Healthy Lives Healthy People: Opportunities and Challenges for the New Public Health SystemDr. Kate Ardern MBChB MSc FFPHExecutive Director of Public Health for the Borough of Wigan

Strategic Drivers: Marmot ReviewStrategic Drivers: Marmot Review

The Marmot Review Fair Society, Healthy Lives (DH, 2010) identifies 6 key policy areas to tackle Health Inequalities and the priority actions:  

Give every child the best start in life Enable all children, young people and adults to

maximise their capabilities and have control over their lives

Create fair employment and good work for all Ensure healthy standard of living for all Create and develop healthy and sustainable places and

communities Strengthen the role and impact of ill health prevention

Cabinet Public Health sub-Committee

SoS

CLGDH

NHS Commissioning Board Public Health Service

NHS Healthcare System

Specialist & National care

Secondary & Tertiary Care

Primary & Community Care

Health & Wellbeing Board

Top Tier Local Authority

Responsibility for Health of Local Population

DPH

GP Commissioning

Pop

ul a

t ion

Hea

lthc a

re

Popu

lation

Wellb

ein

g

Public Health System

Health Improvement

Protection & Resilience

Prevention of ill health

Local Authority System

Social Care

Housing/Transport

Education

Economy

Third Sector

Big Society

Police/Fire

Public Health System

Wigan partnership Health and Well- Being Priorities (6 Outcomes)

Health and Well - Being Board

Health and well-being services

Local Authority & Partners NHS

Social care (children and adults,Third sector Housing, transport, Big Society Leisure, Education, Partnerships, Economy, Social enterprises

Primary & Community

care

Secondary & Tertiary

care

Specialist & National

care

General population

Low level advice

& support

Support at home

Institutional care

Acute care

People choosing less dependent more cost-effective options

Increasing demand on services

NHS “flat cash” funding

£100 m gap in

funding

To foster the best possible health and well being

for every person in Wigan

Help lo

cal p

eople

take

resp

onsib

ility

for t

heir

healt

h

Target resources

correctly Reach out a

cross

partnersh

ipsHarness local knowledge ,

skills and leadership

Peop

le

cent

red

Respect contributions & perspectives

Openness,

honesty, integrity

Ownership & accountability

Best

quali

ty

& inno

vatio

n

Co-productionIncr

ease

aut

onom

y &

perc

eptio

n

Improve accessibility of

services to support

independence

Reduce deaths & disability due to CVD & cancer

Redu

ce so

cial e

xclu

sion

Care closer to home

Safeguarding, dignity & respectRaising and exceeding

public expectations of health and

well-being

To invest in a balanced

economy to focus on wellness

determinants of health and high quality health and social care

Stretching our ambition

and performance

to achieve world class

public health

Innovating and implementing

best practice to achieve best performance

against national

standards

Evidence, knowledge and skills

Productivity and evaluation

H&WBB

Beliefs Values Outcomes

2005 2010 2015 2020

People, Partnerships & Performance: Gestation People, Partnerships & Performance: Gestation from Input to Outcomefrom Input to Outcome

Treat Health Inequalities

Prevent Health inequalities

Sustain & Maintain Reduction in HI

LifeLife Expectancy at Birth

Demand ManagementSystem RedesignStimulating the MarketOptimising the role of the Voluntary and Independent sectorsCommissioning of Health Improvement Services and ProgrammesService re-design to fully incorporate preventative interventionsPublic Health capacity and capability building

Locality workingOptimising the role of the Voluntary and Independent sectors

Develop the assets based approach to community empowerment

Building social capital

Developing co-productionPublic Health capacity and capability building – community health advocates

Public Health Annual Report

PH expert adviceAssurance that commissioning plans incorporate best quality & governance practice Assurance that CQUIN schedules reflect local & national priorities for health improvement, health protection & reducing health inequalities

Develop & implement a Joint Health & Well-being Strategy.

Influencing the wider determinants of health

Building the PH capacity of the wider workforce

Health promoting settings

Corporate social responsibilitySocial Impact Bonds

Screening Programme co-ordination

Environmental public health Communicable and Infectious Disease ControlImmunisation and VaccinationSafeguardingPH resilience and response to incidents and disasters

Research & DevelopmentJoint Strategic needs & Assets AssessmentEvaluation of services and programmesHealth Impact AssessmentHealth Equity AuditsIntegrating critically appraised evidence into programmes & servicesHealth Surveillance and AssessmentHealth Profiling

HEALTH AND WELL-BEING PROGRAMMES FOR CHANGE

Unleashing the Talents of Local People

System Reform

Achieving Best Quality

Health &Well-being Policy

Health Protection

Knowledge Management

How to achieve economies of scale for delivering a national public health and wellbeing system

Using pooled Information, intelligence and place based solutions to undertake new functions

Workforce capacity and capability and resource management to deliver high quality care  

Leadership, partnership and vision to successfully deliver population healthcare and wellbeing

PH System Resilience Risks

Significant clarification needed about role, responsibilities and relationships in planning and responding to public health emergencies and public health input into Major Incident and Civil Contingency planning and response.

Significant concerns about the size and scope of the ring-fenced national public health budget and allocations to local authorities – especially in the light of the Nicholson challenge.

Current proposals for the division of commissioning responsibilities across Clinical Commissioning Groups, Local Authorities, Public Health England and the NHS Commissioning Board potentially works against a whole system approach to commissioning services.

Significant clarity needed about the specialist roles across the new system, the workforce transition and the importance of current and future professional training and professional regulation.

Failure to secure the future of public health specialists currently in training when there are few consultant posts currently being advertised.

Very low morale amongst PH staff who are experiencing significant PCT management cost reduction, freezing of key vacancies and considerable uncertainty about their future given that there is no guarantee of potential for future employment in Local Authorities – especially as many Local Authorities are making significant job cuts amongst their existing staff

Multi-disciplinary nature of public health risks being lost in the future if doctors, dentists and nurses do not see it as a career option.

• Public health capacity to support the construction of JSNA and the preparation of local health and well being strategies and to support the Health and Wellbeing Boards.

• Public health capacity to support the oversight of CCG and NHS Commissioning board activities.

• Capacity to ensure local direction and determination of health protection capacity, particularly that associated with existing health protection units.

• Public Health leadership in informing care pathway development.

• Capacity to support the commissioning of local health improvement services.

• Capacity to discharge responsibility for lead commissioner responsibilities.

 

Leadership in GM: The Greater Manchester Strategy

The Manchester Independent Economic Review

History of collaborative working across GM

A Health Commission which leads on GM wide health and well-being programmes

A GM Strategy which stresses the role of health in growth and employment

Combined Authority and Local Enterprise Partnership

Enablers and Evidence: The case for health collaboration at the GM level.

The View from the Moon

Oldham

Bolton

M/cr

ALW

Salford

T&G

Trafford

Stockport

HMR

Bury

PCT

CMFT

Provider

UHSM

Trafford

PENNINE

Salford

WWL

Bolton

Tameside

Stockport

36.05%36.05%

46.14%46.14%

59.15%59.15%

71.98%71.98%

70.65%70.65%

50.90%50.90%

82.67%82.67%

77.66%77.66%58.26%58.26%

65.30%65.30%

28.50%28.50%

30.33%30.33%

24.85%24.85%

12.91%12.91%

12.94%12.94%

23.87%23.87%

8.69%8.69%

14.07%14.07%

28.51%28.51%24.23%24.23%

24.30%24.30%

8.72%8.72%

11.57%11.57%

6.17%6.17%

8.54%8.54%

17.93%17.93%

6.56%6.56%

8.35%8.35%

6.12%6.12%4.60%4.60%

1st

2nd

3rd

Understanding the primacy of local working, and the emphasis on JSNA, integrated public sector working, democratic leadership and prioritisation

That aggregation to exploit collaborative advantage should only happen from the perspective of local requirement

Recognising the potential future role and responsibility of Directors of Public Health in their own local authorities & that in supporting the discharge of this function DPHs may wish to secure specialist skill and technical expertise not likely to be available in each local authority

Demonstrating where GM DPH working collectively had already invested resource and capacity , where there was related collaborative activity currently hosted within the GM PCTs and where there were other GM structures providing economies of scale for discharge of regulatory function in Local Authorities.

Proposing how to align some functionality to a description of public health function.

Community engagement needs to move beyond consultation into empowerment, which will involve the transfer of power and resources to communities themselves

Work towards integration of primary and community care services with statutory, voluntary and independent sector neighbourhood services, providing a more holistic user-centred focus.

Public health commissioning mechanisms to drive development of health improvement skills, resilience and leadership within local populations, making the concept of co-production of health between services and communities a reality

Making strengthening the core economy of neighbourhood and family the central task of all public services

Using the power of Public Health Commissioning, locally coordinated eg through H & WBBs, to explore new models of integrated delivery. For example, develop forms of community-oriented primary care appropriate to underserved communities with poor health outcomes

Bottom-up action plans to integrate services as part of the co-production approach with communities, can provide the cornerstones of emerging strategic approaches to

Community-based Budgets.

Making Health Everyone’s Business: The Approach

CommunityDevelopment

For Health

Developing Public HealthLeadership/

Culturechange

Commissioninglevers

Investmentin health &wellbeing services

Developing staff skills

& confidence

Staff Health & Wellbeing

MaximisingHealth Gain

Established in May 2010 to reduce tobacco related health inequalities; to reduce smoking prevalence across the borough by developing and delivering a local Tobacco Control Strategy and Action Plan.

Locally, the issues include: a high prevalence of smokers, especially within the more deprived areas, illicit tobacco, and underage sales.

Specific work streams include: reducing the supply of illicit tobacco, promoting smoke-fee homes and play areas, reducing the number of young people that start smoking, and assisting every smoker to quit smoking, particularly from disadvantaged communities. The objectives are to strategically plan and commission effective, evidenced based interventions for tobacco control.

2 Cabinet members assist in Chairing the Alliance and there is clinical engagement on the Steering Group from the Cardiology Consultant at WWL , the PEC Chairman. Other partners are Public Trading Standards , Ashton, Leigh & Wigan Community Health Care, Wrightington, Wigan & Leigh NHS Foundation Trust, Environmental Health, Greater Manchester Police, Greater Manchester Fire & Rescue Service, Children & Young People’s Service’s, Adult Services , Wigan & Leigh Housing, HMRC, Community Engagement, Wigan & Leigh CVS, 5 Boroughs Partnership NHS Foundation Trust, Wigan Leisure & Culture Trust.

Wigan’s major local social housing provider, Wigan & Leigh Housing, has 23,000 properties across the most deprived areas of the borough. Smoking prevalence is high within the tenant population reaching a peak of at 47% on Marsh Green; an estate of around 3000 properties.

Smoking was identified as a joint priority with Wigan & Leigh Housing (WALH) for a number of reasons: These included the cost of re-decoration after tenants who smoked had left but the major factor related to the payment of rent arrears. Staff noted the fact that, when negotiating a repayment plan with the tenants, the large amounts of spend which relating to smoking in their regular outgoings.In the initial stages key staff groups were trained to advise and signpost to smoking cessation services and support. The health Improvement Team maintained their contact with the staff and have continued to support with updates and resources. Wigan & Leigh Housing is working within the Alliance to promote the expansion of the work relating to smoking and debt. In May 2012, event being arranged by our local Council for Voluntary Service, to raise awareness of the issue and of the support and services that can offer help with both stopping smoking and debt management. This will be followed by the local housing conference, run by WALH, on the same theme. To ensure consistency and sustainability Public Health will utilise the ongoing MECC programme to train the debt advisors to advise and signpost re stopping smoking whilst the frontline staff working in other areas will be given training allowing them

to signpost into debt and smoking support.

Making Health Everyone’s Business

The Public Health Directorate leads on commissioning a comprehensive portfolio of services and programmes to promote healthy weight. Our flagship programme is the Lose Weight Feel Great care pathway for managing excess weight in adults that was launched in January 2009.

With services for overweight clients right through to bariatric surgery it has capacity to provide treatment for over 10,000 clients per annum across a range of services. It is one of the most comprehensive integrated pathways in the country and has significantly increased access to highly personalised advice and support services focused on achieving long term weight loss and maintenance.

In the first 20 months of the programme, approvals for bariatric surgery have been reduced by 73% saving the PCT over £440000. Over 13,500 people have called the access hub for help and advice and nearly 11,000 people have been referred into services.

Risk is the fragmentation of the commissioning budget may impact on this type of approach where currently the commissioning for all services related to obesity sits within Public Health.

This approach of developing the skills of frontline staff in basic behavioural This approach of developing the skills of frontline staff in basic behavioural change techniques specifically seeks to provide frontline staff with the change techniques specifically seeks to provide frontline staff with the skills, tools and confidence to embed prevention in their day-to-day work skills, tools and confidence to embed prevention in their day-to-day work with clients. with clients.

Its based on the premise of making the most of the thousands of Its based on the premise of making the most of the thousands of encounters that public sector, voluntary and community organisations encounters that public sector, voluntary and community organisations have with people every week and using these contacts as opportunities to have with people every week and using these contacts as opportunities to raise health issues and signpost people to appropriate support services. raise health issues and signpost people to appropriate support services.

Locally, Public Health is working with a wide range of organisations to Locally, Public Health is working with a wide range of organisations to develop staff skills and confidence in raising health issues and signposting develop staff skills and confidence in raising health issues and signposting people to appropriate support and advice. Organisations committed to this people to appropriate support and advice. Organisations committed to this programme include: Ashton, Leigh & Wigan Community Healthcare NHS programme include: Ashton, Leigh & Wigan Community Healthcare NHS Trust; Wrightington, Wigan & Leigh NHS Trust; Wigan Leisure & Culture Trust; Wrightington, Wigan & Leigh NHS Trust; Wigan Leisure & Culture Trust; Wigan Council; 5 Boroughs NHS Trust; and Groundwork. Essential Trust; Wigan Council; 5 Boroughs NHS Trust; and Groundwork. Essential Public Health is a 2 hour training programme that is being used to provide Public Health is a 2 hour training programme that is being used to provide staff with the practical skills and confidence to deliver ‘health chats’.staff with the practical skills and confidence to deliver ‘health chats’.

Healthy Living Pharmacy Programme

The Healthy Living Pharmacy (HLP) concept was developed by NHS Portsmouth during 2009/10 to develop and demonstrate the quality and effectiveness of community pharmacy services, and to improve their contribution to health and wellbeing services overall.

In Wigan we have 70 community pharmacies, the majority of which are already providing excellent services such as stop smoking, sexual health advice and support for self care.

Pharmacies are a key resource for many borough residents from those who lead an active, working life to individuals suffering from long term conditions; and local pharmacies can be a more appropriate and readily accessible venue than a hospital or GP surgery.

Wigan became one of 20 HLP pathfinder areas in September 2011. The local Pharmaceutical Committee (LPC), Medicines Management Team and Public Health worked together to support 10 pharmacies on the programme with a target of between 6 and 8 achieving accreditation by March 2012. All 10 achieved the set criteria and have now been accredited.

The phase 1 programme has thus far proved so popular with the pharmacies that a further 28 have now signed up for phase 2. The training for counter staff started in June and will be completed on October 3rd. Moving forward the Health Improvement Team will continue to support the pharmacies to continue the progress and to actively undertake or support specific health improvement campaigns. We will have 38 of the 70 pharmacies achieving Healthy Living Pharmacy accreditation. This programme is ongoing in a number of areas but Wigan will have the highest number in England once the accreditation process is completed.

Community Health Champions

The advent of ‘Making Every Contact Count’ (MECC) as a work stream fitted in with the work already underway in the capacity building programme. Wigan puts as much emphasis is with non NHS front line staff and volunteers as on the work with NHS staff.

The changes in the way that housing benefits are paid will impact on the social housing providers and is expected to increase the numbers of tenants falling into arrears. We are using this as an opportunity to increase the work related to spending on tobacco and debt management to more teams within the housing sector and to expand beyond the borough’s main social housing provider.

All the staff and volunteers who have undertaken our training have become part of our Workplace and Community Health Champion Network. A website has been developed which allows us to communicate updates and further opportunities along with continuing to recruit to the ranks of over 1130 champions. www.alwhealthchamps.nhs.uk.

Complex health and well-being challenges Complex health and well-being challenges

Influencing resource decisions across organisations Influencing resource decisions across organisations

Developing trust across organisational boundariesDeveloping trust across organisational boundaries

Harnessing health and well-being leadership skills Harnessing health and well-being leadership skills across local people and all organisational sectors in across local people and all organisational sectors in

the Boroughthe Borough.. For more info see www.phwigan.com