The public health team has contributed to a five year integration strategy bringing together a wide range of adult health and care services. An important public health role is to identify high-risk population groups whose needs impact significantly on both health and social care services, thereby revealing a mutual interest for both NHS and county council to develop integrated improvement and prevention services.
A combined directorate of adult services and health puts the director (who is also the DPH) in a strong position to ensure a public health input to integration. The public health team has contributed with population needs analysis, definitions of outcomes and service specifications to a five year integration strategy bringing together a wide range of adult health and care services. An important public health role is to identify high-risk population groups whose needs impact significantly on both health and social care services, thereby revealing a mutual interest for both NHS and county council to develop integrated improvement and prevention services. Data analysis by public health has enabled integrated commissioning for ages nought to 19 to specify how services are to be delivered as well as defining outcomes.
How public health became involved
The joint director of adult social care and health (DASH) role has provided a way in to close involvement with the full range of council services. Among other duties, the post is directly responsible for managing the integrated commissioning unit which puts the post holder in an excellent position to bring a public health approach to integration, including the BCF proposals for the county.
Public health contribution to integration
Strategic leadership
The DASH is a member of the council’s strategic leadership team. The public health team acts as a bridge with the local NHS, brokering mutual understanding between the council, the CCG and providers of NHS services. Public health staff believe that ‘the relationships are more important than the structures’ in building trust and joint working practices between the council and the NHS.
The Well Connected initiative is the integrated care initiative led by the HWB in Worcestershire. It aims to achieve a progressive integrated health and care system ranging from acute services to prevention and early intervention programmes across the county and across the lifecourse. The DASH is a member of the leadership group which has developed the five year strategy for implementing Well Connected and the various work strands that sit under it.
What others say – Frances Martin, Integrated Care Director:
The combined role of DASH and DPH is a very powerful one. The public health aspect of the role gives us a long-term look at the population’s needs, the ability to access longitudinal studies, a scientific, evidencebased approach and academic rigour. Richard Harling (DASH) has given strategic leadership to our work on integration, including the BCF which we have used as an enabler, not as an end in itself.
A significant number of the services that we are bringing together through our integration programme are commissioned by public health. This brings public health staff into our joint planning and decision making in addition to the strategic role of the senior public health team. It was a big risk when public health moved over from the NHS to the council, but we still succeed in talking closely and in making joint decisions. In our integration planning, the public health team acts as a guardian and champion of a broad approach to health and wellbeing.
Evidence, outcomes and evaluation
The public health team plays a crucial role in developing plans for integration when evidence of effective interventions, population analysis and intelligence, cost effectiveness and appropriately-designed outcomes are required. The DPH sees the role of public health as providing information that enables the NHS and the local authority to decide whether bringing services and budgets together will produce improved outcomes and be the most effective use of their combined resources. Following a decision to integrate services, public health can contribute to the development of a commissioning procedure that reflects the interests of both sectors.
South Worcestershire Integrated Recovery programme
An example of this is the public health contribution to the Worcestershire older people’s recovery service. This is a series of commissioning projects that together will achieve greater integration of health and social care for older people who need support to regain their independence following a crisis at home or admission to hospital. As elsewhere, the local NHS has an interest in effective and timely hospital discharge and reduced readmissions; the local authority has an interest in reducing admissions to social care.
The vision for the programme is to achieve:
- a service in which people and their families will feel safe, supported, and be at the centre of planning for recovery in their own homes
- seamless, person-centred health and social care recovery pathway for frail older people in South Worcestershire, delivered by providers who work across organisational boundaries
- a service that has a single point of access, which makes it easier for people and their carers, as well as professionals to navigate.
The public health team is represented on the project board and has contributed by assisting in the definition of outcomes, analysing the characteristics and needs of the relevant population, modelling care pathways and developing a service specification which draws on relevant evidence.
The programme has considered options for the number of community hospital and social care rehabilitation beds, completed a tender for a nursing and rehabilitation facility, and is progressively integrating community based NHS and social care rehabilitation services.
Social impact bond to tackle loneliness and isolation
Worcestershire County Council and Worcestershire’s three CCGs have awarded the country’s first social impact bond to help 3,000 older people overcome loneliness in the county. The Reconnections Social Impact Bond service is delivered by Age UK Herefordshire and Worcestershire, together with local voluntary and community organisations.
The county council is contributing £540,000 and the CCGs £480,000 collectively towards the payment-by-results programme based on delivery of agreed outcomes.
The public health team was involved in the analysis of evidence about the life changes, such as retirement, death of a partner and loss of mobility which can lead to a deterioration in emotional wellbeing and contribute to someone needing increased levels of health and social care support. They were also involved in establishing an output based currency for the service based on a reduction in social isolation on a measurable scale. This is based on evidence linking improvements on this scale to better outcomes, including a reduction in hospital admissions and entrants to long-term care.
Developing preventative approaches
- A JHWS for 2016 to 2019 is currently in development, led by the public health team. The strategy details five approaches to prevention: creating a health promoting environment
- encouraging and enabling people to take responsibility for themselves, their families and their communities
- providing clear information and advice
- commissioning prevention services based on evidence of effectiveness
- gate-keeping services based on need.
Prevention work with older people
The public health team has been able to analyse the prevalence and distribution within the population of the four key risk factors for older people of entering long term care. These are:
- stroke
- falls
- dementia
- urinary tract infections.
Analysis by the public health team has revealed that these factors are common to both the NHS and social care and that it is therefore in the interests of each service to develop a joint prevention strategy that would improve and extend the quality of life for older people. The analysis has also shown how these are clustered within the county.
Public health specialists have carried out some risk stratification which has revealed that two per cent of patients/service users account for 37 per cent of the budget. The vision of the HWB is to focus prevention work on this high risk group.
Prevention work with young people
The prevention policy for children and young people aged nought to 19 has been developed in anticipation of the transfer of responsibility for public health of nought to fives. It is based on the JHWS, the Children and Young People Plan and the council’s All Age Prevention Policy.
Following an early help needs assessment of nought to 19s, joint social care and public health have produced recommendations for a fully integrated prevention/early help system and workforce across all agencies. The objective is to consider the needs of children as part of a coherent joined-up approach to the needs and contribution of the whole family group.
The work is designed to create a culture that is asset rather than deficit-focused, stop duplication between the support families are receiving from different agencies, ensure that interventions are evidence based, and enable resources and skills to be shared to fill the gaps and coordinate support better.
The workforce will be developed to work in an integrated way to support a ‘whole family’ approach and enable parenting. The integrated prevention service will bring together, with a budget of approximately £9.5 million:
- nought to five public health services (health visiting and family nurse partnership)
- five to 19 public health services (school nursing)
- aspects of the current nought to 19 early help services.
0-19 Prevention model
Integrated pathways are being developed, with the involvement of public health, in the following areas:
- parent infant attachment • maternal mental health
- breastfeeding and weaning
- communication and language
- social and emotional
- drugs and alcohol
- domestic abuse
- young parents
- nutrition and physical activity.
What others say – Simon White, Director of Children’s Services:
Public health has brought us access to evidence-based interventions. We are now in a much better position to specify how we want services delivered rather than just outlining the outcomes. We already had integrated commissioning for children’s services, but we are now re-commissioning the school nurse and health visitors services with children’s centres. Public health is represented on the steering group for this work. Their number crunching and use of data to stratify the population has brought an extra dimension to the way we analyse need. We now have a fantastic opportunity to recruit the most disadvantaged families into wider integrated services.
Contact
Dr Richard Harling
Director of Adult Services and Health
Email: [email protected]