Professor Heather Tierney-Moore

With a background in nursing, Heather has amassed distinguished achievement in the NHS. She has a key leadership role in supporting system-wide transformation, to deliver integrated healthcare services across Lancashire and the wider north-west. Heather is senior responsible officer for the leadership and organisational development workstream for Lancashire Care NHS Foundation Trust and South Cumbria sustainability and transformation partnership.

 

The positive side of where public health now sits in local government, following the 2012 Act’s reforms, is that the wider determinants of health are very much local government’s business. So I can see why that change seemed to be the right move: being able to think about the broader determinants of heath and wellbeing makes great sense.

Sadly, the ongoing financial pressures on local government means this theory is not really working in practice. So we have seen significant financial pressures driving the tendering of public health services, and erosion of public health budgets.

This is happening just when everyone says this is one of most important things to attend to if we stand a chance of achieving the Five-year forward view’s ambitions and changing the health outlook for so many of the public, especially the most vulnerable.

Financial impact

Financial aspects of local government have had real impact on services already: I worry that it’s only going to be more difficult in the coming years 

Where we have seen some mitigation of these risks to public health services is around the increasingly close working between health and local government in the work we’re all trying to do together around population heath.

So, at STP and local delivery plan levels, we have a very strong focus on public and population health, and ambitious aspirations in changing the relationship between citizens and the statutory sector. 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.

Driving innovation

However, 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 

From our perspective at Lancashire Care, we have long had a strong public health focus on early intervention, and employed our own public health consultant four years ago to help us think about how we organise and orientate services, and how staff practice in their jobs.

Our organisation has nearly three million contacts a years with a population of 1.7 million people. It’s almost a 50-50 split between physical and mental health. The vast majority of our contacts are in community settings, so we considered how to have a broader impact on people over and above direct care.

One very practical thing we developed was a training programme for all staff in Making every contact count (MECC). This training works at three levels; the first is a general awareness level, which is enhanced at the second level with specific training on signposting to other resources and support, and the third, highest level being more focused again. 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.

Practical conversations about health change

We track how many times those MECC conversations are held, and see whether people are doing anything different as a result. Our figures for April to August 2017 showed there had been 58,000 conversations in relation to diet; 41,000 on increased physical activity and 15,000 each for smoking.

These are practical conversations on the ground, distinct to the regular previous practice of our staff. We think this is helping our staff practice their jobs in a meaningful public health way, be they a public health specialist or not. I think that is something for the wider health service to think about.

This is about thinking about people in the totality of their lives: not just biologically, but in their social setting – and about the factors that contribute to their lives and physical and mental wellbeing and health.

   

I’m sure that more and more NHS staff are doing this, but perhaps it’s not being systematically recorded in this way. Having invested in developing training, we thought it's important to know whether our staff are using it, and what impact it is having.

Thinking around the whole person

It is also driven by a really strong both-way focus on parity of esteem. So our training has a concerted focus on people as whole people, with physical and mental health to consider 

We know about the significant physical health issues that people with mental health problems face, including the risk of significantly earlier death. So we look hard for opportunities to improve this: we focus on people with long-term conditions with significant mental health comorbidities. If we didn't act on helping the whole person to stay well physically and mentally, we’d be missing the point.

We need people to really challenge their own thinking, whichever bit of the sector they work in – policy, service or practice – about people as people and in their entirety. They’re not just users of one service or bits of a system, they’re not just a diagnosis.

This is about thinking about people in the totality of their lives: not just biologically, but in their social setting – and about the factors that contribute to their lives and physical and mental wellbeing and health.

Systems thinking

Thinking around the whole person in this way takes you to different places and makes you think differently about what might be important to people. In particular, it should force you to think much more in a systems way, focused on individuals in systems. 

In the past, public health has been a bit of a minority sport: the domain of public health doctors and nurses and health visitors. In 2017, everyone working in health and care has a public health role to play.

   

One of the risks about all the current work on accountable care systems or organisations is that we get so sucked in to governance and financial flows and organisational form, rather than really thinking about what makes the real difference to Mrs Smith, who has different needs to Mrs Jones.

We have another example of thinking and working differently where we’ve co-located all our community staff in Chorley – a district council area in Lancashire – with the district council staff, who deal with housing, disabled facilities, grants and environmental health. If we focus on vulnerable communities and want to work preventatively, then we need to be much more upstream in their lives rather than waiting, as is traditionally the case, until the time vulnerable people start to urgently need social services.

We asked ourselves how our services can be really different from those people’s perspectives. 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.

Another consideration is that while the wider determinants of health and early intervention and self-care all matter, there is a big public health secondary prevention agenda, which should involve the acute provision end of our world.

Community prevention

And there are very good examples of work looking across our STP in terms of stroke. A huge risk factor for stroke is under-diagnosis of atrial fibrillation. We’ve done some work, with our academic health science network’s support, using simple hand-held technology that pretty well anyone can use to diagnose cardiac arrhythmia, and trigger a prompt to the person to see their GP to get treatment for their irregular heartbeat.

If this helps primary care to detect and treat atrial fibrillation early, that’s potentially got a really big impact. People think stroke care is all about where your hyper-acute unit is co-located and having A&Es set up for high-tech intervention, but this kind of community prevention – investing more in picking up atrial fibrillation in the general population and getting primary care to treat it well – is likely to save more lives than worrying about where to locate the hyper-acute stroke unit.

I’m not arguing that high-tech medicine doesn't matter, but it’s a question of the balance of where we put our energies if we’re serious about changing our population’s future.

In the past, public health has been a bit of a minority sport: the domain of public health doctors and nurses and health visitors. In 2017, everyone working in health and care has a public health role to play. If we consistently start out from a public health perspective, we’ll probably make some different investment and policy-making decisions, and think differently about staff skills and competencies. And that will benefit us all in the long run.