Transcript Four Es: A public health perspective on moving to local

Working with the new Public Health
Arrangements
Chartered Society of Physiotherapy
18th September
Jim McManus
Director of Public Health
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“the science and art of preventing disease,
prolonging life and promoting, protecting
and improving health through the organised
efforts of society” Sir Donald Acheson, 1988
“Decency, Freedom from infection, Labour,
Dignity”
Sir Alfred Hill, President of the Society of
Medical Officers of Health, 1866-1903
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1st – Poverty, Living Conditions (Up to 1900)
◦ Improvement in incomes, reduction in deaths
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2nd –Communicable Diseases (Up to 1950s)
◦ Now on average 6-11% of deaths in UK. Was 85% of
deaths before 1900
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3rd – Non-Communicable Diseases (Today)
◦ Over 60% of deaths due to lifestyle and behaviour
◦ Poorest fare worst (smoking, diabetes, heart
disease)
Health
Behaviours 30%
Socioeconomic
Factors 40%
Smoking 10%
Education 10%
Diet/Exercise 10%
Employment
10%
Alcohol use 5%
Poor sexual health
5%
Income 10%
Clinical Care
20%
Access to care
10%
Quality of
care 10%
Built
Environment
10%
Environmental
Quality 5%
Built
Environment
5%
Family/Social
Support 5%
Community
Safety 5%
Source: Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute.
Used in US to rank counties by health status
While this is from a US context it does have significant resonance with UK Evidence, though I would
want to increase the contribution of housing to health outcomes from a UK perspective.
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Chadwick
Aneurin Bevan
Black Report 1982 (UK)
Ottawa Charter 1986 (World)
Health of the Nation 1984 (England & Wales)
Our Healthier Nation 1998 (England & Wales)
Healthier Wales 2000 (Wales)
Choosing Health 2005 (England)
WHO Commission on Social Determinants 2009
Marmot Review of Health Inequalities 2010
Science
Art
Outcomes
Then & Now
Then &
Now
Smoking
Heart Disease
Sanitation
Health
Improvement
Now
Care which keeps
People healthy and
independent
Health
Protection
Service Quality
Housing
Now
Environment
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As the factors and services behind health in
the UK improved, key public health
contributions became mainstream parts of
the local government day job (sanitation,
housing, school meals)
How do we work with the new day job?
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Specialist public health is multidisciplinary
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Most public health coming to LAs in 2013 / 2015
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Some going to NHS Commissioning Board
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National Agency Public Health England
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Health and Wellbeing Boards
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Statute and guidance
Boards of commissioners
Provider and district engagement left open
Roadmap of JSNA to Commissioning Plans
Unlikely CSP or Physios will be given
membership per se but each Board is
different
Constitutional anomaly – officers as members
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Influence DPH and lead elected Members
Work with CCGs directly
Where can you add value?
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Prevention
Long term conditions
Working age adults
Frail elderly
Expect JSNA and Strategy and Commissioning
Plans to reflect your contribution rather than
a seat on the Board
Provider Fora?
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Specialist
High level of training in
a technical public health
function, largely defined
by legislation or policy
in West
Application of technical
and specialist skills to
the three domains of
public health
Health
Improvement
Health
Protection
Service Quality
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Policy Mechanisms
◦ Marmot, JSNA, Health and Wellbeing Board
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Commissioning Mechanisms
◦ Applying specialist skills to commissioning
◦ Invest in the right things
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Delivery Mechanisms
◦ Mainstream public health – everyone provider or
citizens understands their contribution
CVD
Events
Primary
Care
Self Care
Vitamin D and TB
Rickets
Vitamin
Supplements
CVD Events
Air Pollution
Acute Bronchitis Admissions
Respiratory
Mental Health
Decent
Homes
overcrowding
educational attainment
Education
Life Expectancy
Planning
Healthier space use
Jobs
Changing culture of activity
Mental Health
0
1
Life Expectancy
5
10
Years
15
20
Needs Assessments
Equity Auditing
Evidence of Effectiveness
Health Impact Assessment
Triangle of critical influence
– where public health
should be most visible
Check whether plans equate
To evidence and need and
Test for equity / inequity
Plan
Model whether need will
Be met by proposed
volume
Community
Engagement
Review Need for
Service and
Effectiveness of
existing services
Contract/Deliv
er
Monitor/
Evaluate
Public Health Input into the
Commissioning Cycle. Can be
throughout or can be on specific areas
playing to the PH strengths
Support and advise on
Evaluation and conduct
Bits of it if enough resource
Support in establishing
meaningful indicators of
delivery and outcome
System
Failure
Primary
Prevention
Secondary
Prevention
Tertiary
Prevention
The shift to prevention
Primary
Prevention
Secondary
Prevention
Tertiary
Prevention
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Understanding key drivers of health and
wellbeing, and interventions to improve
population health
Structured ways of doing needs analysis
Decision analysis and helping with
economic analyses of policy to help
setting outcomes
Supporting the understanding of
complex variables and their interaction in
policy and decision making
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Resource allocation for policy and interventions
Understanding targeting action and interventions
to bring most benefit
Understanding and manage the conflicts between
population and individual concerns (equity)
Finding, assessing and applying evidence
Supporting effective commissioning using 1,2
and 3 above
Evaluation of commissioning against desired
outcomes
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Commission for the whole person’s lived
experience (housing, volunteering, leisure,
transport,)
See Potentials not Problems, assets as well as
needs
Transformation of current system through staged
redesign to preventive and early intervention
Subsidiarity and Access
Co-production
Behavioural Sciences
Pathwayed
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Making this lot work
Burden of avoidable ill-health
Demographic and growing demands
Benefits to citizens
Preventing service use
Moves people into self-care
We cannot afford the coming time bomb
Justice and fairness are public health values
https://www.wp.dh.gov.uk/healthandcare/files/2012/06/system-graphic.jpg