Implementation of health policy in England
Implementation of health policy in England is a political animal, although from April 2013 the politicians had attempted to become more arms length than previously. The levers used do not change markedly, being financial control and appointment patronage. However public health was moved more directly under local political control which was predicted to have problematical prioritisation consequences in due course.
Example Immunisation Policy
An attempt to explain the levers for ensuring that immunisation policy is put into practice as applied in the period 2005-08. The terminology in this article refers to organs and a systems approach that has considerably changed after April 2013.
Healthcare Commission, and 'targets'
CHAI and part of the National Audit Office (NAO) were merged to form the Healthcare Commission (HCC).
The approach of the HCC has been that performance is to be assessed against national standards. These standards are part of what are known as Public Service Agreements (PSAs). Standards are classified into several 'domains'; and domain 7 is 'Public Health', which includes immunisation. The overall approach is that trusts and local commissioners won’t be told how to do anything, just what the targets and standards are, against which their performance will be judged.
There are “core standards” and “developmental standards”.
Immunisation standards appear in the public health domain as core standards, with suggestions as to how the standards might be met, rather than instructions as to how it must be done.
The number of PSAs is decreasing – there were 75 “PSA targets” e.g. reduction in coronary heart disease by 75% by 2010; this has been reduced to 40-50, and will be reduced to about 20 in April 2005 or April 2006, and eventually to no more than 10.
Flu vaccine uptake was a PSA; but that target has now been met, and this will no longer be a PSA.
In addition to PSAs, there are local PSAs (LPSAs). These are slightly different: local areas can develop their own targets; and these are usually developed between a primary care trust (PCT) and a local authority (LA). These are most likely to be used as part of the 'inequalities' agenda, perhaps as part of the 'basket of health inequalities indicators' that was developed by the London Health Observatory, and has since been adopted elsewhere.
'Performance indicators' have been used, but these will be disappearing in April 2005 or April 2006.
'Better Metrics' had been developed for use by[strategic health authorities (SHAs). They were considered by the ten local commissioners, PCTs to carry particular weight. It is a means of measuring performance, with a view to improving performance.
Local delivery plans
Local Delivery Plans (LDPs) are part of the process now. There is a three-yearly planning round. They were previously called Health Improvement Plans (HImPs). The purpose was to consolidate the 25 or so previous planning routes into a single plan; and to give health improvement, access, and prevention greater importance. LDPs for 2005-08 only have to reflect the PSA targets.
Commissioning immunisation services from primary care
The main driver for immunisation programmes is likely to be the drive to reduce inequalities in health. PCTs were given more discretion as to what to (de-)invest in. Some PCTs refused to participate in the “Capital Catch-up” programme (to give measles mumps and rubella vaccine (MMR) in schools).
PCTs commissioned services from GP practices (note now from practices rather than individual GPs). There are 4 routes for this:
- Within General Medical Services (GMS) (agreed at national level, but with some latitude for implementation).
- Personal Medical Services (PMS)
- Alternative PMS (APMS) – including e.g. chiropody services.
- PCT Medical Services (PCTMS).
When after 2013 local councils took over public health commissioning it was quickly discovered that CCGs had little if any incentive or ability to encourage new primary care cooperation in prescribing for public health purposes as cooperation without fee for service and where the responsible commissioner had an even more constrained central budgetary settlement than the CCGs did not work well. There is, so far, relatively little experience in using routes other than GMS for service commissioning. The White Paper published in January 2005 (download the press release or all or part of the document) seems to suggest that a greater use of such routes is envisaged.
Immunisation is part of core services under public health; but the means for commissioning this are now firmly in the hands of PCTs, and DH cannot tell PCTs how they should provide immunisation services. This means that both DH and HPA must rethink the way that they approach immunisation programme design and implementation.
It is not clear what would happen if a PCT decided to opt out of immunisation – but it is thought unlikely that the HCC would permit this.
COVER is currently part of the Review of Central Returns, and is thus compulsory for PCTs (although there is nothing to compel GPs to send it any data).
QMAS is the new GP computer system, used also for GP payments, BNF… It only records “Quality Outcome Framework” (QOF) measures, not immunisation.
Much of GMS and PMS are agreed at a national level. Directly enhanced services (DES) are additional services which PCTs are required by DH to commission as part of GMS and PMS – when a directly enhanced service is imposed by DH, it has to be funded by DH. The Directly Enhanced Service (DES) tool is being tweaked by DH to enhance immunisation services.
Local enhanced services may also be negotiated between PCTs and primary care practitioners. These are not funded centrally. It has been a problem, for example with the 2004-2005 mumps epidemic, that some PCTs have negotiated programmes to vaccinate young adults who require MMR, whereas others have not done so, leaving these people no way of being vaccinated other than through private medical services.
Workforce planning as a route to action:
- If it can be shown that there are workforce implications for a programme, then the workforce planning part of the DH will negotiate with SHAs, and additional money may be allocated for this. This could be a lever to get things done.
Short term implementation of immunisation policy
DH, PCTs, SHA, and HPA (immunisations section of Centre for Infections, and HPUs) seem to be key players.
A 'guidance note' document may be [or have been] issued to PCTs – 'pointers to good practice'. This will be an opportunity to emphasise the likely links between immunisation and inequities, and may enhance the role of immunisation.
It is also important for the HPA to be clear about its boundaries – internal, and external – relating to immunisation. What are the boundaries? What should the HPA be doing with regards to immunisation programmes? What will be the impact of the arms length bodies (ALB) review?
In 2013 a measles outbreak in Wales widely publicised in England was exploited to promote the opportunity to attain a higher take up of MMR among unvaccinated groups