Where’s the integration between public health and primary care in the response to covid-19?

Despite NHS England’s focus on the importance of health system integration, the government spent £10 billion on a largely outsourced Test and Trace system, which has been plagued with criticisms about poor integration with the rest of the health system, poor performance, and opaque procurement processes. [1-3] With a budget close to the combined annual spend on public health (£4.3 bn) and general practice (£7.8 bn) in England, this begs the question of whether this money could have been better spent on strengthening existing public services infrastructure in response to covid-19? [4]

Until the rollout of the covid-19 vaccination programme, the potential contribution of primary care had largely been overlooked in the UK’s response to covid-19. [5] Notably, the potential contribution of better resourced and better integrated local public health and primary care teams has been neglected. Public health and primary care look after communities throughout their life course and deliver care close to where people live. Primary care clinicians know who the most vulnerable people are on their lists and largely enjoy the trust of their patients. [6] Through the electronic health record, general practice has access to patients’ full medical history, contact details, and household members. Almost the entire population is registered with a general practice in the UK. With adequate consent and information governance, the electronic health record allows data extraction at national level. These features enable an understanding of and access to local communities that an outsourced contact tracing centre or, as is becoming evident, mass vaccination sites cannot, and which could support a more effective response. With public confidence in the UK government falling, local public health and primary care teams can help rebuild trust with local communities providing locally tailored responses. [7]

Evidence demonstrates that, together, public health and primary care create synergies which improve population health and health systems performance. [8-10] There are various ways to do so and opportunities extend beyond the potential response to covid-19, to the domains of health promotion and other forms of disease prevention, through: 

  • Coordinating healthcare services for individuals, e.g. by bringing clinical and public health professionals together at one site. 
  • Applying a population perspective to clinical practice, e.g. by using population-based information to enhance clinical decision-making. 
  • Identifying and addressing community health problems, e.g. by using clinical opportunities to identify and address underlying causes of health problems. 
  • Strengthening health promotion and disease prevention, e.g. through education, advocacy for health-related laws or regulations. 
  • Collaborating around policy, training and research, e.g. by engaging in cross-sectoral education and training or conducting cross-sectoral research. [8-10]  

The development of Primary Care Networks (PCNs) in England since 2019 (networks of general practices covering 30,000-50,000 patients), alongside GP Clusters in Scotland, Primary Care Clusters in Wales, and GP Federations in Northern Ireland, present an opportunity for closer working at this interface between population and individual level health. For example, currently proposed areas of work for PCNs in England that overlap with public health goals include improving the uptake of screening and earlier cancer diagnosis, increasing vaccination rates, tackling neighbourhood inequalities, cardio-vascular disease prevention and improving care in care homes [11]. But there are many other goals in common, including addressing obesity, smoking, excessive alcohol consumption, other addictions, anti-microbial resistance, harmful living and working environments, sexual health, travel risks and, of course, responding to covid-19.

While data platforms such as “National General Practice Profilesin England or “Primary Care Information Dashboards in Scotland provide a valuable resource for joint working, and examples of effective collaboration between public health and primary care exist throughout the UK, important barriers remain to systematically scaling these up. These include the lack of a clear national framework setting out how public health and primary care should work together; limited public health content in primary care clinicians’ training and vice versa; and the repeated reorganisation of services with organisational divides  between primary care and public health teams (e.g. in England public health teams moved from Primary Care Trusts to local government in 2012), as well as between different branches of public health itself (e.g. local government-based public health teams in England are separate to local health protection teams that are part of Public Health England—soon to become the National Institute for Health Protection with Test and Trace and the Joint Biosecurity Centre). Disinvestment in recent years has limited English local government public health teams’ capacity, including their ability to build working relationships with local general practices. [12] For general practice, existing clinical pressures, workforce shortages and the relative organisational immaturity of the various forms of GP networks across the UK can make the proposal of sharing public health duties feel unfeasible. [13] Yet with adequate political and financial commitment, these challenges are not insurmountable.   

Well resourced and effectively-integrated local public health and primary care teams are an essential frontline of defence to covid-19. Moreover, they are vital to the long term response to it, as tackling many of the health and social issues which have been made worse by the pandemic or are associated with worse outcomes from covid-19 require a joined-up approach between public health and primary care.

Luisa M Pettigrew, general practitioner & NIHR doctoral research fellow, London School of Hygiene & Tropical Medicine. 

May van Schalkwyk, specialist registrar in public health & NIHR doctoral research fellow, London School of Hygiene & Tropical Medicine.

Bernd Rechel, researcher, European Observatory on Health Systems and Policies, London School of Hygiene & Tropical Medicine.

Richard Garlick, retired general practitioner and consultant in public health.

Acknowledgements: With thanks to Gill Walt (James Wigg GP practice Patient Participation Group, Chair) for providing input from a patient’s perspective, and to Dr David Blane (Clinical Research Fellow in General Practice & Primary Care, Institute of Health and Wellbeing, University of Glasgow) for insights from Scotland.

LP and MvS are funded by National Institute of Health Research (NIHR) doctoral research fellowships. MvS holds an honorary contract with Public Health England. The views expressed are not necessarily those of the NHS, the NIHR, PHE, or Department of Health and Social Care. 

We have read and understood BMJ policy on declaration of interests and declare that LP is a primary care network clinical director.


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