Government and NHS integration in Hertfordshire

Hertfordshire based its work on topics jointly agreed as priorities rather than just what the public health team thought was important. Projects with too many barriers or dependencies were put back while higher priority and more deliverable projects were prioritised.

Elected member, partner and public health leadership were all important components and work is divided into workstreams with named leads to enable different timescales, a flexible approach with different tools, leadership approaches and problem-solving approaches.

These are needed for different issues (eg a project altering clinical systems to enable social prescribing needs a very different approach from clinician training).

How public health became involved

The JSNA for Hertfordshire sets out 32 indicators comparing outcomes in each district of Hertfordshire with the county and England averages.

The HWB agreed a pooled budget of £230 million for 2015/16 for integrated care services. Based on the needs identified in the JSNA, BCF for the area is allocated to a number of priority areas relating to older people and long-term conditions. This fund was developed largely for adults with some childrens’ work. A specific BCF for children is now in development.

The public health team paved the way for its direct involvement in Hertfordshire’s work on integration by taking on several pieces of work through which it articulated the public health role and demonstrated its benefits. A number of areas were identified in which joint commissioning could be undertaken with public health.

For adults, these projects included:

  • a joint prevention strategy for older people
  • applying behavioural science techniques such as motivational interviewing to social care
  • a project to reduce section 136 place of safety calls for people with dual diagnosis
  • a self-management strategy group which among other products developed selfmanagement tools for people with long term conditions
  • a multi-agency and multiple funder project to get more people with existing health and social care needs benefiting from physical activity
  • applying health protection insights in social care including uptake of seasonal flu vaccination and working with care homes and commissioners to develop a new approach to infection control
  • a review of what pharmacy could do for system resilience
  • the DPH leads as sponsor on a multiagency project for adults with very complex needs who use a great deal of criminal justice, district, county and NHS service time.

For children:

  • a system-wide review, led by the DPH, of child and adolescent mental health services (CAMHS) resilience promotion which has led to a whole system transformation approach for CAMHS
  • a review of drug and alcohol services for children and young people
  • integration of health visitors with children’s centre services to provide a more holistic service model
  •  supporting the development of an integrated commissioning strategy for children which is now moving to a second iteration and the development of a BCF for children
  • funding psychologists to work in the Thriving Families programme
  • putting specialist health visitors into the MASH • a joint early years board which is progressing integration of children’s centres and health visitors.

What others say – Councillor Colette Wyatt-Lowe, Chair of Health and Wellbeing Board and Cabinet Member for Adult Social Care and Health:

In embedding public health into the council, we wanted to see a resurgence of the golden age of public health, one of the original drivers of local government, with a particular emphasis on prevention. Nothing in Hertfordshire happens without some public health involvement. This means that public health needs to be involved in all our integration work. We could not have carried out our major review of CAMHS without the number-crunching and statistical context setting and trends identified by public health. Similar skills have also been helpful in developing the BCF – the evidence provided by public health has helped persuade people of the rationale for bringing services much closer together. The skills of the public health team and DPH have also enabled us to take a wider perspective on health determinants, for example in thinking about where we want to go with the next tranche of the BCF and how we will incorporate a wellbeing aspect into our commissioning.

Public health contribution to integration

Strategic leadership
The DPH leads the public health directorate, reporting directly to the chief executive. Public health coordinates and supports public health activities across Hertfordshire through the public health board which has representation from over 30 agencies and feeds into the HWB. Public health staff produce high level CCG locality reports to support health and social care integration: these profiles are aimed at NHS, county and district councils to help identify key issues for joint working.

Brokering relationships:

  • The public health and social care teams are located together and this has proved helpful in developing working relationships at all levels.
  • Public health staff have been training NHS and council commissioners on a public health approach to commissioning and discussions on a shared understanding of the commissioning cycle are already leading to implementation of this in a phased approach
  • Public health recently brought together every commissioner in the county including districts and police and crime commissioners to identify areas of shared work and areas of duplication.
  • A public health consultant is embedded within each CCG to share access to their specialist skills and knowledge.
  • A public health consultant is also embedded in adult social care and children’s services. 
  • The DPH or his deputy is a standing member of the clinical executive in one CCG and the partnership board for the other CCG.
  • Joint executive meetings between CCGs, children's, adult social care and public health now happen regularly.

Evidence, outcomes and evaluation

The JSNA makes it clear that Hertfordshire faces a number of inter-connected public health challenges where the county is not performing as well as it could. These challenges require the development of integrated services across agencies. The public health team has provided evidence, intelligence and foresight to assist in this development.

Year of Mental Health
The Hertfordshire HWB has declared the period between its annual conferences, July 2015 and July 2016, the Hertfordshire Year of Mental Health. The DPH is the lead officer and has provided project management support.

The DPH led on a system-wide review of CAMHS. The review culminated in a number of actions which are now being implemented by a CAMHS transformation board of which the DPH is a member.

A similar review, led by the DPH has just been completed on children’s drug and alcohol services.

Both programmes feed into the multi-agency integrated commissioning executive for children and young people.

HomeFirst care at home
HomeFirst is an integrated community support programme developed jointly by Hertfordshire County Council, CCGs and Hertfordshire Community NHS Trust. The programme provides effective care for people at risk of hospital admission or social care placement.

What others say – Iain MacBeath, Director of Health and Community Services:

The public health team has brought an evidence-based approach. Historically, social care has been less strong in this area than the NHS. With the evidence provided by public health, we’ve been able to be bolder in developing new integrated services such as HomeFirst, using a risk stratification approach and designing our evaluation criteria up front to iterate our roll-out with GP colleagues – and being more decisive about de-commissioning services.

For example, testing a number of new postacute social care pathways to get people home and independent and then using public health expertise and evaluation to select the most successful model.

Overall, Hertfordshire is a relatively wealthy county but there are pockets of deprivation and the public health team have helped to identify these ‘hotspots’ and their specific health problems so that our work on integrating services can be targeted to areas and groups in greatest need.

Integrating health visiting and children’s centres
A major integration project is taking place on services for children aged under five. This is bringing together a number of services including the Healthy Child Programme, health visitor services and Sure Start children’s centres. A joint early years board oversees this, co-chaired by the DPH and director of children’s services.

Proposals for a BCF approach for children are now being developed following a number of projects on improving outcomes for children.

What others say – Jenny Coles, Director of Children’s Services:

At a strategic level, public health is acting as the glue that holds together evidence and practice. Together, we have brought children’s services in a big way into the HWB’s agenda. The transfer of responsibility for nought to five-year-old public health and the opportunity to bring school nurses and health visitors together with children’s centres fits in well with the board’s priority of early childhood. They have helped us on the ground as well as at a strategic level, for example in developing a number of pilot projects around the two-year-old developmental check. The public health team has also played a big part in developing our improvement agenda – they are still involved in the improvement board following the mental health review, led by our DPH.

Family safeguarding
In January 2015, Hertfordshire County Council was awarded a grant of £4.86 million by the Department for Education (DfE) to develop new ways of delivering child protection services. The aim was to develop integrated child protection teams with professionals working together to address the parental behaviours that place children at risk of significant harm or impairment of their health and development. 

The bid was made in conjunction with public health, adult services, Hertfordshire constabulary, CCGs and probation services. Around 85 per cent of child protection cases involve the ‘toxic trio’ of substance misuse, domestic abuse and mental health in some combination. Public health made immediate changes to its commissioning of substance misuse services to shift some of its service delivery to child protection teams, with the grant being deployed to add additional substance misuse capacity to the teams. Having substance misuse workers in the child protection teams has made a significant difference to the assessment of treatment needs, improved identification of risks to children and resulted in more consistent engagement of parents in treatment programmes. It has led to far better information sharing, more positive working relationships with families and shared decision making that has improved confidence and morale of staff working in this stressful area. The project is being evaluated by Bedfordshire University, overseen by the Rees Centre Oxford University, on behalf of the DfE.

Beezee Bodies
Beezee Bodies is a 17 week programme, started as a whole family approach to healthier lifestyle and weight, so it needed to join up families and services. The programme works across services, taking referrals from health and social care. Public health has commissioned the service to deliver the programme in Hertfordshire from September 2014 to July 2016. It was specifically conceived as a life adjustment programme for the whole family, rather than just a weight reduction programme. Over the course of the contract Beezee Bodies will deliver four programmes. Each programme will run between eight to 12 different groups in a variety of locations across the county. Specific areas of deprivation and high obesity prevalence are identified.

The service was commissioned to accept referrals from a range of professionals. Referrals have been received through children’s social services where weight has been an issue and families are on a child protection plan. Beezee Bodies have supported these families to continue to attend the programme and have worked closely with social services to provide a holistic care package.

Developing preventative approaches

The DPH asks stakeholders what they feel should be the focus of the public health annual report and since 2013 it has always been on a topic where integration can bring benefits. In 2014 it was on early deaths. In 2015 it was on district council roles in public health.

Public health’s role in local government and NHS integration 15 As a result, a number of workstreams were set up, each working with a number of health and council partners towards more integrated services:

  • Housing – co-chaired by the DPH and director of adult social care, extensive analysis of housing needs of vulnerable people has been undertaken. Public health also funded the use for every district of the Building Research Establishment housing costs calculator to help districts include health issues in their strategic planning.
  • Physical activity – involving public health, leisure services and the CCGs. A multiagency working group has been tackling key local issues to ensure physical activity promotion is more systematically embedded within the NHS. Progress includes securing £500,000 from Sport England, £300,000 from CCGs and £200,000 from public health for brief interventions in general practices; embedding physical activity into GP care algorithms for long term conditions, training primary care staff and improving the quality of exercise on referral schemes.
  • Falls – with social care, the voluntary sector and the local CCG. A falls liaison service was set up by the public health team and is now funded by the CCG. Hospital admissions have been reduced by seven per cent with a net saving of £800,000.

Dehydration prevention
The public health team recently took over some aspects of commissioning, for example a hydration project, part of a preventative strategy for older people. This was jointly commissioned by public health and adult social care and delivered by the major voluntary sector meals provider, Hertfordshire Independent Living Service. Work on commissioning self-management approaches continues.

Making Every Contact Count (MECC) with older people
A collaborative cross-agency project, led by public health, has developed a pilot information package and video to encourage brief conversations with older adults about some key issues. The package is aimed at staff across the public sector and volunteers across Hertfordshire who have contact with older adults in their own homes.

The areas covered in the package are:

  • preventing falls
  • making sure homes are safe
  • making sure homes are warm
  • preventing loneliness
  • ensuring good nutrition
  • preventing dehydration
  • encouraging physical activity.

What others say – Councillor Teresa Heritage, Portfolio Holder Public Health, Localism and Libraries:

Within the last month, the county council, in implementing one of the scrutiny recommendations, has started a councilwide prevention workstream, led by the public health directorate, the finance department and the fire service. This for us is an important way of recognising most departments have a preventive ethos already and we are contributing to and supporting that, not claiming pre-eminence.


Professor Jim McManus
Director of Public Health