David Buck
Senior Fellow, Public Health and Inequalities
The King’s Fund
Before joining The King’s Fund, David worked at the Department of Health as Head of Health Inequalities. He managed the previous government’s public service agreement target on health inequalities, the process of the independent Marmot review of inequalities in health and informed the implementation of the current government’s approach to health inequalities. David joined The King’s Fund in January 2011 to lead on public health and inequalities
It is critical that the government gets its plans for public health right, not only to meet the stated ambition of improving the health of the poorest fastest but also to play its part in securing the long-term financial integrity of the NHS.
The King’s Fund’s response to Healthy Lives, Healthy People welcomed the government’s ambitions for public health and inequalities and the move to an outcomes focus.(1) However, we expressed serious concerns about many of the proposals, the speed of implementation and how the public health reforms align with those in the NHS.
Whatever the outcome of amendments to the Health Bill, the public health reforms are likely to mean that GP commissioners, with the help of practice managers, will need to strengthen relationships with local authorities, take a full role in joint strategic needs assessments and improve the knowledge and care of the people who have great need but who only rarely come through their practice doors.
They will need to act more strategically and focus on population health as well as that of individual patients. They will need to understand and use public health information and skills more intensively and to become better commissioners and providers of commissioned services from local authorities in order to fulfil their expected new duties on inequalities in the Health Bill and work well with Health and Wellbeing Boards.
However, the bread and butter delivery of primary and secondary prevention of ill health via primary care will remain one of the cornerstones of public health. It is no accident that the last government’s target for health inequalities was backed up by analysis that showed the quickest and biggest impact interventions on inequality were proactive intervention to tackle smoking and diabetes, cholesterol and hypertension control.(2)
Much of the work of the inequalities National Support Team was dedicated to supporting PCTs and practices make this happen and a wealth of tools and case studies have been made available for others to use.(3) Ensuring practices roll out these interventions at scale and systematically throughout the at-risk population will continue to be the single quickest effective thing practice managers can do to improve health and reduce inequalities.
This is still not happening everywhere as it should. Recent research on the QOF has shown that while it has been successful in incentivising more organised approaches to chronic disease management and provides good incentives to engage in secondary prevention there is little incentive for primary prevention or case-finding.(4)
For a number of conditions, practices with more deprived patients are also failing to identify all cases of disease within their practice populations. QOF is also not working well for groups with particularly intensive health and prevention needs, such as the homeless or gypsies and travellers. More generally, the research found that the QOF encourages a medicalised and mechanised approach to managing chronic disease that does not support holistic care or promote self-care and management.
Future revisions of the QOF will therefore need to provide more incentives for primary prevention and inequality reduction. Its reward structure must do more to promote case finding and promote a more patient-centred approach to chronic disease management through incentivising effective self-care and reflecting the multiple comorbidities many patients have. Other mechanisms beyond the QOF need to be developed locally for the care of particularly vulnerable patients.
Finally, it is crucial that primary care’s critical role in prevention should not be allowed to drift, as local authorities take more control and responsibility for public health. Future revisions of the QOF will be one test of whether that is happening or not. It is not a good sign that the Department has wound down, seemingly with nothing in their place, the national support teams that were supporting the most challenged areas to systematically improve inequality reduction in primary care.
References
1. The King’s Fund. Consultation response: Healthy Lives Healthy People. London: King’s Fund; 2011.
2. London Health Observatory. Health Inequalities Intervention Toolkit. Available from: http://www.lho.org.uk/LHO_Topics/Analytic_Tools/HealthInequalitiesInterv…
3. Department of Health. Health Inequalities National Support Team. Available from: http://www.dh.gov.uk/en/Publichealth/NationalSupportTeams
4. Dixon A, Khachatryan A, Wallace A, et al. Impact of QOF on health inequalities. London: King’s Fund; 2011.
