Manchester has some of the most challenging health problems in the country. Life expectancy is amongst the lowest in England, and compared with national averages people are more likely to die from cancer, heart disease, respiratory disease and accidents. There is a wide health gap between the city and the country as a whole.
In Manchester, Practice Based Commissioning (PBC) has been developed in three hubs. Each hub mirrors a local clinical community and is also part of the three distinct health economies which make up Manchester. Within each of these hub areas there is a large secondary care provider for the North (which covers 36 GP practices), Central (40 practices) and South (27 practices) hubs respectively, covering a population of approximately 547,000 between them. Each hub is supported by a management team devolved from NHS Manchester, the Primary Care Trust. The team is led by the Associate Director of Commissioning but calls upon skills and expertise from across NHS Manchester. Each PBC hub currently has a steering group, chaired by a GP. Each PBC hub is now planning to become a GP Commissioning Consortium.
Public sector leaders have recognised that many organisations, not just the NHS, have a vital part to play in improving the health of Manchester's residents and in tackling health inequalities.
Consequently a Joint Health Unit was established to co-ordinate the efforts of all agencies to improve health in the city. It is located within Manchester City Council, is jointly funded by the Council and NHS Manchester, and predominantly focuses on strategic planning and partnership working for health improvement and tackling health inequalities. A joint Director of Public Health oversees public health teams in both the PCT and the Joint Health Unit. It was already planned to merge these teams before the NHS White Paper was published and merger plans are being taken forward, with a merged management structure, although public health consultants are still employed by the PCT.
The Unit leads on a number of key public health priorities. It co-ordinates the Adults Health and Well Being Partnership within the Local Strategic Partnership, and manages the allocation of partnership resources. It supports the work of the Health and Well Being Overview and Scrutiny Committee and also provides a public health information, intelligence and research function to the NHS, the Council and other partner organisations. There are separate arrangements and structures for joint commissioning of cross-cutting health and social care services such as learning disabilities and mental health.
The City Council has worked with Manchester's GP commissioning structures through the joint unit and the public health team at the PCT. Over the coming months the City Council's Chief Executive will be visiting each PBC hub to discuss partnership working with the local authority, as they start to develop formal GP Commissioning Consortia and the proposed new Health and Wellbeing Partnership structure.
Each of the PBC hubs has support from two public health consultants, who work on a number of issues that GP commissioners see as a priority. At the moment, these are largely to do with reducing secondary care admissions and reducing variations across the different primary care practices. However the way that public health works with PBC varies across the hubs. For example, a public health consultant has a formal place on the Board of the North PBC hub, but not on the other two Boards. Such structural factors could influence the ease with which public health can progress the prevention agenda within primary care.
Colin Cox is a public health consultant based within the Joint Health Unit. He has recently taken on the role of supporting one of the PBC hubs and says that this liaison work is:
“very much about the public health function relating to GP commissioning”.
“From the public health and local authority perspective, we would ideally like to see increasing engagement from GP Commissioning Consortia on the preventive side and the broader needs of the community”, Colin explains.
“For example, worklessness is going to be an increasing issue - we would like to see primary care thinking about what it can do to support people back into work. However, we have to be realistic and understand that it's important at this time of transition to support GP commissioners to meet their current objectives, in the hope that they will be able to invest in prevention further down the line.”
Colin convenes the current Health and Wellbeing Board and would like to see the proposed new Health and Wellbeing Partnership developing into a new kind of effective organisation with statutory powers and strong representation from primary care.
“It would be more effective with executive powers and a budget”, he suggests.
However, he also emphasises the importance of having the right people, including senior officers and elected members at the table. This would ensure that commissioning for health across Manchester is genuinely strategic, takes account of the broader social determinants of health and has an integrated and holistic approach to people with diverse health and social needs, including people with learning disabilities and mental health problems.
Colin Cox, Public Health Consultant, Joint Health Unit, Manchester City Council, firstname.lastname@example.org