Ike Anya: Can public health hold it all together in the new fragmented English NHS?

Following the recent Health and Social Care Act, which profoundly changes the structure of the NHS in England, one of the concerns that persists is the potential fragmentation of services and the impact of this fragmentation on patient pathways and care.

Under the old system, each Primary Care Trust had the clearly defined responsibility of directly or indirectly providing or commissioning all health services for its residents. If a resident had a problem with access to, or quality of health services; whether it was a primary care service, a community service, a hospital service, or a public health programme, it was the responsibility of the Primary Care Trust to sort it out.

Under the new system, responsibility for commissioning primary care lies with the National Commissioning Board. Community and hospital services will be largely commissioned by the clinical commissioning groups supported by a commissioning support service, and public health programmes will be largely commissioned by local authorities.

This scenario makes it more difficult to assign clear lines of accountability and raises the spectre of broken or fragmented patient pathways.

My experience as a consultant in public health medicine, suggests to me that public health could play a role in bridging these gaps.  At the moment, I chair a tuberculosis action group in our local area which brings together representatives from primary care, community services, the local authority, the Health Protection Agency, and commissioning colleagues. The group provides a forum where we can look at the challenges that tuberculosis poses at a population level, moving beyond the narrow perspective of each service. For instance, hospitals are primarily responsible for the diagnosis and treatment of people with tuberculosis; the community nursing service is primarily concerned with providing BCG vaccinations; the local authority is responsible for housing; and the Health Protection Agency is responsible for surveillance and expert input to outbreak and incident management.

The experience from this group illustrates the importance of having a forum that brings together representatives from different organisations to work together in partnership to deliver effective services for the population. In this uncertain transition period, members of the group have expressed a strong interest in maintaining the group in the future.

There have been suggestions that the health and wellbeing boards could provide this function of knitting together the different strands of commissioning and provision. However, given the strategic, high-level nature of the boards that are emerging, it seems unlikely that they will be able to build the kinds of relationships at an operational level that will be required to ensure that services and pathways fit together. As the health and wellbeing boards have little in the way of statutory powers to ensure cooperation, relationship building will be key.

There is therefore an imperative for public health colleagues to seek and exercise opportunities to hold the fragmenting NHS together. Most public health colleagues have built relationships across the health and social care sectors in their areas and it will be important that they leverage this for the benefit of their local populations.

Achieving this is not without its challenges—at the moment. I sit in the Primary Care Trust which holds the purse strings and this  gives me a certain clout with providers. In the future, based in a local authority, it may be a greater challenge to draw partners to the table. Also, in areas where relationships have not been strong across organisations, getting partners together will also be more of a challenge.

Nevertheless as transition arrangements gather pace, it will be important for public health and other colleagues to be aware of the potential for fragmentation and the opportunities for mitigation that exist.

Ike Anya is a public health consultant in London.