THE DEVELOPMENT OF THE PUBLIC HEALTH ROLE IN PRIMARY CARE TRUSTS IN THE NORTH WEST Final Report
Dr Marianna Fotaki Professor Joan Higgins Ann Mahon
December 2004 Centre for Public Policy and Management Manchester Business School University of Manchester
combining the strengths of UMIST and The Victoria University of Manchester
About CPPM The Centre for Public Policy and Management was established in 2004, to bring together work in and with public services and government across the new Manchester Business School. Our purpose is to contribute to the advancement of public policy and to the management and leadership of public services and public organisations, through the generation and application of knowledge, skills and learning in research, education and development. We are one of the leading centres in this field in the UK. The work of the Centre is founded on a long tradition of research, teaching and development in public services in Manchester, and we trace our origins to a unit for health management and policy that was established in 1956 by Professor Teddy Chester, the university's first professor of social administration. We continue to have particular sectoral strengths in our work in health and healthcare, but are increasingly working on policy and management issues which cut across sectoral boundaries and domains. We specialise in applied research, policy and programme evaluation, postgraduate teaching, and executive and organisational development. We aim to combine academic rigour and practical relevance in our work, and to bridge the worlds of research, theory, policy and practice. We are part of the new Manchester Business School - the largest UK business school with around 200 academic faculty, and an international reputation for both its research and its teaching programmes. This report is published by the Centre for Public Policy and Management, Manchester Business School, University of Manchester, Devonshire House, University Precinct Centre, Oxford Rd, Manchester, M13 9PL Tel : +44 (0) 161 275 2908. Fax : +44 (0) 161 273 5245 Email :
[email protected] . Web: www.mbs.ac.uk/cppm © The University of Manchester 2004. First published 2004. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic or mechanical, photocopying, recording and/or otherwise without the prior permission of the publishers. This book my not be lent, resold, hired out or otherwise disposed of my way of trade in any form, binding or cover than that in which it is published, without the consent of the publishers. ISBN 0 946250 11 1 A CIP catalogue record for this book is available form the British Library.
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CONTENTS PAGE
1
2
3
Background – Policy Context .............................................................................. 8 1.1
Old and New Public Health Issues............................................................... 8
1.2
National Developments in Public Health Policy............................................ 9
1.3
Public Health in the North West ................................................................. 10
Methods And Sample........................................................................................ 11 2.1
The main research questions..................................................................... 11
2.2
Scope and purpose of the research ........................................................... 12
2.3
Means of investigation ............................................................................... 13
2.4
Selection of study sites .............................................................................. 14
2.5
Methodological constraints......................................................................... 14
Results .............................................................................................................. 16 3.1 Analysis of findings from postal questionnaire with 41 DsPH in the North West….................................................................................................................. 16 3.2
4
Analysis of findings from interviews in 5 selected PCTs in the North West 26
Directors of Public Health.................................................................................. 27 4.1
Section A: DsPH Preparedness for their role ............................................. 27
4.2
Section B: DsPH Position Opened To Non-Medical Candidates................ 28
4.3
Section C: DsPH Leading National Ph Workforce Development................ 30
4.4
Section D: DsPH and their Workforce........................................................ 32
4.5
Section E: Networks................................................................................... 34
4.6 Section F: Partnerships and JointDsPH Appointments With Local Authorities............................................................................................................. 35 4.7
Section G: Local Communities And Inequalities ........................................ 37
4.8 Section H: Improvement By Health Promotion, Prevention And The National Service Frameworks ............................................................................... 38 3
4.9 Section I: DsPH Being Credible And Available To The Local Population And Accessible To The Media .............................................................................. 39
5
4.10
Section J: Priorities And Time Spent On Public Health Activities.............. 40
4.11
Section K: Resources ............................................................................... 42
4.12
Section L: Public Health Potential: Expectations And Goals...................... 43
4.13
Section M: The Impact Of The Second Wanless Report........................... 44
Discussion......................................................................................................... 46 5.1
Profile of Directors of Public Health and Preparedness for the Role.......... 46
5.2
DPH post for the first time being opened to candidates outside medicine. 46
5.3
Composition of the Public Health Team. .................................................... 47
5.4
National Work to Develop Public Health Workforce ................................... 47
5.5
Public Health Networks.............................................................................. 48
5.6
Joint appointments and Partnerships with Local Authorities ...................... 48
5.7
Addressing Inequalities and Improving Health in Local Communities........ 49
5.8
DsPH Credibility with Local People and Accessibility to the Media............ 49
5.9
Resources and “mainstreaming” of Public Health in the PCTs .................. 50
5.10 Time that DsPH devoted to commissioning as opposed to public health activities................................................................................................................ 50 5.11
Priority Attached to Public Health in PCTs................................................. 51
5.12
Public Health Potential............................................................................... 51
5.13
The impact of the second Wanless Report ................................................ 51
6
Policy Implications............................................................................................. 53
7
References........................................................................................................ 55
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Executive Summary
Public health has been given an increased role in the government’s plans for restructuring and reforming the NHS. Public health is considered from a multidimensional perspective that encompasses social and wider determinants of health (Dahlgren and Whitehead, 1991; Black, 1980). The Labour government has placed a growing emphasis on the potential to prevent the causes of ill health and to improve quality of life. This philosophy is reflected in the new public health agenda and the appointment of Directors of Public Health (DsPH) to Primary Care Trusts (PCTs), with a broad mandate to implement this agenda, which was described in “Shifting the Balance of Power. Next Steps” (DoH, 2002). PCTs are the loci where the multidimensional nature of public health should be realised. Directors of Public Health (DsPH) have been appointed to PCT Boards and given a wide range of responsibilities, while high expectations have been placed upon their role and capacity to implement the new agenda. DsPH are expected to play a strategic role in co-ordinating a range of activities with a focus on addressing the wider determinants of health and tackling inequalities to bring about improvements in health care and increases in the welfare of the whole population. In every day practice this translates into them assuming a leadership role in joint planning for health and social care services, initiating and entering into collaborative agreements and joint action with Local Authorities (LAs) in the field of education, urban regeneration, transport and environment but also fostering effective forms of community involvement in health care planning and provision. This study was commissioned by the Regional Director of Public Health, Professor John Ashton and Dominic Harrison of the Health Development Agency and it examines the extent to which PCTs have embraced the public health agenda and the extent to which the aims of 'Shifting the Balance of Power' have been realised. The study was carried out between October 2003 and March 2004 by Dr Marianna Fotaki, Professor Joan Higgins and Ann Mahon. It is a small feasibility study, drawing upon a sample of 5 PCTs, but with demographic data on all 41 DsPH. The project goal was to explore how the public health objectives have been developing in selected PCTs in the North West of England. It was not an assessment of individual performance but a study of organisational responses to the new public health challenges. The study had three aims: to map the profile of all Directors of Public Health (DsPH) in 42 Primary Care Trusts (PCTs) in the North West, to analyse the implementation of the objectives identified in “Shifting the Balance of Power”, and to record the perception of key actors about the roles and functions of public health in five PCTs and the three Strategic Health Authorities in the North West of England. The methodology used combined a quantitative survey of all 41 Directors of Public Health (one of the 42 DPH posts was vacant at the time), by means of postal questionnaire and qualitative in-depth interviews with DsPH, Chairs of the PCT Board, Chief Executives and Chairs of Professional Executive Committees (PECs) in all five PCTs that agreed to participate in our study. In addition, Medical Directors from the Strategic Health Authorities in the North West were also invited to take part in our study. Both our questionnaire and interview schedules were built around the objectives identified in “Shifting the Balance of Power”. We also collected some information on personal characteristics of DsPH including their background (medical or non-medical) and the nature of their contracts (whether held by PCT only or joint appointments between the PCT and LAs). We had a 100% response rate to our postal questionnaire and interviewed a total of 22 respondents.
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Profile of Directors of Public Health and preparedness for their role. We found that adjustment to the Director’s role felt easier for DsPH with previous Board experience. DsPH were more often than not seen as “agents of change” and hence their personal and political skills and capabilities to operate at a strategic level were regarded as more important than their background. The majority of respondents argued that the new public health agenda was about the skills of the whole public health team and good medical and clinical advice was seen as its indispensable component. The DPH post for the first time was opened to candidates without medical qualifications. All respondents saw it as a welcome and a positive development in principle and thought that diversity of backgrounds of DsPH brought new perspectives and truly represented the multidisciplinary nature of public health. It was also seen as representing new ways of working and a pragmatic response to limited capacity in public health. Almost 50% of all DsPH came from a non-medical background. However, several unresolved issues in relation to non-medical DsPH emerged concerning their initial credibility with other agencies, the relationship between doctors and the public, their relative lack of experience at Board level and the lack of medical networks for commissioning acute care. The composition of the public health team. Examination of this issue raised more fundamental questions about the nature of public health. Teams varied in size but this related to organisational arrangements and did not reflect the value attached to public health in the PCTs. Some degree of confusion and differences in perception among key actors was noticeable, although it seemed that most respondents agreed on the systemic approach to public health underpinning the whole PCT. National work to develop the public health workforce. All PCTs displayed little activity in national public health workforce development. The main reason explaining this lack of involvement was that it was too early for PCTs and DsPH, overwhelmed with their own workforce problems, to contribute to the national work. The difficulty was increased by recent organisational changes that led to dismantling of the old at the same time as establishing new structures. The single main challenge to identifying and developing the public health workforce was the problem of capacity which was seen by all respondents as grossly mismatched with the need for qualified public health staff at all levels. The expectation expressed in 'Shifting the Balance of Power' that public health networks could compensate for the lack of expertise in some PCTs was not realized in the 5 PCTs studied here. The key issue was the time investment needed in establishing and cultivating networks. Overstretched PCTs found this difficult to provide. The other factor mentioned was the immense organisational change involved in setting up and staffing PCTs appropriately. In the initial stages this promoted an inward looking attitude. Some respondents felt that PCTs, with their variety of activities, were networks themselves while others thought that star ratings introduced a competitive mentality into the NHS, which was not conducive to sharing experience. Although examples of networks were provided it was unclear how much benefit they provided for DsPH and PCTs. Joint appointments and partnerships with Local Authorities. Joint appointments accounted for 30% of all appointments and some respondents saw them as representing a symbolic commitment, while others considered them to be a vehicle for influencing decisionmaking processes. However, most respondents agreed that good interagency relationships were a pre-requisite for making these appointments work. Generally, there was an enthusiasm for partnerships and a plethora of activities taking place but there was little evidence that they made a difference to health outcomes or that they represented a good use of scarce resources. Respondents agreed that the time needed to form and cultivate
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partnerships, and double accountability, were constraining factors as were the differences in culture, governance structure and decision making processes. The priority attached to public health in PCTs. The majority of respondents did not think that public health was mainstreamed in their PCTs but were supportive of the idea. Many interviewees felt that public health was seen as a priority in the PCT but views differed among respondents. On the whole, Chairs of the PCT Boards felt that public health was, or ought to become, central in the PCT and were often idealistic and less driven by evidence. On the contrary, DsPH were more reserved and focused on what could be realistically achieved. Chief Executives were supportive but adopted organisational perspectives and addressed public health while dealing with other priorities. PEC chairs were supportive too but appeared to be less well informed and placed their expectations on the new GMS contract and its potential impact on public health. Public health potential. Few respondents felt the potential of public health was fulfilled, mainly because time was spent on meeting national access and waiting time targets as well as on commissioning of acute care. At the same time, DsPH were not heavily involved in these activities nor were they distracted from implementing the public health agenda. Also the majority of respondents, across the board, felt that PCTs were rather well resourced, both in terms of financial and human resources. The impact of the second Wanless Report. The first and rather disappointing impression was that some Chief Executives and Chairs and PEC Chairs were not aware of the second Wanless Report at all. Those who were aware commented variously on its potential impact. Attitudes ranged from positive and hopeful about more resources being made available to more reserved and pragmatic views. Only a few people were downright negative and were unconvinced that the Wanless Report would have any impact. In conclusion, all respondents felt that the new public health agenda represented a big organisational challenge for relatively newly established PCTs. Despite that there was a very high level of support and commitment to public health goals, expressed by all actors, but there was also less clarity about how to realise those effectively. Also, perhaps unsurprisingly, PCTs felt more confident about addressing aspects of the public health agenda, rather than dealing with acute commissioning.
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Background – Policy Context 1.1
Old and New Public Health Issues
The evolution of public health, with its shift of focus from communicable disease prevention to a multidimensional perspective encompassing social and wider determinants of health (DNHW Lalonde Report, 1974; DHSS Black Report, 1980; Whitehead, 1995), underpins the current concept of public health. Changes in patterns of disease from infections and accidents to chronic conditions, which constitute the major burden in industrialised countries, have been reflected in different public health models. In the widely used Dahlgren and Whitehead ‘layers of influence’ model the layers relate to genetic and demographic factors, individual life styles and wider community influences, living and working conditions but also to wider socio-economic, cultural and environmental factors (Dahlgren and Whitehead, 1991). In a more complex ‘population health’ model of interactive loops, proposed by Evans and Stoddard, health is distinguished into ‘health and function’ (a subjective experience of the individual), ‘disease’ (as used in health systems) and ‘wellbeing’ (the individual sense of life satisfaction) while main input variables come from social and physical environments respectively, as well as genetic endowment (Evans and Stoddard, 1990). A socio-ecological model of health developed for the Toronto Health Department and championed by the World Health Organisation is another example of explanatory frameworks (Stokols, 1992). There are also multidisciplinary social models of health that take into account attitudes to health that result from individual choices. (Berkman et al, 2000). Although different variables and predictors of health care outcomes have been singled out in different explanatory models and research approaches, the evidence converges to suggest that inequalities of income, employment, education, housing and social support are amongst the strongest influences (DHSS Black Report, 1980; Marmot et al, 1997). Some other important determinants relate to genetic and hereditary factors (Becker et al, 1996) as well as to experience over the life cycle, starting from the earliest inter-uterine period (Graham and Power, 2004). The introduction of multi-factorial and multi-dimensional models of health reflecting sociobiological nature of public health is not new; nor is the recognition of the paradox that most resources are spent on treating ill health, while it is well known that most of the burden of disease is a result of interlinked factors related to human behaviour, environment and socioeconomic disparities. This was first argued in the Canadian White Paper, known also as the Lalonde Report, in 1974 (DNHW Lalonde Report, 1974) and has since then been repeated many times over. The impact of inequalities on poor health was established by the Black Report in the UK in 1980 but not acted upon for financial and political reasons. The costs of implementation were estimated at £2 billion (in 1980s purchasing power) (Wanless, 2004). Meanwhile, different theories elaborated and identified the levels of intervention necessary to make lasting change in public health, focusing on ‘up-stream’ and ‘down-stream’ metaphors (X, Ruth, X) and different levels of intervention needed (Swerisson and Crisp, 2004). However, there is a growing evidence of increased challenges that health systems face, in terms of their long-term sustainability and benefits produced for the resources used (Schieber et al, 1993). The new prominence given to public health reflects the recognition of its crucial role in affecting outcomes of care and the health status of the population (WHO,
8
1995; DoH Acheson Report 1998), but also its potential to reduce the resources spent on acute care in the long run by focusing on prevention and health promotion.
1.2
National Developments in Public Health Policy
Public health has been given an increased role in the Government’s plans for restructuring and reforming the NHS. The Labour government has been placing a growing emphasis on public health and its potential to prevent the causes of ill health and to improve quality of life since it came to power in 1997. Government public health policy has been spelt out in several important documents published during the last seven years. In 1997 the newly established Minister of Public Health commissioned an “Independent Inquiry into Inequalities in Health Report” by Sir Donald Acheson, asking him to identify areas of policy development likely to reduce inequalities (DoH, Acheson, 1998). This report has influenced government public health policy since then, although only a small fraction of its recommendations referred directly to health care system actions (Exworthy et al, 2003). The subsequently published White Paper, “Saving Lives: Our Healthier Nation” deepened the public health approach and moved beyond target setting for reducing morbidity and mortality, from the main causes outlined in “Health of The Nation” seven years earlier (DoH, 1992), to include health inequalities as important predictors of health outcomes (DoH, 1999). “The NHS Plan for England” identified several national standards for service or care groups set in National Service Frameworks (NSFs) and involving public health key interventions that should be matched and examined alongside local priorities (DoH, 2000). Several other documents followed: the Cross Cutting Review aimed to develop the evidence base to tackle health inequalities (DoH, 2002), the delivery plan outlined in Programme for Action (DoH, 2003) and the Wanless Report outlining options for long term financing of the NHS (HM Treasury Wanless 2002). The most recent Wanless Report ‘Securing our Future Health: Taking a Long-Term View’ reviewing the state of public health in England and commissioned by the Treasury (HM Treasury Wanless, 2004) comes as strong evidence of the Government’s interest in public health’s potential and the role it can play in preventing diseases and improving the quality of life. The public health agenda, as defined in Government documents, adopts the ”Social Model” of health care (GOfNW, 2003) and is driven by the realisation that health outcomes and health status indicators are significantly influenced by wider determinants that are outside health and health care provision. This philosophy is reflected in the new public health agenda and the appointment of Directors of Public Health (DsPH) to Primary Care Trusts (PCTs), which was announced in “Shifting the Balance of Power” (DoH, 2002). PCTs are the loci where the multidimensional nature of public health should be realised. Directors of Public Health (DsPH) have been appointed to PCT boards and given a wide range of responsibilities, while high expectations have been placed upon their role and capacity to implement the new public health agenda. The increased visibility of the public health perspective outlined in policy documents and recommendations (DoH, 1998; DoH, 2002; DoH, 2003) and reiterated in the Wanless Report (Wanless 2004) relates to all levels of health care delivery, but its role appears to be particularly important at the interface of different levels (primary and secondary care) and areas (health and social services) of care provision, in Primary Care Trusts (Hunt, 2001).
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1.3
Public Health in the North West
The North West Region, in which this study was undertaken, is an area with most pronounced health inequalities that are reflected in the highest differentials of health status indicators in England when compared with the national average or better performing areas in the country. The starkest inequalities concern male life expectancy but they are only slightly better for females. For example, a male resident of Manchester can expect to live over seven years less than his contemporary in Barnet, and when its comes to healthy life expectancy the gap is even greater. The number of years of life in good health that a man can, on average, expect to live is almost 11 years better in Surrey than in Manchester (Hunt, 2001; GOfNW, 2003). Health inequalities and poor health indicators are marked in CHD, respiratory disease and some forms of cancer to name but a few. Possibly because of these factors the North West Region has quickly responded to the new Public Health philosophy, something that is reflected in the unique structure of DPH appointments. Almost half the appointments are held by individuals without a medical qualification and over a third are joint appointments with Local Authorities. Directors of Public Health in PCTs are expected to work in close alliance with Local Authorities to formulate strategies to attain public health goals, which under certain conditions could be best achieved if DsPH hold joint appointments with their respective LAs. The North West Region has been a leader in this area with the number of appointments that are jointly made and/or funded with different Local Authorities. Furthermore, in recognition of the multi-disciplinary and cross-sectoral nature of interventions needed in modern public health these positions were for the first time opened to non-medical public health specialists. Again in the North West a substantial number of these new type appointments for DsPH were made.
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Methods And Sample 1.4
The main research questions
“Shifting the Balance of Power: Next Steps” identified an ambitious and far reaching agenda for public health development within PCTs, defined as ‘the frontline of public health delivery’. Directors of Public Health were appointed to the PCT boards to work ‘at the heart of new organisations’ and be the ‘engine’ that would drive forward these developments (DoH, 2002; Hunt, 2001). The purpose of this research is to assess how far DsPH have been fulfilling this central role and whether conditions in the PCT created a facilitating, neutral or an adverse environment for these changes to occur. DsPH were expected to play a strategic role in co-ordinating a wide range of public health activities, which focus on addressing the wider determinants of health and tackling inequalities that are necessary to bring about improvements in health care and increases in the welfare of the whole population. In every day practice this translates into them assuming a leadership role in joint planning for health and social care services, initiating and entering into collaborative agreements and joint actions with Local Authorities (LAs) in the field of education, urban regeneration, transport and environment but also fostering effective forms of community involvement in health care planning and provision. The multiple and diverse expectations entailed in the DPH role define the scope of our research, which evaluates how far have these functions have taken up root in the PCTs. These are outlined in Box 1. Although PCTs have a key role in developing strategies and policies to address new public health agenda issues, their two other primary tasks are to deliver effective primary care services to the population and to commission secondary care from providers. This creates a potential risk that public health issues with a broad and wide-ranging scope of activities, complexity of tasks, involving joint actions with local government beyond the NHS traditional focus, and outcomes which may not be immediately identifiable, could become a secondary issue in the PCT Board’s considerations. The study was designed to examine ways in which this was reflected in the priorities set by different members of the PCT Board: in particular Chairs and Chief Executives, but also PEC Chairs. Another potential area of tension was that Government’s short-term preoccupation with acute care; access targets and waiting times could dominate Chief Executives’ attention at the expense of other PCT activities, including public health. The most detrimental scenario could be that Directors of Public Health were making little or no use of their new role and were driven into routine quick-fixes and running of other aspects of the PCT’s business. These might involve activities related to the national targets and star ratings, but also dealing with achieving financial balance in the PCT. One of the questions that this study attempted to answer was how much of the DsPH time was devoted to commissioning acute services, for example, and how much time was spent on pursuing the goals identified in SBoP (DoH 2002) (see Box 1). Finally, it was important to map the profile of DsPH, but also to understand how public health roles have been developing in selected PCTs and to have comparative perspective from respective Strategic Health Authorities. These were the key questions that this research intended to answer, which are discussed in next sections.
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Box 1: New Roles of Directors of Public Health in Primary Care Trusts “Shifting the Balance of Power: The Next Steps” Appendix C Public Health”, (DoH, 2002) Focus their activities on local neighbourhoods and communities. Lead and drive programmes to improve health and reduce health inequalities. Play a powerful role in forging partnerships with local authorities, to ensure widest possible participation in health. Be well known, respected and credible with local people, authorities, GPs and other clinicians. Lead national work on workforce development. Be accessible to the local media, explaining and educating on health and health inequalities.
1.5
Scope and purpose of the research
The overall goal of the research was to explore how public health objectives were taken up and developed in selected PCTs in the North West. It was not designed to be an assessment of the performance of individual DsPH, but a study of organisational responses to the new public health challenges. The study had three aims: • to map the profile of all Directors of Public Health (DsPH) in 42 Primary Care Trusts (PCTs) in the North West, • to analyse the implementation of the objectives identified in “Shifting the Balance of Power. Next Steps”, • and to record the perception of key actors about the roles and functions of public health in five PCTs and three Strategic Health Authorities in the North West. These aims are discussed in more detail below. The first aim of this study was to map DsPH profiles in relation to several personal characteristics. In this context variables such as medical or non-medical qualifications of Directors of Public Health and the nature of their contract were examined and analysed in the light of PCTs’ attitude to public health issues. The activities that Directors of Public Health are performing in their everyday practice, was another component of the mapping. The second, aim was to ascertain how far the objectives and goals set out in Government documents, particularly “Shifting the Balance of Power. Next Steps” (DoH, 2002) have been fulfilled, and to tease out the factors that influence or obstruct their attainment. The third, aim was to compare the organisational responses of the PCTs in implementing the new Public Health agenda and to explore the perspectives of key participants in the PCT (DsPH, Chief Executive, Chairs of the Board and PEC Chairs) as well as the perspectives of the Medical Directors of Strategic Health Authorities in the North West. The possible variation in outcomes for different stakeholders who may have different perspectives, perceptions and even different definitions of ‘success’, was an important part of our research approach. Finally, an assessment of the resources (financial and HR support for personal development) allocated to and/or ring fenced for enabling DsPH to carry out these new responsibilities would be carried out.
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There were several results that we expected to have achieved at the end of our study. These are outlined below: To map the profile of DsPH in the North West and to draw some preliminary conclusions about the role they have played so far in their PCTs. • To evaluate the implementation “Shifting the Balance of Power” in the North West, and to identify likely obstacles and impediments to its implementation. • To understand how public health policy centrally formulated has been implemented at the local level and to identify factors affecting these processes. • To make recommendations about ways of maximising the impact of DsPH in PCTs. • To outline some of the necessary requirements for translating Government policy on the new public health agenda into practice.
1.6
Means of investigation
The methodology combined a quantitative survey of all 40 Directors of Public Health (one of the 42 PCTs was without a DPH at the time of the survey), administered by means of a postal questionnaire, with qualitative interviews with key actors in the PCTs such as Directors of Public Health, Chief Executives, and Chairs of the Board and Professional Executive Committee Chairs. In order to obtain a comparative perspective, Medical Directors from the Strategic Health Authorities of Greater Manchester, Lancashire and Cumbria, and Cheshire and Merseyside were also invited to take part in our study. Both our questionnaire and interview schedules were built around the objectives identified in “Shifting the Balance of Power” (see Box 1, Annex I and Annex II). We also collected some basic demographic data and information on the personal characteristics of DsPH including their background (medical or non-medical) and the nature of their contracts (whether held by PCT only or joint appointment). We added some questions to our interview schedule, that were not identified in SBoP and which we felt were important. These referred to resourcing of public health in the PCT, respondents’ personal expectations and the likely impact of the second Wanless Report. A combination of qualitative and quantitative methodologies was used to capture the range of phenomena occurring for different indicators used in this study. It has been recognised that such a mix best reflects the complexity involved in evaluating public health issues while a plurality of methods helps to delineate the boundaries of the general approach and bring the importance of individual factors into context (Baum, 1995). This is because, while quantitative tools can be best used for drawing the broad picture of facts and problems contained in a given subject, qualitative methods can highlight the underlying causes and reasons providing an answer why these occur in the first place (Mays et al, 1995). Unstructured and semi-structured interviews with key actors were aimed at in-depth explorations of issues, mapped in the postal questionnaire, about the nature of phenomena that may be involved. All issues investigated were examined taking into account the perspectives of different actors involved in PCT Boards, which were then analysed and compared to draw conclusions. Each interview lasted between 45-60 minutes. Key concepts examined were identified in a semi-structured interview schedule (see Annex II) that all interviewers used and were asked in the form of open-ended questions and then probed in order to enable as much thorough exploration as possible.
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1.7
Selection of study sites
Two PCTs from each of three Strategic Health Authorities (SHAs) were selected using a purposive sampling technique. A total of 6 PCTs was selected using the following criteria: alphabetical order personal characteristics of DsPH (medical and non-medical, with or without a joint appointment) health inequalities (two PCTs representing most and least inequalities) The Deputy Regional Director of Public Health provided the register of all PCTs and we also accessed data from the Internet. The first step was to list all PCTs in three SHAs in alphabetic order. One PCT from each Strategic Health Authority was chosen on the basis of DPH background (medical and non-medical) and the nature of their contracts (appointment with PCT only or a joint appointment with the Local Authority). PCTs with a non-medical DPH were pre-selected on the basis of the above criteria for one of the SHAs. In another SHA, PCTs with medical DsPH were chosen. Finally, PCTs with a joint DPH appointment were chosen for the third SHA, as again this type of contract was most frequently found there when compared with the two other SHAs. All PCTs were listed in alphabetic order. In Greater Manchester SHA there are 8 non-medical and 5 medical DsPH and 2 of them have joint appointments with LAs. There is also one joint appointment shared between two PCTs. In Cumbria and Lancashire SHA there is only 1 non-medical and 10 medical DsPH and 1 joint appointment with a LA. In Cheshire and Merseyside HA there are 9 non-medical, 7 medical + 1 dentist DPH and 3 joint appointments. One additional joint appointment was being planned when our study took place. The second step was to match PCTs selected on the basis of the above criteria against highest (Greater Manchester), middle range (Cheshire and Merseyside) and lowest (Cumbria and Lancashire) inequalities as defined by the IMD 2000 Weighted Scores produced by the North West Observatory of Public Health (NWOPH, 2003).
1.8
Methodological constraints
When proceeding with evaluation of policy initiatives in complex environments with multiple and multileveled influences there are methodological constraints involved, which have to be considered. First, and foremost policy evaluations imply depth versus comprehensiveness trade-offs. There is also a problem of counterfactual evidence and time lags involved before the impact of new initiatives have measurable and meaningful results for policy interventions. Finally, there are constraints related to the case study methodology selected for this study that we discussed below. Constraints and limitations apply for making inferences and generalisations on the basis of findings gauged by means of case study methodologies. The small number of study sites evaluated in this research (5 out of 42) indicates caution. On the other hand, case studies can provide meaningful results and in depth understanding of the situation if limitations are clearly delineated (Yin, 1994). Case studies can also be valuable when examining contemporary events within a real life context, when the boundaries between phenomenon
14
and context are not clearly evident, and when multiple sources of evidence are used (Merriam, 1998) to evaluate policies (Harrison, 2001). The problems of counterfactual evidence, and attributability of causality to changes that are investigated, relate to difficulties of controlling for other variables occurring simultaneously within rapidly changing healthcare environments (Pawson and Tilley, 1997). In addition, intangible but meaningful changes that are difficult to measure may not be reflected in an evaluation that relies on quantifiable indicators only. That is why our approach relies on a multi-method inquiry. Nonetheless, caution and considerable care will need to be exercised in assessing and attributing impact. Our sample represents just over one tenth of the total number of PCTs in the North West (5 out of 42), raising obvious concerns about the ability to generalise our findings. This limitation is partly assuaged by the 100% response rate to our questionnaire conducted with Directors of Public Health in 41 of the PCTs. However, it should be made clear that our findings and conclusions mainly refer to this limited sample of PCTs, which we interviewed in this study. The purpose of the study was to serve as a pilot to test our methodology and identify possible areas for future research. Therefore, even though we refer to findings they should be treated rather as indications that could be explored, confirmed or disproved in the course of scientific enquiry using larger sample of PCTs from the North West or comparing PCTs across regions.
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Results 1.9
Analysis of findings from postal questionnaire with 41 DsPH in the North West
Postal questionnaires distributed to all DsPH contained questions about demographic data (age, gender, background, nature of the contract) and questions about DsPH functions and role in the PCT outlined in “Shifting the Balance of Power” (See Annex I). There was also a final section for comments. Data were analysed using SPSS (descriptive analysis and crosstabulation). Cross tabulation performed after potential correlation was identified using test Kendall tau and Spearman rho which indicated correlation of significance larger than 0.01 (positive or negative) and larger than 0.05 (strongly positive or negative). Basic demographic data were collected to map the profile of DsPH. Figure 1 indicates that three quarters of DsPH are female. However, Figure 3 suggests less pronounced gender variation in joint appointments with 7 out of 12 joint appointments being held by men while women tend to dominate PCT held appointments (21 out of 28). Joint appointments make up for one third of all appointments (see Figure 2) while medical and non-medical appointments are evenly distributed 19 and 18 people in each category respectively (see Figure 4) with three missing responses.
Figure 1: Gender of DsPH
GENDER
MALE 35.0%
FEMALE 65.0%
The age structure represented in Figure 5 suggests that the largest group is DsPH in their forties (n.23/57%), followed by a group in their fifties and sixties (n.9/23%) and the smallest group of 6 DsPH in their thirties (15%). 5% of respondents did not indicate their age group.
16
Figure 2: Post type – joint appointment PCT/LA or PCT only DsPH in the Northwest 80
70 60
Percentage of DsPH
40
30 20
0 PCT
JOINT APPT
Figure 3: Nature of appointment (joint with PCT or PCT only) and DsPH gender 30
Number of DsPH
20
21
10 7
GENDER
7 5
MALE FEMALE
0 PCT
JOINT APPT
POST TYPE
17
Figure 4: DsPH background (medical or non-medical) 20 19 18
Number of DsPH
10
3 0 Missing
MEDIC
NON-MEDIC
MEDICAL OR NON-MEDICAL
Figure 5: Age structure of DsPH in the Northwest 30
DsPH distribution in age categories
23 20
10 9 6
0 30-39
40-49
18
50-59
There is a strong feeling among the DsPH that they played a role in selecting their public health team. Thus 20 out of 40 respondents strongly agree and another 12 agree with the statement. Only five respondents seem to disagree and one or two are uncertain of whether this is the case. There is even stronger agreement among respondents on their responsibility for providing public health training and development to other primary care professionals in the PCT (see Figure 7). 19 respondents expressed their strong agreement with the statement and another 20 expressed their agreement
Figure 6: DsPH leading role in selecting Public Health team in the PCT 30
20
DsPH views
10
20
12
5 0 STRONGLY AGREE AGREE
19
UNCERTAIN
DISAGREE
Figure 7: Developing Public Health role of other PHC professionals is key part of my role 20 19
19
DsPH views
10
0 STRONGLY AGREE
AGREE
The majority of respondents felt they spent adequate time in developing health promotion programmes. 25 respondents agreed or strongly agreed, nine disagreed and 7 were not certain (see Figure 8). Similarly, the majority of respondents feel strongly about their role in forging and developing partnerships with local agencies, with 38 respondents agreeing or strongly agreeing with this statement and only two expressing their uncertainty (see Figure 9). There was strong conviction that Board Members had clarity about the role of public health in the PCT with 26 respondents agreeing and another 8 strongly agreeing to his statement (see Figure 10). Respondents’ experience of support received by the Board members was even more overwhelming with 37 respondents declaring strong agreement and agreement with the statement and only 2 expressing uncertainty (see Figure 11). However, uncertainty seems to be the prevailing finding when time spent on developing relationship with local communities to ensure their widest participation in health care is concerned. 15 respondents were uncertain while equal numbers expressed (13 in each group) both their agreement and disagreement with the findings (See Figure 12). Similarly, and probably not surprisingly there was a great uncertainty as to whether public health was achieving its potential in the PCT. Again 15 respondents (over one third of the total sample) expressed their uncertainty whether this was the case. The number of respondents who agreed or strongly agreed that public health was achieving its potential that was largest (16) over those who disagreed or strongly disagreed with this statement (10) (See Figure 13).
20
Figure 8: DsPH spending an adequate amount of time on developing health promotion programmes 20
17
10
8
8
DsPH views
6
0 STRONGLY AGREE
AGREE
UNCERTAIN
DISAGREE
Figure 9: DsPH playing a powerful role in forging partnerships with Local Agencies 30
20
20 17
DsPH views
10
3 0 STRONGLY AGREE
AGREE
21
UNCERTAIN
Figure 10: PCT Board members are clear about the role of Public Health in the PCT 30
26
20
DsPH views
10 8
4 0 STRONGLY AGREE
AGREE
UNCERTAIN
DISAGREE
Figure 11: PCT Board members support the new Public Health role in the PCT 30
23 20
15
DsPH views
10
2
0 STRONGLY AGREE
AGREE
22
UNCERTAIN
Figure 12: DsPH spending adequate amount of time in developing relationships with local communities 14 13 12
12
10
10
8
6
DsPH views
4 3 2
0 STRONGLY AGREE
AGREE
UNCERTAIN
DISAGREE
Figure 13: The new role for Public Health in the PCT is achieving its potential 16 15
14
12 10 9
8
DsPH views
6
8 7
4
2 1
0 STRONGLY AGREE
UNCERTAIN
AGREE
STRONGLY DISAGREE DISAGREE
23
Surprisingly 29 respondents expressed disagreement and one expressed strong disagreement when asked whether they spent more time on commissioning acute care than on conventional public health activities. 8 respondents were uncertain and only one agreed (See Figure 14). However, when asked a more general question whether acute priorities diverted DsPH attention from public health activities only Under half respondents disagreed or strongly disagreed, 11 were uncertain, 10 agreed and 2 strongly agreed. (See Figure 15 and Figure 16).
Figure 14: DsPH spending more time on commissioning acute care than on conventional public health activities
40
30 29
DsPH views
20
10 8
0
2 AGREE
DISAGREE UNCERTAIN
24
STRONGLY DISAGREE
Figure 15: Acute priorities diverting DsPH from public health activities 20
16
11
DsPH views
10
10
2 1
0 STRONGLY AGREE
UNCERTAIN AGREE
STRONGLY DISAGREE DISAGREE
Figure 16: Acute priorities divert DsPGH energies from Public Health in relation to type of post (joint PCT/LA or PCT only)
14
12
10
8
DsPH Number
6
STRONGLY AGREE AGREE
4
UNCERTAIN 2
DISAGREE
0
STRONGLY DISAGREE PCT
JOINT APPT
POST TYPE
25
Below there are some comments (13 out of 40) from the postal questionnaire expressed by DsPH. The first box refers to personal and public team issues and the second to organisational issues. Great opportunity to consolidate team this year. In my experience each PCT, DPH and Chief Executive affects the style of public health in each area One PCT cannot give you a feel for the others: they are all so different! I think you should interview Director of Finance as well - you have ignored them as key leaders in PCTs, but they hold the purse strings! My role has greatly improved since concentrating on [the] Borough. I did not play a key role in appointing team as staff was largely in place. The importance of public health in this PCT is much greater than my experience in a Health Authority. This shows from having non execs and PEC members in touch with local communities.
I strongly disagree with the view that commissioning services is not a core public health activity. It depends on definition of commissioning. Effective commissioning requires detailed public health input on health need, inequalities, effective interventions and patient & public involvement. Focus on acute care and targets, and therefore funding is preventing work on health inequalities from being developed. This is compounded by the failure of the DoH to allocate funding according to need to the most deprived communities. The first 18 months of PCT life has been spent developing infrastructures and capacity across the organisation. There are close joint working arrangements developing. Public health role and balance of activities is different within each PCT and depends on the background of the DPH & other members of the team. The size of the agenda, scale and pace has hampered progress in all aspects of the PCT over the past year. It’s only in the past few months that the PCT has developed greater public health capacity to deal with the agenda. Public health should underpin the commissioning of health services.
1.10
Analysis of findings from interviews in 5 selected PCTs in the North West
Five PCTs agreed to participate in the research. They were selected to reflect a range of public health settings based upon inequality and health outcomes criteria. We interviewed Directors of Public Health, Chairs of the Board, Chief Executives and Chairs of Professional Executive Committees (PEC) in all five of the PCTs that agreed to participate in our study. In addition, the Medical Directors of the Greater Manchester, Lancashire and Cumbria, and Cheshire and Merseyside Strategic Health Authorities were also asked to participate in the study. 22 respondents were interviewed for the purpose of our study.
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Directors of Public Health 1.11
Section A: DsPH Preparedness for their role
Questions were asked about DsPH profile, (public health career paths for non-medical DsPH) and preparedness for their role. “This post will be a high level appointment and it is essential that new posts are taken up by public health professionals of the highest calibre”. (SBoP, 2002) A.1
The majority of respondents were satisfied with their DsPH preparedness for their role. Two reasons influenced this view. In some cases the appointee “fitted” very well within the organisation while in some others the unconditional approval by Board members seemed to reflect support for their organisational choice.
A.2
The overwhelming message was that there is “ good potential”, “PCTs are an experiment and DsPH face the challenges that any director would face in a new organisation”. Against this background previous experience, or the potential to develop, was seen as essential. Some respondents felt that although initially their DPH lacked credibility and capability in a corporate role, after a period of support and development this was less problematic. The most important factors influencing the performance of DsPH were experience at strategic level, political skills, management and people skills.
A.3
All respondents stressed the importance of leadership qualities, communication skills, the ability to deliver and individual capabilities and skills. Not surprisingly similar qualities were highly valued by both Chief Executives and Chairs in all five PCTs although not everyone referred to leadership. In particular they stressed the abilities and political skills to influence the agenda within partnerships and the importance of the “agents of change” aspect of their role. However, only three out of five DsPH had previous experience at Board level.
A.4
This experience seemed to be a key aspect that gave DsPH the confidence to perform well in their position, although again there was a difference in the degree of confidence that individuals expressed. One DPH who did not have this experience said there was “no organised external support and nobody there to mollycoddle you. It was a very busy time and I think we just got on with it”.
A.5
DsPH recognised the challenge involved in taking corporate responsibility at Board level, as expressed by one DPH: “there is the whole thing about being a member of that top team, taking decisions together. If a decision’s been made you don’t slag off each other in public. I found it quite a big leap to make”. Those DsPH who had little previous exposure to strategic decision-making felt prepared for the “public health” aspects of the role, but less prepared for the human resource management and the corporate aspects of the role. For some these were the most difficult areas where some felt they were less prepared and experienced.
A.6
In PCTs where DsPH did not have this experience there was some concern about the extent to which the DPH was prepared for the role. Several interviewees felt that there was a significant gap between the experience of doctors who had been
27
consultants in Public Health, but who had little management experience and the leadership role of the DPH working at Board level. Some Chairs and Chief Executives stressed the need to develop the management skills of incumbent DsPH. A.7
Different respondent groups held different views about the aspects of DsPH preparedness for their role. Thus Chairs seemed to place their focus and value on DsPH political and negotiating abilities, which in most cases they found wanting. One Chair, for example, spoke generally about DsPH lacking political nous, which s/he considered to be an essential skill for success in the role. Chief Executives were generally less concerned about this aspect of DsPH preparedness and felt that this was “part of their professional development”. One Chief Executive felt that the preparation offered for the role had been “very poor” and said that the role of DPH involved “massive change”. PEC Chairs were on the whole supportive but more distant and less engaged than other respondents, while Medical Directors from all three SHAs referred to the importance of leadership and strategic qualities, which they saw as not being uniformly displayed by all DsPH. One SHA planned a development and support programme for DsPH to improve their strategic and leadership skills.
1.12
Section B: DsPH Position Opened To Non-Medical Candidates
“For first time Director post will be open to all suitably trained public health specialists (both medical and non-medical)” (SBoP, 2002) Respondents were asked about the value of the policy, the way non-medical appointments worked, their reception in the organisation, particular challenges they faced (if any) and recommendations for the future. B.1
On the whole, respondents agreed that this was a much needed and unanimously welcomed change. There were two main lines of argument voiced in support of opening the DPH post to non-medically qualified candidates. First, it reflected the multidisciplinary character and breadth of public health that could not be confined to medical or clinical knowledge and the value of the variety of perspectives brought by applicants from different backgrounds. Second, it was also seen as representing new ways of working and a pragmatic response to limited capacity in public health as almost 50% of all DsPH in the North West came from non-medical backgrounds (See Figure 1).
B.2
Three out of five DsPH in our interview sample had a medical background.
B.3
All PCTs expressed their satisfaction with the background of the candidate appointed irrespective of their medical or non-medical background. All respondents felt that, in general, the medical or non-medical background of the DPH was not relevant. Many respondents referred to the challenges that were irrelevant to the DsPH background and resulted from increased responsibility that came with the director’s job and the broad range of tasks s/he had to carry out within and beyond the PCT. Most respondents stressed the importance of previous experience at a strategic level or visible potential to develop the ability to operate at a director level. The latter was particularly strongly supported by Medical Directors from all three SHAs.
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B.4
Members of the PCT Boards appeared to be showing strong support to their DPH while at the same recognising that the medical or non–medical status of the DPH (and the Public Health team) did make a difference. Thus in some there was a strong feeling that it was very beneficial to have a medically qualified DPH and indeed one Chief Executive had deliberately gone out to recruit a medically qualified DPH. The CE felt it was important if a serious clinical incident or public health concern arose requiring a DPH who could plan services with clinical colleagues and have a real influence. The Chair shared this view. Several of the interviewees, especially the PEC Chairs, raised concerns about non-medically qualified DsPH. These were linked to their initial credibility with other agencies, doctors and the public; their comparatively limited experience at Board level; and their lack of clinical networks, which were useful when commissioning acute care.
B.5
PCTs seemed to support the candidate chosen and their views on the value of medical or non-medical appointments depended largely on the type of appointment held. In one PCT where the DPH was a doctor (notably with outstanding strategic experience), all respondents thought that the medical background of their DPH added credibility with other doctors, Council representatives and the population, and that it had also facilitated tasks that required clinical skills, such as control of infectious diseases. Similarly, in other PCTs where the DPH was not a doctor the views were more in favour of candidates from backgrounds other than medicine.
B.6
In one PCT the Board made a non-medical and a joint PCT/LA appointment. They did not actively go out to recruit a non-doctor and expressed support for the applicant being the right person for the job (although no one with a medical qualification applied). However, there were unresolved issues about the non-medical status of the DPH that were also echoed by respondents from other PCTs and related to the perceptions of colleagues, local agencies and the public. In this case the DPH felt, at least initially, under scrutiny, as colleagues reserved judgment on her/his suitability for the post. Several respondents commented that Councillors had traditional or oldfashioned views about a DPH.
B.7
At the same time, the majority of respondents recognised that the new public health agenda was about the skills of the whole public health team and not so much about the focus upon one individual in isolation. In one DPH’s view, the critical thing was to clarify the expectations of the rest of the team before an appointment was made. In addition, access to clinical experience was seen as particularly important for the DsPH who did not have a medical background. Two DsPH felt they had this through their clinical colleagues, although none in the public health team had a medical background. One DPH felt that there was a need for a Medical Director at the PCT to manage clinical issues whilst another was looking forward to having a doctor in the team, although the PEC Chair mentioned this was less of a problem because of the role of the Health Protection Agency played in providing this expertise.
B.8
Views varied according to the category of respondents. The Chief Executive in one PCT for example said that the networks associated with medical and non-medical DPHs are different and the relationship with medics in the acute trust was weaker as a consequence, although s/he did not think this was a problem. Some Chief Executives and particularly Chairs felt there could be some tensions with the PEC Chairs and General Practitioners. While this did not seem to be generally the case, nevertheless the views of PEC Chairs on the value of medical or non-medical appointment were divided. Some felt that a medical DPH will have higher credibility with the profession and will be more able to perform on various DPH tasks; others were more neutral or even felt that a non-medical DPH brought a better balance to
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the PEC and encouraged questioning by GPs who are less likely to challenge or question a fellow medic. B.9
Interestingly, all medical DsPH thought that it wasn’t the background of the candidate but their qualifications, such as core Faculty competencies and personal capabilities that mattered the most. In the words of one of the medical DsPH: “The DPH role should be opened to people from all backgrounds including medicine. People should be interviewed on their merits and not their background”. This view was supported by another medically qualified DPH who also thought that the post should be open to non-medically qualified individuals: “there are some extremely well qualified non medical people and they should be able to go for the top job like anybody else”.
B.10
One non-medical DPH held the view that doctors were not adequately qualified for the job and their appointment did not provide good value for money, predicting that the market will rule out these appointments in the future. Similarly, another DPH pointed out that the distinction between medical and non-medical differentials in pay mattered, stressing the future implications for workforce resulting from PCTs not being able to afford medical appointments.
B.11
However, there was also a divergence of views within PCTs. In one PCT where the DPH was a Public Health doctor, the views on the value of a medical appointment were divided. The Chair thought that medical DsPH would be more credible with the local Council while the DPH, who was a doctor, thought “the rationale to open the post only for people from a very narrow background such as medicine could not be defended”. The Chief Executive focused on the difficulties of appointing well-qualified doctors and the value of different perspectives that non-qualified candidates could bring.
B.12
The overall view was that both medical and non-medical DsPHs worked well. However, a comparative perspective, provided by Medical Directors from the SHAs, suggested that experience was mixed and depended on the personal characteristics of the DsPH, the set up of the new organisation, and the previous experience of DsPH at Board level, which was acknowledged to be less compared with medical DsPH. The most common challenges faced by the former were the clinical aspects of the job and establishing their credibility with other health professionals (particularly with GPs).
1.13
Section C: DsPH Leading National Ph Workforce Development
”National work, lead by the Department of Health, is being undertaken to develop and strengthen public health workforce… to deliver the next generation of public health professionals” (SBoP, 2002) Questions were asked about the main challenges identifying the public health workforce, the DPH’s contribution to development of a national public health workforce, PCTs progress in this area and what examples of such work could be shared. C.1
There was a strong impression that PCTs were very little (if at all) involved in national public health workforce development. The main reason for this lack of involvement was that it was too early for PCTs and DsPH were overwhelmed with their own workforce problems, to contribute to the national work. Also the difficulty of
30
contributing to the national framework was magnified by recent organisational changes that led to a dismantling of old structures and the establishment of new structures. One DPH stressed this: “It is quite an impracticable suggestion to contribute to this especially that former public health structures {Health Authority} have been dismantled”. C.2
The impression was that there was also a lack of clarity and understanding of how this contribution could be enacted. For example two out of the three Medical Directors spoke in rather general terms about the work of workforce sub-groups in Public Health networks. Only one referred in more detail to public health workforce problems at a regional and national level.
C.3
The single main challenge to identifying and developing the public health workforce was the problem of capacity, seen by all respondents as grossly mismatched with the need for qualified public health staff. A closely related issue was the training of public health professionals, including medical and non-medical specialists and the wider public health workforce. Concerns were voiced that inadequate provision of skilled individuals would continue if the training philosophy did not change. Interviewees emphasised the importance of developing public health skills in many areas of the PCT workforce. One DPH commented that there were only 6 people accepted yearly to the public health training scheme in the North-West, which included both doctors and non-doctors and it could not cover the needs of 42 PCTs. One Medical Director identified the risk of a massive loss of frontline public health delivery staff after they got accredited on to the voluntary register and moved to better career options within public health.
C.4
Differences in perceptions and understanding of workforce development issues were reflected in views expressed by different respondents but also among PCTs. DsPH spoke about funding different development programmes for their staff and developing the public health functions of other core and related staff in the PCT, such as school nurses and health visitors. One DPH argued that: “public health is everybody’s job to some extent and it’s not just the people who are employed in the public health department”, a view that was also echoed by several other DsPH from other PCTs. One DPH was developing the skills of some of the community nurses but was also looking at the new contracts of independent practitioners (especially GPs, dentists and pharmacists) to see how their public health contribution could be strengthened. Another DPH raised concerns about the emphasis on competencies at the individual, rather than team level.
C.5
Chief Executives looked at public health workforce issues from an organisational perspective. One Chief Executive for example said they wanted to ensure that public health was “mainstreamed” and “normalised” and was part of everything they did. It was at the heart of all their activities and “not a bolt-on”. Another Chief Executive placed more emphasis on structural reform and its impact on the public health workforce – particularly on the impact of organisational mergers in forming the PCTs. PCT Chairs seemed to be less aware of the developments that took place in this field. One Chair emphasised the importance of health promotion and connecting with local people through developing the health promotion and information-giving function of public health, which was identified as a priority. This Chair also felt the health promotion staff they had were isolated, out of touch and reactive and there was enormous potential to develop them. PEC Chairs had little awareness of public health workforce issues with the exception of comments about primary care and the GP contract.
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1.14
Section D: DsPH and their Workforce
“The Director of Public Health will have a team whose composition is a matter for local determination”. (SBoP, 2002) Questions were asked about the DPH’s role and freedom in determining team composition, its structure and differences with other teams and/or other PCTs as well as evolving models and the development of the public health role of other primary health care professionals. D.1
PH teams in PCTs differed greatly both in terms of their size and composition. One PCT had a large team of approximately 40 people, because the DPH managed to incorporate the health promotion team into the Public Health directorate. In another PCT the public health team comprised just 2 people and there were difficulties in achieving the financial integration of public health and health promotion teams, despite the efforts of the DPH. In another the arrangements were different because certain activities, such as health promotion, were managed by one of the three PCTs on behalf of all of them. As a result the core public health team, comprising seven people, was relatively small compared with teams in other PCTs. Finally, there was a core team which comprised five people, none of whom was medically qualified. In yet another PCT the team was small in which no one else, apart from the DPH, had any formal public health qualifications.
D.2
The composition of all public health teams was determined by the way that preexisting Health Authorities and community trusts were divided. DsPH tried, to a varying degree to provide their input into the process of building up teams, but in most cases there were a few or no additional funds made available for new appointments. Most respondents in all five sites agreed that DsPH had an important role in determining teams but they and the PCT Boards jointly made the final decisions. In one PCT most interviewees said that the PCT had been entirely free to choose their own DPH and to appoint the kind of team they felt they needed. The Chief Executive commented, “Nobody has dictated anything to us”. However in this PCT and others some people had been “inherited” from previous organisations but others, especially those in the core team, were new appointees.
D.3
Views on recruitment issues differed greatly between different respondents. Broadly speaking DsPH saw the process of recruitment more challenging than all other respondent groups, perhaps with the possible exception of PEC Chairs in some PCTs. One DPH had waited for some while before appointing the Public Health team because s/he wanted to make a judgment about what kind of people and skills would be necessary. Contrary to the views expressed by other members of the Board s/he also felt that there had been pressure to make certain appointments: “I don’t think the team was chosen. It was, like, allocated”. Another DPH also reported different views and experiences from the other respondents in the PCT. The DPH found recruitment challenging – all PCTs were competing for the same people in a competitive market. They had tried to make the post more attractive by getting them accredited by the Faculty of Public Health Medicine. S/he was critical of moves by other PCTs who created job titles to make the same post sound more appealing. In contrast other respondents felt they had been slow in getting the team established and felt that recruitment was a problem – people were keen to work with the DPH and PCT.
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D.4
The views on how public health teams differed from other PCT teams were divided. One DPH thought there was no difference while another DPH saw the team as the second largest one in the PCT. The Chair in this PCT thought in terms of a small core public health team and a larger health promotion team. Another DPH thought that the team had more freedom in setting its objectives, having targets and deadlines that would feel less asphyxiating. Also some felt that the culture created by multidisciplinary “amateur managers” in the team was different. The Chief Executive from one PCT confirmed the view that the public health team was less hierarchical and more democratic when compared to other PCT teams. In another PCT there was no real clarity on how the public health workforce was defined. The Chair in this PCT felt the multiplicity of unconnected public health initiatives to be confusing and inefficient.
D.5
There were no particular models evolving in workforce development apart from the attempt to incorporate health promotion teams whenever it was possible. However, there was an increased realisation about the importance of specialists and wider workforce development and closer integration of the public health functions of different PHC professionals. The opportunities for working in partnership with Local Authorities to increase the effectiveness of public health programmes were also identified. Most respondents expressed this view, and it was particularly strong in the areas where there was a history of good and long lasting partnership. One PCT had a Joint Health Unit in the City Council while others were in the process of establishing one.
D.6
There were numerous activities linked to the development of the public health role of PHC professionals in all PCTs. These were mostly targeting health visitors and school and community nurses and activities were extended, in some cases, to funding professional development programmes for staff, such as an MSc in public health and control of infectious disease courses. However, one DPH thought that the target groups should be more broadly considered to include schoolteachers, for example. Another DPH thought that this issue was best tackled by making public health a central function in the PCT.
D.7
The DPH and Chief Executive in another PCT recognised the DPH’s key role in working with the wider public health workforce and efforts so far had focused on nurses, working closely with the Director of Clinical services. The PEC Chair in this PCT also emphasised the role of GPs and the importance of the GP contract in promoting GPs’ public health role. Many interviewees said that, because public health was being mainstreamed in their PCT, they were looking very hard at how to provide the whole team with public health skills, to varying degrees. They saw the new GP/independent contracts as a great opportunity and were developing other models (i.e. public health roles in nursing homes), which they thought were innovative.
D.8
Medical DsPH voiced more criticism as to the wider development of the public health role of primary health care professionals in the PCT. One DPH was not so positive about the degree to which other staff in the PCT were being encouraged to develop their public health skills. S/he said that “Public health staff should disseminate some of their skills to the wider primary care team … other members of the team have the skills but they are not encouraged to use them to the same degree”. Similarly, a PEC Chair did not agree that everyone in the PCT was encouraged to see public health as part of their job and felt that others could be given more encouragement.
D.9
Chairs and PEC Chairs, and to some degree Chief Executives, were on the whole much less cognisant of public health team issues and gave less specific answers to
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all questions asked. PEC Chairs and Board Chairs when compared with DsPH and Chief Executives appeared to be less informed about the public health role and team in their PCTs. For example one PEC Chair said. “If you actually asked me to identify the majority of our public health team – apart from our DPH – I’m not sure I could at this point in time …It’s somewhat disjointed from my point of view”. Medical Directors were asked to take a broader, comparative perspective and came up with general suggestions about many and different programmes such as “all range of people and skills popping up” and stressed the influence of historical differences between PCTs.
1.15
Section E: Networks
“Local public health action needs to be underpinned by a range of specialist expertise which cannot be provided in every Primary Care Trust”. “The purpose of the networks will be to pool expertise and skills in specialist areas”. SBoP (2002) Questions were asked about local responses to this issue. E.1
The overall impression was that networks could not compensate for resources and expertise that were not available in the PCTs themselves. One DPH voiced a more critical view by saying that: “SBoP anticipation of PCTs developing networks was incredibly stupid …because PCTs are the networks - there were no resources that the PCT did not have itself that could be contributed to the network”. Overall the view was that networks had made little impact. Chief Executives and DsPH were the most aware respondent groups and both commented that they had experienced some difficulties in getting the networks established, so it was still “early days”. One PCT was an exception in assuming a leadership role for the provision of specialist skills and supporting network for neighbouring PCTs, especially to the one that had a vacant DPH post. This PCT was also part of the SHA network.
E.2
The time investment required in building functioning and viable networks was identified as a main factor in the slow progress made in developing networks. One DPH thought that it took a long time for the network to get off the ground and it still did not fulfil the functions referred to in SBoP mainly because “there is so much work to be done in each PCT and giving time to the network is really a low priority.” Another DPH indirectly supported this view by saying that his/her low expectations of networks prevented him/her from experiencing disillusionment.
E.3
Respondents’ held mixed views about networks and DsPH views differed from those of the Chief Executives, which were in turn quite divergent from the Chairs’ views. On the whole, DsPH appear to be more pragmatic and more reserved about the present role and value of networks, although there were palpable differences among them on this issue. Chief Executives were more neutral and appeared to be less familiar with networks. One Chief Executive referred to the network established by the PCT, which was developed to support the professional development of the DsPH.
E.4
Some Chairs held the view that networks were not very useful for the PCT. One Chair commented “to be honest regional networks need to be more real and visible for the PCT”, and this Chair also referred to a health and social care network, established and supported by the PCT, as being more meaningful. Another Chair was also sanguine about networks and the extent to which they were developing, commenting: “my experience of the NHS is that people will network within their own areas but are very conservative when it comes to sharing that knowledge and we are no exception”. S/he felt that the Government’s ‘star rating system’ had forced NHS
34
organisations to be competitive. This also meant they were less inclined to share good ideas with others. In another PCT the Chair and PEC Chair were aware of their existence, but didn’t know anything about how they worked. The PEC Chair also referred to the Health Protection Agency networks, responsible for communicable diseases. E.5
Two out of three Medical Directors spoke about their role in providing a linking and co-coordinating framework for DsPH activities but no other respondent reported this. One Medical Director stressed DsPH ability to create opportunities to work together: “they are pretty good (DsPH) at recognising different aggregates needed to accomplish work at different levels”. Another one thought that the “inward looking behaviour” that most PCTs displayed was typical in periods of great organisational upheaval, which led to missing opportunities to create a supportive network framework.
1.16
Section F: Partnerships and Joint DsPH Appointments With Local Authorities
“They {DsPH} will also play a powerful role in forging partnerships with, and influencing all local agencies to ensure the widest possible participation in the health and health care agenda. Partnerships may involve joint appointments of the DPH to a PCT and local authority where this is deemed to be sensible”. (SBoP, 2002) Questions were asked about DsPH role in forging partnerships, the partners they worked with, the value of a joint appointment as a partnership arrangement and the challenges arising from this. F.1
Partnerships seemed to be a great success area, which was unanimously acknowledged by all respondents. All interviewees felt that partnership working was important, which was captured in the following phrases: “Partnership is so essential. We can’t do this on our own”; “it is not about why, it is how”. All PCTs with a long and good history of partnership work with Local Authorities (Borough and City Councils) in many areas, which played a pivotal role in extending partnerships to the health sphere. Some partnerships were more advanced than others so that some had a Joint Health Unit and others had different arrangements for funding DsPH joint appointments.
F.2
Two PCTs were in the process of establishing joint health units with their respective LAs, which was an ambition and a goal referred to by the Chairs and Chief Executives in two respective organisations. PCTs who were more advanced in their partnership work with Local Authorities also reported progress in forming partnerships with the voluntary sector and the wider public sector, such as urban regeneration developments. Most arrangements were carried out in the framework of Local Strategic Partnerships (LSPs). However, no respondents mentioned partnerships with local NHS trusts.
F.3
Interviewees in another PCT felt they had good partnership working with Social Services in particular (partly because they had considered becoming a Care Trust). They had integrated teams for some services and also shared budgets. They also talked a lot about their strong relationships with the voluntary sector, especially Age Concern. There was active partnership working with different parts of the criminal
35
justice system, including the local prison. In general, most activity around partnership working was at the operational rather than the strategic level. There appeared to be a high level of community activity in this particular PCT, much of it developed jointly with other agencies. One Chair felt that Social Services should eventually become the responsibility of the NHS, so that continuity of care for individual clients/patients would be improved. F.4
The Director of Public Health was not so much seen as an agent of change in terms of forging these partnerships but more as “co-decision maker at the negotiating table” “Chief Executive of the public health” and “facilitator and a trouble shooter”. Coterminosity between the PCT and the Local Authority seemed to play a major facilitating role. Some respondents thought that the lack of coterminosity could disable partnership arrangements altogether, some others thought it would need more investment to make them work whilst others were more positive and did not see coterminosity as a determining factor in partnership working.
F.5
Although partnerships seem to have worked very well on the whole, there were many challenges in making them effective and rewarding experiences for the PCTs. These challenges related to the differences in the culture of organisations, accountability and decision-making models, different priorities and the way these priorities were expressed. Other concerns were about territory and a sense that “people were fighting their own corner”, and a belief that things would not improve until particular individuals moved on. One PEC Chair also felt that there was tension about pooled budgets: “One of the main challenges is accepting a pooled budget. There are still some who would say it’s their money or it’s our money”.
F.6
All respondents seemed to agree that these were the key challenges involved in partnership working but the opportunities were seen as greatly outweighing the efforts and investment that were needed. It was generally accepted that developing and sustaining partnerships required a considerable investment in time, a scarce resource for stretched DsPH and PCTs.
F.7
Similar conclusions were drawn for joint appointments. Again there was a divergence of views and coterminosity was seen as important factor but there were other even more important aspects to be considered in the framework of joint appointments. These included the previous relationship between the PCT and LA and the availability of resources to fulfil both the PCT’s and Council’s agendas. Some emphasised the symbolic commitment to collaboration expressed through joint appointments whilst others emphasised more tangible benefits illustrated in the following quote: “the LA is potentially a greater contributor to improving health”.
F.8
On the whole, there was a positive feeling about joint appointments, although interviewees felt that it was early days and it would be some time before it was possible to fully assess how they were working. Apart from DPH membership of health and LA groups and committees, benefits were seen by many as “symbolic” and it was uncertain how a joint appointment or partnership working actually improved health outcomes. Recommendations for more joint appointments were coming from all respondents but they were not seen as an end in themselves and fitted well where there was a pre-existing history of good collaboration. Caution was advised by one DPH: “If the relationship is not good between the two organisations appointing a joint DPH to mend this relationship is not a good idea”.
F.9
There was also a divergence of views about the symbolic and substantive impact of joint appointments. PEC chairs thought this to be more in the realm of the former while Chairs and some Medical Directors emphasised the importance of political
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influence and the role that joint appointments and partnerships played by providing the networks necessary to influence people and decisions. All respondents agreed that joint appointments increased the workload for the DPH and limited the availability of the DPH in the PCT. F.10
Most views were in support of joint appointments but again there were differences expressed among respondents. One Chief Executive felt that the main benefit lay in eliminating duplication. They helped to ensure continuity of care and they could potentially lead to real economies of scale. This Chief Executive also emphasised the importance of structures to support posts. Some respondents also pointed out the more intangible aspects of the joint appointments – such as the recognition of the social determinants of health the need for “humility” on the part of the health service and the recognition of the statutory duty of LAs.
1.17
Section G: Local Communities And Inequalities
“The focus of their activity {DsPH} will be on local neighbourhoods and communities, leading and driving programmes to improve health and reduce inequalities” (SBoP, 2002) Questions were asked about DsPH leading programmes aimed at reducing inequalities and ensuring maximum health improvement. G.1
The quality of responses to this question was variable. Many seemed to agree that reducing inequalities was driving the agenda of public health programmes and even whole PCT activities, but specific examples were rarely given. For example one PCT felt that addressing health inequalities was their raison d’etre but the actions undertaken to address them did not seem systematic. There was a great deal of engagement with local communities but few focused programmes dedicated to tackling inequality. In one PCT interviewees said they were in a prosperous area and there were few inequalities. Inequalities in another PCT were seen as being aligned with the core work of the borough and in another “it has been a building block upon which the PCT has considered all its other work” as expressed by one Chair of the PCT Board.
G.2
Partnerships were referred to as a means for achieving this goal and examples of initiatives aimed at prevention such as “five fruit a day”; addressing teenage pregnancy and healthy life style programmes were given. Many PCTs also referred to a number of public health programmes (e.g. smoking cessation) but there was little evidence of an emphasis on addressing inequalities. Most PCTs appear to have addressed inequalities through the LSP and other respondents referred to equity audits, which were to be published by the PCTs.
G.3
Only one respondent spoke about addressing inequalities in access in areas such as immunisation rates among different GP practices and reducing stigma for mental health patients. One Chief Executive spoke about citizen juries and action aimed at measuring levels of deprivation and a DPH referred to the need to provide evidence based practice in the context of tackling inequalities. One of the few areas in which one PCT was consciously addressing inequalities was in exploring the potential of the new GP contract. The DPH in this PCT said it was ‘one way of addressing the inverse care law’, and that they would not be commissioning the full range of existing
37
services from all GPs but setting priorities to reflect local health needs and patient preferences. G.4
Tackling inequalities also appeared to be a potential area where there was tension between the Executives and the Non Executives on the Board. There were several references to the Non Executives having their ‘pet projects’, where they wanted to see the PCT launch programmes for which there was little evidence of effectiveness. The DPH was very concerned about one programme which the Non Executives had insisted they launch “I don’t know how we will ever manage to get out of it … it would be much better just to tell them [patients] to go out and have a walk …it’s a bit more sustainable as well”. One other particular problem identified by the Chief Executive, Chair and the DPH in another PCT was the existence of “lots of small” projects operating independently and failing to make any impact.
G.5
Although views differed among respondents this rarely resulted in friction within the PCT. For example in one PCT the DPH’s specialist expertise in inequalities was recognised and in particular the Chief Executive, as well the Chair, emphasised the importance of tackling this issue. The Chief Executive stressed nutrition and tobacco as priority areas, and the Chair placed greater emphasis on the need for individuals to take responsibility for their health, the role of health promotion to support this and the need for good Public Relations. All recognised that progress had been slow and the main reason given was that time and energy were dedicated to establishing a team and improvement could not be made until the team was in place.
G.6
Medical Directors and PEC Chairs in most PCTs came up with rather vague and general answers, which is quite surprising given the high level of deprivation in their SHAs and PCTs.
1.18
Section H: Improvement By Health Promotion, Prevention And The National Service Frameworks
“It will be also be the job of the public health teams in the Primary Care Trusts to ensure that maximum improvement to health is brought about by prevention” (SBoP, 2002) A question was asked about whether public health was mainstreamed in the PCTs. H.1
On the whole, answers were positive, but there was a need for definition of the term. Most respondents’ felt that that this process was in its initial stages or that more work was needed to achieve it. There was also recognition of conflicting priorities that interfered with the goal of “mainstreaming public health in the PCT”. The latter was captured by one Chief Executive who said: “The PCT has a strong focus on public health but one has to recognise that the PCT is judged on national access targets and yet has to deliver local improvements”. Many respondents commented that public health achievements were not included in star ratings and this had an impact on the priority, which was given to it.
H.2
An interesting set of contradictions was picked up by one DPH who implied that public health should be widely involved in all PCT activities: but "we still seem to want to sit on the fence giving advice.” The other contradiction was even more crucial and implied that if public health were to achieve its role it could mean that the public
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health team would be weakened: “because mainstreaming meant giving public health away” to everyone else in the PCT. H.3
Responses varied among different participants but it was typically DsPH who specifically referred to the content of the National Service Frameworks (NSFs). Other respondents tended to give general rather than specific responses to this question. The overwhelming impression was that all respondents were extremely committed to the public health agenda and its philosophy. This view was well articulated by one PCT Chair who said, “Public health is integrated to everything we do because if we do not do it we miss a trick” “We also think that public health has a great opportunity to influence the commissioning agenda and having a senior voice to argue public health issues with providers is important”.
H.4
There was broad support for mainstreaming public health into the PCT and an impression was that if given the choice many respondents, particularly Chairs, would have given an even higher priority to health improvements and addressing the broader causes of ill health. A possible exception was DsPH (particularly medically qualified ones) who seemed to have adopted a more cautious approach. The latter was reflected in one DPH’s concern about spending resources on sound and evidence based interventions and s/he also thought that the main improvements in health were due to improving primary and secondary care. S/he was also extremely cautious about having hidden agendas and “too doctrinaire assumptions about changing society and having to align oneself too closely with other agencies to achieve this aim.”
H.5
A good example of varying perceptions about mainstreaming and the role of NSFs in the process were responses given in one PCT where the DPH felt that, on balance, NSFs had been positive and that it was good that all NSFs had a preventive element to them. The Chief Executive also said that the NSFs had been very helpful in helping to mainstream the public health agenda and the PEC Chair felt that NSFs had been useful in helping the PCT to set its priorities and to ensure that public health was a core activity. S/he felt it was a valuable counter to the Non Executives who sometimes wanted to prioritise activities, which were not of major significance to the PCT, because they had a personal interest in the matter. Another Chief Executive said that public health was mainstreamed into a range of modernisation and health improvement initiatives.
1.19
Section I: DsPH Being Credible And Available To The Local Population And Accessible To The Media
“The Director of Public Health will not be a remote strategic figure. She or he will be well known, respected and credible with local people “. “They will be accessible to the local media explaining and educating on health and inequalities issues” (SBoP, 2002) Questions were asked about DsPH credibility and availability to the local population and his/her accessibility to the media, the tension between a strategic role and accessibility and activities related to educating the public on public health issues. I.1
DsPH engagement with the public differed among PCTs but few appeared to be proactive. One DPH responded to invitations and “tried to be out and about” and was pretty convinced that the local population would know who s/he was. In another PCT, the DPH saw this as less of priority. In yet another PCT the DPH felt that, in their first
39
year of existence, the PCT had focused its energies upon internal organisational priorities, they had not had the “luxury of going out”, and that it had not been something they felt was critical in developing the PCT. It was rather something to “work towards”. This DPH felt that it did not sit comfortably with his/her personal style to do external work of this type: “I’m not a publicity seeker. I’d rather the organisation was known more”. I.2
Some interviewees felt that their strategy for handling the media was working well. One Chief Executive was proud of how they managed this aspect of their work, saying the communications manager was almost the best thing s/he has ever done. This Chief Executive felt they had good relationships with the local media. In another PCT they had employed a Public Relation person who had “a target of one good news story a week” whilst in another PCT there was recognition among all parties that engagement with the public and media was an area that needed more development. The Chief Executive particularly stressed this aspect of future work.
I.3
Medical Directors provided a comparative perspective and reported a very diverse picture with a few very pro-active and talented DsPH who had a regular column in the local newspaper and appeared regularly in the media and some others who were less upfront about this aspect of their role. The conclusion was that it depended on the personality and experience of the individuals and also on the nature of the public health issues, which were often associated with negative publicity and serious issues.
I.4
Most respondents agreed that there was an obvious tension between a strategic role and accessibility but this was mostly ascribed to the lack of time to carry out successfully both roles. One Chief Executive felt the DPH was achieving the balance between strategic function and accessibility and was a well-known figure with no apparent conflict between the two roles.
I.5
There was some confusion about who was the front person for the PCT. One Chair said it was the Chief Executive and the Chief Executive and the DPH said it was the Chief Executive and DPH! In another PCT, the DPH thought s/he was well known while the Chief Executive thought that s/he was the PCT’s face that the public would actually recognise. In contrast, Chairs in two other PCTs did not feel the DPH was a well-known figure in the community. One Chair seemed to want more publicity about public health and referred to it in terms of marketing. In another PCT, a recurring theme in the Chair’s responses was the need to develop Public Relations, better communication and greater use of the media to raise the profile of Public Health and the PCT, in order to get across health promotion messages aimed at changing behaviour. Another Chair felt they could use the media more proactively and effectively than they did. They felt they didn’t promote their successes in public health as well as other PCTs.
1.20
Section J: Priorities And Time Spent On Public Health Activities
Questions were asked whether public health was a priority in the PCT and what percentage of DsPH time was spent on specific PH activities identified in SBoP. J.1
Interviewees felt that there were real tensions between delivering the PCT and public health agenda while meeting the requirements of the SHA about Government targets.
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J.2
Many respondents found the question about the time devoted to different activities (presented on a flashcard) difficult to answer, somewhat mechanistic and not reflecting the reality of their work. The DPH in one PCT thought that these activities represented process and not outcomes and were closely interlinked with each other. Another claimed to be spending most of her/his time on managing staff, which s/he saw as necessary and on reporting back. This DPH described the intensity and amount of feedback as a “nuisance” adding: “1/5 of my time is spent on being monitored. It is important to know the direction one is going but reporting on the same issues to several agencies i.e. DoH and SHA creates duplication”. A third DPH felt that most of his/her time went on “dealing with the deluge of messages coming from the DoH and other agencies that want certain things done, a lot of time is spent on management meetings which I have to be part of as a Director”.
J.3
Other respondents stressed the importance of selecting and building the public health team in the PCT during the first year. Currently, the work was focused on local neighbourhoods and communities, partnerships and designing programmes to addressing inequalities in the context of wider determinants of health. The lowest priority was possibly attached to educating the media and wider public on public health and health inequality issues and most surprisingly to activities around commissioning acute care. Health promotion programmes were, in most PCTs, designed and led by health promotion teams. Medical Directors views were inevitably general but when specific answers were given they confirmed the findings of the other respondent groups.
J.4
When answering the question whether this was an appropriate division of DsPH time there was a complaint voiced by Chairs that they would have preferred to deal more with the public health agenda and less with the financial situation or access targets and acute care. Despite the apparent lack of progress in getting the team established and in developing programmes to address inequalities, all respondents felt that public health had a strong place in the PCT.
J.5
When asked about priority areas, different respondents had different views, but all generally agreed that, while public health was a priority for the PCT it was overshadowed by government targets and bad financial situations or low star rating in many PCTs. One Chair felt “there was a lot going on but it needed pulling together”, and that the main priority in tackling inequalities was health promotion. Similarly, another Chair felt that even more promotion was needed and that public health should take place to avoid the need for curative services later on. On the contrary, another Chair thought that PCT should have a more pro-active role in commissioning acute services and the DPH’s role in this process was seen as crucial to influence and understand the process: “PCT should become a more effective commissioner”.
J.6
Chief Executives’ views differed among PCTs while DsPH and PEC chairs were more uniform. One Chief Executive, for example, felt that the greatest priority was forging partnerships and developing programmes to tackle inequalities. Another referred to establishing a good balance around the three PCT functions (population health, commissioning and provision of services) despite the tensions present around access and targets, financial pressures and management of new agendas such as the GP contract. On the contrary, a third Chief Executive pointed at the tension between “accountability on national targets and having to deliver locally”. DsPH felt on the whole, that public health activities did have a high priority but also recognised the need to try to reconcile their public health role with the corporate role. One PEC Chair was most candid about the role of public health in mainstreaming PCT
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activities. S/he felt PCTs were paying providers what they asked for and that PCTs were a long way away from looking at the public health input to commissioning decisions. Other DsPH supported this view. J.7
All respondents uniformly felt that acute care, access targets and waiting times occupied the agenda of the PCTs. Chairs seemed to be the most irritated by this saying: “the most expensive item is acute care. Everyone’s attention gets directed and energy is diverted to focus on how to reduce the cost of commissioning”. Another Chair complained that targets for secondary care and commissioning overshadow all other activities and that public health was not singled out in this respect. However, DsPH agreed that they were hardly involved in commissioning, themselves, and their preoccupation with acute services was not at the expense of time spent on pursuing the public health agenda.
1.21
Section K: Resources
Questions were asked as to how well public health was resourced in terms of both human and financial resources. K.1
Views differed diametrically, particularly among the different categories of respondents and among PCTs. DsPH felt that public health was adequately resourced when size of the population, team composition and money made available for new appointments were concerned. DsPH felt that resources were adequate and compared reasonably well with other activities in the PCTs. Most Chief Executives held similar views and thought that their present and most immediate public health needs were covered although both respondent groups could identify future potential for useful investment of additional resources. All respondents in one PCT felt that they did have enough resources to do their job, although they said that they could always do with more. On the contrary, in another the Chair and Chief Executive complained that nothing was adequately resourced in the PCT.
K.2
Board Chairs and PEC Chairs held quite different views and most of them thought that funding did not reflect the population needs and put a high pressure on already stretched resources. This opinion was well captured by one Chair: “the DPH is very, very, very stretched. His workload is very high and increasing”. “We would have liked to do some more public health joint work with local authorities but the capacity is not there, both in term of human and financial resources”. Another Chair stressed the conflict that financially challenged PCTs faced in their attempts to invest more in public health: “all the money goes to meeting the access targets and fulfilling the recovery plan”. The PEC Chair and the DPH in the third PCT did not complain about lack of resources (although the DPH had previously complained about lack of a team).
K.3
Each Medical Director had a different view on PCTs, but they all were quick to point out that present patterns were a result of the way that PCTs were created after splitting Health Authorities and merging community trusts. One of them explained that there was a large difference among PCTs, which was due to their size and their ability to articulate priorities. In addition, PCTs were bound by the frameworks of collaboration they have established with Local Authorities, and there was also a limit of investment into management capacity in a small PCT. Medical Directors recognised that many PCTs struggled with financial difficulties. Another Medical Director thought that his SHA was under-funded for historical reasons and
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commenting on a broader point s/he could not see that the present funding of public health would achieve the changes advocated in the second Wanless Report: “public health was not an adequately resourced vehicle to achieve this shift”. Yet another was more positive and could see shifts in public health investment in favour of less resourced PCTs. S/he also pointed that the key issue for her/him was whether there was sufficient investment in prevention, which she thought was not the case.
1.22
Section L: Public Health Potential: Expectations And Goals
Questions about fulfillment of goals and expectations in regard to public health and future goals and plans were asked of all respondents. L.1
Answers were diverse but common themes emerging related to job satisfaction and fulfilment that DsPH ascribed to their personal capabilities and experience. A stark exception was one DPH who seemed to be very disappointed. S/he came into post with high expectations and has found it a very tough job. Her/his biggest challenges have been around her/his personal capacity to deliver and the challenges involved in building a team from scratch. Interviewees in another PCT felt that, on the whole, it was too early to comment upon the impact of public health in primary care. Most were positive, although the PEC Chair in this PCT was doubtful that there had been much progress.
L.2
The other theme emerging was the high hopes and expectation of the impact that the new GMS contract could make in public health. Three Executive members of one Board saw real potential in the new GP and other contracts. They felt that, in their commissioning role in primary care, they could start to shift the priorities and performance of independent contractors. They talked about a number of examples, including sexual health, oral health and different aspects of general practice and pharmacy. In most PCTs, PEC Chairs were the main respondent group who mentioned the potential to develop the role of General Practitioners.
L.3
In terms of future goals one DPH spoke about making a “difference in this position and to this city s/he is so proud of”. Another spoke about reducing health inequalities among different groups of the population by introducing evidence based public health procedures. Interestingly, Chief Executives and Chairs adopted an organisational perspective only and hoped to utilise fully the public health perspective in the PCT. One Chief Executive talked about “making a shift from acute care to community based service and promotion”, and the Chair spoke about reducing unhealthy life style conditions. Another Chief Executive worried about succession for her DPH. A Chief Executive elsewhere spoke about “having a long-term development and closer integration with the LA and local communities”.
L.4
Medical Directors took a systemic perspective. Some felt that the momentum to make a breakthrough in public health was right and they could capture the resources to make the change happen. Some others considered the splitting of public health functions among PCTs, SHAs and the Health Protection Agency a major loss. They felt that the Health Protection Agency interfered needlessly with the work of local PCTs in public health. Finally, another Medical Director spoke about the need for more focus on delivery and the modernisation of public health agenda because parts of it were “archaic”.
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1.23
Section M: The Impact Of The Second Wanless Report
Questions about the likely impact of the second Wanless Report and the messages respondents wanted to feed into it were asked. M.1
A first and rather disappointing impression was that some Chief Executives, Chairs of the Board and PEC Chairs were not aware of the second Wanless Report at all. Those who were aware commented variously on its potential impact. Attitudes ranged from positive and hopeful about more resources being made available to more reserved and pragmatic views. Some interviewees were downright negative.
M.2
One Chief Executive thought that Wanless could have an impact by putting government weight behind public health but achieving a Wanless’ “fully engaged” scenario could be a challenge and would need dedicated resources to get there. S/he also added that performance monitoring approaches influence behaviour and therefore should be developed to promote cross–boundary working. A DPH thought that the main changes will be cultural and these would need support. There was also hope that it will involve moving towards an emphasis on health outcomes, which would be positive.
Below there are some respondent views on possible impact of the second Wanless Report. “It is going to have an impact especially in 18 months time when the obsession with waiting times will subside and people will move away from that. Wanless will have an impact on making change to the experience of care in the NHS and non-NHS bodies”. “Hopeful but also have a feeling of reality. If one wants to invest in public health one has to put a cap on hospital spending and I do not think that the government is brave enough to do this”. “The second report will be very influential {like first Wanless Report} and we have to use it very much. Given its provenance from the Treasury it has a chance to make an impact in terms of resources needed for training, research and we have to push for it determinedly”. “Potentially huge. But the recommendations are not very specific which is less useful than it might have been. “We are hoping that it is going to have a similar sort of impact to the first report because it would really give us the resource to tackle health inequalities and move the emphasis away from always doing more of the same to doing something quite radical and quite challenging things”.
There are several messages that respondents wanted to feed into the debate: “Issues around public and non-public bodies in influencing health, issues around food, smoking and life styles so NHS does not have to pick upon issues that we created for ourselves such as obesity, diabetes, children’s health and long term investment in health”. “ Find ways to cap the spending on the acute care” “Do not hold back any more and try to turn things on its head and put PH on the agenda and say treatment is important but this is important as well and we will do it. We have this confidence now to achieve it”. “To avoid time consuming process on defining structures, management mechanisms and the other is the consistency across the government agencies. The thing we need to avoid is that this is seen is as an NHS document by the LA, which may happen if the message is not pushed across all agencies”.
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“There is a need to focus attention on the “hard to reach” groups otherwise strategies will perpetuate inequalities”. “Stop holding PCTs to ransom over targets”. “Be bold”
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Discussion In this section, we discuss our main research finding and emerging themes in relation to the wider policy debate about public health issues. The next section outlines policy recommendations that our findings imply.
1.24
Profile of Directors of Public Health and Preparedness for the Role.
We found that adjustment felt easier for DsPH with previous board experience. DsPH were more often than not seen as “agents of change” and hence their personal and political skills, and capabilities to operate at a strategic level were regarded as more important than their background. The majority of respondents recognised that the new public health agenda was about the skills of the whole public health team, and good medical and clinical advice was seen as its indispensable component. It appears that although, on the whole, DsPH were successful in their new roles there were some issues raised about the leadership qualifications and qualities of the candidates, some issues about the leadership abilities of some DsPH. The range and variety of objectives and activities that DsPH are expected to fulfil call for vision and sense of purpose, in short for leadership. Theoretical frameworks suggest that large bureaucratic organisations such as the NHS, including its smaller units such as PCTs are known to produce managers and certain types of leaders whose main deficiency can be lack of strategic skills. This is because these organisations promote conformity with centrally defined goals (Weber, 1946) and are not conducive to the individuality that is one of the key attributes of leadership (Kets de Vries, 1992; House and Aditya, 1997; Hunt and Conger, 1999). The NHS appears to be on the brink of making a major change in direction with its policies advocating decentralisation and greater user autonomy (DoH, 2003) with leadership qualities being in higher demand than ever. Individual leadership attributes can be employed to maximise leadership across the team members ‘collectively’ and ‘collaboratively’as new theories about leaderful practice that is independent of levels suggest (Raelin, 2002; Raelin, 2003). This could have powerful implications if used in healthcare. External support in form of established and well resourced networks and structured development programmes may be essential in building these skills. A related conclusion is that there maybe a need for sharper focus on fewer key issues that are of local relevance and that could realistically be achieved as opposed to a broad spectrum - a message that is also reiterated in the Wanless Report (Wanless, 2004). Therefore, DsPH will have to prioritise their time and resources to achieve tangible and lasting results.
1.25
DPH post for the first time being opened to candidates outside medicine.
All respondents saw it as a welcome and a positive development in principle and thought that diversity of backgrounds of DsPH brought new perspectives and truly represented the multidisciplinary nature of public health. It was also seen as representing new ways of working and a pragmatic response to limited capacity in public health. However, several unresolved issues in relation to non-medical DsPH emerged, which were linked to their initial credibility with other agencies, doctors and the public, their comparatively limited experience
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at Board level and their lack of clinical networks, which are useful when commissioning acute care. The diversity of backgrounds represented in non-medical appointments in the North West, indicates the success of policies aimed at attracting candidates from backgrounds other than medicine. The DPH post seems to attract women more than men but joint appointments are more evenly distributed among the genders. This development fits with wider government priorities in relation to health workforce capacity building and new ways of working. Changes in jobs and roles are frequently an essential part of wider initiatives to redesign healthcare processes and systems in order bring about different performance improvements, as has been demonstrated in a number of redesign and re-engineering programmes (Locock 2001; McNulty and Ferlie, 2002), and most recently in the redesign initiatives of the Modernisation Agency and the work of the collaborative programmes (Modernisation Agency, 2002; Bate et al, 2002). They are also important to the success of moves to redesign organisational relationships and structures across the boundaries between health and other care sectors. However, it is also imperative that good medical and clinical public health expertise is available in the team within the PCTs and not just externally, such as Health Protection Agency and public health networks.
5.3
Composition of the Public Health Team.
Examination of this issue raised more fundamental questions about the nature of public health. Teams varied in their size but it related to organisational arrangements and did not reflect the value attached to public health in the PCTs. Some degree of confusion and differences in perception among different actors was noticeable although, it seemed that most respondents agreed on the systemic approach to public health underpinning the whole PCT. A major difference among respondents was indicated in their perception of health promotion teams. In some PCTs they are regarded as a structural part of the public health team while in others they are not financially integrated but less integrated into the public health team. A closely related issue was the training of public health professionals, including medical and non-medical specialists and the wider public health workforce. Concerns were voiced that inadequate provision of skilled individuals would continue if the training philosophy did not change.
5.4
National Work to Develop Public Health Workforce
All PCTs displayed little involvement and activity in national public health workforce development. The main reason explaining this lack of involvement was that it was too early for PCTs and DsPH overwhelmed with their own workforce problems, to contribute to the national work. Also the difficulty of contributing to the national framework was magnified by recent organisational changes that led to dismantling of the old and establishing new structures. The single main challenge to identifying and developing the public health workforce was the capacity, seen by all respondents as grossly mismatched with the needs for qualified public health staff.
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5.5
Public Health Networks
The expectation expressed in “Shifting the Balance of Power” that public health networks could substitute for the activities and expertise that was not available in PCTs has been challenged. The reasons provided were various and many but the key issue was the time investment needed in establishing and cultivating networks, that overstretched PCTs find difficult to provide. The other factor mentioned was the immense organisational change involved in setting up and staffing them appropriately, which in the initial stages promoted an inward looking attitude. Some respondents felt that PCTs with their variety of activities were networks themselves while some others thought that star ratings introduced a competitive mentality into the NHS, which was not conducive to experience sharing. Institutional theory of governance differentiates between markets, hierarchies and networks (Williamson et al, 1991). The current government policy is disinclined, at least in theory, to rely on markets for improving service provision, although this seems to be changing (DoH, 2003) and the Government favours networks over hierarchies. The problems associated with networks when they are used as a governance structure is that they require intense investment and usually need sustained (possibly also external) support to function, while their accountability and benefits are more often than not unclear (Dowling et al, 2004). This is exactly what our findings suggest for networks and more broadly for partnership arrangements that fall into network typology (Glendenning and Dowling, 2004).
5.6
Joint appointments and Partnerships with Local Authorities
These were 30% of all appointments and some respondents saw them as representing a symbolic commitment while others considered them to be a vehicle for influencing decisionmaking processes. However, most respondents agreed that good interagency relationships were a pre-requisite for making these appointments work. Generally, there was an enthusiasm for partnerships and a plethora of activities taking place but there was little evidence that they made a difference and represented a good use of scarce resources. Research findings from elsewhere suggest that while agencies seem to enjoy working in partnerships there is little evidence of the difference they make to service provision (Glendenning and Dowling, 2004). Respondents agreed that time needed to form and cultivate partnerships, and double accountability were constraining factors as were the differences in culture, governance structure and decision making processes. The evidence from evaluating partnerships suggests that they tend to work better when they are formed as a result of clearly defined purpose or to fulfil a specific task. Experience from introducing pooled budgets, lead commissioning, hospital discharge arrangements and particularly integrated care between Care Trusts, and intermediate care suggest that it may even lead to some degree of adjustment between traditional health and social care jobs/roles (Hudson et al, 2002; Young et al, 2002). Respondents views particularly from PCTs who opted for joint appointment support the view that partnership are more effective if they are preceded by a history of good collaboration and if they are established and cultivated at a strategic level. Using evidence in effective policy making is important for its success but there is a danger that initiatives with measurable improvements might be promoted at the expense of other less tangible, but equally important, ones. Partnerships and joint appointments studied here may have created other outcomes such as interagency
48
communication and trust building - both necessary prerequisites for partnerships to work. Therefore, there is a need for sound evidence about the results produced and trade-offs involved with measures capturing less tangible results of these collaborations. This is at present scarce and it may be that time is needed to demonstrate successes or failure of this approach.
5.7
Addressing Inequalities and Improving Health in Local Communities
Although addressing inequalities was seen as a priority for all respondents there was little evidence of substantive progress in this area while programmes and activities seemed reactive and did not address the causes of inequalities. This was possibly due to the lack of evidence to guide and support actions but also to multiple organisational changes occurring simultaneously, limited capacity of public health and in the PCTs generally. However, it could also be related to the level of interventions that are needed to effectively tackle and reduce the causes of inequality. Swerissen and Crisp provide a typology for evaluating effective actions in health promotion (Swerissen and Crisp, 2004) that derives from commonly used public health metaphors about ‘upstream’ and ‘downstream’ interventions broadly translating to macro-economic health policies as opposed to micro-economics of disease (Scott-Samuel and McDonald, 2004). Tackling health related inequalities with specific programmes aimed at reducing the burden of disease from preventable causes is essential. However, more structural causes of inequalities such as gender conditioned behaviours, literacy and poverty also need to be included in broadly considered public health programmes as they are all known to be related to differentials in health outcomes (Stanistreet et al, 1999; Marmot et al, 1997; Waldron, 1995). This might or might not be seen as being within the public health remit, but should and can be part of partnership strategy that public health leaders are and will increasingly form with local governments to address health inequalities. Finally, an active involvement of communities and neighbourhoods in achieving lasting improvements in health is also indispensable in addressing health inequalities. Our research suggests that, while the majority of respondents state their very pro-active stance towards reducing inequalities, there was little involvement of services users or those affected by inequalities.
5.8
DsPH Credibility with Local People and Accessibility to the Media
Respondents in our sample did not seem on the whole, very active with the media, which was influenced by a variety of reasons such as lack of time, a perception that it was still early days for this type of activity, and absence of a qualified communications manager. The overall impression is that DsPH did not see this aspect of their role as the most important. However, Chief Executives and Chairs in particular felt that this was a significant area for the PCTs, and there was need for more investment and more work to achieve desirable results. The picture as reported by Medical Directors was a very diverse one with few very pro-active DsPH who had skills in this area. The conclusion was that it depended on the personality and experience of the individuals and on the nature of the public health issues. However, the reason for this limited involvement maybe that publicity and marketing aspect of public health in the media is only one, and possibly not the most important, aspect of the DPH role. It is also about accessibility to the local population while performing strategic functions and assuming a leadership position in the community. The potential for tension between those two has been recognised by quite a few respondents while some others did not think it to be
49
a problem. The overall impression is that this aspect of the role is as yet to be developed for the majority of DsPH.
5.9
Resources and “mainstreaming” of Public Health in the PCTs
Most respondents felt that resource allocation to public health in PCTs was on the whole, fair and adequate in relation to the activities performed and staff employed. There were no complaints about financial resources but there was more dissatisfaction in some PCTs with the human resources employed in public health. There was a widespread resentment about PCT priorities being pre-determined and resources being directed to meeting government access targets and reducing waiting lists. Also most respondents (particularly Chairs of the Board and PEC Chairs) felt that commissioning of acute services captured a lion’s share of the PCT resources, some of which could be spent on public health with more benefit for the population. These findings suggest two things. Relative satisfaction with the resources allocated to public health may be a result of a very low starting point or a real genuine increase in funding. More importantly, the recognition of the likely impact that ‘mainstreaming’ public health in the PCT could have on preventing the causes of ill health, thus reducing high costs of treatments, is well documented in research (Lalonde Report, 1974; Black Report, 1980; Dahlgren and Whithead, 1991). A complementary approach could be that commissioning is evidence based and not driven by previous patterns of care provision. Public health would in this case have a crucial role to play in population needs assessment and in informing decisions about the amount and type of care required.
5.10
Time that DsPH devoted to commissioning as opposed to public health activities.
Public health does not seem to influence commissioning significantly and while this dominates the PCTs budget and agenda there were few examples of proactive approaches, although this was expected to change with new contracts for independent providers. Few DsPH felt that commissioning acute care diverted their energies from public health. This finding could be interpreted in two different ways. DsPH were hardly involved in commissioning as they were given space to concentrate on public health activities proper or public health input based on needs’ assessment is not used for pro-active commissioning. Both of these explanations could be correct. PCTs have been given a key responsibility for commissioning comprehensive packages of care for their populations. However, this seems to create tensions for Chairs and nonexecutives. Even Chief Executives who consider this to be a core aspect of their job seem to be ambivalent about the value of their efforts spent on acute care when compared with the potential benefits that higher investment in public health and prevention could produce. Very few DsPH see involvement in commissioning as part of their role. In reality they spent very little time on this and there seems to be no expectation, let alone pressure, from the PCTs for greater involvement. This finding is rather surprising given the fact that PCTs are government’s arm length commissioners of services for their population. Uneasiness of respondents about this divided loyalty also raises questions about long-term sustainability of the present arrangements. In addition, it raises questions about PCTs suitability in performing all multiple, and sometimes also mutually exclusive, functions that need further consideration.
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5.11
Priority Attached to Public Health in PCTs
In addressing this issue we asked whether respondents felt that public health was mainstreamed in their PCTs. On the whole, respondents did not think this was the case but the majority was supportive of the idea. The majority of interviewees thought that public health was seen as a relative priority in the PCT but the views on this issue differed among different respondent groups. On the whole, Chairs of the PCT boards felt that public health was or ought to become central in the PCT and were often idealistic and less driven by evidence. On the contrary, DsPH were more cautious and focused on what could be realistically achieved. Chief Executives were supportive but adopted an organisational perspective and addressed public health while dealing with other priorities. PEC chairs were supportive too but appeared to be less well informed and placed their expectations on the new GMS contract, and its potential impact on public health. It is encouraging to see that public health enjoys broad support by all key actors in the PCTs studied although the findings have to be treated with caution both because of the so called ‘halo effect’ where interviewees present a rather over-optimistic picture of themselves and also because of the content of the implied support. It is rather worrying that the strongest conviction about public health’s role and potential comes from those respondents who are vague about how this can be achieved in practice. It also raises some further questions about the non-executive role and quality of input in decision making at Board level. Evidence is needed to decide how best to utilise their commitment and the community perspective they bring.
5.12
Public Health Potential
Few respondents felt the potential was fulfilled mainly because time was spent on meeting national access and waiting time targets as well as commissioning of acute care. However, DsPH were not heavily involved in these activities nor were they distracted from implementing the public health agenda. Also the majority of respondents across all respondent groups felt that PCTs were rather well resourced both in terms of financial and human resources. The conflict between centrally defined goals and targets and the need to deliver outcomes that are meaningful locally is a real one. It is encouraging that despite the pressures and tensions the new public health agenda is not sacrificed to fulfil targets and meet evaluation indicators. However, uneasiness of respondents about this divided loyalty raises questions about long term sustainability of the present arrangements. In addition, a question about PCTs suitability in performing multiple and sometimes also mutually exclusive functions should be considered.
5.13
The impact of the second Wanless Report
A first and rather disappointing impression was that some Chief Executives and Chairs and PEC Chairs were not aware of the second Wanless Report at all. Those who were aware commented variously on its potential impact. Wanless was given the important task of delivering an impartial and external evaluation of the public health potential and role in improving health outcomes and well being of the
51
population. The unparalleled success of the previous report in influencing health policy and increasing dramatically health spending for the years to come (Wanless, 2002), raising expectations that were placed upon it by both by public health professionals and by the other stakeholders in health policy (Hunter, 2003). The hope was that it would bring public health into policy focus in the same way as the first report did. However, our finding was that, at the time the interviews took place, the Report had attracted little attention even in the public health community.
52
Policy Implications In this section we will outline necessary prerequisites for translating government policy on public health into practice. We will make recommendations as to the necessary course of action to maximise the effect of DsPH presence in the PCTs, bearing in mind the limitations of findings implied by the size of our sample and methodological constraints inherent in policy evaluations. The key lessons learned from reviewing the experience of DsPH in the North West are discussed below. On the whole, we felt that DsPH have successfully responded to their multiple roles although some aspects of their role were more successfully developed than others. Partnerships were developing well while the visibility and accessibility to the population and media seemed to have attracted the least attention. Also work with, and involvement of, local neighborhoods and communities was variable, which is quite surprising given respondents high commitment to addressing health inequalities. A quite clear message was that DsPH have to priorities their time and resources to achieve tangible and lasting results, and need support in performing their multiple roles (i.e. public relation specialists in promoting public health role). Developing the strategic capacities of DsPH was the single key priority identified by all respondent groups. It might therefore be advisable, to have a sharper focus on fewer key issues that are of local relevance and could realistically be achieved instead of a broad spectrum of goals; a message that is also reiterated in the Wanless Report (Wanless, 2004). External support in form of established and well resourced networks and structured development programmes may be essential in this process. Opening up the post of DPH to suitably qualified candidates outside medicine was seen as a very positive development, despite the unresolved issues that remained. This development is likely to continue and possibly also increase given the workforce capacity problems. However, it is imperative that good medical and clinical public health expertise is available in the public health team within the PCTs and just externally. While public health networks, when properly developed, and the Health Agency Protection can partly fulfill this role, they cannot substitute for reliable input on an everyday basis to shape the provision of health care services at every level of care. Public health teams and DsPH are heavily dependent on clinical input to perform many of their core roles and every effort should be made to ensure this is available in the PCTs. This can be achieved, in part, by appropriate policies aiming at developing public health workforce capacity at all levels but particularly its frontline, clinical and strategic components. Most respondents in our study have identified over and again, a failure to provide a suitably trained workforce in areas with public health needs. An appropriately trained and adequate (in numbers) public health workforce is also an essential precondition to achieve a ‘fully engaged scenario’ and shift to a ‘wellness service’ advocated in the two Wanless Reports (Wanless, 2002; Wanless, 2004). Experience from a number of NHS initiatives which have been designed or intended to extend and reshape the roles of particular clinical professions and the boundaries between them (Audit Commission, 1995), and a continuing programme of policy research aimed at developing better understanding of workforce configuration issues (DoH, 1997) could be also used in developing public health capacity. Working in partnerships seems to be a great success area, which should be built and capitalised upon. However, trade-offs in terms of time and resource needed to develop and
53
cultivate partnership imply that there is a need for sound evidence about results it produces in terms of improved health outcomes and increase in well being of the population. This is at present scarce and it may be that time is needed to demonstrate successes or failure of this approach. Similar conclusions can be drawn for joint DsPH appointments. The issue of evidence-based approaches is even more crucial in addressing health inequalities, the core issue that drives and underpins the new public health agenda. There is a wealth of research demonstrating the impact of wide determinants on health but there is much less evidence of what are the effective interventions that might alter this impact. Even when evidence exists, appropriate incentives have to be put in place to promote its implementation. It is somewhat perplexing that many DsPH are uncertain or negative about the part of their role that involves developing relationships with local people to ensure their participation in public health programmes. It is also difficult to see how health inequalities might be addressed without this participation and involvement. It is suggested therefore, that apart from focus on developing an appropriate evidence base, a framework for implementation needs to be in place. Possibly a way forward would be to performance managing addressing inequalities and to include community involvement as a criterion. The role of PCTs in developing an evidence-based approach to addressing health inequalities is also crucial. National Standard Frameworks (NSFs) have proved useful in mainstreaming some aspects of prevention in the PCTs and quite a few respondents mentioned the usefulness of targets in focusing attention on public health achievements, despite the disincentives entailed in target setting. Seen from this perspective, targets are an important measure of performance of other aspects of service provision such as access and waiting times focusing attention on their attainment. They tend to be seen as a proxy for the value attached to the aspects of care that are included in star ratings, thus intentionally or not conveying the message of their higher importance. The implication for policy is that public health functions in the PCT and their outcomes could be seen as key areas if they were performance managed. Respondents felt that commissioning of acute care should be underpinned by public health inputs that would be based on population needs assessment and not on previous patterns of acute service provision. The GMS contract presents an opportunity of altering the commissioning philosophy but DsPH involvement in commissioning needs to be recognised as a priority in the PCT. This means that DsPH input into this process needs to be recognised as a priority in the PCT to make the shift to a pro-active approach in commissioning. Our research findings suggest that Non-Executive Directors took a broad but also a detached perspective of public health issues. They were often less informed about the different aspects of the public health function such as team composition, type of activities carried out and the Wanless Report on public health. This is understandable given their rather limited input on operational matters. However, because of the importance of their role and position there is a need for rigorous appraisal and evaluation of their contribution. Last but not least, this small study has mapped some important issues concerning the development of the new public health agenda in the PCTs in the North West. It also identified areas for further research such as the nature of effective leadership in health and comparisons with leadership in other sectors, the purpose and role of effective partnerships and their contribution to governance in health and the role of public involvement and nonexecutive board members in improving the responsiveness .of health care to the needs of the populations.
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References Audit Commission (1995). The doctor’s tale: the work of hospital doctors in England and Wales. HMSO: London. Bate, S.P., Robert, G., McLeod, H (2002). Report on the breakthrough collaborative approach to quality and service improvement within four regions of the NHS. Health Services Management Centre, University of Birmingham: Birmingham Baum, F. (1995) “Researching public health: behind the qualitative - quantitative methodological debate”, Social Science and Medicine 40:459-468 Berkman, L., Glass, T., Brissette, I and Seeman, T. (2000), “From social integration to health: Durkheim in the new millennium”, Soc Sci Med Vol 51 (6) pp. 843-857 Dahlgren, G, and Whitehead, M. (1991) Policies and Strategies for Promoting Social Equity in Health. Institute for Future Studies: Stockholm Department of Health and Social Security (1980) Inequalities in Health, Report of Research Group (Black Report) DHSS:London Department of Health (1997). Policy research programme: providing a knowledge base for health, public health and social care. DoH: London Department of Health (1998). Independent Inquiry into Inequalities in Health (Acheson Report. HM Stationery Office: London Department of Health (2001). Shifting the Balance of Power: Securing Delivery. DoH: London Department of Health (2002). Shifting the Balance of Power: Next Steps, Appendix C Public Health. DoH: London Department of National Health and Welfare, Canada (1974). A New Perspective on the Health of Canadians (Lalonde Report). DNHW: Ottawa Department of Health (2002). Cross Cutting Review of Health Inequalities. DoH: London Department of Health (2003). Tackling Health Inequalities: A Programme for Action. DoH: London Dowling, B. and Glendenning, C. (2004), “Partnerships: what is the evidence?” paper presented on IPEG “Public Services under Labour – a Symposium and mid-Term Review” 22-23 January 2004, University of Manchester Evans, R. and Stoddart J.G. (1990) “Producing health consuming health care”. Soc Sci Med 31 (12): 1347-63 Exworthy, M., Stuart, M., Blane, D., Marmot, M. (2003). Tackling Health Inequalities since the Acheson Inquiry. Bristol: Policy Press Government Office for North West (2003) Investment for Health. A Plan for North West 2003. Government Office for the North West: Manchester Graham, H. and Power, C., (2004). Childhood Disadvantage and Adult Health: a life curse framework. Health Development Agency: London Harrison, S. (2001) in “Policy Analysis”, in Fullop, N. (ed) Studying the organisation and delivery of health services: research methods. Routledge: London
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HM Treasury (2002). Securing our Future Health: Taking a Long-Term View, Final Report (Wanless Report). London: HM Treasury HM Treasury (2004). Securing Good Health of the Whole Population, Final Report (Wanless Report). London: HM Treasury Hudson B., Young R., Hardy B. and Glendening C. (2002) National Evaluation of Notifications for Use of the Section 31 Partnership Flexibilities of the Health Act 1999. 3rd Interim Report. Submitted to the Department of Health, June 2002. House, R. J., & Aditya, R. (1997) “The social scientific study of leadership: Quo vadis?”, Journal of Management, 23, 409-474. Hunt, J. Lord (2001) “Lord Hunt’s Speech to the Faculty of Public Health Medicine, 13th November 2001”. Hunt, J. G., & Conger, J. A. (1999) “From where we sit: An assessment of transformational and charismatic leadership research”. Leadership Quarterly, 10, 335-343. Hunter, D.J. (2003) “The Wanless Report and public health”, BMJ, Vol 327, 13 Sept. Kets de Vries, M.F. (1998), “Leadership in Organisations”, (Working paper) Fontainebleau: INSEAD Locock, L. (2001). Maps and journeys: redesign in the NHS. Birmingham: Health Services Management Centre, University of Birmingham. Marmot, M., Ryff, C.D., Bumpass, L.L., Shipley, m., Monks, N.F., (1997) “Social Inequalities in Health: next questions and converging evidence”. Soc Sci Med 44 (Suppl): 901-910 Mays, N. and Pope, C. (1996) “Rigor and Qualitative Research” in Mays, N. and Pope, C. (eds) Qualitative Research in Health Care, BMJ Publishing Group: London McNulty T, Ferlie E (2002). Re-engineering healthcare: the complexities of organisational transformation. Oxford: Oxford University Press. Merriam, S.B. (1998), Qualitative Research and Case Study Application in Education: Revised and Expanded from Case Study Research in Education. Jossey Bass Publishers: San Francisco Modernisation Agency (2002). Improvement in the NHS. DoH: London Pawson, R. and Tilley, N. (1997). Realistic Evaluation. Sage: London Raelin, J. (2002) ‘Leaderful Practice’, Executive Excellence, November, 19 (11): 6 Raelin, J. (2003). Creating Leaderful Organisations: How to Bring Out Leadership in Everyone. Berrett-Koehler: San Francisco Schieber, G.J., Poullier, J.P. and Greenwald, L.M. (1993) “Health spending, delivery and outcomes in OECD countries”, Health Affairs 12 (2): 120-129 Scott-Samuel, A, McDonald, R. (2004) “The Wanless review: a missed opportunity to refocus upstream” Public Health X Stanistreet D, Scott-Samuel A, Bellis MA. (1999), “Income inequality and mortality in England”. J Public Health Med 21:205-207 Stoklos, D. (1992) “Establishing and maintaining health environments: Towards social ecology in health promotion” American Psychology, Jan 47 (1): 6-22 Swerissen, H. and Crisp, B. (2004) “The sustainability of health promotion interventions in different levels of social organisation”, Health Promotion International Vol 19 No 1
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ANNEX I Questionnaire (Questionnaire appears here as it was sent out. Stationary reflects old MCHM) The Manchester Centre for Healthcare Management The University of Manchester Devonshire House University Precinct Centre Oxford Road Manchester M13 9PL Tel: 0161 275 2908 Fax: 0161 273 5245
The Role of Directors of Public Health in Primary Care Trusts in the North West - Feasibility Study Questionnaire Some questions about your post 1. What is your professional background? (please list relevant qualifications and roles)
2.
Is your post: i) ii)
a PCT appointment a joint appointment (PCT / Local Authority)
Some questions about you 3.
Are you: Male Female
4.
Your age? 20-29
30-39
40-49
58
50-59
60+
Some questions about your role and your PCT
(please read the statements carefully and tick the appropriate box that applies) Strongly agree
Agree
Uncertain
Disagree
5. I played a lead role in the selection of the PCT Public Health team 6. Developing the Public Health role of primary care professionals is a key part of my role 7. I spend an adequate amount of time in leading and developing health promotion programmes 8. I play a powerful role in forging partnerships with local agencies to address Public Health issues 9. I spend an adequate amount of time in developing relationships with local people to ensure their participation in Public Health programmes 10. The new role for Public Health in primary care is achieving its potential in reducing health inequalities 11. PCT Board members are clear about the role of Public Health in PCT 12. PCT Board members support the public health role in the PCT 13. Public health issues are not priorities for the PCT 14. Acute priorities divert my energies away from public health activities 15. I spend more time on commissioning services than on conventional Public Health activities
If you would like to add any further comments please write them in the space below.
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Strongly disagree
Annex II INTERVIEW SCHEDULE 1.
Every PCT Director of PH of highest calibre. How well prepared do DsPH feel for their role?
2.
For first time post open to non-medical PH specialists. What is the value? How have the non-medical DsPH been received
3.
DH leading national work to develop PH workforce
4.
The Director of PH will have a team whose composition is a matter for local determination. Also ensure development of public health role of primary care professionals
5.
Specialist expertise cannot be provided in every PCT. This need will be fulfilled by PH networks to pool expertise and skills in specialist areas of public health. How has 0this gone down here?
6.
Forging partnerships with local agencies to ensure the widest possible participation in health and social care. Partnership arrangements may involve joint appointments. How are they doing this? What are the challenges? What is the value of joint appointments?
7.
Local communities and Inequalities. How have you addressed this in your PCT?
8.
Health Prevention and the role of the NSFs. Has public health been mainstreamed in your PCT?
9.
Well known, respected, credible with local people. How has your PCT taken it forward?
10.
Accessible to local media – explaining and educating on health and inequalities? How has it gone? Any achievements?
11.
Is Public Health a priority in the PCT? Do other priorities take precedence over? What are they? The use of DsPH’s time on different functions defined in SBoP
12.
Resources – is public health adequately resourced in terms of finical and human resources?
13.
Potential of public health in primary care. Have you fulfilled your expectations? What are the future plans and goals from public health?
14.
Impact of “Wanless 2“? What is it going to be? What message would you like to feed into the debate?
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