In the current financial climate, the NHS cannot expect real funding increases. Someone must make hard decisions about which services best meet the needs of local people, and someone must address the persisting problem of health inequalities.
The Health Bill describes extensive changes to the mechanisms for planning, developing and localising health services and putting control in the hands of GPs and local authorities (LAs), their partners in local communities.
Local people's health
Access to most NHS services is controlled by GPs. Their prescriptions and referrals are the main triggers for NHS spending. GPs (and other community clinicians) are well placed to recognise threats to local people's health. But while it makes sense to empower GP consortia to commission services to meet local needs, the process is not straightforward.
Commissioning requires a systematic approach to understanding the needs of the whole population - not just of those who present in GP surgeries.
It also requires skills to assess the effectiveness of different forms of care. These must be compared for cost-effectiveness so that available resources can deliver the greatest population benefits. Rigorous assessment of published evidence is as vital for choosing services to commission as it is for making clinical decisions.
Published evidence is essential for assessing effectiveness, cost-effectiveness and quality of service models. Equally, local evidence is key to evaluating the quality of local provision.
Interpreting the evidence may seem simple, but balancing the evidence for different treatments in order to choose between them is complicated.
Choices will be examined in detail by LAs' new health and wellbeing boards and they must be made robustly if local people are to trust decision-makers.
It is unusual to find a perfect patient pathway. Weighing up the patient journey from the community, through various services and providers, then back to the community is vital.
Setting up effective joint-working relationships to identify barriers at each crossing point in the pathway, mechanisms to overcome these, and data to monitor whether the pathway is operating successfully, will be important.
Patient pathways are not restricted to health services, and GPs must have access to public health resources to work effectively with LAs' fellow commissioners, along with community, private and voluntary sector providers.
Responsible for outcomes
Consortia will be responsible for the outcomes delivered by health services and will share responsibility for the health of their population with LAs.
This will require new levels of co-operation between consortia and LA directors of public health.
The public health White Paper describes a radical shift in tackling challenges to population health. The problems are familiar - rising rates of obesity, alcohol-related illness, continuing problems of illicit drugs, smoking and poor sexual health, and underlying mental health issues - but they are particularly challenging in times of economic hardship.
National legislation can reduce smoking in public places, but cannot commission local cessation services.
The RCGP says that 'general practice has to continue to play a role in ensuring the health of the public as we move into a world where GPs will be responsible for the population's health'.
To deliver improved and cost-effective outcomes, GPs will need access to public health skills and resources.
Big picture assessment
Improving population health and reducing inequalities requires the skills to analyse, interpret and present information from different sources.
Most NHS data relates to the use of services. If inequalities are to be reduced, it must be combined with other organisations' data to create a picture of local needs.
Such needs assessments can be 'big picture', as in joint strategic needs assessment (including NHS, LAs and other partners). Or it can be more focused (redesigning single services, for example). But it must be methodologically sound. Proper analyses are essential for monitoring the impact of commissioned services.
GPs already use immunisation, screening and health information to prevent illness or encourage healthier lifestyles.
While few practices are large enough to monitor trends of illness over time, or respond to acute events, such as infectious disease outbreaks or environmental contamination, they will be responsible for ensuring that preventative services remain effective.
Consortia will need to create, maintain and operate effective emergency plans in conjunction with LAs and health and social care providers.
Public health professionals
Whether doctors or other professionals, public health specialists are proficient in assessing population needs across different sectors.
They interpret and present evidence to answer relevant local questions, and are expert at engaging partners to evaluate, commission and improve services. They complement the clinical expertise already available to GPs.
Their colleagues, the public health practitioners, are expert at delivering health improvement interventions in areas ranging from smoking cessation to personalised health improvement programmes (for example, by school nurses).
GP consortia will want to be confident that they can access high-quality public health skills and resources to identify local needs and causes of inequalities, choose cost-effective services and commission the most appropriate providers to meet these needs.
Given the right tools, consortia will be able to work with local partners to improve health for the people.
- Dr Sinclair is a public health consultant at NHS Solutions for Public Health (www.sph.nhs.uk) and former director of public health for NHS Berkshire East