Andrew Lansley points to joint powers in public health

Shadow health secretary Andrew Lansley does not flinch at the observation that there is little mention of primary care trusts in the Conservatives’ public health policy, A Healthier Nation, except to criticise what they do at present.

It would be rash to think that PCTs and local authorities have yet got all the skills they need

Instead, in a joint interview with HSJ and its sister title Local Government Chronicle, he issues PCTs a challenge: “A large part of what the job of the PCT consists of will entirely depend on the confidence they’ve built with GPs locally that they can undertake commissioning on their behalf,” he says.

But he does not have anything terribly positive to say about PCTs’ commissioning skills, highlighting the greater experience held by local authorities. Councils too could commission some services, such as for dementia, on behalf of GPs.

He confirms that the public health budget will go directly to PCTs, although local authorities will gain a greater say in how that money is spent.

The budget will be “administered” by PCTs, and he will require them to ensure it is managed by a team led by the director of public health, who will have to be appointed jointly by the PCT and the council.

“It would be rash to think that PCTs and local authorities have yet got all the skills they need for this purpose but I think local authorities probably have some of the additional skills that are necessary,” he says.

These include a “broader understanding” of the relationship with the voluntary sector, greater experience of multidisciplinary working through teams such as crime and disorder partnerships, and their statutory responsibility for general wellbeing, “which has given them a basis for thinking about all this”.

He adds: “Local authorities have been engaged in commissioning for longer and have been more focused on their commissioning function rather than their provider function for longer.”

Greatest potential

Mr Lansley says the public health budget will be “an agreed programme between the local authority and the primary care trust”. He is not proposing to define precisely what the money can be spent on; it does not need to be restricted to health service activities and “can be spent on whatever looks to have the greatest potential in delivering health gain”.

This could include adaptations and assisted technology in the home for older people, provision of counselling in occupation health schemes and even “things like gritting the roads in the county of Durham”.

Mr Lansley says the attitude of NHS organisations has typically been: “Do not bring all those councillors near us because then they will try to make decisions on voters rather than evidence.”

But PCTs will have responsibilities beyond the public health budget. They will still need to contract dentistry and pharmacy services and tender for services where there is a potential conflict of interest between GPs as commissioners and providers.

In addition, they will be “the local representatives of the NHS board”, assisting in the performance management of the contractual relationship with GPs as commissioners.

Asked why public health is the one responsibility a Conservative government would retain centrally, as opposed to giving it over to the proposed independent board, Mr Lansley says: “The job of the NHS board is to commission NHS services on behalf of patients. Public health is an objective which we see as being a responsibility of government - both central and local government.

“We are going to have to mobilise action across a wide range of governmental responsibilities and indeed beyond government.”

Too often public health has been seen as something that “occurs within the NHS rather than something which is an integral part of how one builds wellbeing within wider communities”, he says. “My attitude has always been this is something I see as integral to the job of our government department, the department that I hope to lead. And delivering on improving health outcomes is my objective.

“Just as I know that in the NHS we have to focus on outcomes, I know that the NHS will not be able to do its job as successfully as I hope it will in circumstances where there is not in parallel a focus in the department on delivering the public health environment for that to happen. So I’m not letting it simply be divorced from the NHS because the NHS depends on us having a successful public health strategy.”

The government has a “central public health responsibility” to respond to problems such as swine flu or a chemical or biological release, Mr Lansley says.

“There is no way ministers could or should say ‘this is something being responded to by our public health service and it is not the job of ministers’.”

Improving public health outcomes depends on a wide range of factors, he explains. The government can influence those in a variety of ways, and so it makes sense for public health to be a central government responsibility “with a cross-cutting remit and a budget that’s able to be deployed across government”.

As such, a Conservative public health secretary would lead a team of ministers from across Whitehall. Mr Lansley mentions children and families, the Department for Work and Pensions, the transport team, ministers with a responsibility for sport and, of course and Communities and Local Government - and says the list could go on.

This would be mirrored at the local level, and is the rationale for insisting public health budgets are managed by both PCTs and councils.

The Conservatives would set a baseline public health budget for each area, Mr Lansley says, according to how much is being spent locally at present and factors such as the age and deprivation of the population.

He “can’t imagine” this baseline will be less than 4 per cent of the total NHS budget. With plans to reward areas that demonstrate the greatest improvement in public health outcomes via the “health premium” announced in the Tories’ draft health manifesto, the proportion of the total budget devoted to public health could increase.

“We have had years and years where the way to get more money has been for your outcomes to be worse. We are literally now going to try and create the opposite effect that the more progress you make the more you are able to have money added to your baseline and locked in for the future.”

Mr Lansley insists it won’t take decades to show results in public health. Improvements in infant mortality or childhood obesity could be demonstrated within a decade, he says.

“If we were to be successful in improving our dietary response among children I think at most you would be saying within five years you would begin to see some change in the underlying trend; probably within 10 years you would see whether it’s been established or not.”

Similarly, he says, while it will take decades to prove a reduction in premature mortality from lung cancer, or to reduce “chronic drinking”, measures of the prevalence of smoking among young people, or alcohol related hospital admission rates, can be used as a proxy.

In the meantime, Mr Lansley expects the focus on public health and the collaboration he will require locally is likely to lead to more joint senior appointments. He says it is important he is not prescriptive about this, but he mentions the joint chief executive of Herefordshire PCT and council and adds: “I think the public health budget will serve as an incentive for it [management] to be brought together because then they can bring infrastructure and the budget into the same place.”