With the fanfare of the launch of the The New NHS, Modern, Dependable white paper beginning to fade away, much manouevring and speculation is beginning to emerge about how the primary care groups will form, which professionals will be involved, what funding will be available and how future roles and priorities will be decided on.
With such detailed discussions it is easy to lose sight of the main functions of primary care groups as stated in the white paper, which are to:
Contribute to the health authority's health improvement programme;
Promote the health of the local population;
Commission health services;
Develop primary care;
Better integrate primary and community health services.
How much serious thought will be given to how to approach the promotion of the health of the local population?
The green paper Our Healthier Nation has focused on four of the five the priorities identified by the earlier Health of The Nation strategy: mental health, accidents, and heart disease and stroke - and has made brief mention of poverty, deprivation, social exclusion, unemployment and other inequalities in health.
The document also mentions the need for local authorities, businesses, voluntary bodies and the NHS to work together to reach the targets set but not the mechanism of how to achieve this. Health will be expected to lead the way via the health improvement programmes, but it will be up to each primary care group to implement the targets.
What views do those at the sharp end of primary care have on such national public health matters? We conducted structured face-to-face interviews with 20 GPs in 20 practices in West Surrey. Among the towns included in the study were:
Addlestone, Camberley, Farnham, Guildford, Haslemere and Woking. Thirteen of the practices were fundholders and seven were non-fundholders. Six were training practices.
Seven GPs interviewed were from practices with four partners or fewer, and 13 were from practices with five or more partners.
We asked the GPs about the major health promotion priorities facing primary care, the vulnerable groups within their practice populations and their perceptions of their role in health promotion.
Interviewees were asked to identify the three major health promotion priorities facing their practice. Some listed more than three. Nineteen interviewees cited coronary heart disease prevention and associated risk factors as a priority; ten said smoking, and four each said asthma, alcohol and screening (cervical cytology, prostate and breast).
Other areas identified included mental health, drugs, diabetes, older people and adolescents.
Eight GPs made a distinction between the priorities facing general practice and those facing primary care as a whole. The major health-promotion priorities facing primary care as a whole were identified as coronary heart disease, cited by six GPs, and accident prevention, mentioned by four. Mental health, older people, children, adolescents, and chronic diseases (ie diabetes and asthma) were all mentioned by two of the GP interviewees.
Generally the GPs seemed to be in line with the priorities highlighted in Our Healthier Nation, although the flexibility for local target setting would allow for the addressing of other local issues of concern. More than half (13) of the GPs felt they had a direct responsibility for health-promoting activities in their routine practice.
Asked to what extent they considered health promotion part of their responsibility as a GP, six said they were partially responsible for it in their practice, citing other members of the primary care team, and agencies in the community such as social services and the voluntary sector, as also being responsible.
The vulnerable groups Most of the GPs (18) were clear that issues beyond the scope of the health service played a key role in the lives of some vulnerable patient groups such as single parents and older people. As a consequence many GPs felt that they could not provide a complete service to those patient groups (see box 1).
The interviewees recognised multi-agency working was the way to tackle the inequalities in health status. But they were unsure of how to approach this process - reflected in the patchy level of knowledge and use of the available services the health-promotion department could offer.
Fifteen doctors were unaware of the services available and ten said they did not have time to investigate what was available (see box two). There was little awareness of the department's multi-agency activities such as networking, alliance building, policy development and community participation, all of which will be crucial to the development of health improvement programmes by health authorities and primary-care groups.
Two GPs said they were not on the health-promotion department's mailing list, and six did not know if they were.
The messages for primary care groups GPs consider that they have a responsibility for promoting the health of their practice populations. The question is how to translate this into a primary-care group function, with the emphasis on cross-agency working.
Examining the use of the various services offered by the health promotion department in the study above, it is apparent that these professionals are underused.
Much of the work required of primary care groups in the new NHS needs more dialogue and discussion across different organisations to be encouraged. Those who have expertise in this arena, the health-promotion specialists, can facilitate this.
The skills of teambuilding, networking, achieving user involvement and training and education can support the formation and consolidation of primary care groups and aid the development and consultation on strategy work.
Also, the health improvement programmes will need to address the health promotion and disease prevention requirements of their local populations as part of the overall plan. Health promotion departments are ready to adapt and contribute to the new environment; the challenge will be for primary care groups to respond.
Number of GPs using health-promotion services and awareness of practice/attached staff using services
GP Practice staff
Needs assessment and research 1 0
Advice and consultancy 1 5
Team-building and development 8 9
Networking and alliances 0 0
Workplace policy development 0 0
Public and media relations 1 0
Education and training 1 9
Community participation 0 0
Resource and information centres 9 8
Youth counselling service 15 0
GPs and vulnerable groups Vulnerable groups Issues Number of doctors mentioning
Older people Access to health and social services, accident prevention, healthy living, retirement 12
Mentally ill Management in the community 8
Young single parents Parenting, social skills, healthy living, coronary heart disease prevention, mental stress 6
Youth/adolescents Lifestyle, drugs, alcohol 5
Ethnic groups Language barrier, cultural attitudes to health 3
Young children/families Family planning, at-risk children, head lice 3
People with alcohol and drug problems Housing 3
People with learning disabilities Appropriate support 1
Long-term unemployed Occupation/mental stress 1
Interviews with GPs from 20 practices in West Surrey found little preparation to deliver on health promotion, as envisaged in the New NHS white paper.
The GPs were uncertain how to set about multi-agency working to improve the health of the local population.
Knowledge of the services of the local health-promotion department was patchy.
Thoreya Swage is an independent consultant in healthcare management. Judi Linney is head of health promotion, West Surrey health authority.
1 Department of Health. The New NHS; Modern, Dependable. London: HMSO, 1997.
2 Department of Health. Our Healthier Nation: A Contract for Health. A consultation paper. London: HMSO, 1998.
3 Department of Health. The Health of the Nation: Strategy for Health in England. London: HMSO, 1992.