Dudley’s public health team has been a key partner in supporting the development of Dudley’s multispeciality community provider (MCP) which aims to incentivise preventative approaches to improve health and wellbeing and reduce the need for intensive health and care services. It also has a lead role in supporting the council’s vision to develop new ways of working with communities, based on promoting community resilience rather than traditional, top-down services.
Dudley is a predominantly urban borough in the West Midlands, with five main towns interspersed with smaller towns and urban villages. It has a population of around 313,000 people, and a mix of affluent and disadvantaged areas. Nearly a quarter of the population live in areas that are in the 20 per cent most deprived in England. Life expectancy for men is slightly lower than the average for England; for women, it is the same as the average. It is estimated that between 18.6 and 21.7 percent of adults smoke, and over 170,000 are overweight or obese – higher than the national average. Dudley Council is co-terminous with Dudley CCG, and is part of the Black Country STP.
Organisation
In 2015 Dudley had a new DPH and a series of changes were made in order to integrate public health more effectively within the council and with external partners. At the time, public health was divided into small, topic-based teams and was located away from other council services.
A model of public health was developed which was based on a people (life course) and places approach. The public health team has four consultants (heads of service) responsible for the following areas:
- children and young people’s health and wellbeing
- adults and older people’s health and wellbeing, including health protection
- healthy communities and places
- healthcare public health – the main link with the CCG.
The DPH oversees the health and wellbeing division within the people directorate, and is colocated with other people directorate functions. The DPH oversees three teams: public health; environmental health and trading standards; and libraries and archives. As with other chief officers in Dudley, the DPH is responsible for several cross-cutting corporate functions – for health and wellbeing these are equality and diversity, community development, and emergency planning and resilience.
The DPH works to the cabinet member for health and wellbeing and is a member of the clinical commissioning group (CCG) board. Public health involvement in Dudley’s multispeciality community provider Dudley is a vanguard area for new care models, and in June 2017 started the procurement for an MCP. This is built around general practice, and initially will integrate primary care, community health, mental health and some public health services.
The MCP will manage a single, whole population budget over a contract period of up to 15 years with a contract value of between £3,495 million and £5,445 million. Criteria have been developed for whether other council services (including adult social care) will be phased into the MCP during the course of the contract. The MCP is based on prevention – supporting people to become healthier to reduce demand for hospital care and for high levels of health and social care in the community.of local people in our new health and wellbeing strategy. We have also started to embed health and wellbeing across the council to help address the important determinants of health that are within our control. Our aspiration now is to focus on increasing opportunities for local people to participate in activities to improve their community, their lives and their wellbeing.
Designing the system
The public health team had an active role in designing the system which will enable the shift to prevention to take place, based on incentivising the MCP provider to improve population health outcomes. Elements of the GP Quality and Outcomes Framework, which involves tariffs that reward activity, have already been replaced with an outcomesbased long-term conditions framework which
rewards achieving health outcomes. The outcomes framework for the MCP has four sections:
- population health
- access, continuity and coordination
- empowering people and communities
- systems and staff.
Developing the MCP
A single consortium bid to deliver the MCP, made up of GPs and four local NHS trusts was received. Following evaluation, Dudley CCG, with Dudley Council, has started a dialogue process with the bidder to test out how well its proposals match the vision for an organisation able to deliver integrated services to improve the health and lives of local people.
The MCP will be expected to develop mechanisms to enable population planning, risk-factor monitoring and planning of GP-led preventative services. For example, building on the opportunities provided by all the GP practices using the same IT system, and the existing data sharing agreement between the public health intelligence team and every GP practice in the CCG.
Public health services in the MCP
Some public health services will be delivered or commissioned by the MCP, with funding to be pooled under a Section 75 agreement. These are:
- integrated sexual health treatment pathway
- integrated adult substance misuse service
- integrated adult wellness service
- NHS health checks
- school nursing
- health visiting and family nurse partnership
- integrated young people’s wellness service.
These services are currently commissioned from a range of providers from across the NHS and the voluntary, community and social enterprise sector. At the end of their contract periods they will fall under the remit of the MCP to either re-commission, sub-contract from existing providers, or directly deliver. As a commissioner of the MCP, public health will support this process.
The services fit well with the integrated place and population approach of the MCP, with clusters of services around GP practices. For example, Dudley’s new integrated adult wellness service integrates the five key lifestyle services with a single point of access and an approach built upon empowering people to make the behaviour changes that are most important to them. While this is a universal service, it also has a system in which people who are at high risk of developing poor health – such as people identified through an NHS Health Check – can be referred to the service. The NHS is already a key referrer to the service, and beibeing part of the MCP will enhance this route.
System-wide impact on health and wellbeing
As commissioners, funders and developers of the MCP, public health also anticipates wider benefits from being involved in a large integrated system which has the potential to promote prevention throughout its work. Over time it is envisaged that many opportunities will open up; initial measures include the following:
- Prevention embedded in all pathways – a Specification for Prevention has been developed which describes in detail the prevention approaches GPs and other services should undertake in the MCP.
- Frontline staff trained to Make Every Contact Count (MECC) and able to signpost patients to health and wellbeing services or connect them to community assets.
- Healthy working practices adopted by the MCP to protect and improve the wellbeing of staff.
- Services responsive to the different needs of local communities, vulnerable populations and those facing health inequalities – for example, looked after children, or people with learning disabilities.
The above initiatives are already underway and will be further shaped and developed within the MCP. A key role for public health will be to integrate preventative work within the MCP with the focus on the social determinants of health carried out within the council and other partners.
Public health within the council
The Healthy Council Programme
There are many examples of how improving health and wellbeing has been integrated into council functions, including:
- health and wellbeing supplementary planning guidance
- a workplace health champions programme
- work to address illegal tobacco and alcohol sales, active travel, air quality and fuel poverty.
The Healthy Council Programme formalises the contribution of council directorates to tackling the social, economic, and environmental determinants of health. Dudley Council is facing significant budget reductions, and all parts of the council have developed proposals for delivering efficiency and savings. Public health’s contribution to the savings target will be used to contribute to council services that impact on health but would otherwise be reduced. In the programme, directorates and divisions have signed agreements with public health that set out how the investment will be used, including a work plan and outcomes to be delivered. Public health heads of service are responsible for supporting and overseeing the process.
Examples include:
- Children’s services – fund and develop the role of the family support worker to deliver health and wellbeing priorities, including parenting skills targeted at the most vulnerable families: progress measure: 95 per cent uptake of healthy child programme.
- Housing – fund the winter warmth team/ home improvement service to continue to tackle fuel poverty and social isolation: progress measure – number of clients supported.
- Regeneration business support – contribute to the revenue budget to integrate advice about healthy working practices into employer engagement programmes: progress measure – number of businesses taking on workplace wellbeing charter.
As well as activity related to public health funding, generic requirements that apply to the council as a whole are included within all healthy council agreements. These are the key actions all directorates can take to improve health and wellbeing, and include initiatives such as MECC and workplace wellbeing.
New ways of working with communities
New public health responsibilities and the move towards a focus on longer term outcomes, as well as the financial constraints under which it is operating, have meant that Dudley Council is developing a new relationship with its local communities and partners. The aspiration is to move away from a traditional paternalistic view of public service towards a model that fosters community resilience, engagement, enablement and connectedness. With cross-council responsibility for community development, the DPH has been at the forefront of leading and supporting this approach.
Dudley has a well-established Healthy Communities Volunteer Programme which has achieved ‘Investing in Volunteer’ status. The programme provides opportunities for people to gain skills, knowledge and experience to help them improve their own health and wellbeing, and to help other people improve their health, as volunteers.
In addition to the volunteer programme, public health supports people who live or work in the
borough to become health champions, using their skills to support others to make positive lifestyle change. Health champions are often based in locations such as pharmacies, opticians and libraries and may support particular groups, including young people, older people and new and expectant families.
Dudley also has a well-established and nationally recognised suite of evidence-based
self-management programmes, delivered by volunteers who support people who are living with long-term conditions, and their carers.
Make it Happen is a small pot of funding through which public health supports small projects aimed at promoting self-help and mutual support. Decisions about funding happen at sociable events where people pitch their ideas to other applicants in a supportive, co-creating environment.
The ideas are then discussed and voted on by participants who decide which project should get the most funding. As well as money, projects leave the events with skills and resources offered from other people and projects. The winner of the most recent event was Action Art, a project from parent carers sharing skills in arts and crafts to reduce isolation and improve mental health.
Future plans and challenges
The MCP presents huge opportunities for improving health and wellbeing, but as a new and untried system it also involves risk. As the MCP moves closer to implementation in April 2019, public health will continue to contribute to planning to ensure that it gets off to the best start. Once underway, the role will be to support the progress of the MCP, address any initial problems, and to influence
the system to maximise opportunities for promoting health and wellbeing.
The MCP is also a major building block of Dudley’s accountable care system (ACS), and public health will contribute to the development of governance arrangements across the CCG, MCP and the council to oversee the ACS.
A further challenge will be to ensure that the health and wellbeing work of the MCP is integrated with work by the council and other partners to tackle the social determinants of health. For example, ensuring there is a continuity in health messages through MECC across all settings.
A councillor’s perspective
Public health in local authorities has brought about significant change. Before the transfer, public health was rarely discussed. Now councillors are now much more aware of the importance of health and wellbeing, and health improvement is being taken forward across council directorates. We have had a lot of success with joint working. For example, recently trading standards, with the police, raided three shops and found two selling illegal tobacco and one farming cannabis. In Dudley we are working to establish a new relationship with communities, moving away from a traditional model of service provision, to a shared responsibility for preventing poor health, and for developing active and sustainable communities. Public health is an important part of this.
We have also recently simplified priorities to focus on promoting healthy weight, tackling poverty and reducing loneliness and isolation. Health problems are often intergenerational, and it is particularly important to work with young people and schools to help children to have a healthy start in life so they can influence future generations.
Key messages
- Incentivising the MCP to deliver on prevention is a unique opportunity to maintain investment in preventative services at a time when NHS and local government funding faces continuing pressures.
- Thorough planning which pays attention to detail is required to make such a complex development work effectively. This applies to both systems that underpin the MCP and the relationships that are needed for it to run smoothly. For example, NHS Health Checks have been designed to generate direct referrals to the adult wellness service, but also provides a detailed health profile record for people who are not yet ready to make lifestyle changes. The information can also be analysed to help plan and target prevention services more effectively in future.
Contact
Deborah Harkins, Chief Officer Health and Wellbeing (Director of Public Health)
Email: [email protected]
Documents and links
Available from the contact above.
- Integrated adult wellbeing service: specification
- Make it happen community funding – evaluation report
- Public Health Grant: embedding health and wellbeing outcomes throughout council services – the Healthy Council Programme
- MCP procurement documents