Bridge over troubled healthcare

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How will Public Health England bring together the NHS and local government?

 Public Health England (PHE) is the national executive agency of the new public health system, which will be driven by local government. PHE will be responsible for improving public health and reducing health inequalities through a range of local policies aimed at reducing health risks to individuals and communities.

From 1 April 2013, when PHE becomes a statutory body, public health services will shift from the NHS to local government. PHE will take £4 billion (5%) of the annual NHS budget with it, and will form an economic and organisational bridge between health and social care.

Like the NHS Commissioning Board, PHE will provide national leadership and guidance for local organisations but will not control them. According to Duncan Selbie, its Chief Executive designate, PHE will combine “a national voice with local action”. It will bring together experts from newly-dissolved public health bodies such as the Health Protection Agency and the National Treatment Agency.

Local authorities will commission public health services, employing local Directors of Public Health as ‘health ambassadors’ to lead discussions on public health spending. To engage with this locally-controlled system, PHE will develop public health outcome indicators and a ‘public health premium’ incentive system.

PHE’s broad function has been defined as “helping people to lead healthier lives”. That covers a wide range of interventions, from driving health awareness campaigns to a more practical role in vaccination programmes. In terms of impact on behavior, PHE will follow the Nuffield ‘ladder of interventions’ model, which relies on using evidence-based arguments rather than regulatory controls.

Leaders, not bosses
PHE will operate through 15 centres across the four regions identified by the NHS CB: North, Midlands and East, London, and South. This structure articulates the national role of PHE with local authorities: the regional bodies have more responsibility for national initiatives such as health emergency response, while the centres are more involved with local initiatives such as specialised commissioning.

The senior leadership team of PHE, like that of the NHS CB, will combine medical and commercial expertise. The medical leadership will consist of a Director for Health Protection, a Director for Health Improvement and Population Health, and a Chief Knowledge Officer. These will be supported by a Chief Operating Officer and Directors for Strategy, Programmes, Finance and Corporate Services, and Human Resources.

Chief Executive designate Duncan Selbie promises that PHE will offer the new public health system “leadership without hierarchy”. Selbie is an experienced NHS leader who was recently Chief Executive of Brighton and Sussex University Hospitals NHS Trust. He has been described as ‘popular’ and ‘likeable’, despite being a man of relatively few words. Notably, he survived the 2005 crisis of NHS governance under Sir Nigel Crisp with his professional credibility intact.

PHE is currently engaged in setting up its board and management team, and in matching roles between the old and new public health systems.

Health of the nation
The underlying medical goals of the new system are defined by the Public Health Outcomes Framework (January 2012), which groups outcome indicators into four domains:

  1. Improving the wider determinants of health – improving against wider factors that affect health and well-being.
  2. Health improvement – helping people to live healthy lifestyles, make healthy choices and reduce health inequalities.
  3. Health protection – protecting the population from major incidents and other threats.
  4. Public health and preventing premature mortality – reducing the numbers of people living with preventable ill-health and people dying prematurely.  

Selbie’s document My vision for Public Health England (July 2012) states that the agency “will lead nationally and enable locally a transformation in the health expectations and, in time, outcomes of all people in England”. He promises a focus on “collaboration” to provide a national voice for local public health expertise in councils, and says PHE will achieve “transformation” by changing people’s behaviour.

PHE’s three directorates, described in a separate factsheet, indicate the agency’s chief responsibilities:

  • Health protection – concerned with reducing infectious disease and environmental harm. PHE will lead the field epidemiology service, the national immunisation programme, and emergency preparedness, resilience and response. It will also be responsible for investigating and managing environmental hazards such as radiation and chemical exposures.
  • Health improvement and population health – concerned with reducing health inequalities and improving preventative healthcare. PHE will advise NHS commissioners on policies for disease screening and specialised commissioning, and will use social marketing to achieve behaviour change. It will promote innovation in this area of public health, reaching out to all providers and commissioners of health and social care, with the long-term goal of achieving improvement across the first, second and fourth domains (see above) of the Public Health Outcomes Framework.
  • Knowledge and intelligence – concerned with delivering “a new national evidence and intelligence service” to support assessment of public health need and track performance against key outcomes. PHE will seek to raise the national standard of disease registration, and will work in partnership with NICE to assess the effectiveness of treatments in improving public health. Notably, cancer registration will migrate from the NHS to PHE by April 2013, when PHE will launch a new Cancer Registration Service to “collect consistent high quality, near real-time data” on all cancers diagnosed in England.

Making communities safe
The health protection functions of PHE bear a complex relationship to the NHS. The agency will investigate risks to public health including infectious disease outbreaks, and assess the availability and effectiveness of drug treatments for these threats. PHE will take over the functions of the Health Protection Agency, which will impact on the health protection activities of CCGs, the NHS CB and local authorities.

For example, PHE will have a strategic role in immunisation. The NHS CB will commission vaccination services, but PHE will set their quality standards, assess their performance, fund and manage the development of new programmes and the extension of existing ones, and even purchase, store and distribute the vaccines; while CCGs will commission treatment of infectious disease and work with PHE and local authorities on outbreak control.

It is not surprising, therefore, that the Faculty of Public Health has expressed concern about the “complex new arrangements” for disease control and warned that the system will require “excellent communication and very close collaboration between GPs and their teams, public health staff and hospital services”. This, rather than changes in people’s lifestyles, is most likely to be the area on which the effectiveness of the new public health system is judged.

Pharma and public health
Public Health England may only have 5% of the NHS budget, but its impact on prescribing and other NHS services should not be disregarded. The agency will act as a communication network and body of expertise to guide the new public health system within local government – which in turn will influence and work collaboratively with CCGs and primary and secondary care providers.

PHE’s impact on immunisation and disease control is likely to be particularly important. However, in keeping with the Government’s ‘nudge’ approach to unhealthy lifestyles, it is unlikely to intervene decisively in ‘lifestyle’ and ‘wellness’ issues.

Where the pharmaceutical industry can contribute in concrete terms to PHE’s agenda – for example, by providing better immunisation solutions or affordable drugs that help to prevent serious illness – it may find the agency a willing ally that can impact on GP and hospital prescribing.

At other times, it may find PHE inclined to promote non-drug solutions to public health issues, especially in terms of behaviour change; the industry needs to engage constructively with these issues.

As well as public health outcomes, PHE will be concerned at all times with helping the NHS and local government to save money. Pharma will thus have opportunities to align itself with PHE’s agenda by offering solutions that reduce the cost of public health improvements.