Health plans tie GPs to councils

Local authorities are set to enjoy significant influence over GP consortia decisions, writes Nick Bostock.

The determinants of health, including housing and lifestyle, come under the remit of local authorities (Photograph: Alamy)

Any optimistic GPs tempted to take the last White Paper's title - Liberating the NHS - at face value may have had a shock reading the DoH's latest policy document.

Although the public health White Paper Healthy lives, healthy people, published last week, promises to 'empower local leadership', it sets some clear limits on the freedoms GP consortia will enjoy.

The public health White Paper makes clear that, in taking the lead on public health, local authorities will enjoy significant influence over GP consortia's decisions.

Local authorities will make the bulk of public health commissioning decisions, and local authority-based directors of public health will oversee GP consortia decisions to ensure they reflect the best interests of public health.

Consortia will be legally required to have a set number of GPs on local 'health and wellbeing boards' to work with local authorities to agree shared priorities as part of a joint strategic needs assessment.

A new branch of the DoH, Public Health England, will monitor and publish details of GPs' success in tackling public health and health inequalities.

Public Health England will also handle 'elements of the GP contract' including a block of QOF cash that it will be able to use for 'public health and primary prevention indicators'.

Health inequalities
So is this liberation, or a new set of shackles? On the upside, close links with councils may increase GPs' ability to cut health inequalities.

The share local authorities receive of a £4 billion pot of NHS cash the DoH plans to ringfence for them to spend on public health will be weighted by deprivation. GPs may be as able to influence council spending as the local authorities are to influence consortia decisions.

NHS Alliance chairman Dr Michael Dixon says of the White Paper: 'This document rightly states that the determinants of health are far wider then healthcare, and include housing, transport and the local economy. The move to put local government into the driving seat on public health, directly employing directors of public health, could prove very effective as many determinants of health are within their remit.'

Research has shown that some factors that influence patient outcomes are simply outside GPs' traditional sphere of control.

Ultimately, ties with local authorities could help consortia boost their chances of earning the 'quality premium' payments available if they achieve good patient outcomes.

Londonwide LMCs chief executive Dr Michelle Drage says the traditional PCT model, with no control over some of these wider health factors, and a tendency for public health spending to play second fiddle to plugging deficits, could be improved upon under the White Paper plans.

'With good dialogue, maybe we can achieve more through local authorities than we have through PCTs,' she says.

But she warns that severe funding cuts for local authorities mean public health cash may get 'sucked out by social services' unless an army of auditors checks how it is spent.

DoH clinical director for GP commissioning Dr James Kingsland points out that the White Paper is a landmark that highlights how public health has moved on.

'The epidemics now are not cholera, but obesity, alcohol, smoking and poor diet,' he adds.

Better prevention
Nothing in the White Paper should give clinicians cause for alarm - the overall aims of better prevention and pushing people towards better self care are laudable, he says.

But its success will depend on how well the government and the NHS see the plans through. 'It's not so much about the principles, but the delivery. We have always struggled to deliver on health inequalities. This is another attempt to tackle them,' he says.

Dr Kingsland points out that one of the final acts of the last Conservative administration was the 1997 Health Act that introduced PMS contracts.

'This was about getting people into deprived areas, so there's nothing new in trying to focus on health inequalities.'

But he adds: 'We got lost on PMS becoming an alternative contract. If the plans deliver this time, fantastic.'

Whether the government sticks to the plans for long enough for them to work will be outside GPs' control.

But they can control how well they forge working relationships with local authorities. Consortia that succeed may genuinely find the reformed NHS liberating.

  • £4 billion NHS cash ringfenced for local authorities to spend on public health.
  • New branch of DoH - Public Health England - to hold part of QOF cash.
  • Local authority-based directors of public health to oversee consortia decisions.

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