Douglas Noble on healthcare public health

douglas nobleThe recent move to transfer the balance of commissioning power within the NHS to GPs, although laudable, raises a number of serious questions.  Perhaps they are best summed up by a comment made to me recently by a GP colleague.  In exasperation he declared: “I only get seven minutes to see a patient, so where am I going to get time for all this?”  It’s a good question.  The answer, I think, lies in the provision, translatability, and effective use of information which is already available. 

Yet, information is not a commodity which is easy to interpret, far less to use in commissioning decisions.  Local health information has been held in the stronghold of the health intelligence section of public health departments – for the most part in PCTs, but not exclusively. 

I never really understood what grey literature meant until I worked in one of these departments.  The reams of descriptive information are almost endless, and much of it is unknown, even to commissioners.  The golden chalice – the joint strategic needs assessment – is an extraordinary information resource. 

This information could be put to extraordinarily valuable use in the right hands.  Far more than just describing health needs, it contains a wealth of information about health services.  For example, “care closer to home” initiatives could rely on geographical patterns of health needs and service usage patterns.  

Public health is much more than mere description.  Many specialists, especially those with clinical backgrounds, are heavily involved in prioritising commissioning decisions.  Sometimes they work as medical or quality directors in acute trusts and this is where the use of population information is especially interesting. 

The perpetual dichotomy for clinicians lies in prioritising the needs of their population of patients against the individual patient in front of them.  This is where “healthcare public health” comes into its own.  Public health specialists in this area have a unique vantage point.  They have the skills, the bird’s eye view, and the information to look beyond the individual patient to serve a population group of patients.  Their skills offer an opportunity to ensure that commissioning decisions are made not just on the basis of the traditional utilitarian values that underpin “healthcare public health,” but also on the best prioritisations which ensure the highest quality of care.  Performance measures such as QOFs (Quality and Outcomes Framework) and CQUINS (Commissioning for Quality and Innovation Framework) in the hands of “healthcare public health” steer towards robust quality measures like the WHO Surgical Checklist and away from the less measurable, less attractive, yet remarkably popular initiatives such as quality of discharge summaries. 

GPs have an uphill battle ahead.  Unscrupulous venture capitalists, who will no doubt offer apparently fantastic and expensive deals for providing health information, will seek to win them over at every opportunity. 

Talk of a public health service seems reasonable, especially if ring-fenced budgets can be constructed that deliver the power public health needs at a local level.  How the “healthcare public health” part interacts with GPs will be critical.  The combination of accurate knowledge about individual patients with wider public health data for the prioritisation of commissioning, holds one of the best hopes for a cost effective and high quality service.  Without this, the pseudo-information providing money devouring capitalist vultures will descend, and “bleak” does not begin to describe the future.

Douglas Noble has worked in surgery, emergency medicine, public health and for WHO. From 2006 to 2008 he was clinical adviser to the chief medical officer for England.