Professor Chris Packham
Associate Medical Director
Nottinghamshire Healthcare NHS Foundation Trust
As associate medical director, Chris leads on the trust’s public health strategy. He is an honorary professor in the Faculty of Medicine at his trust and he chairs the UK Faculty of Public Health’s health services committee. He is also vice chair of the public health advisory committee at the National Institute for Health and Care Excellence.
From an NHS perspective, we’re disadvantaged by the reduced role that public health as a specialty is able to play since the 2012 legislative changes. The amount of input public health specialists can now give at the local level in the NHS is extremely variable.
For people like me working in big provider trusts, rarely if ever do we see a public health specialist either as a provider or in commissioning meetings. I believe this means bad things for the whole system, as it weakens us in two main areas.
The prevention gaps
The first is in the prevention role of the NHS. Of course there is some great work going on – some fine staff health programmes, and good work on sustainability and community citizenship. Some organisations do put prevention into their care pathways – but it’s very patchy. Prevention needs to be more systematic, especially in provider trusts.
The second weakness is that where care pathways are being developed or refined, there’s now a significant lack of public health input into getting the most prevention/health gain out of the resources we’ve got. We need to both prevent ill health by getting upstream, and also have more effective care and treatment.
There doesn't seem to be a particularly strong systematic approach and it all feels very piecemeal. This is particularly true of the systems approach to RightCare optimal value pathway work which requires a strong, coordinated and technically informed approach that clinical commissioning groups can rarely do on their own. This is just as true for care outside hospitals: the involvement of public health professionals and thinking in care pathways for local and community services (if it happens at all) sometimes comes down to the discretionary efforts of a local GP or consultant who champions this agenda. Of course, that means it’s often very variable by region.
Disempowering clinicians’ contributions
One obvious consequence of this is that when prevention or balancing the different aspects of the care pathway is considered in care pathway redesign, it’s often not implemented in the most cost-effective way.
A particular weakness is apparent in the way that doctors, nurses and other allied health professionals working in providers often feel very disempowered in taking part and contributing to decisions on what’s being commissioned – or decommissioned.
Public health specialists often get no opportunity to comment on prevention and value for money, especially in the work done within big provider units. To fix this, we need to see a consistently stronger population healthcare approach for trusts supported by public health specialists familiar with often quite complex healthcare.
So public health specialists often get no opportunity to comment on prevention and value for money, especially in the work done within big provider units. To fix this, we need to see a consistently stronger population healthcare approach for trusts supported by public health specialists familiar with often quite complex healthcare.
This goes wider than just the prevention agenda, important as that is: it means promoting the leadership role of public health approaches to clinicians in trusts, and giving them access to actual possible solutions as a vital part of the conversation and the planning process. We think this is very important, and it’s not happening nearly often enough.
The cost-effectiveness question
The NHS needs to clarify its role in system-wide discussions about the cost-effectiveness of public health initiatives. There are things that council-based public health teams can and should do to make big changes, but our current system struggles when it comes to the NHS’ role in prevention and particularly in maximising Making every contact count.
Asking busy frontline acute clinicians to talk to every patient they see about smoking, weight, diet and exercise is impractical. Rather than try to ‘do it all’ in that way, we find that it’s more effective to train people to do one thing really well and to a strict evidence base. So our efforts in mental health targeted smoking cessation – a well-known problem of a huge health inequality in deprived communities with severe mental illness. There is a massive health benefit available here, but unless we really dedicate effort and time and training, then we struggle to achieve much change and we won't make the difference we should.
The devil is always in the detail of how you deliver these interventions, be it for smoking, alcohol, or other brief interventions, but evidence continues to grow about successful approaches (a recent Lancet publication has shown that brief interventions for weight management can be effective). The important basic principle is to be careful about what extra work you’re asking hard-pressed frontline staff to do – and when you’ve chosen what you’ll focus on, to do the work in small bite-sized chunks.
We also have much to do on the optimal value pathways for the ‘big-ticket’ areas like atrial fibrillation, heart failure and COPD. In these areas, there is potential for some genuine net cost savings, but I’m quite sure that these are not fully implemented in every place everywhere. As always, we need to do what we know works to the maximum. In other areas such as mental health, much more work is required.
Busy acute clinicians can't go back to teaching patients about the basics of the determinants of better health. Public health specialists should play into that health literacy gap much more than they have.
A crucial element of secondary prevention includes getting specialist clinicians to actually comment on how effectively the money is currently being spent in their care pathway. If we do genuinely want to move efforts and resources upstream and into prevention, in some instances, we’ll need the specialists on board to help a really informed debate about how to balance resources across the care pathway. First and foremost, we need their help to ensure we identify all those with the relevant medical condition in the community. This is basic: support all stakeholders, including big provider trusts, to take a genuine population-healthcare approach once the responsibility for the catchment area has been agreed.
Matching supply to demand
Again, there could be some big gains to be had by doing this. Muir Gray describes the example that highlights what a system needs to know to be truly operating ‘population healthcare’: If we have a hospital COPD specialist who can see 300 patients a year, how do we ensure that the specialist sees the 300 patients in most clinical need, and not just the 300 who happen to navigate their way through the system to the clinic?
Many consultants tell me that they see some patients far too often, and others far too late: we have to fix this. Often, provider trusts feel relatively powerless to influence this. STPs could offer a genuine opportunity to address this shortfall, but they’ll need technical and community support to make it happen. Busy acute clinicians can't go back to teaching patients about the basics of the determinants of better health. Public health specialists should play into that health literacy gap much more than they have. The limited Public Health England resources are excellent, welcome and much is available electronically but experts on the ground are sometimes needed to develop and help utilise these resources.
Whichever the area for which you are clinically and/or managerially responsible, think about how great it would be if you had the information to contribute to decisions about how care is provided, so that the available resources on your care pathway are being used to the best possible advantage of your population. That’s what the NHS has always tried to do but never has it been more vital to succeed.