Graham Jackson

Dr Graham Jackson is the clinical chair of NHS Aylesbury Vale CCG, the co-chair of NHS Clinical Commissioners and has worked as a GP within Buckinghamshire continually since 1988. He has been a long-time advocate of clinically-led commissioning and is involved in the emerging accountable care system in Buckinghamshire.

 

It’s difficult to fully understand the intention behind moving public health out of the NHS and into local government in the 2012 legislation. 

It appears to have led to five years of disinvestment in public health at a time when arguably that should have been the priority investment.

I’m sure that was not the intention. Maybe policy-makers didn’t see the local government funding deficit level coming as fast as it did. Either way, today, that move to local government seems like an unusual choice.
 

Improving long-term conditions management

Looking at the management of long-term conditions (LTCs) from both commissioner and provider perspectives, we nowadays talk much more than ever before about public health and prevention as vital parts of the LTC management plan. I always say that I want the preventative stuff bolted on to the front of any LTC management I commission. It’s a pre-investment, which should prevent or at least delay some spending further down the line by reducing the disease burden and therefore the need for treatment.

Primary care is key to prevention

The issue of investment is vital. Primary care has always had a key element of prevention: from weight management support to smoking cessation, healthy lives matter. The frontline generally gained support from public health colleagues in the primary care trust, or latterly the local authority, who could provide tools to support that health promotion agenda.

As commissioners, we now look more widely to other partners to support the prevention agenda, but with public health sat in local authorities, there’s a worrying disconnect between the two. As we move into the world of accountable care systems (ACSs) or accountable care organisations (ACOs) those kinds of disconnects are no longer viable or acceptable.

As commissioners, we now look more widely to other partners to support the prevention agenda, but with public health sat in local authorities, there’s a worrying disconnect between the two.

   

Awaiting connection?

It’d be fair to ask if these are real disconnects, or bits of the system that are simply yet to be connected. Clearly, innovations such as academic health science networks (AHSNs) for example, didn't exist five years ago: now they are able to offer structure with a strategic approach, and involvement and engagement linking into the strategic commissioning and delivery of healthcare. The additional links with industry can be essential to support funding streams for preventative services, among others.

Some traditional public health components of the NHS system now sit within AHSNs, and we need to network this effectively, via the sustainability and transformation partnerships (STPs) and ACSs into more effective collaborative arrangements.

In Buckinghamshire, for example, we’re one of eight ACS pilots; we are trying to work together with partners to deliver the best outcomes for our population. Public health experts locally are key to our plans – they are very good on the determinants of health and local population needs analysis. In the broader sense, they understand what to do with our data in a preventative way to get better health outcomes.

STPs and AHSNs can be the network and glue between the service and industry. As a system, we’re establishing the public health resource that we’ll need to pull in as we reconstruct the jigsaw – we’ll have to use all the system’s resources for our locality.

 

STPs’ effect and effectiveness

The effect and effectiveness of STPs varies predictably, with issues such as geography and local relationships playing a part in this.

As a clinician, I want a local population focus to understand and meet that local healthcare need, which implies a smaller geographical footprint, but a small footprint can make it too hard to commission properly or reshape provision meaningfully.

 

The local and the national

We need a balance, with some planning local, some broad-based – both are needed. And we shouldn’t commission in isolation of each other: STPs need to know about local demography from the frontline of primary and secondary care provision.

 

We need a balance, with some planning local, some broad-based – both are needed. And we shouldn’t commission in isolation of each other: STPs need to know about local demography from the frontline of primary and secondary care provision.

   

Clinical commissioning groups strengthened clinical leadership of local population health. Local authorities appreciate that clinicians understand their local population too. For STPs to make reconfiguration decisions without understanding that local knowledge and constituent components will be difficult.

I’m not convinced that the prevention agenda can solely be delivered at big geographical footprint level. We know that the big ‘don’t’ messages that now sit with Public Health England (don’t smoke or eat or sit too much) are more effective alongside community delivery of public health messages

 

Providers and prevention

Then we have to link public health prevention into providers and how they’ll work to deliver and help the system promote preventative medicine to keep NHS services sustainable for the future.

This will mean changing payment methods: not removing the purchaser-provider split, but weighting more incentive away from payment-by-results style activity to help providers work with the rest of the sector to defer or reduce the activity we have to deliver down the line.

Historically, commissioners talked to providers to collectively deliver the services their population needed within budget. In an ACS world, we need to make sure those outside that thinking, particularly providers, come to the public health party. Our aim is to decrease the burden of LTCs by highly effective, motivated investment in preventative medicine as we haven’t done ever before.

I am relatively optimistic that if we can get people to understand that argument, it’ll work. Because I don’t think it’s an option to fail. Look at the gradient of life expectancy in the last 70 years, as the NHS has grown and delivered! It’s fantastic, but it’s being outstripped by our healthier population living longer with conditions that cause morbidity. The burden of disease bites back.

One final thought: we’ve run the health system in 12-month fiscal cycles for decades – it’s no way to deliver population health. It makes no sense to run a £110bn-a-year business in 12-month cycles, so we need the bravery to talk about how we’ll invest for the future to get a public health return.