London Borough of Southwark: a Health in All Policies approach

Southwark Council is transforming the role of its public health directorate, ensuring that it is more visible, engaged with and accessible to all council departments.

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Key among this has been the adoption of a Health in All Policies (HiAP) approach by the public health directorate, which aims to maximise how health and wellbeing interventions and outcomes are integrated across the council. 

Through novel partnerships with colleagues in Southwark’s culture, leisure, environment, planning, regeneration, human resources, and housing departments, the public health team now has a range of collaborative initiatives, jointly developed, monitored and delivered. And the benefits of this approach are already being observed: collaboration with public health has had a significant impact on the development of the proposals in the New Southwark Plan, currently in consultation.

Social regeneration, which prioritises wellbeing as primary outcome of all local regeneration efforts, is now included as a central theme in the plan. A free ‘Swim and Gym’ programme, a collaboration with the council’s leisure team, has had notable success in registering nearly a quarter of the borough’s residents and attracting 50 per cent of attendances by BME residents and 50 per cent by women. An award-winning online sexual health service has been developed, serving thousands, transforming service delivery, increasing clinic capacity, and contributing to better HIV/STI control. Healthy free school meals are now provided for all primary school children and the public health team has worked with colleagues across the council to identify significant under-claiming of the Government’s free school meals and the pupil premium.

Southwark’s public health directorate continues to learn and adapt as staff implement new HiAP programmes. Emerging keys to success include: visible political and chief officer leadership, cross council understanding and support for health and wellbeing, identifying tangible collaboration between departments, small investments in staff time and resource where needed, identifying unexpected opportunities for collaboration, demonstrating measurable progress, and celebrating success.

Background

The inner London Borough of Southwark has a population of 309,000, projected to rise to 332,000 by 2020. Forty one per cent of the population are from an ethnic minority group, as compared with 13.2 per cent for England as a whole. Southwark is one of the 20 per cent most deprived local authority areas in England and about 28 per cent of children live in low income families. Life expectancy for men is lower and for women higher than the England average. The life expectancy gap between men in the most deprived and in the least deprived areas of Southwark is 9.6 years and 5.6 years between women in the most and least deprived areas

. In Year 6, 26.7 per cent of children are classified as obese, worse than the average for England of 19.8 per cent. Levels of GCSE attainment and breastfeeding initiation are better than the England average. Among adults, the rate of smoking-related deaths is worse than the average for England, while estimated levels of adult excess weight are better than the England average.

The incidence of tuberculosis is worse than the England average and the incidence of new sexually transmitted infections (STI) is very significantly worse at 2,798.8 per 100,000 of the population than the England incidence of 795 per 100,000.

Local priorities in Southwark include the wider social and economic determinants of health; giving children and young people the best start in life; reducing the risks for poorer health; improving the detection and management of people with long term conditions; supporting the most vulnerable people; and strengthening local approaches to integration so that seamless services are accessible, effective and efficient.

Organisation

Until June 2016, there was a joint Lambeth and Southwark public health team structured thematically around traditional public health lines. While obvious to those with a health background, the traditional organisational structure made it somewhat difficult for council departments outside public health to know which parts of the organisation to relate to.

In June 2016, the Lambeth and Southwark public health team separated into two borough specific organisations, and this provided an opportunity for the creation of a new Southwark public health directorate, restructured into cohesive groupings that allowed an easier ‘read across’ between key council and health priorities. Within the directorate, there is now a healthcare section that includes adult social care, and a section with a remit around ‘healthy spaces’, including housing, planning, regeneration, parks and leisure. A third section is focused around children, young people and safeguarding issues.

There are also clearly designated ‘link people’ in the public health team with different council functions, so that council colleagues across all departments know who to liaise with on health issues. With the arrival of Southwark’s new Director of Health and Wellbeing in spring 2017, the public health team developed a new FY17/18 business plan, which articulated an overarching narrative of public health’s role and functions in the council; clarified the directorate’s five strategic priority areas; identified core values underpinning the directorate’s work; and strengthened the link between the directorate and the council’s strategic priorities. ‘Making health everyone’s business’ is now the directorate’s strategic priority related to HiAP, which has resulted in a significant enhancement in the prioritisation, resourcing and accountability for this work.

Today, Southwark’s public health directorate has made a commitment to spending between 10 to 20 per cent of staff’s time working across established council functions, with 60 to 70 per cent being spent on more traditional public health work such as school nursing and immunisation, which also links in with the council’s corporate objectives. The expectation that all public health staff should be collaborating and contributing across the council is now well established, and so too is the openness for other departments to reach out to and call upon the public health team’s core competencies and functions.

Health and wellbeing initiatives

After five years in local government, Southwark can point to a number of examples of really transformative change where the public health team has developed its understanding of the opportunities provided by being part of the council to address the wider determinants of health. At a strategic level, embedding public health within the council has worked to the benefit of both. For example, there has been a shift in perception of the role of town planning as

‘spatial planning’, addressing issues like social cohesion, rather than simply ‘land use’. Being in the council has enabled public health to contribute to the Southwark Plan at a strategic level, but also at a specific level, for example by using public health specialists’ knowledge of ‘what works’ to target groups of people not participating in leisure services (see more detail below). The team is now taking full advantage of its place within local government, contributing to a wide range of local authority functions. Innovative partnerships have been forged, new approaches to prevention developed and a HiAP approach has been promoted across the council.

Social regeneration: embedding health into planning

Southwark has established a strong strategic working relationship between planning and public health. The council has taken a HiAP approach with committed leadership from the director of health and wellbeing, the director of planning and colleagues specifically identified within the public health team and in planning, with lead roles to work on optimising the synergies between planning, regeneration and health. Wellbeing (including health) is now a key central driver in the New Southwark Plan (currently in consultation). There are strategic policies to maintain and improve the health and wellbeing of residents, encouraging healthy lives by tackling the root causes of ill health and inequalities in society.

A strategic policy for social regeneration is also being proposed that places people at the heart of regeneration to ensure that new developments encourage healthy behaviours for all. To ensure that opportunities for health improvement are realised in all aspects of planning, the New Southwark Plan for land and spatial use places a high priority on active travel and air quality; sets high standards for the protection of and access to green space and new housing; and emphasises the development and sustainability of a strong local economy with good access to employment and training opportunities. It is explicitly recognised that all of these opportunities will impact positively on the wider determinants of health. Specific development management policies underpin the strategic policies, such as policies on hot food takeaways, betting shops, pay day loans and active design. Southwark intends to push the boundaries and be an exemplar of how planning and public health can work together by co-producing a plan for a Healthy Old Kent Road – one of the next major regeneration areas in Southwark and a designated opportunity area by the London Mayor, where up to 20,000 new homes and an extension of the Bakerloo Line are expected.

Southwark Free Swim and Gym programme

Southwark has pioneered a new approach to help residents lead healthier, more active lives by providing free access to its leisure centres at weekends. Southwark borough residents are now able to use the swim and gym facilities for free in six of the borough’s leisure centres, operated by Everyone Active in partnership with Southwark Council. Registration is now open for Free Swim and Gym. The offer is available anytime on Friday (subject to programmes and timetables); Saturday and Sunday afternoons from 2pm to close. Over 60s can take part in any ‘silver’ sessions for free, and disabled residents will Public health transformation five years on 59

be able to use all leisure centres for free, seven days a week.

Over the last decade the council has put almost £50 million worth of investment into leisure facilities in the borough and it is continuing to prove its commitment to getting Southwark active with this scheme. The council, with the support of the public health team, recognises that the best way to be proactive about health and wellbeing is through prevention, by making it easier for people to make healthier choices and to achieve a more active lifestyle.

Today, following introduction of the programme, 23 per cent of residents (71,000) can now swim or use the gym for free. It is a resounding success with 50 per cent of attendances made by BME residents and also 50 per cent of all attendances by women, bucking usual participation rates.

Transforming sexual health in South London

Southwark has some of the highest rates of sexual ill health in the country, a reflection of a number of unique demographic, behavioural, service provision and socio-economic characteristics. Poor sexual and reproductive health can have long term consequences, and testing and treating low-risk individuals in traditional sexual health clinics can be costly. Southwark Public Health partnered with Lambeth, the Design Council, local sexual health services, and Guys and St Thomas’ Charity, to develop an innovative new online sexual health service, SH:24, to improve patient experience and encourage self-management, reduce costs over time, reduce waiting times, and improve access to sexual health services.

The service has been fully operational since April 2016. Users can order an STI test kit online, take samples themselves at home, return their samples and get results by text message. Users who do not need treatment never have to visit a clinic, freeing up clinic time to treat those who do.

This innovation has provided a service to thousands of residents in Lambeth and Southwark, transformed service delivery in local sexual health clinics, and won a number of awards. Online services of this scale are now being developed in various parts of the country (for example, pan-London sexual health e-service). The development, delivery and lessons learned from SH:24 have helped to shape the sexual health landscape of the future.

Universal free healthy school meals for primary school children

Southwark has placed public health and tackling inequalities central to many major children’s programmes. One of these programmes is the provision of universal free healthy school meals to all primary school children. This flagship programme means that all primary aged pupils attending schools in the borough get at least one healthy nutritious meal a day, puts money back into the pockets of parents on lower incomes and provides an opportunity to make healthy eating central to the school.

However, when the initiative was introduced, it was noticed that fewer parents were now self-registering their children as eligible for the Government’s free school meals. This means that by making school meals universally free, a key income stream was reduced for the council and also for schools who were missing out through a lower pupil premium. Together with education and benefits and revenue colleagues, the public health team led a health intelligence approach to investigating this thorny problem. By applying simple principles such as observed to expected ratios – commonly used in estimating under-detection of health conditions – a joint exercise has identified up to approximately £350,000 that the council is under-claiming for on behalf of pupils who are already entitled to the Government free school meals because they are in receipt of benefits. The council has now started the process of claiming some of this income stream.

Outcomes

As a relatively newly created directorate with new senior leadership, the past year has been one of significant change for public health within Southwark Council. In addition to HiAP, the team is now progressing other strategic priorities including social regeneration, improving health outcomes, promoting better health and care for all, and workforce development. Nevertheless, the team can point to a number of key accomplishments which augur well for pursuing the HiAP approach in the future. These include:

  • Work across council to develop Southwark’s strategic approach on social regeneration with the publication of a draft Framework on Social Regeneration approved by cabinet in autumn 2017.
  • Cross-council collaboration on the Southwark Conversation, a comprehensive engagement with those who live, work, play and pray in the borough on the borough’s future, how change is affecting them and what they’d like to see more of or less of as a result.
  • Work with council emergency preparedness and response colleagues in the response to the June 2017 London Bridge terror attack, where public health took a lead role in coordinating the mental health and wellbeing response and coordination across health partners. This novel approach led to significant learning for future responses and informed the revision of pan-London and national Emergency Preparedness, Resilience and Response policies.
  • Integration of health and wellbeing as a primary outcome and objective in the New Southwark Plan laying the foundation for the council to fundamentally reshape how it negotiates with developers in major regeneration programmes.
  • Collaborating with colleagues in leisure services to expand population coverage of engagement in physical activity through Free Swim and Gym programmes, linking this to the NHS Health Check and exercise on referral programmes. 
  • Work with Southwark’s libraries to maximise opportunities to integrate health campaigns, promote wellbeing and social cohesion. 
  • Collaboration with human resources to pilot novel approaches to scaling up flu vaccination for all council staff and partnering to develop new, evidence based programmes for mental health and wellbeing and smoking cessation.
  • Collaboration with culture colleagues in Southwark’s bid to be London Borough of Culture, ensuring health and wellbeing opportunities were maximised and the link between the arts, health and wellbeing are actively promoted. 
  • Collaboration with education colleagues on scaling up Southwark’s Healthy Schools Programme with plans to take a more integrated approach to school nursing and health promotion in the future.

Future plans and challenges

A health in all polices approach and strategic priority is justified and appropriate and is already yielding benefits, but there is more that can be achieved. As the directorate begins its business planning for the financial year 2018/19, it will be more deliberate in reaching out to, and capturing collaborations with other departments across the council.

With the upcoming local government elections there will be new priorities, which the directorate will need to support. However, given the strong commitment to ensuring wellbeing is at the heart of everything that Southwark does, the public health team anticipates that there will be the need for more integration, not less.

The directorate will also need to be mindful of and prepared for the challenges ahead: cross-council collaboration and integration can be resource intensive and support will be needed for staff to work efficiently and in new ways. There are potential opportunities to have staff from other departments work in the public health directorate, to build their competencies and experience. And finally, the directorate will continue to focus on a few things, do them well and demonstrate impact. This will help build confidence in this approach as well as inspire other teams to work in this new way.

At the heart of the council’s work in public health is a recognition that healthcare only accounts for a minority of what generates and sustains health in any community. While work with our NHS colleagues remains paramount, there is much more to be gained by building on the wider assets across the council in a more systematic and strategic way. The HiAP approach provides a structure and methodology for this work and one which Southwark will continue to develop moving forward.

A councillor’s perspective: Councillor Maisie Anderson, Cabinet Member for Public Health and Social Regeneration

The council’s Labour administration is committed to health being embedded in all policies. We see ourselves as a bold authority and are proud that we’ve been able to improve the public health offer in Southwark, and even innovate, despite the challenging budgetary environment. Creating my double brief for social regeneration and public health was a deliberate move to bring together the physical environment with the community’s health and wellbeing.



For example, our public health team has been front and centre in developing plans for a large-scale regeneration project on the Old Kent Road, which will create a whole new part of London. This is still at an early stage, but already there have been many discussions about green space, air quality and health provision. Public health has been instrumental in bringing together the CCG and the planning department as part of this process.



What we are doing now is to look at existing services with a new eye, for example leisure services, to see how we can get even more health benefit from them. We have also developed a new obesity strategy, of which our leisure services will play an active part. The public health team has been brilliant in helping with this and I feel it is really getting in its stride now. I also want to give all credit to the rest of the council for seizing the opportunity and being prepared to work in partnership with public health.

Key messages

  • Public health structures and roles need to be understood, visible and proactive across the council to underpin a Health in All Policies approach.
  • Councils’ planning powers provide significant opportunities for a focus on health in spatial planning, both at
  • a strategic level and in the detail of specific policies.
  • A health intelligence approach can be used to support departments in maximising resources across councils, not just in public health.
  • Southwark’s Health in all Policies programme has already yielded a number of key accomplishments which augur well for continuing this approach in the future.
  • Emerging keys to success include visible political and chief officer leadership, cross council understanding and support for health and well being, identifying tangible collaboration between departments, small investments in staff time and resource where needed, identifying unexpected opportunities for collaboration, demonstrating measurable progress, and celebrating success.

Contact

Professor Kevin Fenton, Director of Health and Wellbeing

Email: [email protected]

Jin Lim, Consultant in Public Health

Email: [email protected]