The justification for the current reorganisation of strategic health authorities and primary care trusts is to strengthen the commissioning function of PCTs and to save £250m in management costs. But are these good enough reasons and will the mergers create a period of stasis?
Commissioning a Patient-ledNHS,published over a year ago, heralded possibly the most far-reaching of the 12 reorganisations of the NHS in England since 1974, with three alone under New Labour since 1997. A consistent theme of these reorganisations has usually been the creation of two management tiers below the Department of Health and repeated changes to the geographic reach of organisations - this year's reform of strategic health authorities and primary care trusts is a case in point. Such frequent reorganisations are hugely disruptive, give rise to 'planning blight', and distract from the challenge of delivering better care for patients and improving the public's health. While moving the NHS furniture holds ever more appeal for politicians, it is time to reach a consensus on the anatomy of the NHS and to stop meddling with it.
The justification for the current reorganisation of SHAs and PCTs is to strengthen the commissioning function of PCTs and to save£250m in management costs. Are these sufficient reasons for major structural change, and will the mergers not create a period of stasis rather than strengthen commissioning and the achievement of improved health outcomes?
The bedrock of public health practice is the description and interpretation of health and disease in geographically defined populations as the basis for improving health and minimising inequalities. We need stable populations at both tiers over long time periods so that we can look back and track trends in health and disease. In short, we need to reach consensus on the structures of the NHS below the DoH. How else will the NHS become, in public health terms, a 'population with a memory' at regional and local level that can remember where it has come from in order to plan collectively for its future improved health and clinical outcomes? This should not be a narrow aspiration for public health professionals, but one that is shared by the entire healthcare community, by our local authority partners, and by the wider population.
Out of the ashes
The emergence of 10 new SHAs out of the ashes of the former 28 organisations creates a tier of sufficient size to provide strategic leadership for health and healthcare delivery across their large populations, although it looks remarkably similar to the structure which existed some 10 years ago. The appointment of a single director of public health spanning each of the new SHAs and the government offices for the regions could be a positive move for the delivery of the challenging public health agenda presented in the white paper. But success will depend on having sufficient capacity and capability at this tier and a willingness to delegate and work with public health departments in the new PCTs. The close links between the public health observatories in England and the 10 SHAs ought to facilitate greater partnership in the surveillance of health and disease at this new regional tier.
In the new configuration, 70 per cent of the PCTs will be coterminous with the boundaries of local authorities with social services responsibilities in comparison with about 44 per cent of current PCTs that are. This move should benefit the attainment of the public health dimension of a 'fully engaged scenario' as articulated by Sir Derek Wanless and to which the government has signed up - although we remain concerned that the step change required to realise this scenario has yet to happen. However, three in 10 PCTs will still relate to local authorities with two-tier administrations, making joint commissioning and integrated public health programmes more complex to deliver than need be. If local government is to move towards having a single tier throughout England coterminous with the NHS, some PCTs may need to restructure unless unitary authorities follow the new PCT boundaries. At the second attempt to create PCTs, the architecture remains neither quite fit for purpose nor very stable.
There is a tension in striving for localness and effective public and clinical engagement, yet at the same time having organisations of sufficient size to commission and plan for health improvement and health and social care provision cost-effectively. Although the population covered by each PCT will rise from an average of around 165,000 to one of just below 330,000, they range from 90,000 to 1,253,000. However, there is no perfect structure - only a less imperfect one. We are close (again) to a 'good enough' structure, so let's declare a moratorium on further wholesale structural change beyond those implemented in October 2006. Sir Derek warned against 'repeated restructuring' because of its 'negative impact', insisting that further mergers of PCTs should only occur where support existed locally. Instead of weakening the NHS further, we should focus on securing effective partnership working with the clinical community and with local authorities to make the whole greater than the sum of the parts. Only by doing so can we adapt a complex system and deliver real and sustainable health improvement for our communities.
David J Hunter is professor of health policy and management at the school for health, Durham University. Dr Jeffrie Strang is public health and medical director at North Yorkshire and York PCT.