there is also a more general likelihood of fragmentation of delivery of public health services due to the ‘any qualified provider’ model. The idea behind this approach to commissioning is to increase quality of care via a wider field of competition, on the presumption that increased competition will drive out poor providers and reduce the total number of providers. However, there is a risk that the overall effect of this policy will be that public health-related care is divided over a larger number of providers. The effect on GPs may be twofold. The first is simply that services that were once provided by GPs will be provided elsewhere, such as NHS Health Checks. The second effect, which is likely to be the more common one, is that patients will have to seek out many geographically separated providers for services such as sexually transmitted disease treatment, cancer screening and nutrition advice. This may be confusing and frustrating to patients as well as GPs, requiring good communication between different agencies to minimise this confusion. GPs must be kept aware of which providers are providing which services so they can properly advise their patients on where to seek care. Additionally, GPs must be able to keep track of what care their patients have received from other providers. Co-ordinating with other providers and keeping detailed records of their patients’ care, particularly when it comes to routine screening and immunisation, are key roles of the GP. It will be crucial to build in a way for all commissioners and providers of public health services to share their knowledge and records with GPs so that GPs can continue to do their jobs effectively. For example, there has been a long tradition of health visitors being ‘GP attached’, and parents and children within GP practices will lose this direct relationship with their GP services when health visitors are commissioned by the LA to provide a community-based service.
Ultimately, this will lead to postcode variation in provision or a variant of the ‘inverse prevention’ law if commissioning is more effectively supported and undertaken in healthier, wealthier areas (as, historically, has tended to be the case).
The opening up of public health delivery and practice to a more diverse range of providers calls into question the future role of entire categories of providers already working in public health, including health visitors, midwives and school nurses. Investment in health visiting is discussed in the White Paper37 and is welcome, but other key members of the local primary health care team who deliver public health are not mentioned. For example, the crucial role of school nurses is not mentioned in the documents and it is not clear where this service will need to focus its attention or how it will be integrated into the rest of public health delivery.
One mechanism for prioritising the general practice role in public health is via the Public Health Outcomes Framework.37 As it currently stands, the Public Health Outcomes Framework indicates the few places where responsibility for achieving indicators is shared with the NHS. Just eight indicators in the entire list refer to the NHS, and most of them are around reducing premature death in people with chronic diseases rather than disease prevention or health promotion. It is not clear what this shared responsibility refers to: provision of funding or delivery/planning of services. Looking at the entire list of public health indicators it is clear that GPs, and therefore the NHS, can be instrumental in delivering many services beyond the ones singled out – in services relating to sexual health or smoking cessation, to name just two areas. When LAs and local HWBs are considering how to best respond to these indicators (which they are driven to do by the ‘health premium’ payments), they should keep GP services in mind for many indicators beyond those with designated NHS involvement. Additionally, the boards may find that GPs are particularly well primed to the idea of indicators, having now been working with the QOF for over 6 years. While these two sets of indicators are very different in character, GPs may be comfortable with the idea of indicators and may have ideas for how to incorporate this new set into their practices.
While HWBs have been given a key co-ordinating role, it is questionable how far they will be able to fulfil all the expectations placed upon them. At the current time there remains considerable ‘fuzziness’ around the exact role of HWBs. The lack of statutory powers given to the boards means that it is only by developing good local relationships that they will be able to fulfil their potential. In recent research on the development of CCGs, the development of a strong ‘co-ownership’ model, where CCGs, LAs and HWBs saw themselves as joint owners of the developing strategy, with all partners being actively involved, was noted in some areas. However, in others, CCGs were developing quite separately from their HWBs, with CCG representatives attending meetings but contributing little.63,334 Marks et al.63 have highlighted the difficulty of aligning priorities across large geographical areas and where organisations were not coterminous. This may prove a problem again, as many of the 211 CCGs cover smaller populations than their HWB, and the ability to respond to local concerns and problems will be important as HWBs develop. Ultimately, despite HWBs having ‘strategic influence over commissioning decisions across health, public health and social care’ as one of their main roles,461 there is a danger that, as new local public health systems develop, they may become more fragmented in terms of the relationships between LAs, CCGs and HWBs as well as having to cope with a new national context with PHE and NHS England. This may create additional complexities for local co-ordination by the HWBs and raises important questions about how public health activities in general practice will be incentivised, managed and supported in the future. This uncertainty was of concern to many of the GPs we talked to during the research.
Current developments
In line with the government’s coalition agreement (of 2010–15) policy focused on the health improvement role of general practice.35 In addition to proposals to revise the QOF to include more primary prevention criteria, the recent Mandate for the NHS Commissioning Board highlights prevention within the concept of making ‘every contact count’, ‘in focusing the NHS on preventing illness, with staff using every contact they have with people as an opportunity to help people stay in good health – by not smoking, eating healthily, drinking less alcohol, and exercising more’ (p. 8).462 This approach is now reflected in NICE Public Health Guidance with the publication of the draft revision of physical exercise guidelines (currently out for consultation). The proposed revised guidelines specifically target primary care practitioners proposing that they:
Assess the physical activity levels of all adults in contact with primary care services and identify those who are not currently meeting the UK physical activity guidelines. This could be done:
opportunistically during a consultation with a GP or practice nurse (or while people are waiting)
as part of a planned session on management of long-term conditions run by a practice nurse
as part of a consultation with a pharmacist.
p. 8463
With this guidance, primary care practitioners are being encouraged to identify inactive patients, assess their level of activity and deliver a brief intervention to encourage them to increase levels of activity. Concerns have been raised about whether or not it is appropriate for more and more elements to be placed on GPs and nurses given the limited consultation time in practice. These questions have also been raised in connection with a pilot study that examined adding cancer-screening questions into the NHS Health Check. The pilot study involved a screening survey of 4250 patients with high cardiovascular risk undergoing NHS Health Checks. The study, reported at the October 2012 Society of Academic Primary Care conference in Glasgow, found that the process involved substantial nurse and GP time but led to only four cases being identified.464
Conclusion
The Royal College of General Practitioners argues that GPs should be proactive in carrying out public health activities and interventions, and it is expected that GPs should possess a wide range of skills related to ill-health prevention and public health.7 Since 1990, GPs in particular, have been encouraged to carry out more public health activities through changes to their contract and the potential of the primary care public health role was highlighted in the Wanless Report on public health.3,48 However, research continues to find that the relationship between public health and general practice in England focuses primarily on secondary prevention, and many GPs state they lack the skills needed to deliver effective health promotion.432 The King’s Fund Inquiry on quality in general practice concluded that there is enormous potential for general practice to take a more proactive role in ill-health prevention and public health.18,465 In fact, a key criticism of much of general practice (when it comes to public health) is that it focuses on either secondary prevention or just information and advice. While both of these activities are useful, other interventions can be more effective. All of these considerations and criticisms are of particular importance when it comes to the QOF, which is a key driver of GP practice.
The Public Health White Paper37 outlines a number of key changes to the organisation and delivery of public health in England. However, while the public health role of general practice has been the subject of much debate over the past few decades, the government does not appear to have grasped how this role can be integrated, developed and supported within the proposed changes. Relying on changes to the QOF is both short-sighted and overly narrow. The fragmentation of the commissioning and delivery of public health is likely to lead to problems of co-ordination. It is not clear how HWBs – responsible for local public health co-ordination – will build integrated approaches with both CCGs and PHE as well as the wide range of local delivery organisations, including general practices. Previous approaches to primary care-led commissioning have not demonstrated that GPs can work closely with LAs or other agencies.453 A further problem may be the attitude of many GPs themselves, as studies suggest that they are more comfortable managing illness than promoting health. How effective the new proposals will be at engaging GPs and other primary care staff in public health activities is still open to question, as for many GPs there is still a significant amount of distrust.334
In this chapter we have identified a number of potential problems that may result from current policy developments and organisational changes. While an emphasis on health improvement is welcome, there are a number of potential threats to the ability of primary care, and general practice more specifically, to deliver public health. First, commissioning approaches need to be aligned across the different agencies that will be responsible for aspects of public health. In particular, commissioning agencies need to urgently identify how services from existing groups of primary care-based public health providers (midwives, school nurses, etc.) are commissioned and supported within the new structures. Thought also needs to be given to how health improvement activities that have formerly been funded through GMS, PMS and other local contractual arrangements can be continued, and how local variations in funding and service delivery can be incorporated into the new systems and structures. Developments in health improvement in general practice have benefited from local negotiation and relationships with the public health department in the PCT. Concerns have been raised about the ongoing links between public health and general practice now that LAs have taken on public health responsibilities. While policy is increasingly emphasising public health roles being embedded in primary care practice, many of the current organisational changes are creating potential problems for the commissioning and delivery of many important health improvement activities.
