In Cumbria, integrated care consortia have had “hard” budgets distributed to six localities since April. There are six GP consortia or localities, each covering roughly 100,000 residents, aligned with District Council boundaries.
Between them, the consortia now control about 70 per cent of the PCT's (NHS Cumbria) budget. Next year, they will be directly commissioning about 90 per cent of local NHS healthcare for the county. At the moment, a locality's budget covers prescribing, community services and tariff-based secondary care - emergency admissions, outpatient referrals and their consequent procedures. The consortia are coordinated and led by a “Clinical Senate” (successor to the PCT's Professional Executive Committee) which includes a lead GP from each locality. Existing expertise within the PCT is being apportioned to each of the localities.
In their early stages, the consortia have concentrated on moving care out of the two large hospital trusts in Cumbria closer to home. Community hospitals are used to allow earlier discharge from the acute trusts and prevent unnecessary admissions. Consequently, while emergency admissions have risen across most of the country, they have fallen in Cumbria. The money that has been freed up by shifting care from hospitals into the community is being used to commission more specialised care from the acute hospitals for which patients might previously had to travel further afield.
This sounds like moving some care ‘upstream' so that the money can be used further ‘downstream' for specialist secondary care. But what about the option of moving money upstream for prevention and health improvement? Or moving it from healthcare into social care as a form of prevention? Paul Musgrave leads the Public Health Network in Cumbria. Part of the Network's role is to work with all parts of the system including local government to ensure that public health features in community-oriented primary care and in the design and commissioning of services. He acknowledges that historically prevention may not always be at the forefront of GPs' thinking, but recognises the importance of the support the public health has been given by the GP consortia.
“We've got a strong relationship with localities and primary care”, says Paul, mentioning the support shown by GP leads.
“With a good level of public health involvement on the GP Commissioning Consortia Boards, we'd like to champion much more ‘upstream' prevention - for example, more rounded smoking cessation and prevention interventions, interventions to prevent harmful alcohol consumption, a better promotion and take-up of exercise on prescription”. Paul is aware that, with the proposed move of some public health functions to local government, there is a danger of disconnection between public health and primary care. “Having public health specialism on Locality Boards is potentially an important step in stopping that happening as is a strong Health and Wellbeing Board”, he says.
How will the proposed Health and Wellbeing Boards fit into the new structures?
“I would hope that the Health and Wellbeing Board would have the scrutiny and accountability role and would also link to the National Public Health Service. We would want the new Health and Wellbeing Boards to be statutory bodies with teeth and not be seen as an optional extra. These are the forums where prevention, treatment, communities and the wider public sector will meet.”
He acknowledges that all sides may find this relationship difficult in the early stages of the new structures; and also suggests that local authority elected members may have limited experience in challenging health systems (although the experience of Health Overview and Scrutiny Committees may have helped many elected members overcome their diffidence).
“How well the new Health and Wellbeing Boards will work will depend very much on the level of detail and the statutory powers they have in forthcoming legislation.”
The location of some key public health functions within local authorities will be an important contributor to the success or otherwise of the transfer to local government, Paul thinks.
“Local authorities sometimes align public health and prevention activity only within a social services context. But this is a corporate function across the whole of the local authority which should be answerable at Chief Executive level.”
In making the links between GP commissioning and local government's public health work, Paul thinks that he and his colleagues will need to find common ground that local authorities will respond to. He gives workplace health as an example, pointing out that the NHS and the local authority are often the two largest employers in an area. “If we can get the GP Commissioning Consortia to understand that commissioning for workplace health could have an impact in reducing primary care needs further down the line; and if we can get the local authority enthusiastic about the health impact it can have as a major employer, this could be a catalyst for real success in the future.”
Paul Musgrave, Network Manager, Cumbria Public Health Network firstname.lastname@example.org