This case study shows the excellent work that public health in local government is doing to commission for quality and best value across all areas.
Derbyshire County Council has a population of around 771,000 and covers an area of around 1,000 square miles. It is made up of large rural areas with some urban centres, mainly in the form of market towns including Buxton, Matlock and Chesterfield. The health of people in Derbyshire is varied compared with the England average. Life expectancy is lower than the England average and around 15 per cent of children live in low-income families. Population health needs are diverse, and levels of health and wellbeing vary significantly across the county, with some areas of deprivation and health inequalities, particularly in the ex-mining towns of the North East.
Derbyshire Public Health is a department within the Directorate of Adult Care and has taken on the knowledge and intelligence function for adult social care. The department has brought the contract for lifestyle services in house, from an NHS provider, to develop these so they are more integrated and accessible, and focused on engaging with the health needs of communities, particularly those at risk of health inequalities.
Derbyshire Health and Wellbeing Board has recently updated its health and wellbeing priorities, moving from a focus on tackling specific health conditions to addressing the wider determinants of health and supporting the development of healthy neighbourhoods and environments. This is in line with plans by the county council to develop its role as place leader, working in partnership with other organisations and with communities.
Erewash district public health annual report
Working with district and borough councils to develop their potential for promoting health and wellbeing is a priority, and local partnerships, each supported by a locality lead from Public Health, have been established. The partnerships have specific needs-assessments, priorities, outcomes and plans which reflect their local areas. For example, some are more focused on the mental health needs of younger people, others on the needs of carers and older people. The partnerships manage a devolved public health budget to fund and commission activity to meet local and county-wide priorities. Over time, and with a reducing overall budget, the local partnerships have focused more on harnessing assets to work more effectively together. The Director of Public Health (DPH) views himself as DPH of each borough and district as well as for the county as a whole. There is an annual DPH report, presented in infographic style, for each partnership area and for the county – See example for Erewash district.
Public Health also intends to establish relationships with town and parish councils to support the development of health and wellbeing initiatives within neighbourhoods.
Derbyshire works closely with the four CCGs and local NHS providers, which are involved in many of the initiatives described below. Derbyshire’s CCGs have a £95 million deficit and have proposals for cuts, including preventative services in the voluntary, community and Social Enterprise (VCSE) sector, which would have a major impact on health and wellbeing support across Derbyshire.
The DPH for Derbyshire chairs the prevention board which oversees the prevention workstream of Derbyshire STP – Joined up Care Derbyshire. The STP is working with the council to develop a place-based approach to integrated health and care, and public health is keen to accelerate this agenda to put more focus on prevention, as well as tackling NHS pressures.
Challenges and impact of budget reductions
Making major developments in public health services can bring challenges because people and organisations start from different stages and need time to get on board with change. However, once reforms embed, new approaches have proved very successful.
The biggest challenge facing public health is lack of funding, which is limiting the speed at which it can establish new initiatives. Cuts to the public health budget have been compounded by overall council cuts and the poor financial position of partners in the NHS.
Public health puts considerable attention on how to attract new funding and make the best use of current resources. For instance, it worked with Sports Direct, which is based in Derbyshire, on workforce development, and received funding to develop health and wellbeing support for its workforce.
Much has been achieved with limited funding. Many initiatives require funding to kick-start a process, then, once embedded, require coordination and updating which involve lower levels of resources. An example of this is working with districts and boroughs to limit takeaways around schools; the main work was in setting up the system.
Such initiatives are good investments, however initial funding and staff resources to keep things on track is essential and with the reduction in the public health budget new developments cannot be tested or scaled up as quickly as public health would like. If the budget had not been reduced, Derbyshire would move more quickly to:
- align and embed lifestyle services across the borough and district footprint
- invest in children’s mental health and resilience with low level interventions that could reduce demand on Child and Adolescent Mental Health Services
- scale-up work on obesity, active places and mental health.
- Councillor perspective
I have been involved in promoting health and wellbeing for many years, as leader of Erewash Borough Council, as Chair of Derbyshire Local Strategic Partnership and now as Derbyshire Cabinet Member for Health and Communities. Through this time, I have seen how understanding of public health and the importance of prevention has increased greatly. Some wonderful programmes are taking place across the county, often involving third sector organisations delivering in local communities – sports for young people, keeping active for older people and many more.
Partnership working is fundamental to improving health and tackling health inequalities. It is even more essential when money is scare to ensure that there is no overlap or duplication and to identify creative, cost effective ways of working. For example, Derbyshire County Council and Derby City Council HWBs have started to do some work together to look at shared priorities across the Derbyshire STP footprint.
A challenge currently facing Derbyshire is the large budget deficit in the county’s CCGs, leading to proposals from them to reduce funding to the third sector. We will continue to work in partnership to resolve these issues together.
Councillor Carol Hart
Cabinet Member for Health and Communities
Derbyshire County Council
- Health in all policies
All eight districts have signed up to a strategic statement in their Local Plans to bring principles of ‘active by design’ into planning developments. For example, comments from public health on a development of 300 dwellings resulted in additional cycling infrastructure and vehicle charging points. Public health has also completed a health impact assessment on a major development of former industrial site which identified opportunities for connecting open space, linking new children’s play spaces with green infrastructure, good design for community safety and links to healthier food.
Where tackling fast food near schools is a local priority, districts have set limits on the number of takeaways within 400 metres. For example, the borough of Chesterfield has recently refused two applications for takeaways. Public health intends to extend the fast food approach to tackling gambling, which is proving a growing problem in some urban centres.
Derbyshire has designed a local approach to brief health interventions, working with a psychologist and community health provider to develop ‘quality conversations’ – local stakeholders did not think the brand of making every contact count (MECC) was the best way of encouraging people to get involved. Training in brief interventions has taken place with staff in sexual health services, health visitors and general practice and is now moving into social care and other council services.
- Community Wellness approach
Derbyshire is developing an ambitious approach to interconnecting lifestyle services with support for social determinants of health, such as debt advice, and housing. Many of the building blocks of this approach, such as Live Life Better Derbyshire (LLBD) are described below. These services already have good links – for instance LLBD teams have a strong relationship with the Citizens Advice Bureau, but the new model intends to go further and deeper. As a first stage, LLBD community-based teams are being established on a borough/district footprint which align with Joined Up Care Derbyshire ‘places’. The teams will work from ‘wellness hubs’ providing face-to-face, as well as a digital support. This is an evolving model which will develop alongside health and care community integration over the next two years.
An important part of the model is shifting the way that public health works, from a deliverer of health services to an enabler of people taking charge of their own health. This will involve better conversations with communities about what is important to them, and a focus on volunteers, peer support and self-sustaining groups. Derbyshire also operates to the principle of proportionate universalism – all areas receive some health and wellbeing support, but more focus and resources are given to those with greater deprivation and health inequalities.
- Living life better Derbyshire (LLBD)
LLBD is a county-wide advisory service which provides integrated access to a range of health improvement services that are either directly provided by the county council or networked from other providers. Topics include stop-smoking, losing weight, getting active, mental wellbeing, alcohol awareness, falls prevention, healthy housing, healthy workplaces, and debt and money advice.
The LLBD website provides advice and information, and access to individual or group support through an online self-assessment using a wellbeing, assessment and care management tool called OCTIGO. Individuals can self-refer to the service or be referred by a professional. A personalised priorities plan is developed for everyone who completes OCTIGO, based on the topics listed above.
Over time, the vision is for front-line staff and volunteers to be able to signpost people they are in contact with to complete an OCTIGO assessment. Since OCTIGO went live in January 2018, over 2100 people have completed an assessment and consented to onward referral.
- Derbyshire Citizens Advice GP programme
This well-established programme continues to be a national leader in providing citizens advice sessions in GP surgeries and, more recently, children’s centres. It helps reduce health inequalities in rural and deprived areas by helping people with complex financial and social pressures such as redundancy, debt, homelessness, child poverty and domestic abuse. Key outcomes from the public health funded advisory services during 2017-18 include:
- help and advice given to 12,232 individuals or families
- additional income of £16,297,728 secured for individuals and families
- debts of £6,913,434 rescheduled or written-off
- Active Derbyshire
Active Derbyshire is one of the 44 county sports partnerships in England. It receives investment from the county council, including a contribution from public health, and also attracts funding from Sports England and other external funders, bringing additional resources to the area. The county council and the eight districts are Active Derbyshire partners and help shape its strategic approach.
In recent years, as part of the LLBD approach, there has been a shift from a focus on sport to providing a range of offers for people of all ages and abilities to get moving. This includes the mile-a-day in schools, inclusive activity aimed at people with disabilities, physical activity for women and girls, walking for health and a workplace challenge. Active Derbyshire has been very successful at getting people moving. For example, Jog Derbyshire has a network of 6,500 joggers and is further developing its work to attract people with health conditions such as diabetes.
- Healthy workplaces Derbyshire
The Healthy Workplaces Derbyshire team provides tailored support for organisations seeking to reduce worker absence and turnover and create happier and more productive organisations. The type of support provided includes:
engagement with senior management and employee groups to identify shared priorities for improving health and wellbeing
- reviewing policies and procedures
- onsite health MOTs and LLBD support
- mental wellbeing events and training
- training health champions.
- Derbyshire Suicide Prevention Partnership Forum
Derbyshire Public Health leads the multi-agency Suicide Prevention Partnership which includes Derby City Council. A key priority is skilling professionals and volunteers in suicide prevention, and the training programme for primary care staff was shortlisted for the 2018 Health Service Journal awards. There has also been national recognition for the Forum’s work with Network Rail to reduce the number of suicides on Derbyshire’s railways, and for its collaboration with league and non-league football clubs on World Suicide Prevention Day. In September 2018, suicide prevention information was given to an estimated 30,000 fans attending five matches.
- Falls prevention and pathway development
Public health is involved in several initiatives to support the implementation of a new system-wide falls pathway. These include:
- a place-based pilot on identifying older people at risk of falls
- a social marketing project to develop consistent and effective messages about falls across system partners
- the development of resource guides and training.
- Knowledge and intelligence function
Public health has been working to improve data collection, analysis, intelligence and evaluation to support health and care integration and the work of the local partnerships.
- A collaborative project using a market segmentation tool within a health equity audit to identify communities with low take-up of bowel cancer screening and develop targeted interventions within communities delivered by a range of partners.
- Providing analysis capacity to the STP to focus on the drivers of poor health and to move towards measuring outcomes rather than attendance and activity.
- Identifying financial and social return on investment – public health uses this information to provide clarity about what needs to be done to improve health, and to raise awareness of its potential for reducing demand on health and care services. For example, the return on investment in citizens advice services is £15.23 to clients for every £1 invested, and every £1 spent on drug and alcohol treatment saves £4.
Sexual health programme
The council and partners in the NHS and VCSE sector are part-way through a programme to make sexual health support more effective and accessible in a large, predominantly rural, county. Measures include:
- Social marketing project – talking with local communities and at-risk groups, co-creating the Your Sexual Health Matters campaign, and analysing the results.
- Working across the STP to improve access to long-acting reversible contraceptives for women in high-risk groups.
- Greater use of digital technology and online STI testing and information, for example, using YouTube. A pilot for online screening has been extremely successful in terms of uptake and returns rate.
- Services for children and young people
Services for children and young people 0-19 are commissioned from Derbyshire Community Health Services NHS Foundation Trust which provides a programme of prevention and early intervention services covering breastfeeding, 0-5s health visiting and 5-19 school nursing. Performance on achieving children’s reviews is significantly better than the England and East Midlands average. The Trust works very closely with public health and co-hosts a children’s health psychologist based with the team. The Trust is seeking to embed a public health approach across its organisation. The 0-19 service is increasingly being aligned with council children’s services including children’s centres. Developments include intensive home visiting for vulnerable families and breastfeeding peer support.
- Key messages
- It is important for public health to make a short, clear, repeated case for the benefits prevention brings to outcomes for all partners, and to keep reinforcing the message that health and wellbeing is everyone’s business.
- Public health involves identifying and going with ‘the energy’ – taking opportunities where others are working on issues with a health and wellbeing element and capitalising on this. Public health also needs to generate energy and enthusiasm in others.
- In planning pilots and new services, it is important to build-in evaluation from the start, rather than trying to assess impact retrospectively. Some interventions will need exit plans, such as developing peer support and involving volunteers.
- The public health workforce will need to change over time, becoming multi-skilled and able to work in a range of areas, including community development, behaviour change, and helping people tackle wider determinants of health.
Director of Public Health
Derbyshire County Council