THE FUTURE ORGANISATION OF PUBLIC HEALTH
IN GREATER MANCHESTER
A Discussion Paper
1.1 Ther are a number of reasons to review
the future organisation of public health in Greater Manchester.
The need envisaged in the National
Plan for entities larger than the current health authorities for
a number of key strategic tasks.
The creation of Primary Care Trusts
with an important role in the development of the health of their
The devolution of important strategic
public health functions to local authorities with their new duty
to promote public health. "Modernising Local Government"
also states that all functions will be reorganised co-terminously
with local authority boundaries as opportunities permit.
1.2 This paper suggest how public health
might reorganise to fulfil its functions within the new structures.
2. PUBLIC HEALTH
2.1 Work in public health has to be carried
out at a number of population levels: neighbourhood, PCG/PCT,
borough, hospital catchment and at county level. New powers to
delegate health authority functions to NHS bodies or to local
authorities create the potential for statutory authority to exist
at these different population levels.
2.2 It is our view that the most coherent
way of addressing these different population levels is by organising
public health predominately at the borough level and at the county
level. This is not to neglect the other three levels. The reasons
for this view were expressed in our response to "Fit for
3.1 The functions of public health can be
broadly described in three areas: health policy which promotes
health in communities ie Our Healthier Nation; health protection;
and health care development and management. A number of functions
need to take place at a strategic (health authority level) and
local (borough or PCT) level.
3.2 A Greater Manchester Health Authority
will be mainly a strategic body focusing on the functions set
out in Leadership for Health and the NHS Plan but will undertake
some other functions that are best organised at this level. The
public health strategic role will include stimulating policy to
improve health; contributing to performance management within
the NHS; and providing specialist advice to policy makers in organisations
inside and outside the health service.
3.3 The role of public health at borough
level is implementation of the public health functions outlined
above (para 3.1), for example the National Service Frameworks.
Health improvement can be promoted at borough level through input
in the PCT or CT, acute trust or local authority.
4.1 Several different organisational models
may achieve these public health functions. We feel this will best
be met by establishing a Greater Manchester Health Authority with
each borough having either a borough-wide Primary Care Trust or
Care Trust with substantial devolved health improvement functions
or a statutory delegation of those functions to a section 31 partnership
or a formal sub-committee of the health authority.
5. PUBLIC HEALTH
5.1 In this paper we consider the need for
specialist public health practitioners (public health doctors
and public health specialists). We have not yet considered other
groups involved in improving public health for example health
promotion specialists, human ecologists or environmental health
officers. We have as yet only considered public health nursing
in the context of communicable diseases control and not in its
wider role in community development, school nursing or health
visiting. The strategic direction of these other professional
groups will need further consideration.
5.2 It is this current resource of specialist
public health practitioners which we would initially deploy at
Greater Manchester and borough level. We need to undertake a detailed
piece of work looking at current skills, future requirement and
career aspirations of the current practitioners. We believe there
will be a need for public health capacity building within organisations
and more public health practitioners will be needed in the future.
6. PUBLIC HEALTH
6.1 We see managed public health networks
as being the future organisation of public health practitioners
across Greater Manchester. Public health networks will involve
practitioners at borough or PCT level, county level and academic
institutions. Networks will ensure that there are sufficient mixes
of skilled staff to input at the level of borough and county.
We do not wish to see fragmentation of public health staff and
professional isolation. We propose a Greater Manchester Public
Health Network but envisage that local networks will develop across
practitioners working in boroughs for example working in PCTs,
acute trusts and local authorities. The organisation of these
local networks will depend on the organisational structures agreed
below the Greater Manchester level. It will be important that
these networks include other people with expertise that can work
with public health such as health economies and social scientists.
6.2 The Greater Manchester Zonal Public
Health Observatory and public health academic institutions will
be key components of this network. Links with academic departments
can support education and training; research and development;
and enhancement of specialist expertise. Service public health
practitioners should be able to contribute to both undergraduate
and postgraduate education and the members of academic department
should be able to contribute to the training of public health
practitioners. The nature of the proposed organisation outlined
in this paper has the potential of allowing joint posts particularly
in those areas where there is local academic expertise. The most
obvious academic links are with public health departments but
links should not be confined to such departments, for example
other departments may include geography.
6.3 There is a need for the Greater Manchester
Health Authority to take a lead role in research and development.
The responsibility for research and development needs to be linked
to the public health agenda, for example health inequalities.
A public health presence within the Health Authority will be required
for these responsibilities.
6.4 All public health practitioners need
ready access to strong information and library services at their
place of work. The Greater Manchester Health Authority and/or
the Public Health Observatory will be key in ensuring access to
public health intelligence. The information links will also provide
communication channels for the Greater Manchester Public Health
Network of public health practitioners.
7. BOROUGH LEVEL
7.1 A public health practitioner needs to
have the formal personal professional responsibility of analysing
the health of the borough and reporting upon it. If a borough-wide
PCT or CT has taken on the extended role of leading the health
improvement process it will need to reflect that in its structure.
It will be logical for the lead public health practitioner to
be a member of the Board and the Executive Committee.
7.2 The formal organisational base for this
public health work should be a single borough-based unit constituted
either as a section 31 partnership or as a part of a borough-based
PCT or CT. However there will not be borough-wide PCTs or CTs
in all ten boroughs and even where there are they may not wish
to expand their role in this way. The arrangements in Boroughs
where there are not PCTs or CTs will need further consideration.
7.3 We believe more detailed work needs
to be undertaken on staffing levels but as a preliminary guide
an independent report by Secta/Dearden Consulting in Salford and
Trafford Health Authority has suggested the existing Primary Care
Trust which serves half the Borough requires on public health
consultant w.t.e. The report also states that "access to
a wide range of skills, not often held by a single individual,
needs to be secured".
8. GREATER MANCHESTER
8.1 There will be a Director of Public Health
with public health practitioners responsible for priority areas.
The priority areas need to be chosen on the basis of priorities
included in Saving Lives: Our Healthier Nation and the areas covered
by the National Service Frameworks. There may be other issues,
which may be partly easier to deal with at the Greater Manchester
level because of the way other bodies are organised; these may
include transport; ambulance services and prisons.
8.2 There will be some health care commissioning
at a Greater Manchester level that will need the support of public
health practitioners. These services include intensive and high
dependency care; renal; neuroscience; spinal injury; cystic fibrosis;
clinical genetics; and burns.
8.3 Dental public health will be provided
through a unit at the Greater Manchester Health Authority although
members of the unit will have some geographical responsibilities.
8.4 If there is more than one health authority
in Greater Manchester, there should still be only one strategic
public health department, which will provide a Director of Public
Health to each health authority and will provide strategic advice
to all health authorities.
9. HEALTH PROTECTION
9.1 It is our view that there will be a
need for a degree of centralisation of the health protection function
across Greater Manchester although some functions will remain
at PCT or borough level. Work is being undertaken to develop the
most appropriate organisational arrangements for health protection
in Greater Manchester. Professor Ashton is also leading a group
considering the "Future Provision of Health Protection Services
in the North West". A Greater Manchester DPH and Consultant
in Communicable Disease Control are contributing to this group.
9.2 Public health responsibilities for HIV/AIDS
in Greater Manchester will be discharged through a group working
at the Health Authority. This group of officers will also be responsible
for working with primary care trusts on other policies relating
to sexual health.
10. GREATER MANCHESTER
10.1 The National Plan announced the creation
of public health departments serving Government Regional Offices,
Regional Development Agency and NHSE Regional Office. The National
Plan also indicated that in future some of the RO performance
management functions could be devolved to health authorities.
10.2 Work at regional level that could easily
be undertaken locally includes work supporting specialist commissioning
within the Greater Manchester tertiary care providers and work
on NSFs and clinical governance. There will be other areas of
work where Region may keep a responsibility but that responsibility
will be considerably simplified by the co-ordination at country
levelperformance management, health protection, and organisational
development may well be examples. It may be appropriate therefore
for some of the public health resource at Region to be transferred
into the new authority, perhaps through the mechanism of joint
11. NEXT STEPS
11.1 This is a discussion document which
needs further consideration by all public health practitioners
in Greater Manchester. There are issues, which will need further
work, for example employing authorities and service level agreements
to achieve a public health network. Further discussions will be
needed with the Consultants in Communicable Disease Control and
the public health nurses they work with on the future direction
of health protection services. The strategic direction and levels
of leadership for other groups promoting public health, for example
health promotion specialists need to be considered.
11.2 Detailed work now needs to be undertaken
to map the key public health resources in Greater Manchester and
to estimate the future workforce requirements.
1. The Chief Executives of the Greater Manchester
Health Authorities agree to the way forward outlined in this paper.
A further paper will be submitted when more
detailed work and discussion has taken place.
2. Directors of Public Health, given the
above agreement of Chief Executives, work collaboratively to create
a Greater Manchester Public Health Network.
3. Each Health Authority:
(a) Identifies for each borough whether the
focus of public health activity locally will be:
(i) A borough-wide Care Trust or Primary
Care Trust with an expanded health improvement role or
(ii) A section 31 partnership
And puts the appropriate arrangements in
(b) Identifies the strategic lead public
health practitioner for each borough.
4. Note the Regional Office lead on the
future provision of health protection services and that Greater
Manchester proposals for health protection services are being