Leading questions: How can PCNs improve public health?

Professor Jim McManus, president of the Association of Directors of Public Health and director of public health at Hertfordshire County Council, discusses PCNs and population health management

What’s your view of PCNs as a vehicle to improve the health of their populations? 
They have a very important role, but they need to understand the parameters, because they’re not going to massively solve wider determinants such as housing or education. If PCNs and their partners build the right relationships, they could be a game-changer in health. 

How can public health work with PCNs? 
We can do the joint strategic needs assessment, preventive services and building pathways and protocols. We can build relationships with the third sector because we’ve got commissioning pathways. We can help you reach out to people. There’s a lot of stuff we can do that PCNs don’t need to revisit. 

Would you advise clinical directors (CDs) to get in touch with their public health department? 
This will sound very time intensive, but not by having a board meeting. Instead, sit down and have a discussion on what you want to achieve. Improving the health of the population is like creating a machine to build the services. There are cogs and parts that do different things. You need to get a working model of that system. That is best done sitting around a table talking, not in a board meeting. 

Is the public health directors’ link with the NHS at place level rather than directly with PCNs? 
It varies. If you look at Hertfordshire, we’re a massive county geographically, 37 settlements. As a team you need relationships with the multiple bits of the NHS. There are other places, maybe unitary authorities, where the geographical layouts are less complicated. I can’t have a strong relationship with every PCN and pharmacy team in the county, even though I’d want it. But we do need some relationship. Most directors of public health will tell you their commissioning budget could be a lot bigger and they could commission a lot more from primary care. And we know it’s effective. We know that for every £1 you spend on it, there’s a £4 return from public health. 

How do you think you’ll work with the NHS in this new structure?
The first thing for me is how the local authority leans into the integrated care system (ICS). I think that’s a corporate thing, not just a public health thing. In our area, a lot of us are leaning into the ICS as a team. The Department of Public Health (DPH) is not just interested in public health issues. We’re looking at system issues as a local authority. That goes into places like the integrated care board (ICB) as well as the integrated care partnership (ICP) and then the place boards. I think you want somebody in the public health team to be leaning into the place boards. But the issue is which input is best for which bit of the system. So where does the joint strategic needs assessment input, for example? Does it input just to the ICB or to the ICP where they’re planning stuff, or into place, or all of them? There are no rules on this, which is a good thing if you can find local solutions. The risk is if you don’t find any solutions. The challenge we now face is how we wire what public health can bring into the ICS organism, which is a multi-system organism. Local government can do more about social determinants than our NHS colleagues. But that means you need a mature conversation across the system about what prevention means, whose job it is and the role of public health. To say it’s everybody’s job is not enough. 

What kind of data does public health hold that CDs could benefit from but don’t know about?
Public health teams have some data, but we get data from other people and we start with local authorities. Most local authorities will have lists of people who are vulnerable, need their bins collected, are known to social care or on benefits. During Covid, the areas that successfully supported vulnerable people compiled a list of lists, and contacted people for delivering things like food parcels. Now, a lot of those data streams have been shut off, and arguably we should be continuing them. Data protection issues can lengthen the process. One of the lessons from Covid is that we shared information, and we need to keep doing that. If you compare the bin list with a GP practice list, which has been done in a number of areas, it produces interesting composite results. It isn’t the legislation that’s the primary barrier. It is the mindset and the existence of shared secure data systems.  

What’s the difference between population health and public health? 
We’ve complicated the language. Either we should talk about public health, or population health. My personal preference is public health because it has a 150-year pedigree. Population health management is a sub-discipline of public health that seeks to understand differential risk in defined populations in clinical services. It identifies ways to improve healthy life expectancy. Population health management started as bringing together data analytics, clinical pathways, algorithms and evidence for clinical service populations. It is not just public health done by doctors. It is a sub-discipline that crosses the boundaries between clinical public health, clinical medicine and clinical healthcare, and requires all of those to be sitting around a table, and centres on a defined clinical population. It won’t change all of the health of a population. It won’t prevent smoking, and we know that from the evidence. But it will massively improve lives by getting people healthier and out of the GP surgery. I call it really good data-driven clinical care. I think the language has complicated something that is about the best of primary care, the best of public health and the best of the voluntary sector all working together to get the best for patients.