Hull City Council: public health transformation six years on
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.
Hull is a port city in the East Riding of Yorkshire lying on the Humber Estuary, with a population of around 270,000. The health of people in Hull is generally worse than the England average and there are large health inequalities. Hull is one of the 20 percent most deprived districts/unitary authorities in England, with some neighbourhoods among the most deprived in the country. Hull is a thriving city with a rich and varied cultural heritage and was a highly successful UK City of Culture in 2017.
Organisation
In Hull City Council the Director of Public Health manages the directorate of Public Health and Adult Social Care which includes public health, adult social care, integrated commissioning, and public protection. This means that a public health approach, which drives the agenda of prevention and early intervention, is at the heart of the council.
Hull City Council and Hull CCG are coterminous and both share a passion for making Hull a great place to live and work. They have a joint finance plan which combines budgets for children’s, adult and public health services. Rather than a public health budget of around £25 million, Hull can develop shared priorities and responses across a budget of over £400 million. Health and care services are integrated in Hull, including a new Integrated Care Centre.
Priorities
In the build-up to UK City of Culture, the focus was placed on economic growth. This has brought benefits of more jobs and a growing economy – all of which are helpful for health and wellbeing. However, there was a realisation that more needed to be done for people who were not benefiting from the economic upturn – generally those facing the greatest health inequalities. In light of this, the City Plan was refreshed and is now focused on Hull as an Inclusive and Fairer City.
The role of the Health and Wellbeing Board (HWB) was also reviewed. The HWB has refocused its work to drive the system-wide changes needed to address social and health inequalities. Unhealthy choices often start in social inequalities, and the Board is supporting work to investigate the causes of inequality and to work with communities to take ambitious system-wide or deep-dive action to address the social determinants of poor health. Examples of interventions so far are described below.
The focus for 2019 is on examining and tackling the causes of obesity which will be supported by the Towards an Active Hull strategy 2018-28 which aims to increase physical activity levels and reduce inequalities across all ages.
Challenges and impact of budget reductions
The geography of the STP, Humber Coast and Vale, is challenging for Hull since it crosses council boundaries and encompasses North East Lincolnshire, North Yorkshire and York. Hull is involved in the STP in the elements that contribute to positive developments and pathways for the city, such as mental health. Hull is concerned that its well-developed integration arrangements could be damaged by any national requirements for arrangements with larger populations and geographies. It believes that where things are working well, they should be supported to continue.
Attracting and retaining a skilled and experienced workforce is a challenge to future health and wellbeing developments.
Hull has made savings and prudent financial decisions, and operating a shared financial plan means that partners can achieve added value and economies of scale. When savings in adult social care and children and young people’s service have had to be made, it has been possible to consider this from a public health perspective and increase investment in prevention and early intervention. This includes allocation of the public health grant to prevention in adult social care, housing, and the children and young people’s healthy lifestyle team.
However, there is no doubt that the background of local government budget reductions, including significant reductions in the public health budget, is having a negative impact. With more funding and capacity, it would be possible to upscale work in mental health wellbeing and in tackling health and wellbeing in NHS settings, such as supporting mental health and acute hospital settings in treating smoking as an addiction. There would also be investment to expand prevention and support in drug and alcohol and sexual health services.
n Hull we are looking to promote inclusive growth to create the sort of society and environment which are good for people’s health. Health is not issue or organisation specific – it involves a whole range of factors, including housing, education, leisure, employment, planning and licensing and many more. We are moving away from silo working to tackle all of these, and by doing so we intend to reduce the need for expensive NHS and social care support.
Having a director responsible for both public health and adult social care has given us the ability to take a 360 degree view of health, care and wellbeing. It has meant we are able to make money go further, even in the face of growing demand and budget cuts.
We have a very good partnership with Hull CCG but working in the sustainability and transformation partnership (STP), which is not a good geographical fit for Hull, is difficult – involving many meetings and committees. STPs should be designed to support effective health and care systems that improve people’s health and wellbeing rather than trying to create new systems.
For the future, we hope to put more emphasis on practical ways to support carers, on reducing mental health problems and on tackling obesity. We will also be working to make sure that the work that we do to tackle health inequalities is on a sustainable footing.
Councillor Gwen Lunn
Cabinet Member Adult Services and Public Health
Hull City Council
Levels of debt and the use of high interest and unregulated lenders are high in some areas of Hull and have a negative impact on health and wellbeing. The council has supported Five Lamps, a charity credit broker, to set up a scheme to support people with little or no financial resilience by providing access to cheaper, safer borrowing. Hull Money also gives access to savings and current accounts through a credit union and provides budgeting and savings advice. The council is not funding the service, which went live in summer 2018, but public health and council colleagues supported its development through research, community engagement and making the case to city leaders, over a planning period of three years.
Sustainable Food Cities (SFC) is one of the Inclusive Growth strands of the City Plan. Hull Food Partnership is working towards achieving the SFC bronze award which involves developing a Healthy Food Charter which will set out the food vision for the city and pledges from a range of organisations to take practical action. The Healthy Food Charter is fully supported by the Cabinet and HWB.
By signing up to a Healthy Food Charter, the council and it partners are committing to a strategic framework aimed at creating a culture of sustainable, healthy, equitable, affordable food for everyone in the city. It will build on work already undertaken, including such as limiting new fast food outlets near schools, as set out in Hull Local Plan – seven applications have been turned down in recent months.
This year-long project which ended in October 2018 is a partnership between local communities, stop-smoking services and neighbourhood teams who worked together to identify the city assets that could be used to stop smoking. The project identified several opportunities including:
promotional campaigns delivered in community locations
training more people in very brief advice
stop smoking in community settings – community hubs, pharmacies, health centres, dental surgeries and many more
Promotional campaigns include the following.
A Dog Trust joint campaign offering free dog chipping with conversations about the impact of second-hand smoking on pets resulted in nine referrals to stop smoking services.
Smokefree (school) gates campaign – children in 25 schools have taken part in activity to abolish smoking outside school, with a media campaign and a voluntary code for smokers.
Smokefree sidelines – a toolkit was created to help youth football clubs to implement a voluntary smokefree code for spectators. 400 young people from 36 clubs launched the project in a day of matches. The code will be rolled out to other sports like rugby through the work of Active Humber.
Monitoring figures show the project has contributed to city-wide year on year improvements:
three percent increase in people accessing stop smoking services
12 per cent increase in people achieving a four-week quit
260 per cent increase in people trained to deliver very brief advice on smoking.
The project made recommendations for future work, such as considering the best geographical scope, exploring a community champion model, continuing community support to develop trust, and considering using an asset approach to tackle other health issues like obesity.
The city used Five Ways to Wellbeing (connect, be active, take notice, keep learning and give) as the underpinning approach to developing health and wellbeing benefits from City of Culture. Research and development grants were awarded to 11 projects for creative health and wellbeing activity. The volunteering outcome of City of Culture was a volunteer on every street and 3,000 people still volunteering. Public Health, with partners in the council, the CCG and the voluntary and community sector will be building on this enthusiasm through a range of community-centred approaches.
Making it Happen was a celebration by 30 different community groups to acknowledge what they achieved and plan for the future. A survey of 250 people who had been involved showed high scores for feeling they had made a difference to the city, interacting with people they would not normally have interacted with, being more likely to help the community, and feeling happier.
Hull has operated integrated children and young people services 0-19 with a single provider for several years. Services are due for re-commissioning, with a greater emphasis on mental resilience and the first 1001 days, in the next 12 months. Mental resilience is being informed by learning from the HeadStart Hull programme.
HeadStart Hull commenced with a pilot, supported by the Big Lottery Fund, which aimed to increase emotional wellbeing and mental health resilience in children and young people to reduce the need for specialist mental health services. The pilot was led by the council’s Early Help and Commissioning team working with a wide range of partners, including public health, who supported with project design, engagement, research and insight into behaviour change. Extensive engagement took place with 1300 young people aged ten to 19 supported by smaller focus groups in schools and youth centres and discussions with parents, which shaped the project’s design and development. The project ran across ten primary and three secondary schools and tested a range of targeted and universal interventions with ten to 14-year-olds including:
young people able to identify a ‘Trio of Trusted Adults’ in school, community and home and Positive Peer Networks – friends who support each other targeted interventions including peer mentoring project with trained peer mentors, emotional resilience coaches, group work and counselling an App designed by young people to provide safe reliable information and support online training for school and community-based staff on discussing mental health with young people.
Examples of ongoing activity include campaigns developed for mental health week:
The You are not alone campaign led by young people in which inspirational messages were played via speakers on the Humber Bridge walkway and marina.
Talking Tables in which secondary school pupils combat isolation by talking together at lunch times.
The pilot led to the development of the five-year Headstart Hull programme, launched in 2016, which supports children and young people aged five to 16 at a universal level, and aged ten to 16 at a targeted/early help level. The programme works with families, all schools across the city, with health services, youth services, the voluntary, community and social enterprise (VCSE) sector, and wider early help services. The vision is for children and young people to have positive mental health and wellbeing, thrive in communities and bounce back from life’s challenges.
Monitoring information for the programme shows an improvement in emotional health and wellbeing outcomes for those accessing the targeted/early help services, with improvements on all domains including physical health, feelings and behaviour, confidence and self-esteem, and feeling safe. Some young people who have been waiting for clinical mental health services no longer need it.
Public health has been involved in supporting the development and design of the Integrated Care Centre, which was opened in 2018 in the week of the 70th anniversary of the NHS and was built through NHS Local Improvement Finance Trust (LIFT) public-private partnership funding. The first centre of its kind in the UK, it is a clinically led, multidisciplinary centre with a team of clinicians, nurses, GPs, pharmacist, social workers, therapists and the voluntary sector. The team will support 12,000 frail older people at risk of hospital admission at home and in the centre. Humberside Fire and Rescue has an operating fire station onsite and also provides a falls service, with discussions underway to explore crews supporting the rehabilitation and recovery of service users. As the centre embeds, other pathways are likely to develop, such as supporting people with chronic obstructive pulmonary disease. The Newbridge Village bungalow development of social housing for older people is sited close to the centre.
A city-wide social prescribing service commissioned jointly by the council and the CCG was launched in September 2017, with Citizens Advice Hull and East Riding as lead provider. Connect Well Hull social prescribing model offers people advice, support and links to community groups, services and activities to help people aged 16 and over make positive changes that improve their health and wellbeing. Local people can meet a wellbeing coordinator or welfare advisor at a wide range of locations across the city including GP practices and community venues. Referrals can made by GPs, other health and care professionals or individuals themselves online or by telephone. A key responsibility for the service is that it collates, analyses and reports to commissioners on service provision, trends, gaps and capacity issues relating to health and care. A £1.8 million social prescribing community fund was set up by commissioners to respond to gaps identified by the service, with decisions made through a joint commissioning panel. Further investment in early intervention has been agreed through this route.
The Connect Well Hull service has assisted people from all wards in the city. In its first year nearly 7,000 appointments were provided, assisting clients with over 4,000 different problems. The most frequent issue on which people sought advice was benefits, while loneliness and isolation were the most significant wellbeing issues. The income gain for clients totalled £1,112,970, with the vast majority relating to benefits and tax credits. Satisfaction from clients is high, with many indicating how the help has made a real difference to their lives.
The way forward to tackle health inequalities is for partners to look systematically at the causes of poor health and to work with communities to identify system-wide solutions.
Being director of public health and adult social care brings many opportunities to embed early intervention and prevention. However, this is a wide span of control which is made achievable by having an excellent team and working in a council that has embraced tackling the social determinants of health.
