Commissioning for public health - changing priorities

The direction of health policy is currently going very much one way. From the health and well-being framework through to Our Health, Our Care, Our Say to the Darzi review, it all points towards more focus on prevention and health inequalities.

Now PCTs are beginning to take this on in their management structures, aligning public health and commissioning in new ways. Several of the trusts leading the way are in the North West and three in this region are led by a new generation of non-medical directors of public health.

Possibly most advanced is Tameside and Glossop PCT, where the roles of director of public health and health strategy have been rolled into one, in the person of Melanie Sirotkin.

'I'm leading on the commissioning function for the whole organisation,' Melanie says. 'We are managing the local development plan and the delivery plan through the public health function.'

Melanie has a background in teaching and then working in local authorities in environmental health. In 1995 she was one of the first four non-medics to join the public health training scheme.

She spent several years in Oldham, working in partnership with the local authority to develop new services such as a healthy living centre and refuges for South Asian women experiencing domestic violence.

She came to Tameside and Glossop five years ago as deputy director of public health where, among other things, she set up a 'health for life' programme targeting people at risk of coronary heart disease.

'We did a particularly careful evaluation of this,' she says. 'It showed it was very significant value for money in terms of delivering outcomes such as smoking reduction and healthy eating.'

These are early days for the work she is trying to develop at Tameside and Glossop. 'I've only been in the post a few weeks,' she says.

Focused commissioning

'What we are trying to do is use public health to determine how we shift our resources more towards prevention rather than the current focus on acute care. But we need to do it in a managed way.'

Key to delivering public health focused commissioning will be practice-based commissioning, she says. 'We will turn the PCT around to help practices deliver.'

Public health specialists have been placed in project teams looking at complex care pathways.

'Public health can mean advocacy and lobbying,' she says. 'But public health information and data must make a difference in terms of commissioning; it is not just advice.

'I want to make a difference to the way services are delivered and structured. That means integrating the skills of public health and commissioning.'

At Salford PCT, public health director and deputy chief executive Julie Higgins says: 'When I took on this role I was very clear that I did not want a public health department producing fantastic strategies that no-one was ever looking at.'

Julie came into public health from a PhD in immunology. Like Melanie, she sees her PCT as a 'champion of public health' and she is also aligning commissioning with public health.

She says: 'The director of commissioning and I have aligned ourselves and our teams so that they are joint, with joint appointments, shared objectives and shared work programmes.'

The aim is for public health commissioning that tightly specifies services, targets and activities.

So, for example, where once the PCT might have commissioned an open access teenage sexual health service, new public health commissioned services will describe how many people might use the service and how many of them should get onto long-acting contraceptives.

'The commissioning for health and well-being really starts to spell this out,' says Julie. 'All our health improvement delivery is in neighbourhoods and the people running these programmes will become local commissioners working with local populations.'

Power of data

Again, these are beginnings. 'To be honest we are struggling to manage our current workload and make the shift,' admits Julie. 'It will take another two years to really embed this and the service level agreements that relate to it.'

Another pioneer in commissioning is public health director Jan Hutchinson at Bolton PCT, although she claims to be at an earlier stage than her two regional peers. A trained nurse and health visitor, she also came into public health via the masters programmes of the mid-1990s.

'We have recently created a public health post within commissioning around the 18-week target and urgent care,' Jan says. 'It's about public health data and ensuring that we understand what needs we have to address and trying to provide for that in as straightforward a way as possible.'

A particular challenge she identifies is that of getting public health data into a form that is meaningful to practice-based commissioners. 'When they do understand what's happening with their practice population, it is extremely powerful.'

The process is, as Melanie, Julie and Jan have all said, at an early stage. Much of what they are focusing on finds echoes in the world class commissioning work emerging from the Department of Health.

Some in the North West say, rather provocatively, that this movement to align public health and commissioning makes the notion of a traditional director of commissioning rather passŽ.

None of the three agrees with this view. 'I wouldn't want to be locked in endless contract negotiations,' said one. Another felt the skills of a public health director and director of commissioning were complementary.

Julie says: 'We are public health organisations and should have that way of understanding. What we might begin to see is more chief executives coming from a public health background.'