Dr Arif Rajpura

Following an array of clinical jobs, Arif’s first consultant in public health post was in 2004.  Since 2007, he held the position of director of public health of NHS Blackpool and latterly Blackpool Council.

Arif was involved in national lobbying around alcohol policy and is currently leading on a new approach to tackle obesity within Blackpool.

 

The repositioning of public health in the 2012 legislation, moving it from its former seating in NHS primary care trusts to being the responsibility of local government, offered a real opportunity for public health to truly influence a wide range of things that determine population health.

This rather large focus on wider determinants of health contrasts with the more traditional tendency of public health sitting in the NHS. This wasn’t true everywhere: in our area, we had long worked closely with the local authority, and I was given a post as a joint appointment by the NHS and local government, so we had strong existing links. That helped us make the transition more successfully than may have happened in some areas.

Local government has a major influence on so many things that are key determinants of population health and wellbeing – housing, environment, education, employment – that it should become easier for public health thinking and approaches to have greater influence and impact.

Another benefit of public health now sitting in local government is that it’s physically far closer to the population than when it was sitting in the NHS. We’re more visible, closer to the population and to other partners like the voluntary sector.

One thing that will be vital to successful integration between health and social care will be to ensure that the voluntary sector’s offering is designed, networked and weaved into any offer we have.

The hidden healthcare system

I always describe the voluntary sector as ‘the hidden healthcare system that’s usually unrecognised by the statutory sector’. The voluntary sector is generally doing a very good job, but its work needs to be better integrated with the statutory sector.

So one of our key tasks is weaving the voluntary sector’s work into the jigsaw of health, social care and public health. Our aim must be that we essentially provide the right intervention for the right person at the right time in the right place. In doing this, we must also ensure that we move resources and services upstream and provide early intervention with a prevention orientation.

Local government has a major influence on so many things that are key determinants of population health and wellbeing – housing, environment, education, employment – that it should become easier for public health thinking and approaches to have greater influence and impact.

   

Repositioning public health in local government has helped do all of that, and allows me to describe my role as being the glue, putting all this together and coordinating the whole jigsaw and making sure that it feels coherent to users.

Practical value

Along with that, it allows me to work on all sorts of initiatives in wider determinants of ill health: in education, we’re working with schools, and we fund a universal free breakfast from the public health grant, which feeds 11,000 pupils in Blackpool primary schools.

This is an important intervention for a very deprived population with low income and high health inequalities, and by allowing us to ensure a healthy diet and educational attainment, will make a very positive difference: hungry kids don’t do well in school. This is just one example of how an initiative derived from having public health in local government allowed us to work with schools on something that will boost health and educational attainment.

We have to look at what would be effective interventions at lower cost. The key things we want to do are improve health, life expectancy, health literacy and reduce health inequality: all these are fairly long-term aspirations. For the NHS and the public health system to achieve these, it’s going to take a 10-20-year timeframe.

The Five-year forward view highlights public health and prevention, but we’re not going to see real progress on these within its five years. My thinking is that what we can achieve in a timeframe of five years or less is for areas to get that right intervention to that right person at that right time in that right place, regardless of who provides it and whether their badge says NHS, local authority or voluntary sector – the aim of our integrated offer should be that people are providing upstream, preventive services.

2020 vision

So my vision is that by 2020, we will have an offer for people where we’ve done the integration for them, and it’s not left for individual service users to do, as it often is now. We’ll have a workforce who are skilled in interventions, without hand-offs between organisations, and a seamless place-based public sector offer, regardless of who delivers it, for health, social care and public health at the local level.

That is all fairly low-cost stuff: it’s about using existing services in different ways. This starts off with my team doing a lot of bringing people and services together and mapping user journeys. For all the effects of austerity, there’s still a lot going on in our borough in statutory and voluntary sectors. We’re probably not making best use of what is already going on, and we could use resources better to make a better-integrated, place-based offer.

The way we operate needs to change. We have to get out of silo mindsets, and recognise that we’ll need a huge workforce transformation to work with different professionals in different ways.

   

One key area is quite obvious locally: we have such a bad health impact from substance misuse in our borough. We lose so many lives to drug and alcohol issues, that if we want to have an impact on life expectancy locally, then a key priority is to tackle this.

Brisk approach needed

We need lots of national intervention to help with this. Locally, we struggle with cheap alcohol in Blackpool. The fact that we’ve still not got minimum unit pricing is a big missed opportunity to have a big impact on alcohol-related harm. National legislation on tobacco has been far more effective: we have had tax rises, plain packaging, crackdowns on illicit contraband cigarettes, and the smoking ban. All of that has contributed to the big impacts we’ve seen in the significant decrease in smoking rates.

We need a similarly brisk approach with alcohol: to learn from what’s clearly worked with tobacco and use that approach for alcohol and obesity (healthy weight initiatives and more). The beverage sugar tax looks like a great start, but there’s much more to do, especially on marketing and regulation so we don’t advertise junk food to young people. These will have huge, measurable short and long-term impacts on the big health determinant issues. And we need a much better-integrated and upstream whole public sector offer, working together in a place-based and provider-agnostic approach.

Workforce transformation and organisational development will be vital to this. The way we operate needs to change. We have to get out of silo mindsets, and recognise that we’ll need a huge workforce transformation to work with different professionals in different ways. This will involve a lot of letting go and a lot of people gaining new skills – be it in specific brief interventions or in making every contact count. Many people will have to move out of their professional silos and work in new approaches that deliver services and care in more integrated, user-centred ways.