EHJ August 2002, volume 110/08, pages 236-238 The much-maligned NHS has been going through a period of massive organisational and structural change. David England explains some of these changes and examines the ways in which local government, and EHOs in particular, can join with the NHS to improve the health prospects of their residents.

This year has been something of a watershed for the organisation of the NHS nationally. Twenty-eight "combined" health authorities (soon to become strategic health authorities) have replaced the previous 95 area health authorities; 309 primary care trusts (PCTs) have come into being to provide the cornerstone of NHS service provision for their residents.

Each PCT is locally based and comprises two main sections. First, there is a Trust Board, which is the organ of strategic decision making, and has a "lay" majority consisting of a chairman and five non-executive directors. The other members of the board are the chief executive, the director of finance and the three representatives of the other section of the Trust, the Professional Executive Committee (PEC).

The PEC is the "engine room" of the PCT and is there to carry out the policy decisions of the board.
It consists of professional clinicians such as GPs, nurses, a social services representative and other allied health professionals, including a director of public health.

The "lay" members of the board live within the PCT area and are personally dedicated to the provision, maintenance and improvement of the NHS locally. They are able to make objective decisions on the provision of health care in their area unfettered by the shadow of the ballot box, as in the case of local government. The chairman of the PCT and the non-executive directors are appointed by the newly-created NHS Appointments Commission, in order that all appointments are transparent and made purely on merit.

This local focus for the NHS is in stark contrast to the previous structure where policies and actions were decided by the area health authority, based in what many of us perceived as remote ivory towers and with little contact with or feeling for the needs and desires of local users of the service. PCTs are now seen as the main instrument of primary care delivery from the NHS and the Chancellor of the Exchequer says that at least 75 per cent of all NHS funding will be channelled through them.

PCTs have the duty to provide services which include commissioning secondary care at acute hospitals, financing prescription charges and directly providing intermediate care, specialist services and GP services. All PCTs are expected to deliver on a number of national government-set targets and provide improvements and innovation within budget. A number of national targets (national service frameworks) are already in place for subjects, including cancer, older people and coronary heart disease, and there will be more to come.

HOW MUCH MONEY?
Each PCT has its own unified budget based upon a capitation scheme weighted in accordance with the demographic make up of the area, including deprivation, housing standards, transport problems etc. Therefore, a PCT in an inner city area will be allocated more funding than, say, an affluent rural area. In my PCT, South Leicestershire, the budget, to cover a population of approximately 150,000 is in the region of £100m per annum but the need to commission secondary care and to cover prescription charges takes up the majority of this, leaving precious little for local initiatives and innovation. The performance of all PCTs is monitored and audited, with scrutiny by the strategic health authority, patient forums, patient advisory and liaison services and eventually, as in the acute sector, star ratings.

RELEVANCE FOR EHOs
The new NHS structure gives EHOs a first rate opportunity to work closely with the parallel organisation devoted to improving the health of residents. For the first time since the NHS was formed in 1948 it has "come home", and is positively dedicated to the welfare of local residents. Everyone will have real access to their local NHS, either directly or through their health forum. The NHS will no longer be perceived as a distant entity.

EHOs and their local authorities will be able to have a voice in the work and direction of these trusts, provided that they become involved and are prepared to work together. There is an enormous amount of resource and expertise which can be tapped into, particularly in the fields of health promotion, teenage pregnancy, anti-smoking and other health education issues; but also in fields traditionally left to local councils, including air quality, housing standards, healthy lifestyle and exercise.

From my own experience as an EHO, I know that co-operation between the council and health authority has sometimes been rather tentative, with the underlying feeling that one was usurping the other's duties. With the post of director of public health needing to work more closely with local authorities, this situation should be superseded by a much closer co-operation and will, in the fullness of time, give rise to genuine "joined up thinking". In south Leicestershire, we have already made a start on this with jointly-funded posts with two of our local authorities. The post holders are already working hard to co-ordinate the local strategic partnerships and other initiatives.

MAKE A DIFFERENCE
There are a number of ways in which EHOs and the council can make a difference on behalf of local residents:

• promoting positive partnership dialogue and co-operation with your local PCT;
• agreeing practical targets within and without the local strategic partnerships;
• ensuring that the voice of the local authority (both elected members and officers) is heard on the PCT Board and in the professional executive committee;
• taking an active part in the local patients forum, the patient advisory liaison service and health forum; and
• helping the PCT and local authority environmental health department provide a seamless service.

I regard this as an exciting challenge with a once in a lifetime opportunity to bring two previously separate but parallel services together for the benefit of all local residents. Now is the time for EHOs to grasp the opportunity to be part of the new NHS. Take this opportunity to become personally involved in the work of your local health service - the opportunities are there, the challenges are great, but the rewards can be magnificent.

David England is chairman of South Leicestershire Primary Care Trust. He became involved in the work of the NHS when, as head of environmental health at Oadby and Wigston BC, he saw the potential for a closer working partnership between the council and the NHS locally. He was appointed first as the public representative on the Board of the Oadby and Wigston Primary Care Group, a sub-committee of the health authority and a forerunner of the PCT. After retirement
from his local government post, David was appointed chairman of the new PCT.

Further information on this subject can be obtained from: "The NHS plan - A plan for investment - A plan for reform", July 2000, and "Delivering the NHS plan - Next steps on investment - Next steps on reform", April 2002.