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Archive for February, 2014

  • by Dr Anne Eyre
  • Trauma Training

I recently met a Director of Public Health. We were both in the lunch queue at a conference which was focusing on civil contingencies, the needs of people in disasters and organisational structures for addressing local resilience.

As we queued I asked her about provision of psychological (trauma) support services in her area for addressing the needs of people in the event of a major emergency. She replied, somewhat curtly, that she did not know: it was not her responsibility she said; it was not her budget. I was told I obviously hadn’t read the Health and Social Care Act, 2012.

Somewhat bemused, I sought reassurance. Perhaps I had misunderstood; she was not suggesting that psychological support services are not to do with public health? Sadly, I did not get that reassurance.

Just to be clear I went away and re-read the Act, and also the Department of Health’s guidance on the roles and responsibilities of Directors of Public Health in Local Government. This says that, among other things, Directors of Public Health (DPH) should offer leadership, expertise and advice on a range of issues, from emergency preparedness through to improving local people’s health and concerns around access to health services.

With regard to health emergency, preparedness resilience and response (EPRR) the role of Local Authorities, via their DPH, is to:

  • Provide leadership for the public health system within their local authority area;
  • Take steps to ensure that plans are in place to protect the health of their populations, and
  • Fulfill the responsibilities of a Category 1 responder under the Civil Contingencies Act.

This is encapsulated in the Emergency Preparedness Framework 2013 (NHS Commissioning Board, 2013).

At a time of tight budgetary constraint, and pressures on all those working within our public services, keeping trauma support and other mental health services on the agenda remains a formidable challenge in ordinary time, let alone in the context of major emergencies and disasters.

Perhaps this helps to explain why psychological support services, and indeed broader aspects of humanitarian assistance, remain the poor relation when it comes to emergency planning, response and longer term recovery in so many areas of the country. But these are integral aspects of public health, and not just in the event of disasters.

It is a worrying thought that our sense of health responsibility could become limited only to those activities over which we have direct budgetary control. Directors of Public Health in particular have a key role to play in delivering real improvements in local health in today’s health system. They are corporately and professionally accountable; with such seniority comes responsibility.

The challenge and expectation on all those who lead on health-related initiatives before, during and after emergencies, is that they will think holistically about people, across phases of disaster, beyond rigid organisational structures and within a multiagency framework in responding to the needs of their communities. For a long time this idea has been encapsulated in the concept of integrated emergency management and it is integral to so many of our organisational philosophies today.

I think it is important that we never forget that public health is about people and that responding to disasters – before, during and after they strike – is about helping and supporting people, including through the provision of robust public mental health services. This is not to say it is easy, and not to acknowledge that addressing mental health and other needs in today’s world of limited budgets and organisational structures can be difficult. However the challenge to those in leadership positions, and indeed all of us, is to work with and through these, not be constrained by them.

The public and those we serve will help ground us in this. Try telling those affected by the recent floods, or any other disaster for that matter, that public health in emergencies is not to do with psychological support.

References

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  • Alison Macfarlane
  • Professor of Perinatal Health
  • City University London

with

  • Professor Allyson Pollock
  • Professor of Public Health Research and Policy
  • Queen Mary University of London

The NHS England leaflet ‘Better information means better care’, sent to every household in England has triggered a campaign to encourage people to opt out of the new care.data system by telling their GP that they do not want their health records uploaded to it.

Opting out will undermine both the new system and use of data from our existing national statistics  for research and national clinical audits. It will play into the hands of the private sector as it means  that data will be inadequate to assess the impact of government policies to privatise the NHS.

The aim of care.data is to link together coded records from general practice with data from other national data systems, starting with Hospital Episode Statistics. The plans are to provide ‘linked data, that will eventually cover all care settings, both in and outside of hospital.’ This is explained by the Health and Social Care Information Centre. England is well behind Scotland and Wales both in data linkage and in engaging with the public about it.

Care.data should not be confused with Summary Care Records, the purpose of which is to share clinical information between individual patients and the professionals who provide care to them. There are no plans to upload these records into care.data.

Although England has had NHS hospital data analysed at a national level for a long time, this has not been the case with data from general practice, where most care takes place. Because of this, the GP Extraction Service (links to pdf)  was set up in 2011 with a budget of £40 million to extract data from general practice systems and analyse them at a national level for England.

If this and the further data linkage works, it would provide valuable population-based statistical information for commissioners, public health and researchers. It would allow us to, for example, monitor inequalities in access and unmet need and changes in rates of heart disease and cancer.

The care.data system will cost over £50 million and its website gives no indications of any routine analyses to be done in-house. Meanwhile cuts of £9 million to the Office for National Statistics include cuts of £1 million in its statistical outputs which will lead to the loss of a range of highly regarded health statistics.  The future of the decennial Census, which dates back to 1801 in England and Wales and is essential for public health as it provides data on the whole population, is also uncertain.

There are justifiable concerns that the government is preparing the way for the commercial exploitation and use of our NHS data and that the private sector will have priority in accessing the data for analysis.  The person in charge of care.data, in his role as National Director for Patients and Information at NHS England, is former Sunday Times journalist, Tim Kelsey, founder of Dr Foster, a company which has been the subject of a critical parliamentary Public Accounts Committee enquiry.

Dr Foster analyses NHS patient data then sells back the analyses to the NHS organisations which collect the data.  Roger Taylor, co-founder of Dr Foster, has been appointed to a senior role in the Care Quality Commission and Kingsley Manning has been appointed Chair of the Health and Social Care Information Centre.

He is the former head of health at Tribal, now part of Capita, and the founder and former managing director of health and information consultancy firm Newchurch, which provided advice on PFI and sell off of NHS assets. These corporate appointments are akin to putting bankers in charge of NHS hospitals.

To make matters worse, Clinical Commissioning Groups do not analyse data in-house to inform their decisions. Since the Health and Social Care Act came into force, vital information functions have been outsourced to Commissioning Support Units, organisations which have no basis in law and are temporarily hosted by NHS England.

Plans to float these organisations on the stock market have been suspended in favour of turning them into social enterprises, staff mutuals, customer controlled social enterprises or joint ventures. Clinical Commissioning Groups should demand that these information functions and the associated NHS funds and staff be returned to them before any privatisation takes place.

Campaigners are concerned that pharmaceutical industry and health insurance companies will be simply ‘given’ the data, although Section 251 of the NHS Act 2006, requires them to state what uses will be made of data and how they will be stored securely.  They will also have to answer similar questions from the Health and Social Care Information Centre’s Data Access Advisory Group.

While applicants do not get ownership of the data they are able to use them and this raises serious questions about the purposes to which the data will be used and the extent to which analyses may be sold on.  There is still no clarity or transparency about the ownership and control of the data, how they will be accessed and used by the private sector or how statistics about NHS funded private care will be made available to all.

We need reassurance from government that the data will be used to produce and publish national statistics in line with the National Statistics Code of Practice. The Code, overseen by the UK Statistics Authority, is designed to be observed by all the public bodies that produce official statistics, is considered to be central to maintaining a unified statistical service that meets the needs of government and society and is both trustworthy and trusted.

As the government is privatising health care, it is crucial to have complete and high quality data to monitor the impact of these policies. The private sector has a poor track record for data collection. The atrocious quality of private sector data returns made it impossible to monitor contract compliance for independent sector treatment centres, the government’s £4 billion programme for elective surgery, where NHS funds were diverted to for-profit providers.

General practices owned by private companies such as Virgin, The Practice plc and SERCO will be protected from scrutiny if their patients opt out, as there will be no data about them as is already the case in nursing and residential care homes.

Instead a public campaign is needed to promote public data and oppose privatisation of both our healthcare services and data functions.  Patients and the public need to make it clear to NHS England that their consent for coded medical records to be uploaded to care.data is conditional on them not being used for commercial purposes or handed over to third parties, such as drug companies and health insurance and health care corporations.

Such a campaign must make links between opposing the privatisation of the data collection and analysis systems and opposing the privatisation of our health services and ensure that NHS England and Care Commissioning Groups oppose both.

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