Feature

An unhealthy focus on illness

The health service is too preoccupied with treating disease to act as an effective cornerstone for New Labour’s public health strategy, argue Stephen Peckham, Pat Taylor and Pat Turton

Whatever the claims made for the NHS in curing disease, there is little evidence of success in promoting public health. For many people a central problem has been the hijacking of public health by the medical approach which dominates the NHS. Things have been made worse by the internal market and recent changes in primary care. The resulting organisational and professional structures pose significant barriers to promoting a public health agenda, which should ideally involve a wide range of agencies as well as communities themselves. To realise the potential of the recent green paper Our Healthier Nation, attention must now focus on these barriers.

The green paper emphasises the need for a collaborative framework for public health, but still leaves the main responsibility for the programme with health authorities. Meanwhile the white paper The New NHS makes the case for a primary care-led NHS through the creation of Primary Care Groups (PCGs), within the context of locally agreed ‘health improvement programmes’ (HIPs). Although PCGs must develop a ‘multi-agency approach’ and should involve local people, it is unclear how this will actually happen. HAs will continue to retain the main responsibility for developing public health and collaborative health strategy but, perhaps inevitably given the current context, they see GPs as the major players. But, with some heroic exceptions, GPs are not known for their skills in collaboration, or their appreciation of the potential contribution of their patients. Their main focus is on direct individual patient care or the commissioning of secondary health care services. And there are few explicit policy connections between the green and white papers.

In 1995 a research project was commissioned by the Public Health Alliance to develop a public health model of primary care. The project arose from a national conference where people from a variety of primary care, community and public health backgrounds shared their experience of trying to sustain a public health focus in their work. Their frustration, and the findings of our research, give cause for concern that the government’s public health strategy may founder because the NHS — and particularly general practice — remains over-focused on illness.

Our research has been carried out over the past two years, with the main aims of clarifying the nature of a public health model of primary care, and then testing this model in areas where conventional approaches to primary care coexist with other, more public health-based, approaches.

The study was in two phases. The first involved a literature review of public health and primary care, and a survey of existing practice in addressing public health issues at the primary care level. We used a definition of primary care derived from the World Health Organisation,¹ but it soon became clear that in Britain the focus of primary care policy has been general practice, which has been seen both as a substitute for broader primary care and as a proxy for consumer choice. Because of this close association between primary care policy and general practice many people who would be included in a broader definition of primary care felt that they were excluded from the policy process.

Our definition of public health encompassed the ideas of public health both as a resource and as an action. Public health as a resource includes the activities of information gathering (epidemiology) which inform the decisions made by others in the allocation of health resources and the actions taken by others to improve health status. Public health action, in contrast, describes those activities which promote health and which may be taken by health care agencies, local authorities, businesses, voluntary and community groups, and last but not least, by families and individuals.

The literature review and survey of practice highlighted the fact that primary care and public health operate within a wider social context and that any complete understanding should include a community dimension. The diagram below shows how the three sectors of public health, primary care, and community, each containing a wide range of unrelated activities, have the potential to overlap. This overlap contains the public health model of primary care. In addition, the research suggested that the factors drawing the different sectors together were the concern to address inequality in public health, the recognition of the importance of collaboration in primary care, and the wish of the community to participate.²

The second phase of the research aimed to explore the model in practice. Using a case study approach with interviews and group discussions, we looked at a number of areas where there was clear evidence of health activities in the community. We identified the potential benefits of these, together with practical and feasible ways in which they could be facilitated and sustained. This was followed by group discussions on the case study findings at middle management level, including the voluntary sector, and an ‘expert panel’ discussion with individuals at national policy level. To validate the overall findings, an important component was a further literature review beyond the parameters of traditional health-related disciplines.

Our findings suggest that people working in primary care already feel overloaded by constantly changing agendas and the demands placed upon them, leaving little energy to search the horizon or develop new courses of action. Common themes emerged across all organisational and professional boundaries, which significantly affect the ability to achieve health policy aims. These included problems about the definitions of ‘public health’, ‘primary care’, ‘community’ and ‘locality’; the emphasis on competition; short term funding of community health projects; inequality being seen as an issue for someone else to tackle; the disease focus of general practice and the lack credibility of ‘lay people’ as seen by professionals.

A voluntary care scheme organiser told us: ‘Generally health professionals distrust volunteers — they are seen as encroaching on their territory of expertise and they feel threatened. Once they know you have a similar background, they are more relaxed and start to value your contribution.’

And a community worker said: ‘Local GPs were focusing on flu and bronchitis — local people may be raising issues of housing, damp, heating, and street lighting. Whole streets in this neighbourhood are collectively depressed.’

The research also identified other factors which would underpin a public health orientated approach. But these were often not recognised as being important from a specific organisational or professional standpoint, nor by valued by senior management. This led to many people — both professionals and volunteers — working close to or beyond the boundaries of their own organisations and formal roles, but at the centre of the public health model.

We found that:

• committed individuals are important for the success of innovative projects, but there is often little organisational support to sustain enthusiasm, or to continue once the innovators move on;
• projects and/or workers play an essential bridging role in enabling lay people to link with professionals in primary care;
• a geographical base providing a ‘neutral’ venue is helpful for professionals and lay people to meet together and to enable community health activities to develop independently;
• access to, or control over, an element of funding and resources is an important component of success. Resources are not just financial, but include professional and personal skills;
• a shared understanding of community helps professionals to work collaboratively, particularly if they both live and work in the community, or undertake other non-medical functions – for example, being a school governor as well as community nurse or GP;
• supportive organisational strategies such as jointly funded posts, imaginative management, or established corporate structures can significantly contribute to success.

We explored these issues further by reviewing the literature on inequality, organisational collaboration and public participation. We discovered that many of these issues are already well recognised but that the evidence tends to be ignored in practice. So how do we help the NHS and other agencies to make a public health approach central to their strategies?

The research demonstrated the central importance of collaboration, participation and equity within any public health approach at primary care level. But, to date, the NHS has not demonstrated a good track record in any of these. It is worrying that, in the public health green paper, responsibility for public health rests with HAs in the NHS. Both white and green papers are strong on the rhetoric but weak on the specifics of joint working, collaboration and public involvement.

At present the main objective for HAs is to establish PCGs, and there is every indication that they will be too absorbed in the details of managing the transition from GP fundholding and locality commissioning to undertake a radical re-think of their public health strategy.

We argue for a new public health approach which addresses accountability and organisational issues, and which is based on collaboration and participation. This requires a national public health strategy, a health/local authority health strategy and community/locality public health action plans. Our findings clearly show that successful collaboration and public involvement will be most meaningfully established at a community or locality level – in contrast to the HA level suggested by the green paper.

And collaboration will not happen automatically. Managers and professionals must actively reflect on existing organisational structures and management styles. The research provides a way to identify both where people are now, and progress which is made, via the existence of pointers such as jointly funded posts, shared budgets and appropriate process measures.

Recent work on achieving equity points to the importance of reducing relative social and material inequality between individuals and between communities. On this score, the government’s approach is to be welcomed. But a commitment to reducing inequality must recognise the need to reduce the power gap between lay people and professionals and between different professional groups. The white paper identifies the need to involve non-doctors in PCGs, but the framework suggested is still medically-dominated and the current status quo in terms of power remains unchanged. There is a need for greater accountability to local communities, openness of information, and access to the policy process and decision-making, both for lay people and a wider range of professionals.

Issues such as joint approaches to public health and broadening the public health agenda were raised in the Acheson Report and again by the Public Health Alliance in 1988,³ but the view from the top has led to medically-dominated public health departments in HA purchasers. 10 years later much of this framework is again acknowledged, both implicitly and explicitly in Our Healthier Nation and in the Chief Medical Officer’s report on strengthening the public health function.⁴ But lack of attention to the details of implementation at a local level is a major problem. Our concern is that the current emphasis on re-configuring only the general practice element of primary care will limit the development of effective public health strategy and action.