SUPPORTING PUBLIC HEALTH IN THE AVON AREA
INTERIM REPORT OF THE WORKING GROUP
Government policy, as expressed in the White
Paper Saving Lives: Our Healthier Nation, is focused on
health improvement. Leadership for Health makes clear that
the future strategic role of the Health Authority will be as a
public health organisation. This role, however, must be played
in partnership with Local Authorities, which have a duty to bring
about improvements in the well being of the citizens they serve.
The role of other partners, including Primary Care Trusts, will
also be crucial. The Government has made a commitment through
the Modernisation Fund to strengthen the capacity of the public
health function in all these sectors in order to deliver health
improvement. There is widespread agreement that the NHS, local
government and other partners need to work together to tackle
the root causes of ill health.
As part of the work to define its future roles
and responsibilities, Avon Health Authority established a Working
Group in January 2000 to consider the future of the public health
function in the Avon area. This Working Group has taken the form
of a "select committee" made up of experts representing
the range of Avon organisations concerned with improving public
health (Appendix 1). The Working Group's terms of reference were
agreed as follows:
to develop a shared vision of the
public health function at the three levels (communities,
Primary Care Trusts, Health Authority) of practice in the Avon
area in terms of activity, workforce and networking;
to achieve this by an analysis of
the current position and estimating the future needs within the
wider Avon health community, the Health Authority, Local Authorities
and voluntary sector, and with particular regard to the emergence
of Primary Care Trusts;
to estimate the education and training
implications of this analysis; and
to make realisable recommendations
to the programme director
on a project plan for achieving change within the wider organisational
In February 2000, the Working Group invited
written evidence from a wide range of interested parties in the
Avon health community, and verbal evidence from a small sample
of interested parties representing different levels of public
health activity. The tight timescale for the overall process of
organisational change meant that evidence needed to be received
by the first week in March 2000.
2. EVIDENCE RECEIVED
Written evidence was received from 28 local
individuals and organisations concerned with public health in
the Avon area, and oral submissions were taken from six individuals
representing the different levels of communities, Primary Care
Groups, Local Authorities, the Health Authority and the Regional
Office of the NHS Executive (Appendix 2).
3. A SHARED VISION
There was widespread consensus among witnesses
and within the Working Group on the principles which define public
goals which involve population health
strategies which cover the broad
range of what determines health in a population; and
active interventions involving communities
themselves and many disciplines in several organisations.
With the Government's modernisation agenda and
re-organisation throughout the public sector, the challenges and
opportunities lie in making the new linkages work.
Our vision is the establishment of a strong
and mutually supportive network involving communities and public
health specialists and practitioners working in a collaborative
partnership to improve the health of the population (Figure 1).
4. CURRENT POSITION
Currently, the public health resource in the
Avon area includes:
the Public Health Directorate at
the Health Authority;
Health Promotion Service Avon currently
based in the North Bristol NHS Trust;
Trust community staff, in particular
other Trust based staff including
those responsible for clinical governance;
primary care practitioners including
GPs and practice nurses; and
Local Authority staff including health
and environmental services, community development and regeneration
Within the Public Health Directorate, there
are currently 6.4 wte consultants in public health (and one vacancy),
3.5 wte public health specialists/managers, one part-time consultant
in dental public health and a varying number of public health
trainees and other staff. Directorate staff are responsible for
programmes of work in priority areas (eg cancer, coronary heart
disease, mental health) which includes monitoring the health of
the population, devising strategies for improving health and tackling
health inequalities, as well as geographic/PCG responsibilities.
Recently the Directorate has developed a Public Health Network
based on four Local Authority area multi-disciplinary Public Health
Health Promotion Service Avon represents a significant
part of the Avon public health workforce. It employs approximately
50 people and its work includes:
strategy development and implementation,
in conjunction with Avon Health Authority and partner agencies
for inequalities, accidents, smoking, mental health etc;
running health promotion programmes
focused on priority topics such as smoking and sexual health;
working on community health development
in areas and communities of high health need; and
providing training, education and
publicity materials, co-ordination of programmes and support for
health promoters from the NHS, Local Authority and voluntary sectors.
The strong and consistent message from witnesses
to the Working Group was the need for the focus of public health
activity to be much more "out there" with practitioners
and communities while, at the same time, maintaining central "critical
mass", the quality of public health specialist practice and
key central functions (eg strategic leadership, infection control,
training). Similarly, those who commented on Health Promotion
Service Avon (HPSA) felt its focus of activity needed to be more
"out there" in PCTs while maintaining economies of scale
and specialisms. Existing public health specialists were also
reported to be working to capacity, mainly on Avon-wide priority
programmes. At the same time, witnesses identified a substantial
public health development and support agenda at PCT and community
levels. In order to balance these competing demands, we recommend
the Public Health Directorate be
maintained as a central public health resource based at the Health
Authority for the entire Avon health community;
all public health specialists from
the Public Health Directorate be outposted to PCTs for an average
of 0.2 wte each. With 10 or more public health specialists (medical
and non-medical) in the Directorate, plus trainees, this would
represent a contribution on average of a team input of over 0.4
wte public health specialist to each of the five prospective Avon
further work should be undertaken
to identify how best to integrate public health and information
support to PCTs;
the management of HPSA should be
transferred to one PCT to provide a service on behalf of all PCTs/communities,
with operational staff outposted to PCTs;
planning should commence for the
new role of PCT public health lead, to be developed and funded
from new resources (Appendix 3); and
the PCT public health lead should
co-ordinate a public health team drawing on health and Local Authority
practitioners, outposted public health specialists and health
promotion specialists and the PCT information analyst(s).
Given the existing demands on public health
capacity, it is recognised that implementing these changes will
require hard choices to be made within both the Public Health
Directorate and HPSA to free up resource for outposting to PCTs.
It is likely that the development of a PCT public health lead
role will depend upon interim arrangements with outposted specialists
from the Public Health Directorate. Planning the PCT public health
lead role will need to draw upon the contributions both of the
Public Health Directorate and all those involved in PCT development.
The ways in which the PCT public health lead
will co-ordinate and provide public health leadership for a multi-disciplinary
and inter-agency team will need further exploration. It is anticipated
that the teams may evolve out of the public health forums currently
being established in each local authority area.
Table 1 below summarises the implications of
the Working Group's recommendations for the structures, processes
and outputs for public health in Avon.
Table 1 FUTURE
PUBLIC HEALTH STRUCTURES, PROCESSES AND OUTPUTS
||Primary Care Trust/Local Authority/NHS Trust
||Primary Care Team/Community|
|Structures||Public Health Directorate:|
Public health specialists
Clinical governance support
Control of Infection Unit
Public health resources:
Public health network central co-ordination and support.
|Public health lead role established.|
Outposted public health and health specialists.
HSPA managed by one PCT on behalf of all, with resource centres in all four LA areas and health promotion specialists outposted.
Public health team/forum:
Outposted specialist team
Local Authority specialists (environmental health, community development)
Other specialist (public health nurses, information)
Primary care (health visitors, GPs)
|Public health team/forum support to wider group of practitioners and the community.|
Health service appraisal and care programmes.
Equity audit and health needs assessment.
Education and training.
Public health network.
|Service level agreement between Health Authority and PCT.|
Link between PCT and Health Authority leads.
Public health team/forum for collaborative.
Service level agreement between HPSA host PCT and other PCTs.
Support to Partnership Board.
Support to PCT decision making.
Support for NHS Trust service development.
Health need assessment.
Development of relationships with local Authorities.
prevent disease (screening, health promotion and primary prevention)
ensure community participation and development (eg Surestart)
|Outputs||Health Improvement Programme.|
Standard setting and performance monitoring, National Service Frameworks, Joint Investment Plans, Public Health Intelligence and Annual Health Report.
|Strategies and plans (eg Health Improvement Programme).|
Support for change management.
Joint Health Report with Local Authority.
|Local health profiles.|
Local health priorities.
Support for change management.
5. EDUCATION AND
Strengthening public health capacity at the PCT and community
level will require sustained development of public health education
and training. There is currently a high quality regional training
scheme for public health specialists; there is no similar comprehensive
framework for the education and training of public health practitioners,
and no clear framework for the new role of PCT public health lead.
There are, however, a number of education and training opportunities
which have been identified in a recent NHS Executive scoping study
of public health education and training opportunities in the region.
The Public Health Directorate has initiated a Public Health Network
across the Avon area, and Public Health Forums in each Local Authority
area, in order to address the continuing professional development
needs of practitioners involved in public health activity (Annex
4). In order to build on this foundation, the Working Group recommends
a new Public Health Education and Training Working
Group be established involving a range of stakeholders including
practitioner representatives PCGs/PCTs, NHS Trusts, academic partners
and the Avon, Gloucestershire and Northern Wiltshire Education
the Working Group should lead the development
of a public health education and training strategy for the Avon
health community; and
the education and training strategy be based on
available national evidence and a systematic scoping assessment
of local public health education and training need.
6. PLANNING FOR
The advent of PCTs and the wider process of organisational
change in the Avon health community requires a relatively rapid
process of change. By July 2000, PCGs will decide whether to start
formal consultation about an April 2001 target date for PCT status.
As consultations are likely to take place over Summer 2000, it
will be advisable to have guidance and plans for public health
in PCTs (and therefore across the Avon health community) in development
by this time. The Working Group recommends that between April
and July 2000:
public health development plans for each prospective
PCT are drafted in partnership between the Public Health Directorate,
Geographical "clusters" (ie the Health Authority's Geographical
Directorates and PCGs), Health Promotion Service Avon and the
appropriate Local Authority;
the role of, development process for and funding
arrangements for the PCT public health lead are clarified including
interim arrangements involving the Public Health Directorate and
longer term arrangements for training and developing individuals
to take on this new role;
service level agreements are drafted between the
Public Health and Geographical Directorates/PCTs for public health
specialist support/outposting to PCTs;
a project management process is agreed for the
transfer of HPSA management to one PCT, and the development of
a service level agreement between the host PCT and other PCTs;
the HPSA Service Manager should be invited to
attend the Public Health Directorate management team and a Directorate
link person identified for HPSA.
Communities may be defined in either geographical terms or as
communities of interest. Back
The Health Authority's chief executive is acting as programme
director for the wider organisational change process in the Avon
health community. Back