28th February 2011 Capita Conference Mc Manus

A New Approach to Public HealthMonday 28th February 2011

Jim McManusJoint Director of Public Health, Birmingham City Council

The Local Authority as Strategic Driver on Health and Wellbeing Boards

Issues

• Strategic Practical and statutory issues for getting public

health into local government – role of DPH

• Understanding local authorities as strategic health partner

• Taking forward joint working with HWBB

• New governance focus for public health

• How will boards be monitored for compliance and be

accountable

Networks not Deficits

• Much wider than the DPH although the DPH role is important

• AND

• The DPH is not bringing health into local government for the first time. Understanding the Polity and politics of this will be crucial

Health Improvement

Health Protection

Service Quality andImprovement

Commissioning priorities, Evidence, making it work, supporting implementation

Ensuring we have the right frameworks in place

Long term, medium term, short term, matrix

Domains of Public Health

Local Government Public Health

IS• A portfolio of activities

• part of a Matrix

• About doing our Core Business in a Healthy Way as well as these new functions

• About complex and strategic working

• About partnership

• About People, and Places, and Exposures

IS NOT

• A replacement for the NHS or good primary care

• Going to improve life expectancy tomorrow

• Lacking in Evidence• Lacking in Implementation• Always Short Term• About shifting all energy

from NHS to Local Authority services

The Vision as I see it

1. Public health at heart of strategic role for LA

2. JSNA – Outcomes, Commissioning and system wide

3. Opportunities for health improvement short, medium and long term

4. The big prize is not the 20% ringfenced budget

1. In the LA, but not focused solely on the LA

2. Get this right for primary care

3. Take to heart the NAO criticisms

The new public health duties

Coming into Las where….• Money has been removed

and services cut. Whole landscape changed

• There’s a ring-fenced budget and everybody wants some of it

• Public health is not a known or necessarily trusted quantity (just how joint is your joint DPH?)

Implications

• DsPH need a lot of preparation

• Identify value and priorities with clear business case linked to core authority priorities

• Identify what you can add to LA core agenda and what outcomes

• Identify other outcomes too

So what does it mean?

The Core Business

• Doing the core business of the Local Authority in a way which– improves the health of the

population– Reduces inequalities in

health caused or acted on by social determinants

The Ringfenced Budget

• Opportunities but need to be seen in the context of the core business

• The DPH is “MORETHAN” the 20% of the 4%

• The DPH is not EVERYTHING in LA terms though

Transition

Models

• Directorate• Corporate• Commissioned• Outsourced• Matrix

Issues

• Balance between corporate role and PH core role

• Person-organisation fit• The Outcomes

frameworks do NOT align

The Accountability Challenge for the DPH

• Either everyone wants you or you wonder which Lion will bite you first…

• At least some of that is down to the System, and some of it is down to the DPH

• Which type of DPH will you be – control, enable, make, share or buy?

You might have got it wrong if…

Elected Members

HWBB

SoS / CMO / DH / A-Z

LA CMT

NPHS

Staff Team ?

GP Consortia

PROVIDERS

DPH

Vision, but what about outcomes?

Health minded andhealth-seeking peopleBoth workers and citizens

(Self care, and self management reduces reliance on services)

SHAREDOUTCOMES

JSNA

Shared DataSets

Commissioning Priorities

H & WB Strategy

High Quality Strategy

SHAREDOUTCOMES

Governance, Leadership and Organisation

High Quality PartnershipStructure

HWBB Others

CitizenEngagement & Co-Production

Delivery Areas

ProvideIntegratedServices

Deliver shared outcomes

CitizenEngagement & Co-Production

Adapted with thanks from Newcastle Model

Issues for us to work out

System• Clarity of governance• Boundaries• Deliverables• Outcomes Framework• Early Wins with HWBB• Systems Working, Matrix

Working• Pressure Valves• Complexity

Person• Capacity v DASS/DCS• Partnership Oriented• Strengths• Support• Boundaries• Working with elected members• Working with GPs• Resilience• The myth of independence• Political Restriction

An OD Programme for the Organisation and the DPH

Some Golden Rules

• Position – Council Plan, Directorate Plans, HI Plan

• A good time to refresh outcomes, strategies and delivery – keep momentum and morale

• Phased Positions

• Formation/Learning/Preparation

– Members– GPs– DsPH– LA Directors – PH Staff

Birmingham Policy Framework

• Council’s Big Three includes Behaviour Change by Services AND Citizens

• The Council Plan – Be Healthy

• The Prevention Framework and Prevention Strategy for Birmingham

• The Public Health Strategy 2011

• Transition Programme but day job

Models for new services

• Provide

• Outsource

• Commission

• Matrix

• Network

• Mixed Economy

• Stimulate Social Enterprise

Some Must dos

• Ensure a robust JSNA

• Ensure HWBB have outcomes

• Support effective commissioning at GP consortium and LA level

• Monitor outcomes

• Control big risks – Health protection, contraception

Context

• Birmingham’s support for the White Paper

• Desire to do things differently

• View of members and GPs that public health isn’t working optimally

• PH refreshing and reshaping its vision

Some History• Public Health Acts 1836 and 36 subsequently• Public Health into NHS in 1974• LA Public Health Movement since• Environmental Health• Promotion of Health 1984 Act• Range of Public Health Functions endured in LA:

– Communicable disease– Social care– Housing– Waste disposal, sewage, waste collection

• Marmott !

The Opportunities

• System wide outcomes

• Wider networks and systems approaches

• Interface between GPs and Social care to save both sides of the system money

• Behavioural solutions to thorny and expensive problems

Our Burdens of Disease

Primary Secondary Tertiary

Role for corporate and roles for core here

The Challenge

• We are doing tertiary prevention first because of where we are epidemiologically

• Understand which levers pull short, medium and long term

Short Term – primary careEXPOSURESLIFESTYLE

Medium to Long Term – LA and other playersEXPOSURES. PLACES. LIVES

Time

So what is the Birmingham approach since 2008/9?

• Policy Commitment– The Council Plan

• An assessment of work and priorities across the council

• Each service area playing its part

• Corporate areas playing their part

• Scrutiny of Delivery

Each Service Area Playing its Part

• Regulatory services – workplace health and also nutrition through food outlets serving food to people in low paid/deprived areas (the healthy food sales awards)and work on young people and tobacco/alcohol

• Housing and Health• Adult Social Care and Health including our strong work on

prevention and integration between health and social care• Childrens’ JSNA and helping to reshape commissioning and the

work they are doing on emotional development• Worklessness and health, work just starting• The Core Strategy including clear commitments on health

Corporate Area Playing its Part

• Shaping the Place to reduce risk and exposure – Protective Factors (Good Housing, Good

Education, Good Economy, Decent Public Realm)

– Vulnerability Factors • Be Healthy as a Key Priority (for our CORE

business)• Health of our staff as a key part of a corporate

strategy for our human resources

Birmingham Approach to theWhite Paper

• Shadow HWBB• GP Engagement• Public Health

Strategy• Transitional

Programmes• Shared Leadership

across City• develop HWBB

• Public Engagement• Member and GP

shared learning • Prediction &

Prevention– Falls prevention in

social care– Telecare

Some approaches to a Board

Loose, Strategic, Agree Priorities

Task GroupOther Agency or Partnership (CDRP)

What is more important for the Board? Governance or Agreement?

Outcomes and monitoring them

Health minded andhealth-seeking peopleBoth workers and citizens

(Self care, and self management reduces reliance on services)

SHAREDOUTCOMES

JSNA

Shared DataSets

Commissioning Priorities

H & WB Strategy

High Quality Strategy

SHAREDOUTCOMES

Governance, Leadership and Organisation

High Quality PartnershipStructure

HWBBOthers

CitizenEngagement & Co-Production

Delivery Areas

ProvideIntegratedServices

Deliver shared outcomes

CitizenEngagement & Co-Production

Adapted with thanks from Newcastle Model

Transition Streams

Thank you!A copy of a supporting paper “some thoughts on the DPH transition” should be in your pack

[email protected]

Or

[email protected]

Email – a lesson in joint working???