In April this year QualityWatch launched the Focus on: Public Health and Prevention report, which examined changes in public health outcome measures, and reported opportunities and challenges identified by those working in public health within a new legislative and financial environment.
On June 8th the Nuffield Trust hosted a QualityWatch seminar bringing together local and national representatives across public health to reflect and build on the report, and to address the question, ‘Reform and austerity – what does the future of public health services look like?’
The conversation, far from dwelling on the structural reforms or financial challenges of the past, present or future, focused on working in partnership, across communities, providers and support services, with the common goal to achieve more with less. Yes, the system reorganisation and austerity may have provided the impetus, but other prompts included the better care fund, care act, and development of sustainability and transformation plans.
The key themes from the discussion focused on the added value of public health within local government. There was a shared sense around the table that public health, which now sits within local government, has greater opportunities to develop innovative holistic approaches to improving the population’s health. Moreover public health is not confined within the terms of the 'public health budget', but is now able to provide a welcomed perspective to improving the population’s health through all aspects of local government.
Systems leadership
Seminar participants agreed that system leadership and systems translators are key to developing and strengthening these wider partnerships across local government. They are needed to help prompt and facilitate discussions on what austerity means to local areas, and how to mobilise the assets available to drive change.
For example:
Place and communities: We heard how, in the London Borough of Richmond upon Thames, prevention is viewed as a smarter way to invest public money. The public health team there are advocating a more sustainable approach looking at healthier uses of open spaces, dementia friendly communities, and workplace health - all reflective of local needs and priorities.
People: Coventry has been designated a 'Marmot City' taking a holistic approach to addressing health inequalities. We heard how great focus has been placed on building the social capital of the city by making the economic case for better public health. Public health and prevention are being deployed to prevent disability in working-age men and women, increasing the potential for economic growth and development. The approach in Coventry has been based on building working relationships across the city council, and on developing partnerships with communities. Community engagement is leading to local ownership of the issues and social mobilisation to identify and implement solutions.
The sustainability and transformation plans have also helped facilitate a collaborative approach to health. Every health and care system needs to plan how local services will work together to improve the local health economy – with system leadership again recognised as being a key enabler.
However, while relationships are being forged with other local services, we also heard about some of the difficulties public health teams faced in engaging with the NHS. There is in some places a need to encourage some roles to reflect on the value of public health working with the NHS, engage with others to address the wider influences on health, and potentially to reduce demand and pressures on NHS services.
The argument that improving the health of the working-age populations makes good business sense is also gaining traction in some areas, given potential changes to the local government business rate retention model in 2020 and an ongoing emphasis on economic growth.
How can we measure the added value Public Health provides?
Looking forwards, a pertinent question for QualityWatch and the national outcome frameworks, including the public health outcomes frameworks, is how to measure the added value public health provides in local government. As highlighted in our report by one respondent, the value of the reforms is not in the commissioning of new services, but the ability of Public Health to influence all council functions. How then do we measure success, and look beyond aggregated national data on specific indicators such as smoking quit rates?
At present the PHOF largely focuses on process and outcome measures related to the wider determinants of health (eg school readiness), health improvement (eg smoking), health protection (eg vaccine uptake) and health care (eg premature mortality). But a different nature of indicator may be needed. At our seminar it was suggested that the quality of relationships across local government might be a meaningful measure for use in comparing the added value public health is bringing to different authorities. But what might this look like and how robust could measures for this be? The dilemma is similar to that around trying to measure ‘social capital’.
Finally, whatever these indicators may look like, they need to help identify those doing well, but also help identify those that are not. There will inevitably be variability across systems and regions, but encouraging areas which are forging ahead in the new world to share learning and support those areas which are only starting on that journey is essential to ensure that the potential achievements are within the grasp of all.