A healthy future? Public health in Local Authorities and the new NHS

Robert Dingwall

What were the problems the NHS was supposed to solve? • Lack of co-ordination between primary

and secondary care• Lack of co-ordination between acute and

chronic care• Lack of access especially for women and

children and people outside the southeast

• Bankruptcy of most key institutions

The English System in 1939

• Voluntary Hospitals• Local Government services

– Public Health– Poor Law/Public Assistance– Mental Health/Mental Deficiency

• National Health Insurance

Voluntary Hospitals 1

• A patchwork – some medieval but most 18th & 19th century creations of particular entrepreneurs– Average size was 68 beds – Proliferation of small cottage hospitals– Concentration in London

Voluntary Hospitals 2

• Bankrupt – Lack of revenue

33% from gifts and investments; 60% from fees

Competition with GPs for out-patient care– Ageing equipment

Fund-raising for showpiece kit that could not be used because of revenue costs

– Low wages– Inadequate staffing

Public Health

• Local Govt from 1840s– Tensions between MoH and local councils– Tensions with GPs over expansion of

M&CW work– Infectious disease control– School health– Cancer treatment– Uneven quality – Inverse care law

Poor Law

• Evolution from workhouse system under 1838 Act– Growth of hospital system

Taken over by local councils in 1929 Care of elderly remained with Poor Law

until 1948 Largely free

– Rivalry with GPs

Mental Health/Mental Deficiency• Provided by local authorities but

residents paid for by Poor Law authorities– Warehousing facilities– Eugenic separation of the mentally

deficient

National Health Insurance

• National Insurance Act 1911– Coverage of workers but not their

dependents– No coverage of unemployed– Rose from 26% of population in 1911 to

43% in 1938– Unpopular with GPs but stabilized their

incomes

Health Services in 1939: 1

• Hospitals– Patchy local authority provision of

increasing quality but limited capacity– Voluntary hospitals failing: needed huge

cash injection and effective nationalization to meet wartime needs

– Poor distribution of specialist care because of lack of market

Health Services in 1939: 2

• Public Health– Patchy provision but the best of high

quality in some cities with reasonable tax base

– Uneasy relationship with GPs– Uneasy relationship with voluntary sector

Health Services in 1939: 3

• Primary Care– Mostly single-handed GPs providing 24 hour

cover for small lists– GPs outside London struggling to make a

living Leadership was hostile to NHS but rank

and file signed up in droves– Under-investment, isolation and competition– Poor distribution

NHS Act 1946

• Essentially left division between local authorities, primary care and hospitals– Tripartite system

• A nationalization measure using central planning to take out inefficiency and address market failure

• Investment curtailed by UK’s poor economic performance

Post-War Developments

• Benign neglect for most of 1950s– Struggle with Treasury over costs

• Hospital plan of 1960s– Attempts to improve management– Poor cost control by clinicians and low

status of administrators

• Integration in 1974 reorganization

Public Health and Local Authorities

Dr. Corinne Camilleri-FerranteNHS Derbyshire County

Public Health

‘the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society’

Acheson Report 1988

Public Health Functions

• Health Protection– Infectious and non-infectious environmental

hazards (HPA, SHAs, PCTs)

• Health Improvement– Health promotion; health education (PCTs)

• Health Care– Quality; commissioning; cost-effectiveness

(PCTs, Hospitals, SHAs)

The New Scaffolding

• GP Consortia• NHS Commissioning Board• Health and Wellbeing Boards• Local Authorities• Foundation Trusts• Public Health England (part of DH)• Monitor• Commissioning Support Units

Advantages

• Local accountability – Health and Wellbeing Board – PH represented– Individual GP accountability

• More clinical involvement• Integration of health and social care

Challenges to PH

• Fragmentation– Difficult to create programmes of care– Reduction in ability to work together– Reduction in primary prevention

• Population perspective– Who takes responsibility?– How does the accountability work?– How does it fit with population choice?

Challenges 2

• Reconfiguration of services• Role of Commissioning Support Units• Performance management• Links with social care• Quality of care• Detail – Bill is very unclear

Challenges 3

• Lack of clear accountability• Competition - Monitor• Any Willing Provider• Increase in inequalities (cancer drug fund)• Size of consortia• Conflicts of interest• Coterminosity with LA

Public Health Emergencies

• HPA function will be part of DH• PH departments no longer in PCTs • SO: who will take responsibility for e.g.

– Flu pandemic?– Major infection outbreak in school?– Meningitis outbreak?

• Remember that the Acheson Report was a direct result of an ID disaster!

Public Health Emergencies 2• Lines of accountability unclear• GPs recently told that they had made a mess

of ordering flu vaccine• We currently have an On-call rota: who will be

on it in the future?• Yet a major ID disaster is the only thing for

which a DPH can be directly sacked by the SoS. Responsibility without power?

Public Health Training

• Local decision making• Trusts will have both a planning and providing

role• PH training appears to be separated from the

rest of postgraduate training• No clear accountability• Where will we train?• How do registrars fit in LAs?

Performance Management

• Clinical governance of GPs• What happens to any surplus?• Responsible Officer (revalidation)• Accountable Officer (e.g. resources,

controlled drugs)• Financial problems• Local arm of National Commissioning Board

In Conclusion

• Is this the end of the NHS?• Devil’s in the Detail: My crystal ball is a little

murky, but I believe there will be an intermediate tier and I believe we’ll somehow make it work

• This is high risk: evaluate the Pathfinders and put PH back in the centre of things, not on the periphery

Questions?