Public Health in Local Government: A Model for Public Sector Reform

LONDON, March 9 -- The Association of Directors of Public Health issued the following news release:

The Association of Directors of Public Health (ADPH) is the representative body for Directors of Public Health (DPH) in the UK.

It seeks to improve and protect the health of the population through collating and presenting the views of DsPH; advising on public health policy and legislation at a local, regional, national and international level; facilitating a support network for DsPH; and providing opportunities for DsPH to develop professional practice.

The Association has a rich heritage, its origins dating back 160 years. It is a collaborative organisation working in partnership with others to maximise the voice for public health.

Introduction

The new public health responsibilities given to local government as part of the Health and Social Care Act 2012 saw the return of Directors of Public Health (DsPH) and their teams to local authorities after nearly 40 years in the NHS. The move has largely been seen as a success.(1)

The transfer of public health to local government, despite a number of challenges, has resulted in a number of positive improvements to the function. It is also having a wider impact on the way local government operates in its place-shaping role.

This paper describes the reasons for this success and how this is relevant to wider public sector reform.

Ten Reasons for Success

1. Public health provides input to existing functions

DsPHs have been able to add value to a range of local government functions, from social care to transport planning. At its best, this has brought a constructive challenge to the purpose of the function and how it is best delivered.

Case Study - Use of Health Impact Assessment in Planning

Wakefield Council's Public Health team worked with planning colleagues to develop a proportionate approach to assessing the health consequences of planning developments. This then allows discussion on how negative impacts might be mitigated and positive elements further developed. This approach has now been adopted across the West Yorkshire Combined Authority (6 local authorities).

2. Public health makes better use of data and evidence

Public health is an evidence and data-driven function and the application of this rigour to other local public services has led to tangible improvements. Public Health teams are used to asking for the evidence-base underpinning interventions. This need not limit innovation but avoids needless thinking 'outside the box' when there is a proven action which would suffice.

Case Study - Using Data and Evidence across Organisations

Coventry City Council as part of its commitment to be a 'Marmot Council' has merged its public health-focused data analysis function to become part of a wider public health responsibility for 'insight' i.e. research and intelligence, including both quantitative and qualitative data, providing support for the whole council.

3. Public health listens to the citizens' voice

Contrary to the perceptions of the nanny state, public health prioritises the citizens' voice (e.g. 3 out of 4 smokers, if asked, will say they want to quit). DsPH have applied this approach to some of the new challenges faced by local government.

Case Study - Using citizen outcomes to drive service integration

The council and the CCG in Richmond upon Thames are moving jointly towards an integrated outcomes-based adult community health and social care service. Accountability to residents is the explicit driver for partners and integration is a means to achieving the outcomes that Richmond people say matter to them most. The DPH is seen as a key partner in this and public health skills have helped drive this forward.

4. Public health uses asset-based approaches

Whilst historically the public sector has focused on meeting residents' needs, public health often uses asset-based approaches. For example, many have developed the requirement to produce a Joint Strategic Needs Assessment to incorporate an assessment of relevant community assets.

Case Study - Asset Mapping

Bracknell Forest Council has mapped community assets which support the evidence-based Five Ways to Wellbeing. They are presented in an easily accessible format for the public. And can be accessed here (http://jsna.bracknell-forest.gov.uk/community-asset-map).

5. Public health focuses on evaluation

The public sector can be poor at knowing whether or not what they are doing works. Public health teams have been involved in evaluating services and providing recommendations on how they might improve. This is especially important when an action has not yet got an evidence base. Directors of Public Health are held to account for improvements in the Public Health Outcomes Framework.

"With the evidence provided by public health, we've been able to be bolder in developing new integrated services and more decisive about de-commissioning services."

Iain MacBeath, Director of Health and Community Services, Hertfordshire County Council

6. Public health makes creative use of funding

The Public Health grant has been used in innovative ways to unlock the potential of existing assets and investments. However, this has become more difficult since the reduction to the grant.

Case Study - Social Determinants of Health Fund

Blackburn with Darwen Borough Council has established an investment framework for the Public Health Grant which involves a shift from a medical to a social model, and uses the World Health Organisation tool for evidence-informed decision making in public health. New ways of working in Blackburn with Darwen's public health operating model include a 'Health Included in All Policies' (HIAP) - a health impact assessment process to ensure all relevant policies decisions and investments in each directorate contribute to health improvement, for example through the development of existing staff. The model also includes a GBP1 million Social Determinants of Health Fund invested for two years across all council directorates so they can take direct action on health

7. Public health focuses on prevention and health in all policies

Much of focus of the Public Health grant is on prevention, but Public Health teams have also been able to lever other change within the system to support the prevention of ill-health.

Public health is now a central function of local government in England and the approach of getting health into all policies could be replicated for other priorities e.g. best start in life. The LGA has recently published a range of case studies on this topic.(2)

8. Public health specialises in behaviour change

Public health specialists have applied their expertise on behaviour change to new opportunities presented by local government.

Case study - Making Every Contact Count

South Tyneside Council is tackling health inequalities by tapping into the potential of its 3,500-strong workforce. From social workers to refuse collectors, staff from across the organisation are being trained to offer brief health advice and support to local residents.

9. Public health uses whole system thinking

Directors of Public Health are experienced at influencing across organisations and systems in order to improve health.

Case Study - Whole System Thinking

The "Live Well" weight management programme, commissioned by East Riding Council Public Health is for people who would otherwise need bariatric surgery. Using the programme has reduced bariatric surgery from around 100 cases each year down to 15-20 and has transformed the lives of many people. Not only that, but the programme has acted as a catalyst for council provided leisure services to become more of a health and wellbeing service. Many more people of all shapes and sizes now pay to use the facilities and Leisure finances have been transformed by more than GBP1 million from needing subsidy to profit. The programme won the Local Government Chronicle Award for Partnerships in 2016.

10. Public health does effective commissioning

Most public health services transferred from the NHS have been reviewed and in many cases recommissioned. This has delivered better value, services based on evidence and outcomes and added social value. The need to deliver financial savings has delivered creative solutions.

"I was surprised at the lack of rigour in the contracts we inherited [from the NHS] .... I am particularly proud of the way we have managed to commission smoking cessation in GP practices. I think it's crucial that on the day that someone finally decides to stop smoking they can see the right person straight away."

Cllr Jonathan McShane, Hackney Council

11. Public health works collaboratively to achieve results

Public health teams are great at collaborating across local authority areas to tackle pertinent public health issues. Sharing ideas and ways of working across local areas leads to innovative and effective approaches.

Case Study - Collaborative Working

The London Sexual Health Transformation Programme is a great example of cross-borough working led by a Director of Public Health. It consists of three work streams: creating an online e-service, developing a London-wide service specification, and developing an integrated tariff. The e-service is set to go live later this year and every borough has adopted the integrated tariff. Partnership was key to making the programme work, as was transformational leadership and a robust governance system.

The above functions give examples of the added value of an in-house public health team, which also provides the system leadership needed to effect change.

Footnotes:

1. Jenkins LM et al. Integration, influence and change in public health: findings from a survey of Directors of Public Health in England. J Public Health (2016) 38 (3): e201-e208.

2. Health in all policies: a manual for local government http://www.local.gov.uk/publications/-/journal_content/56/10180/7970816/PUBLICATION LGA, London, September 2016.

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