To quote Professor Sir Michael Marmot in his interview for us: “Public health is everyone’s business”. Rightly so. By its nature, public health matters to us all, whether we believe this to be the case or not. It is this characteristic that can make public health one of the most difficult aspects of our health and care system to define and delineate. Yet it also makes public health one of the most important elements of our system. It has the potential to deliver huge benefit in terms of individual and collective health and wellbeing. And, in this sense, it is the most inherently democratic: it is more able than other parts of the system to make use of formal and informal social and political structures.
This report uses 12 interviews with NHS trust leaders, from the hospital, mental health and ambulance sectors, as well as academics, system leaders, local government representatives, and those with strategic responsibility for delivery and commissioning, to help gain a better understanding of NHS providers’ role in shaping and delivering public health and care. What their words show is that there is a proliferation of ideas and perspectives. Some interviewees are population health advocates, others see the structured focus on the individual as key, while some promote prevention every step of the way. What links these interviews, however, is a shared understanding that a focus on public health has never been more important, nor more challenging.
Health inequalities
The thread that runs through any consideration of public health is health inequalities, and more specifically the wider determinants of health and wellbeing. A precondition to good public health is socio-economic prosperity and equity: individuals and communities being enabled to access the support they need to thrive. It is appropriate that public health’s national leader, Duncan Selbie, chief executive of Public Health England (PHE), talks so passionately about this:
“…A job, a safe and warm home and someone to care for and about are the foundation of what works for improving health and closing the gap between those who are affluent and those who are not…”
Professor Sir Michael Marmot goes to the heart of what we need to deliver equity:
“Really, it’s a question of social action. Individual behaviours matter enormously, but they are influenced by and conditioned by environments and social determinants.”
Finally, it is interesting that Wayne Bartlett-Syree’s broad view of public health – as East of England Ambulance Service’s strategy director – is informed by an updated version of the Beveridge’s five giants. “Squalor, ignorance, want, idleness and disease. Those five are still valid today, although the language changes...”
Squalor related to slums – now our issues are about social isolation and the gaps between rich and poor. Ignorance speaks to the power of education as a social leveller. Want has been turned on its head; the challenge now is consumption. Idleness is now inactivity “getting people moving has massive benefits”. And then disease; although the big public health killers such as cholera or diphtheria may have gone the context now is ‘multimorbidity’ rather than the single disease.
Perhaps none of these perspectives are brand new, but the context in which we are now operating makes the need to act even more pressing.
Navigating the system
No institution or individual can deliver public health alone. That is its strength. However therein lies an inherent weakness. Who leads? Who sets the strategic direction? Who is accountable and responsible for such a wide ranging set of roles, functions and initiatives?
With the UK in the midst of Brexit negotiations it might seem strange to turn to an EU concept for the answer to these questions. However one of the underlying themes to emerge is that public health is everybody’s business in different ways. A form of subsidiarity – operating at the appropriate level, closest to the people – is a key concept here. National bodies, councils, trusts, the third sector all have a different relationship to the individual. They operate at different levels and in different ways. It’s about identifying the most appropriate level for the most appropriate action. Alongside this, without genuine integration of services and functions, effective, value for money public health will be impossible to deliver.
National bodies, councils, trusts, the third sector all have a different relationship to the individual. They operate at different levels and in different ways. It’s about identifying the most appropriate level for the most appropriate action. Alongside this, without genuine integration of services and functions, effective, value for money public health will be impossible to deliver.
It is critical that we remain true to the core intention to improve public health. One way of doing this is to think about how the structure of health and care delivery relates to the individual and wider communities and how this structure then impacts on them.
At a system level it is funding, strategic direction and national level actions that predominate. How much will we allocate to public health expenditure in aggregate, what is our strategic priority – prevention or promotion, and will national approaches make a difference?
Developing a sense of place is also critical and is likely to be a key determinant for successful public health. Getting the right unit of planning and defining the right community/communities is key here. This is where sustainability and transformation partnerships (STPs) and the move to accountable care are important. And where we also see the importance of geographical boundaries and operating at an appropriate scale.
Individual institutions – NHS trusts, councils or voluntary sector organisations – have a key role in delivering public health strategies. Each type of organisation has different accountabilities but they share the same need to align what they do with national public health priorities and have the right impact on the individual members of the public with whom they interact.
This latter point is key: the individuals that constitute the public of public health must be afforded proper agency. Any approaches where people are ‘done to’, sanctioned or punished will not work. In the words of Dame Gill Morgan: “We need to think about how to help young people use technology for health gain in exciting non-deadening ways. Too much public health messaging is boring, punish-y, “don’t eat this or that”. We need a school of social marketeers on how to encourage and nudge people effectively towards healthier decisions...”
Recent structural changes
Back in 2012 the much debated Health and Social Care Act introduced a new system for public health in England. At the heart of these reforms was the creation of the national organisation, PHE, and the transfer of public health functions from the NHS to local authorities. Every top tier authority (unitary or county council) appointed a statutory director of public health. This took place in April 2013.
Now PHE and councils both have a legal duty to reduce health inequalities in the commissioning and delivery of their services. PHE’s role is to provide national leadership as well as delivering appropriate services to protect and promote the public’s health. It also funds public health activity by commissioning services or allocating funds to councils.
Councils’ role is to improve the health of their population. A simple statement with a whole host of complexity underneath. Statutory health and wellbeing boards (which sit within councils) bring together health and social care commissioners, elected representatives and HealthWatch to integrate health and care to improve health and wellbeing. Their primary task is to produce a joint strategic needs assessment which sets out the needs of the local community. This should then translate into local commissioning priorities.
This structure has been in operation for four years. Overall it has delivered some significant benefits, with widespread support for councils leading the delivery of improved health outcomes for local populations, given their closeness to their local communities. A Commons health committee report indicates that the shift of public health to local government has been “largely positive”, integrating public health across policies and actions that relate to the wider determinants of good or poor public health.
However some challenges remain. The structure is relatively complex, and these changes were introduced at a time of huge system upheaval with the implementation of all the proposals in the Health and Social Care Act. At the same time, local government has been through an unprecedented period of financial austerity with all local government budgets, including public health, heavily squeezed. PHE has also seen in-year and ongoing financial constraints.
A focus on the NHS trust role
Although the views expressed in the interviews are diverse, a number of issues relating directly to the NHS trust role in public health emerge:
- the impact of STPs and accountable care approaches
- funding challenges
- innovation and the need to embrace digital technology
- population health and the role of the public health clinician
- enduring importance of a condition specific approach
The next section sets out more detail on these five areas.
Impact of STPs and accountable care approaches
For the NHS and local government STPs and accountable care are the new kids on the block. But the foundations on which they build have been around for a good while: the integration of health, care and other public services and the importance of a sense of place.
They have an important role in improving population health and reducing health inequalities as a key mechanism through which all parts of the health and care system can come together and agree shared plans, approaches and solutions. Many STP plans have been rooted in the notion that improving population health will reduce demand on the NHS, although that should not be its sole aim. This is reflected in the views of our interviewees, although not without challenge:
“We are starting to see a change of emphasis with the work of the sustainability and transformation partnerships which is refocusing our attention on system-wide solutions and on population health – helping people to achieve their maximum potential – rather than treating people when they get sick.” David Sloman
“In my view, STPs offer us an excellent opportunity to transform the ways in which health and care go about trying to improve the health of their patients and populations, and they are a smart way of looking at the health and care economy’s broader impact.” Professor Michael Marmot
“So, at STP and local delivery plan levels, we have a very strong focus on public and population health… This is driving us as leaders to think differently about people’s overall health and wellbeing… Can this be enough to help us mitigate the full impact of the financial challenges for public health? I’m not convinced.” Professor Heather Tierney-Moore
Within STPs and accountable care, service integration and the need for connection and joining up is a persistent theme – both from the organisation’s perspective and the individual’s:
“As commissioners, we now look more widely to other partners to support the prevention agenda, but with public health sat in local authorities, there’s a worrying disconnect between the two. As we move into the world of accountable care systems (ACSs) or accountable care organisations (ACOs) those kinds of disconnects are no longer viable or acceptable.” Graham Jackson
“So from this co-located joint working, we can pull in colleagues from primary care, social services and acute care. This started as joint work with the district council, and it really changes the conversation and makes us all as providers and commissioners think differently about how best to support people.” Professor Heather Tierney-Moore
“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…” Dr Arif Rajpura
There has been much discussion around the geographical footprints for STPs. The need for that all important sense of place has come through strongly and also the need to operate at scale. Public health good practice can be plentiful at a micro-level, but we need to scale them up to macro-level actions:
“The Royal Free London is one of four trusts across the NHS chosen to develop a group model… Our vision is of a group of hospitals which have the scale and partnerships to be commissioned to improve population health outcomes. If we can organise ourselves at a population-based scale then we stand a better chance of solving our population health paradox.” David Sloman
“The effectiveness of STPs varies predictably, with issues such as geography and local relationships playing a part in this. As a clinician, I want a local population focus to understand and meet that local healthcare need, which implies a smaller geographical footprint. But a small footprint can make it too hard to commission properly or reshape provision meaningfully.” Graham Jackson
Funding challenges
Barely a day goes by without NHS funding making the headlines in one way or another. Cuts to health and council funding and their impact certainly predominate in these interviews:
“The financial challenges have too often led to a focus on short-term finances, and prevention efforts don't always fit into short-term timescales… When you need cashable savings, it is that much more difficult to prioritise prevention efforts. It isn't easy, but taking a medium to long-term approach is really critical if we agree to tackle the major health issues our nation is facing at the moment.” Jeanelle de Gruchy
“Reductions in local authority spending impact on the types of services people need from the NHS and services have become disconnected. Many of the demands of the most chaotic mental health service users are linked to drug and alcohol use/abuse and it is the early support services that have been damaged.” Dame Gill Morgan
“The money has dried up in local government, less so in the NHS although it’s more opaque as there’s less transparency on the detail of the NHS’ public health and prevention funding and spending…” David Buck
But it’s not just about cuts. It is also about the need to reform how we pay for the different inputs that make up the public health offer and put in place incentives to devise different approaches and types of activity. Graham Jackson’s commissioner perspective is insightful:
“This will mean changing payment methods: not removing the purchaser-provider split, but weighting more incentive away from payment-by-results style activity to help providers work with the rest of the sector to defer or reduce the activity we have to deliver down the line…we’ve run the health system in 12-month fiscal cycles for decades – it’s no way to deliver population health. It makes no sense to run a £110bn-a-year business in 12-month cycles, so we need the bravery to talk about how we’ll invest for the future to get a public health return.” Graham Jackson
But it’s not just about cuts. It is also about the need to reform how we pay for the different inputs that make up the public health offer and put in place incentives to devise different approaches and types of activity.
Innovation and the need to embrace digital technology
Innovation is often born of a crisis. There has been much change, and even turmoil, in terms of changes to both the architecture of public health delivery and also the levels of funding. Against this backdrop many councils in particular have been innovative in finding different, and often more efficient, ways of making inroads into health and wellbeing, as demonstrated by the LGA’s report into public health transformation.
“… the other thing that those financial issues have done is to drive innovation. I’m seeing more and more people recognising the benefits of the third sector and what they can bring, thinking about strength-based and asset-based approaches. This has always been one school of thought in public health, but we in the more traditional statutory sector now need new ideas on how to support people to support themselves.” Professor Heather Tierney-Moore
“However, the cash crunch enabled local government to really look at ways to transform what it does: in that sense, it created opportunities to look to innovate and do things differently, and gave a chance to step back and explore how to improve population health through all elements of councils’ work…” Jeanelle de Gruchy
Digital technologies are an important means of delivering innovation, not only by diversifying how we engage with populations and the efficiency of interventions but also increasing the effectiveness of the data held. The interviewees with a provider background were particularly keen to emphasise this:
“The big enabler for positive changes to public health will be digital technology. We know that the expectations of our patients are higher than ever and in the digital age they want convenience, and expect data that’s bang up to date… We need more data and less intervention. Around 80% of healthcare data is currently unstructured, and digital technology can help us knit this together.” David Sloman
Population health and the role of the public health clinician
Over time the role of both the public health clinician in secondary care and the impact of population health more generally in strategic and service-level decisions has declined. Although this became more pronounced with the transfer of the statutory public health responsibility into local government four years ago, this was the speeding up of a pre-existing trend.
Public and population health approaches now lack their previous level of influence or popularity in NHS trusts. A lack of public health consultants can leave specific expertise gaps, including the data analysis to support healthcare decision-making. This is a loss to strategic capacity.
“We tried, but failed, to recruit a director of public health to advise our board, our executive and our staff… Without this expertise, our board decision-making and staff and patient behaviours lack a much-needed public health ethos.” Maureen Dalziel
“So public health specialists often get no opportunity to comment on prevention and value for money, especially in the work done within big provider units. To fix this, we need to see a consistently stronger population healthcare approach for trusts supported by public health specialists familiar with often quite complex healthcare…” Chris Packham
Alongside this, focusing more effectively on prevention in the secondary care sector is probably the area with the biggest potential short-term impact. By Making every contact count and changing the approach of clinicians to prevention some trusts are now playing an important role in population health management.
“One very practical thing we developed was a training programme for all staff in Making every contact count… Well over 50% of our staff are now trained in supporting patients in the areas of diet, activity, smoking, adverse childhood experience and behaviour change.” Heather Tierney-Moore
Enduring importance of a condition specific approach
So far this narrative has focused on populations, communities, places, services and approaches. However the importance of focusing public health work on prevention – both primary and secondary – of specific activities, conditions or behaviours endures. And rightly so. The biggest health gaps stem from the prevalence of smoking, obesity, drug and alcohol abuse, mental health conditions and the frailty of our older population:
“For us as an ambulance trust, our two biggest demand areas are mental health and falls; that makes up over 25% of our activity – mental health about 10% and falls 15-20%, most of which are in the frail elderly population…In mental health, it could be seeing patients through things like the blue light partnership, and using a street triage car to address those who come in to any of the 999 services…If we took a non-traditional service approach to this, it would be a question of how, as a provider, we could get into helping frail older people not to fall through home welfare checks.” Wayne Bartlett-Syrie
The final words in this section go to Duncan Selbie who exhorts the NHS to go completely smoke-free.
“Smoking accounts for half of the health gap between the poorest and most affluent and helping people to quit remains the number one opportunity to address this. Today in the NHS, 1 in 4 inpatients is a smoker and fewer than 1 in 13 of these has had a conversation with a doctor or nurse or any healthcare worker about why this might not be a good idea. There are more than half a million tobacco related admissions every year and for every smoker who dies early, 1 in 2, another 20 suffer tobacco-related diseases.”
Where next?
Public health is everybody’s business, it operates at every level and matters to national government as much as individuals.
The wide-ranging interviews in this report, reflecting the views of commissioners, providers, those operating nationally, regionally and locally, do provide some pointers about where we should be headed next:
- structurally – maintain and enhance the focus on the public health role of STPs and accountable care
- financially – reverse the cuts to local government public health budgets and shift payment systems so that the incentive is to prevent rather than cure
- clinically – reinstate a strong and strategic role for public and population health clinicians in provider organisations which will benefit all other parts of the public health system
- culturally – bring about a change in mindset across the NHS that is focused on public health and its role in empowering individuals to look after their health
- as the public sector – continue on the journey of influencing fundamental determinants of health and health inequalities.
Let’s give Dame Gill Morgan the final words here: “So let’s get back to a proper debate. Health services are not bad; primary prevention is not a panacea for the challenges of the NHS. A proper population and value-driven approach is needed now more than ever.”
Saffron Cordery
Director of Policy and Strategy
NHS Providers
Thanks also to Georgia Butterworth, Policy Officer for additional research