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.
Hampshire is a large county on the southern coast of England with a population of around 1,365,000. It has a mix of rural areas, including the New Forest National Park, large conurbations, such as Andover, Winchester and Basingstoke, and many market towns and villages. The health of people in Hampshire is generally better than the England average. Hampshire is one of the 20 per cent least deprived counties/unitary authorities in England. However, there are areas of deprivation and around 10 per cent of children live in low-income families.
Hampshire County Council contains 11 borough or district councils. The largest settlements in the area, Southampton and Portsmouth, are administered separately as unitary authorities. The Isle of Wight unitary council lies off the coast of Hampshire.
Organisation, partnerships and priorities
Public health moved to Hampshire County Council as a team in Corporate Services. Since then it has joined with Adult Services to form the Directorate of Adults’ Health and Care. Public health has built on a history of working with district and borough councils on health and wellbeing, with a link officer to support the work of each council and a public health consultant responsible for overall coordination and relationship building.
The DPH leads the prevention workstream of Hampshire and Isle of Wight sustainability and transformation partnership (STP). The workstream is making progress with supporting smoke-free hospitals, tackling smoking in pregnancy, rolling out Make Every Contact Count (MECC) training and other plans to embed prevention. It is set to review its work to take a broader, more social determinant approach to prevention. Public health also inputs to the other STP workstreams and will be leading on developing better systems of population data management and intelligence.
Hampshire is refreshing its Health and Wellbeing Strategy to put greater emphasis on tackling the social determinants of health. Priority workstreams include: improving mental and physical health in children; tackling the risk factors for long term conditions and enabling people who have long-term conditions to live healthier lives; developing connected communities; creating healthy home environments; and ensuring that for people of all ages the last phase of life is as good as it can be.
Challenges and impact of national budget reductions
The STP has a complicated geography which covers Hampshire, Southampton, Portsmouth and the Isle of Wight, with some of North East Hampshire in Frimley STP. This means that planning and working arrangements involve multiple partners.
The reduction in the national funding of the public health grant, combined with the reduction in the council budget has presented some challenges. The ring-fence on public health funding has provided protection and the department had done a lot to make efficiencies while maintaining and even improving services but even so, it has been difficult to fund new interventions for prevention and early intervention.
An increase in funding would mean public health would have more capacity to work with and influence partners to take action on the wider determinants of health – to instigate new activity in areas such as early intervention in early years settings, workplace health, support for older people isolated in rural areas, and building assets in communities facing deprivation.
- Councillor perspective
When public health came to the council it had a low profile and we had to push on doors to engage with colleagues from other departments. But over the years, there has been a huge step-change, and now there is a great understanding of the importance of health and wellbeing. All departments across the council are interested in being involved, as can be seen in the examples in the case study, and the Public Health team is working flat-out to support all the opportunities that have arisen.
This also applies to districts and boroughs which are supported by link workers in Public health to improve health and wellbeing and tackle local health inequalities such as healthy town initiatives and the health implications of major planning developments.
Financially, it has been tough. Public health has been very resilient, finding ways to provide the same level service for less, such as through digital media. Also, developing innovative solutions has often resulted in better services, such as improved access. However, we are approaching a deadline and without further funding we are likely to have to start focussing services more exclusively on what we are mandated to do.
It would be helpful if more areas of public health were given a mandatory responsibility to give more ‘bargaining power’ in discussions about funding across councils and with health partners. If we were funded more effectively we would be able to extend our influence across the system and be able to commission more evidence-based prevention and early intervention initiatives, particularly for children and parents and to promote good mental health. Aligned with this would be the continuation and extension of close work with planners of proposed new developments, the promotion of a better food environment and better access to local green space – all of which would reduce pressures on health and social care.
Councillor Patricia Stallard
Executive Member for Public Health
Hampshire County Council
- Alcohol licensing
Most boroughs and districts have a statement in their licensing policies so that the health and wellbeing of communities is considered in relation to alcohol-related harm. Public health has also developed a screening tool so that its representations can be submitted to councils if there is concern. For example, after discussions with partners, including the police and a district licensing team, the Director of Public Health (DPH) made a representation to reduce alcohol harm in a music festival for 60,000 people which was planning to increase capacity by a third. Owing to the number of concerns, including by the public, festival organisers withdrew plans to increase in size.
Public health and district planning departments have agreed a Hampshire Planning and Public Health Position Statement which facilitates public health responses to major planning applications. For example, Public health recently responded to a planning application for two drive-thrus on a leisure site in Hampshire. The response provided evidence on air quality, obesity, nutrition, deprivation and inequalities, and recommended planning permission should not be granted.
Public health has supported a local district council to produce a Healthy Borough Assessment which provides the basis for draft local plan policies to create healthy homes, healthy neighbourhoods and sustainable travel. This includes recommendations for policies that restrict fast-food outlets and gambling premises and encourage high quality green space and the adoption of minimum space standards for new homes. Public health hopes to use the learning from this to support other districts to introduce similar policies, either as part of local plans or within supplementary planning documents.
- Healthy new towns
Public health supports the development of active lifestyles being the norm in Whitehill and Bordon – a development integrating new housing and infrastructure into an existing town, which is part of the Healthy New Town programme. Work has included insight work with local people, developing opportunities for integrating physical activity into everyday lives with children and families and involving the council’s Active Travel team.
More broadly, the Active Travel team is focused on supporting areas with high obesity levels through work such as promoting the use of scooters and balance-bikes for younger age groups. Improving air quality is a growing priority in which the team is becoming increasingly involved.
- Developing integrated 0-19 services
Hampshire’s children’s health visiting and school nursing services have been developing new community-based and digital approaches. For example, building on the successful texting service for 12-16 year olds provided by school nursing, a new ChatHealth texting service for parents of children 0-5 was launched by the health visiting service in October 2018. This allows parents to get advice and support on a wide range of health and wellbeing issues such as crying babies, sleep disruption and behaviour problems. The service has already proved very popular with parents, who are still able to speak directly with a health visitor or meet face-to-face in a baby clinic or at home if needed.
Work is underway to develop a combined 0-19 service for children, young people and families through a series of aligned procurements covering public health nursing, CCG community services and CAMHS. The approach is underpinned by extensive engagement with service users, the public, frontline staff and system leaders. Increasingly the system is co-designing the new service model with service users.
Discussions have taken place with partners which identified much common ground but also identified some differences in priorities. A children and young people’s outcomes framework has been developed, with key outcomes identified for issues that are best tackled at system level, such as childhood obesity, school readiness and childhood emergency admissions.
Other recent partnership developments include:
- A multi-agency board established to tackle long-standing challenges such as smoking in pregnancy, sustaining breastfeeding, maternal healthy weight, and perinatal mental health. Service improvements are being implemented through midwives and health visitors, sharing a public health approach.
- A new multi-agency children and young people’s mental health strategy that focuses on individual mental health, service improvements, the links between physical and mental health and developing environments that support emotional wellbeing.
- ICON – public health and health visiting are promoting a support package for new parents that is being developed by Hampshire’s Safeguarding Children’s board. There is a focus on supporting new fathers, for example coping with crying, with the aim of reducing abusive head trauma.
- A shift to recording breast feeding rates by health visitors instead of GPs. Breast feeding rates are now more accurate, jumping from an apparent rate of about a third at 6-8 weeks to over 55 per cent. The system can now focus on the families that find it hardest to sustain breastfeeding.
- Tackling obesity
Public health commissions an outcomes-based service from Weight Watchers in which payment is only made for people who lose five per cent of their body weight. This includes services for pregnant women and for men, who have been more difficult to engage. Some sessions now take place in GP surgeries because it has been found that more men attend these services compared to community settings. Public health has undertaken insight work with men to understand how they can best be prompted to reduce weight. These insights are being delivered through a social media campaign – the Be size-wise campaign. Part of Be size-wise is the POWeR (Positive Online Weight Reduction) programme, developed by Southampton University which Hampshire Public Health helped to make available to the public.
- Stop smoking: e-cigarette voucher scheme
Hampshire’s commissioned stop smoking service Quit4Life is piloting an innovative voucher scheme for smokers who want to quit using an e-cigarette. The voucher is offered as a one-off alongside weekly NHS smoking cessation support for up to 12 weeks and can be exchanged at a selection of local vape shops which have been assessed by and signed an agreement with Quit4Life. Although there has been interest in the scheme from smokers and retailers, it has not yet resulted in a significant rise in numbers attending the service. The model has been amended to work with vape retailers to train staff as stop smoking advisors to offer on-site stop smoking support. The scheme will be closely monitored to assess its impact.
- Sexual health
Following consultation, public health has introduced Sexually Transmitted Infections (STI) home sampling kits in place of face-to-face appointments for low-risk, asymptomatic adults. Evidence shows that the service is reaching people that have never visited a sexual health clinic and is finding STIs, including a new diagnosis of HIV that might have continued to go undiagnosed if the service had not been in place. Average savings are £45.64 per STI testing intervention – a 76 per cent reduction.
- Substance misuse
Hampshire has commissioned an integrated substance misuse treatment service for adults and young people which aims to intervene early, reduce harm and achieve recovery. Services take place in community hubs across the county and through telephone and digital media. Elements of transformation include:
- a whole family approach with multi-disciplinary family recovery workers where there is parental substance misuse
- innovative solutions to work with people with complex needs incorporating longer periods of structured treatment and recovery plans with a focus on education, training and employment support
- peer-to-peer education combined with specialist outreach clinics to identify and treat more people with Hepatitis C.
- Postvention protocol in schools and colleges
A protocol for schools and colleges has been established to help them support young people when there is a death by suspected suicide. In some parts of the country the trauma of experiencing a suicide has translated into a contagion effect where several young people have taken their own lives. The protocol aims to support schools and colleges with the postvention process (support after a suicide takes place) and to think about how they could actively help prevent any future deaths.
- Men's Hub project
The Hampshire Suicide Audit identified that 76 per cent of recorded suicides were men, and almost half of these had experienced relationship, debt or redundancy issues. This indicated that it is not just people with mental health problems who need support with mental wellbeing. Men are less likely than women to seek help from a GP or any other professional, and previous attempts to attract more men into mental wellbeing services had limited success.
To tackle this, Hampshire joined forces with Kent County Council in a joint funding bid with ten partners across the EU. This resulted in a collaborative, cross-border project to improve men’s health, wellbeing and employability inspired by the success of the Men’s Sheds movement (community spaces for men to connect with each other). A new model is being co-produced with groups of men and will be evaluated by the University of Chichester.
- Domestic abuse
A key priority for Public Heath is reducing the impact of violence. As part of this, it is transforming domestic abuse services to ensure they deliver effective and improved outcomes that meet the population’s changing needs whilst also making efficiencies within the system. This includes tendering for a new perpetrator service aimed at changing the behaviour of perpetrators to prevent a cycle of abuse. The service, which starts in April 2019, will focus on key groups, such as persistent or high-risk offenders, and will involve community and behaviour-based interventions.
Other changes to services are:
- an integrated single point of contact (front door), assessment and triage for victims and perpetrators
- peer support and mentoring
- whole family approach for those wishing to remain in their relationships
- capacity building and engagement with professionals and communities.
Domestic violence services have been given a boost through a successful bid to the government’s Domestic Abuse Fund for projects to reduce domestic abuse and help survivors turn their lives around. Hampshire received £1.3 million (plus £477 thousand for Portsmouth and South East Hampshire) as part of a partnership bid led by Hart District Council and working with partners across Dorset and the Isle of Wight. The project which starts in January 2019 will focus on areas including:
- extension of the Hampshire Making Safe Scheme enabling victims of abuse to remain safely in their homes
- specialist refuge provision
- early identification and referral of domestic abuse in health services and communities.
- Key messages
- Working in local government provides huge opportunities for public health, even at a time of austerity. It is important to be creative and make best use of resources. All council investment should be considered with a view to making the best impact on health.
- Although much progress is being made, it is important to realise that health and wellbeing problems and health inequalities are not just a public health problem, they are a societal issue. Public health can lead but it cannot solve these problems alone.
- Re-commissioning services and engaging partners with public health takes a lot of time and effort but results in greatly improved outcomes.
Dr Sallie Bacon
Director of Public Health
Hampshire County Council