HC 1048-III Health CommitteeWritten evidence from Dr Ann Hoskins (PH 41)

Summary

We support the commitment to the recommendations of Sir Michael Marmot’s review on health inequalities and welcome the opportunity to provide written evidence on the work undertaken by the North West, including “Living Well”, an Asset-based approach, the Well-Being Survey and Wellness Services.

We welcome the opportunity to comment on the Select Committee’s new Public Health Inquiry.

The creation of Public Health England would require clears lines of accountability as well as independence.

We welcome the transfer of responsibility for health and wellbeing to local government to ensure a holistic and integrated service and will help address the wider social determinants of health.

The role of Director of Public Health needs to be clearly defined, independence retained and lines of accountability agreed to ensure the role is effectively serving the public.

As part of their statutory powers Health and Wellbeing Boards must be able to bring all those partners responsible for NHS commissioning and tackling wider social determinants to the table and to be held accountable.

It must be recognised that a whole pathway approach is needed for commissioning of NHS services.

The variety of commissioning routes may lead to fragmented commissioning for a number of public health services, it is therefore vital that public health expertise is provided to all the different commissioning routes.

Public health intelligence functions must to be retained at local and intermediate as well as at national levels of organisation.

We welcome the well-structured and robust outcomes framework, however decisions for improving population health should be made as locally as possible, informed by evidence of what works.

A local budgeting approach to the health of the public has shown to promote a more joined up approach. The health premium needs to be incentivised by allowing local flexibility as to which outcomes will count towards the premium.

We welcome the Government’s emphasis on the need to build on the achievements and skills of the current public health workforce, but it supports statutory regulation for all public health specialists.

Introduction

1. We welcome the opportunity to submit evidence to the Select Committee’s Public Health Inquiry. The following memorandum sets our view on some of the key issues covered by the Select Committee, although these are addressed in more detail in the NH NW response to the public health white paper. In particular we believe we have developed an important body of knowledge for tackling Health Inequalities and we welcome the opportunity to set them out here in more detail, the evidence base for the approach the North West is taking in its response to the Marmot review and improving the health of the population.

The Creation of Public Health England within the Department of Health

2. There are a number of issues resulting from the division of the public health function between Public Health England and public health teams working within local authorities and other organisations including commissioning consortia. The relationship of the director of public health with Public Health England (PHE) is unclear. With the functions of the HPA and PHOs located within PHE, the health protection function would no longer be an independent one. The workforce will become fragmented, employed by different organisations on different terms and conditions. This fragmentation could lead to the loss of substantial expertise resulting in some local public health services being inadequately resourced to function effectively and safely. Although cross-local authority pooling of resources may be possible, arrangements will be vulnerable to local changes within separate local authorities and will add to the blurring of accountability.

3. We view the Public health functions within Public Health England and the NHS Commissioning Board to be generally the responsibility of public health specialists, and PHE should become an a Special Health Authority or Executive Agency in order to ensure its’ independence.

The Future Role of Local Government in Public Health

4. The transfer of responsibility for the health and wellbeing of local populations to local authorities brings opportunities to align resources and activity to reduce inequalities and to improve health outcomes by addressing some of the wider determinants of health in a more coordinated and holistic manner than has previously been possible.

5. Local Authorities are ideally placed to commission integrated Wellness Services and align expertise on smoking cessation, alcohol brief interventions, weight management, stress management and relaxation with the support on finding work, managing debt, occupational health, family welfare, housing, mediation and befriending. There will be a good opportunity for skills and knowledge to be shared across existing public health and local authority staff, supported by training and development.

The Appointment of Directors of Public Health

6. The Director of Public Health (DPH) is the only defined role at local authority level when the NHS public health function moves to the local authority and the local authority becomes responsible for population health improvement. The role of the DPH should be defined as a public health adviser to the Local Authority Health and Wellbeing Board, responsible for providing advice and developing, implementing, performance managing and reporting on the population health of the area and the integration of health, care and wellbeing delivery through the Joint Strategic Needs Assessment, the Joint Health and Wellbeing Strategy and the Public Health Annual Report on behalf of the Board.

7. In order to carry out this role effectively the DPH should be invested with statutory powers to ensure control of resources and accountability to and from other public functions. The DPH must be positioned at Executive Director level in the local authority, directly accountable to the Chief Executive and with strategic overview of all local authority functions rather than restriction to health and social care. Lines of accountability need to be nationally agreed. Finally the DPH must retain the independence of the public health function, able to speak at all times on behalf of the health and wellbeing of the local population rather than from a political or administrative position.

The role of Health and Wellbeing Boards, Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies

8. The creation of Health and Wellbeing Boards (HWBs) in every council area with statutory powers will ensure all partners are delivering their organisation’s contribution to health and wellbeing. They will become the focal point of health policy and health service delivery ensuring that clinical services are commissioned in a way that is efficient and levers maximum health gain out of investment to support local priorities.

9. HWBs must have sufficient powers to deliver on its responsibility to co-ordinate health and well-being commissioning with power to sign off the (JSNA based) commissioning plans of the GP Consortia and councils for investment in health, care and wellbeing outcomes. It is essential that as part of these statutory powers the Health and Wellbeing Boards is able to bring all partners to the table that can contribute to both NHS commissioning and tackling the wider health determinants and hold them to account. There needs to be clarity on the proposals for partnership responsibilities and accountability and considerable developmental work around building common understanding and capacity to enable effective future working between HWBs and GP Consortia.

Arrangements for Public Health Involvement in the Commissioning of NHS Services

10. The population health perspective for designing, commissioning and delivering health services is vital to avoid wider health inequalities and poorer health outcomes. It must be recognised that for many services a whole pathway approach to commissioning is vital to ensuring efficiency savings are met eg tackling increasing alcohol admissions needs to be addressed through interventions along the entire pathway from prevention to treatment.

Arrangements for Commissioning Public Health Services

11. The variety of commissioning routes may lead to fragmented commissioning for a number of public health functions and priorities (eg screening, sexual health, immunisation), which will impact adversely on the meeting of local needs, compromise the quality of service provision and reduce individual commissioner accountability. We would wish to see public health expertise and input provided to all the different commissioning routes for the identified public health priorities/functions and the delivery of health care. Public health expertise in evidence based decision-making and prioritisation is key to ensuring services are cost effective and commissioned according to need.

12. GP Consortia should commission Public Health input from the local authority based Public Health team particularly for population interventions such as screening programmes. The expertise for commissioning and monitoring screening programmes currently rests within the director of public health and this should be retained. GP consortia and the NHS Commissioning Board need to participate in an agreed series of local operational commissioning commitments and strategies– through the medium of the Health and Wellbeing Boards, which they agree to be bound by, and publicly accountable for.

13. NHS NW has already raised concerns in its response to the public health white paper around the fragmented commissioning of children’s services and programmes, particularly the proposal that children’s services for five to 19 years are to be commissioned by local authorities while those for the under five years are to be commissioned by the NHS Commissioning Board and at some time transferred to local authorities. There is a strong evidence base that the healthy child programme will improve health and wellbeing. Local authorities need to be in a position to commission children’s services for the under five years once Public Health England is established rather than waiting until it is devolved from the NHS Commissioning Board, thus making local authorities the sole commissioners of the complete healthy child programme from 0 to 19 years. This would also encourage a whole life-course approach, with potential impacts on positive outcomes, as well as take a whole family approach. We are also of the view that these changes would significantly strengthen safeguarding systems and practice across health, social care and education, which has been a persistent area of concern from many Serious Case Reviews.

14. Like the Marmot review, the North West Region gives a high priority to children, particularly early years. The NHS NW has developed a Guide to support GP, PCT and local government commissioners to improve health and wellbeing outcomes for children, young people and expectant mothers. The Guide identifies child and maternal health priorities for improvement and evidence base for these priorities, describes key features of effective commissioning for child health and provides each local area with a child and maternal health profile to assist with prioritisation. A central aspect of the Guide is the focus on the life course of a child to the age of 18, and to the importance for commissioners to focus on intervention in early years. Many of the critical child health issues have their origin public health in its widest sense; the emerging Health and Wellbeing Boards will therefore be critical to the successful commissioning and provision of services.

Future of the Public Health Observatories (PHOs)

15. The experience of the Regional Public Health Observatories shows that national analyses tend to be better undertaken by regional or local bodies and academic communities that have specific expertise in the domain in question, rather than through the central consolidation of analytical work. Local areas and “supra-local” areas with particular expertise should be commissioned to undertake national public health intelligence work on behalf of the wider public health community.

16. In the North West the public health observatory fulfils a regional public health information and intelligence function, supporting public health professionals working in the NHS, local authorities and other services to improve the health of the North West population. To enable this it has provided some valuable tools including bespoke reports using a wide range of health-related datasets, for example annual alcohol profiles. (See http://www.nwph.net/nwpho)

The Structure and Purpose of the Public Health Outcomes Framework

17. We welcome the well-structured and robust outcomes framework and the proposal for data to be collected nationally, as far as possible, to allow for comparison and transparency as well as reducing the burden on local areas. However, the national function needs to support the principle that decisions for improving population health should be made as locally as possible, informed by evidence of what works and as such local areas must have the flexibility to identify and agree local priorities, informed by the Joint Strategic Needs Assessment.

18. The Public Health Outcomes Framework should not “second guess” what local communities will co-produce as local public health priorities. Local areas should be rewarded for tackling locally agreed priorities, not for delivering a standard set of nationally defined outcomes – in some cases standing still might be a success in terms of public health.

Arrangements for Funding Public Health Services (including the Health Premium)

19. Some local authorities have expressed concern that they may not receive sufficient funding to commission and deliver health improvement services because the national formula for public health resource allocation will not be sensitive enough to identify current variation in Primary Care Trust investment. A local budgeting approach to the health of the public has been shown to promote innovative, joined-up and whole-systems approaches to improving health. Therefore, where appropriate the public health budget needs to be aligned and/or pooled with other budgets to maximise overall public health impact in local areas.

20. The health premium needs to be incentivised by allowing local flexibility as to which outcomes will count towards the premium. In general, public health action towards delivering locally defined priorities is likely to deliver more benefit in terms of reducing inequalities than will public health action towards delivering national priorities.

The Government’s Response to the Marmot Review

21. Health is determined by wider socio-economic influences most of which sit outside the NHS, that have an effect from pre-birth and throughout life and that public health is everyone’s responsibility. We welcome the life-course approach to improving public health, particularly the focus on early intervention and prevention. However, more emphasis is needed on the transition within children’s services and between services for children and adults.

22. Despite massive investment and enormous effort by dedicated people and innovative organisations, patterns of inequality in health, income and aspiration persist across the North West – and there are newer challenges on the horizon, which have the potential to undermine existing gains. In 2010 the North West produced “Living Well: Across local communities- prioritising wellbeing to reduce inequalities”:

(http://www.nwph.net/hawa/writedir/a862Living%20Well.pdf.pdf) It builds on the recommendations and evidence of the Strategic Review of Health Inequalities in England post- 2010, and describes a way of working to remove entrenched inequalities. “Living Well” is not a framework with solutions as these are for local partners and communities to work through, but a long term approach that promotes a way of working locally to bring about improvements in health and wellbeing.

23. Important concepts that support local delivery of Living Well include: Investment for Health and Social Value – where the aim is to help decision makers create more health and wellbeing from their investment/disinvestment activity; and Social Value – designed to maximise the value of the money spent during commissioning.

24. Health Outcomes should reflect the presence of health and wellbeing in a population. This should include health assets and protective factors and not merely deficits in the population’s health or risk factors for ill health. Supporting wellbeing and enabling people to live well is our approach to achieving lasting reductions in inequalities. This new approach needs different outcomes measures which are evidence-based and measure changes in status as a result of an intervention.

25. To support this approach the North West developed an “Asset-based approach”: (http://www.nwph.net/hawa/writedir/2fa6The%20Asset%20Approach%20to%20Living%20Well.pdf). The approach values assets and identifies skills, strengths, capacity, and knowledge of individuals and the social capital of communities. It provides a positive and outcome focused picture that values what works well and where health is thriving. Community pride and spirit is therefore high and people are engaged in solutions that are more sustainable for that community, with use of outside support where it is needed most.

26. The asset approach could therefore make a significant contribution to:

Tackling the social determinants of health and reducing health inequalities.

Strengthening health protection resilience.

Focusing on health and wellbeing outcomes.

Strengthening Joint Strategic Needs Assessments.

Fostering co-production of health and the provision of health and social care.

Building the Big Society vision of empowered communities.

Supporting the systematic engagement of communities in partnership.

Maximising the role of the voluntary sector.

Enabling greater condition management, self care and care closer to home.

Improving individual and community resilience in challenging times.

.Improving demand management and service efficiency.

27. Improving positive mental health has been a growing priority over the last decade. The North West Mental Wellbeing Survey was undertaken in 2009 in response to a growing need to understand more about the positive mental wellbeing of people in the region. With a total sample of 18,500 people across Cumbria, Lancashire, Greater Manchester, Cheshire and Merseyside, the North West Mental Wellbeing Survey was the largest survey of its type ever conducted in the UK. It found stark differences in mental wellbeing across the North West; and that those living in disadvantaged circumstances have, in general, much lower levels of wellbeing. It found that an individual’s connection and interaction with their community is critical; in particular having a sense of belonging to the neighbourhood and feeling one can influence decisions about the local area, make a big difference to mental wellbeing.

28. The groundbreaking research is of national importance given the relative lack of data on population mental wellbeing in the UK. The information gathered gives a better understanding of mental wellbeing, highlighting what it is to be well and stay well across a series of determinants in relation to physical health, social capital and health inequalities. It will also help inform Joint Strategic Needs Assessments and targeted commissioning and have the potential to provide baseline data for evaluation of interventions to inform outcome-based commissioning. The North West Mental Wellbeing Survey is the most significant and detailed investigation of the region’s mental health and wellbeing ever undertaken and should inform service provision for years to come.

29. There is increasing evidence and emerging policy of the need to address both mental (and psychological) well-being AND physical health. Individuals with poor levels of mental well-being are much less likely to be able to make sustainable lifestyle changes, be in good physical health or to manage and recover from illness than those with high levels of mental well-being. In turn, people with poor physical health will have poorer mental health.

30. Wellness services provide a holistic and seamless service to support people in improving their health and well-being. Traditional lifestyle services have often been provided separately, making it difficult for patients to navigate between. This is especially so for those with complex needs where support on a number of health issues is needed. Such models have potential therefore to cause inefficiencies in patient pathways and commissioning.

31. Work in the North West is supporting the development of Wellness Services across localities (see Annex A). The Transforming Community Services programme is a lever to enable this, alongside developing the new Public Health Service.

32. Local Authorities are ideal partners in the provision of Wellness Services. Alongside expertise on smoking cessation, alcohol brief interventions, weight management, stress management and relaxation is the support on finding work, managing debt, occupational health, family welfare etc.

Conclusion

33. We recognise that the Government’s call for a public health system that can deliver world-class outcomes raises huge opportunities for public health. We support and welcome the increased focus on population health and in particular the commitment to the recommendations of Sir Michael Marmot’s review on health inequalities. We see the transfer of responsibility for the health and wellbeing of local populations to local authorities, together with the transfer of directors of public health as an opportunity to align resources and activity to reduce inequalities and to improve health outcomes by addressing some of the wider determinants of health in a more coordinated and holistic manner than has previously been possible.

June 2011

Annex A

LIVING WELL WITH WELLNESS SERVICES

Proposed new approaches to public health provide a rare opportunity to create a sea change in the way we view health - from illness to wellness. Are we really aware of what could be achieved in this new world in terms of a truly people centred approach that focuses on wellbeing? It’s possible that many colleagues, who are understandably focused on the change process, may not have had the opportunity to consider its full potential.

In the North West, we have been exploring what the wellness approach would look like as part of a new wave of public health.i We took up the challenge, working alongside the Marmot review team, with publishing a call to action document - Living Well: prioritising well-being to reduce inequalities ._ The regional well-being survey clearly showed that those with high levels of well-being are much more likely to be able to make sustainable lifestyle changes, be in good health, manage and recover from illness sooner and use health services better than those with poor levels of well-being.

The creation of a new Public Health Service with Local Authorities and the reconfiguration of community health services are providing an opportunity to develop integrated and holistic wellness services. The time is right for a new approach to support people in “living well” that goes beyond the traditional availability of single-issue healthy lifestyle services and a focus on illness, rather than wellness.

The new strategy for public health in England, Healthy Lives, Healthy People,ii places increased emphasis on tackling both physical and mental health as part of healthy lifestyles. Factors of self-esteem, confidence, resilience, social networks and sense of control are all seen as key to decision-making and the ability to lead healthy lives and maintain well-being.

Increasing control is also a priority within the Marmot Reviewiii which holds a vision of “creating the conditions for individuals to take control of their own lives” and puts prevention in the context of the social determinants of health. Thus, individual responsibility for health is achieved through individual and community empowerment and proportionate availability of prevention services.

The North West Living Well documentiv is a regional response to Marmot and a call to action to prioritise well-being in order to reduce inequalities. The Living Well concept focuses on creating the conditions that support well-being and enable people to live well. It calls for new approaches to address the background causes of good health and a focus on how people feel and function (well-being) as key to individual change.

Research in the North Westv vi also shows that individuals with high levels of well-being are much more likely to be able to make sustainable lifestyle changes, be in good health, manage and recover from illness sooner and use health services better than those with poor levels of well-being.

Traditional lifestyle services have often been provided separately, making it difficult for patients to navigate between. This is especially so for those with complex needs where support on a number of health issues is needed. Wellness services have potential therefore to provide a holistic and seamless service - to create easier and consistent pathways for patient and referrer rather than going between different services for different aspects of their health.

A broader well-being focus to a wellness service might provide holistic assessment at the point of access and generic interventions that address psycho-social determinants. There is a clear need to have a stronger focus on enhancing sense of control, coherence, self-efficacy, motivation, self determination and social skills. A good level of well-being is needed before any individual can start to make healthy choices and changes.

Specific interventions would focus on a whole range of factors that influence a person’s ability to live healthy and well (see figure 1): healthy lifestyle, self care and independent living, family support, work & learning, personal health protection & safety, welfare and community development & leisure.

A partnership approach is therefore needed if wellness services are to be effective in providing quality services and in addressing inequalities. The Health & Well-being Board is ideally placed to support joint and integrated approaches for this across the Local Authority, Commissioning Consortia, NHS Trusts, voluntary and independent providers and local communities. The Public Health White Paper emphasis on health as a positive sense of well-being and not merely the absence of illness will be demonstrated through the Board’s Joint Health & Well-being Strategy and the type of services available locally.

The role of community members in contributing to providing such services is fundamental to a new Living Well approach of empowerment and building community assets and resilience. The Big Society approach can involve more appropriate forms of support being available at a neighbourhood level, people coming together to provide their own services and people more involved in what services are needed. Understanding and building on the health assets of individuals and communities is fundamental to the new approach of focusing on health as wellness rather than illness and deficits. Likewise the development of Community-oriented Primary Care and Health Promoting Organisations are the key shifts needed within the delivery system to implement the White Paper and support the wellness approach and make every contact with the public an opportunity to address health and well-being.

Building momentum for change also involves increasing the significance of personal health to people’s lives and the ability to sustain good health. For many people this remains a challenge and the availability of good information and appropriate support will enable us all, and the most challenged, to look after our own health, participate in improving our community’s wellbeing and removing the barriers to living well.

Many localities have already started to shape a new wellness service with examples of integration as outlined in Figure 1. The Liverpool Public Health Observatory has recently published a review of wellness services,vii commissioned by the Cheshire & Merseyside Public Health Network to support the development of local models. The report draws on learning from existing holistic services such as Well Women Centres, Jobcentre Plus Condition Management Programmes, Partnerships for Older People Projects, Social Prescribing, Health Trainers, Occupational Therapy and Psychological Well-being interventions.

Specific innovation within the North West region detailed within the report is summarised below. Within Halton and St Helens a partnership between GPs and the Citizen Advice Bureau provides support to patients on issues around debt, employment, benefits and housing. It resulted in 38% of patients having their mental health intervention stepped down. Within the Wirral Health Action Area health trainers, community health development workers and lifestyle advisors provide a range of physical and mental health activities and support. The partnership approach also includes employability programmes that seek to improve health and well-being alongside employment skills and support. The community programme was cost effective with a cost per client at £32.75 and per QALY of around £16,000.

Within Knowsley the proposed one-stop shop for lifestyle services is based on individuals needing generic behaviour change support (eg assess current status, set goals, set out plans, access support and keep them motivated and informed) and not necessarily needing specialist topic based skills at all stages. The historic target focus on individual behaviours was felt to be a barrier to taking a person centred approach, especially when working in deprived areas where each service potentially targets the same people (eg the person who smokes, drinks heavily and is inactive etc). The Knowsley model also includes social care partnerships through including independent living services such as aids and adaptations.

Well-being Sefton is a pilot programme offering one to one consultations utilising a Life Balance Assessment and provision of support on housing, debt, welfare issues as well as weight management, anxiety and broader social prescribing for mental well-being, bibliotherapy, arts, CAB, exercise, volunteering and green gyms. There is a single telephone number for access and information.

The St Peters Centre in Burnley is a combined leisure and primary care centre providing a holistic one stop shop and quicker direct access to specific services such as exercise on prescription or smoking cessation. This demonstrates a good partnership between sectors to achieving local outcomes.

Salford is working up a radical redesign of its lifestyle services to unify them into a single way to well-being service. This will integrate health improvement, work & skills and neighbourhood teams and incorporate community based activities alongside public sector interventions. “The holistic approach will ensure both that people’s health issues are dealt with in the context of the wider social context in which they arise, and also that common approaches and skill sets apparent in the variety of services covered by the work are managed more effectively.” vii

Achieving fully integrated wellness services will be a challenge that requires leadership, vision and an element of risk taking and openness. Sharing learning across localities will be an important task to maintain throughout the reforms, supported by Public Health Networks and other Improvement agencies.

References

i Hanlon P, Carlisle S, Hannah M, Reilly D, Lyon A (2011) Making the case for a “fifth wave” in public health in Public Health 125 (2011) 30-36

ii Department of Health, 2010, Healthy Lives, Healthy People: Our strategy for public health in England, London: HMSO www.official-documents.gov.uk

iii Marmot M., 2010, Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England post 2010, www.marmotreview.org.uk

iv NHS NW, 2010, Living Well across communities: prioritising well-being to reduce inequalities, Manchester: NHS NW www.nwph.net/hawa

v Deacon L et al, 2010, North West Well-being Survey 2009, Liverpool: NWPHO

vi Hennell T, 2010, The contribution of well-being to health inequalities presentation Warwick University

vii Winters L, Armitage M, Stansfield J, Scott-Samuel A and Farrar A, 2010, Wellness Services – Evidence based review and examples of good practice, Liverpool Public Health Observatory

Figure 1

INTEGRATED WELLNESS SERVICES

Prepared 28th November 2011