Feature

How the NHS risks ignoring the health experts

Local people are often the experts on local health problems – yet the NHS is fast losing their support, warn Stephen Peckham and colleagues

How do primary care organisations relate to their local communities on public health issues? One way of understanding the dimensions of public involvement in public health is to distinguish between public health resources and public health action.¹ Public health resources refers to the range of expertise and services that can protect and promote health such as health promotion and disease surveillance. Public health action refers to activities in wider society that promote health and well-being – and can include the activities of groups, communities and individuals who may not necessarily see themselves as being primarily involved in health.

It is public health action that provides the context for partnership and joint working and the rationale for the importance of involving lay people in public health. But such approaches challenge the accepted nature of public health expertise. The involvement of ‘non-experts’ brings into question both the idea of expertise, and who the experts on the public’s health really are. The aim of the Bringing People In project was to see how far people in local communities are involved in setting public health agendas and taking action together with primary care.

Our research was undertaken in a number of areas of England between 2000 and 2002. A key issue was to understand what brings local communities and primary care organisations together. Our findings are being developed into a website for the UK Public Health Association.

Since Labour came to power in 1997, there has been a strong emphasis on improving the health of the population and addressing health inequalities. The government’s strategy cuts across all departments and includes action at national, local and individual levels. Targets have been set and frameworks established to encourage public health action on specific diseases, such as coronary heart disease and mental health, and in specific settings, such as schools, workplaces and local communities. But at the same time there has been increasing central pressure on the NHS to achieve centrally driven policy goals such as reduced waiting times and faster access to general practice. This has led to a tension between national targets and local action. The drive to establish new ways of working – the creation of PCTs, the break up of health authority public health teams and changes in local government – has led to existing relationships dissolving.

Case study 1

In one PCT area there was long experience of developing user and carer involvement with different client groups. There were active local groups with good links with social services and health, and with a diverse programme of community based activities. The reorganisation of both health and social services meant link staff changed and trust and co-operation was lost. Worse, the community forums found meetings with health and social care link staff were dominated by new policies – ‘NSFs’ and ‘HIMPs’ – with little chance to develop their own ideas. Forum members complained about the change and soon attendance at many of the forums declined.

Similarly for patients, lay people and communities there is a gap between the reality of public involvement processes in PCTs and the pressure on PCTs to meet targets and deadlines imposed by central government. We found community based activities that had previously engaged with primary care but were now only able to stay involved with PCTs by accepting their agendas, rather than developing shared ones. Result: disillusionment among many of the community participants and isolation of those who had joined initiatives from their community roots.

Case study 2

A local authority community development worker, three voluntary sector managers and a primary care manager began developing a group of workers and volunteers at grassroots level to tackle poverty in their local area.

They met regularly between main group meetings to develop the agenda, discuss courses of action and identify ways to encourage statutory agencies to engage with the group. This was crucial in developing trust and understanding between them. One of the voluntary sector managers chaired the group and saw clearly how it should relate to the wider partnerships in the area. She eventually became the vice chair of the local strategic partnership.

We found a general lack of acknowledgement or acceptance among primary care staff that local communities are key contributors to their own health.² This simple recognition could provide a clear basis for engagement between primary care and local communities on public health. Tackling public health problems requires the combined experience and resources of local communities, primary care and other local and national organisations. But the focus of PCTs has shifted from their local communities to addressing government priorities – yet many of these central priorities can best be met by stronger links with the local community. Our research suggests that, rather than developing processes for involving patients and the public with their own concerns, PCTs should instead be looking at how they can become engaged with the concerns of their communities.