Leicestershire County Council: a social model of public health

At the community level, local area coordinators and a time banking scheme support the empowerment of individuals and communities.Primary prevention includes a welfare and social support service and programme work by a public health programme delivery team. Secondary prevention includes an innovative;in-house smoking cessation service and an integrated lifestyle service. A Health in All Policies approach has led to joint work with planning to embed Active by Design guidelines in planning policy and decisions.Mental health has been a priority across the county and has included investment, perhaps unique, from public health. A Warm Homes scheme to tackle fuel poverty and winter deaths has been integrated into housing support services.

Background

The county of Leicestershire has a population of 675,000, projected to rise to 698,000 by 2020. Nine per cent of people in the county are from an ethnic minority group, with the proudly diverse city of Leicester having about half of its population identifying as from an ethnic minority. Leicester has the highest proportion of British Indians in the UK (28.3 per cent of its population.Leicestershire is one of the 20 per cent least deprived local authority areas in England, although about 12 per cent of children live in low income families. Life expectancy for both men and women is higher than the England average.

The life expectancy gap between men from the most deprived areas of the county and the least deprived is 6.1 years. For women, the gap is 4.8 years.Among children and young people, obesity, alcohol harm and teenage pregnancy rates are lower than the England average. Similarly for adults, most health and socio-economic indicators, including rates of alcohol harm, smoking, road deaths and injuries and unemployment are better than the England average.

While, overall the health of the county is in reasonable shape, challenges persist. Although life expectancy has increased, there are stark variations, with a 10-year difference in life expectancy between men living in the more deprived Lemyngton ward of Loughborough and the more affluent ward of Bosworth. Rural health issues, such as depression, are a priority as is taking action on adult obesity.

Health priorities in Leicestershire include enabling people to take control of their own health and wellbeing; reducing the gap between health outcomes for different people and places, ensuring children are safe and can achieve their full potential; and ensuring sufficient weight is given to mental health and wellbeing and that people can access the right support throughout their lives.

Organisation

Through the work of the public health team, the county council has been moving towards a social model of public health and prevention and away from a more traditional narrower model concerned with diseases and lifestyles. This model has led to public health leadership in a number of services, with a strong emphasis on supporting community capacity building, including the following, which are all part of the public health department:

• investing in a local area coordinator system (see below)
• putting in place 1st Contact Plus, a lifestyle, welfare and debt advice and social care support hub
• bringing the timebanking scheme, Time 4 Leicestershire, into public health.

Since moving out of the NHS, the public health team has wherever possible brought the delivery of public health services in-house, setting up a provider arm within the team, with close matrix working with the specialist public health professionals.

Health and wellbeing initiatives

Leicestershire Local Area Coordination Initially delivered as a pilot in 10 very different local areas across four of the county’s districts, Leicestershire Local Area Coordination (LAC) is a complex community based intervention, operationally delivered by eight Coordinators with varied backgrounds and different working styles. Also referred to as an Asset Based community Development programme, LAC’s fundamental aims are to increase individual and community capacity while reducing demand for costly primary and acute services, as well as other public services, by working with beneficiaries who are vulnerable and often experiencing a range of multi-layer complex challenges. LAC is designed to have an impact on three levels: individual, community, and health and social care integration.

Local area coordinators are trusted individuals who are not seen as representatives of formal agencies. Their brief is to offer support with people-focused solutions that are non-service-based, outcome focused, easy to access and sustainably low cost.

An evaluation completed in September 2016 indicated that in the year to that date Coordinators had worked with almost 2,000 beneficiaries at Level 1 (signposting) and Level 2 (more intensive support), providing information, advice and guidance enabling local people and places to ‘become the solution’. There had been 510 referrals to LAC from a wide range of both voluntary and statutory organisations, and 395 referrals from LAC to a similar wide range of organisations, plus hundreds of self-referrals and referrals from friends and neighbours. First Contact Plus, the support hub, is a key referrer and a pathway has been developed to enable this for individuals who need a face to face visit but don’t require a formal service. Approximately 520 Outcome STARs (a set of tools for supporting and measuring change) were completed in the first year along with 420 action plans. Approximately 174 people were supported to access welfare benefits and approximately 21 referrals from the police to LAC resulted in LAC contributing to a positive outcome.

The evaluation identified that over a 12 month period, local area coordination in addition to the benefits to individuals, communities and services had avoided 53 critical incidents to ‘high impact, high cost’ individuals thus creating an avoidance cost of £4.7 million. Measurable outcomes had been achieved to a good extent for individuals and to a moderate extent for health and social care integration. Although measurable community-based outcomes were achieved to a lesser extent, it was recognised that these could take longer to achieve and that the ‘glue’ was in place to enable coordinators to have a good knowledge of local assets and to ‘match’ these effectively to assist a beneficiary. The director of public health notes that the LAC scheme works well where there is good liaison with a district coordinator within a district council.

Smoking cessation in-house service

The reduction in the public health grant drove the need to deliver a smoking cessation service at vastly reduced cost. Technological solutions and the desire to bring services in-house to prompt closer working across lifestyle services led to QuitReady Leicestershire stop smoking service (QR SSS).

QuitReady has pioneered advanced technological support which goes well beyond the motivational text messaging that some services provide. It offers 12 weeks of behavioural intervention support via the telephone, texting, live chat, email and webchat. Patients have the option of choosing the most suitable contact method. This technological model is based on models used in other countries such as Sweden and Australia with good evidence to suggest that it is as effective as conventional face-to-face intervention.

All stop smoking support is provided by the core stop smoking team with no subcontracted services.

All patients also receive 12 weeks of pharmacotherapy which can include nicotine replacement therapy (NRT). Depending on the type of NRT, this is either provided by pharmacists by using a Patient Group Directive (PGD – enabling pharmacists to dispense drugs for a defined group of patients) providing an option for patients to receive their NRT via the pharmacy, without the need for patients to make an appointment with their GP – or by NRT being requested by the service from the service user’s GP.

To try to reduce health inequalities, the service and stakeholders are required to identify proactively and deliver services to:

• residents in deprived areas of the county
• routine and manual workers
• people with a diagnosed mental health condition
• pregnant smokers and their wider family network
• people with long term conditions.

Residents in deprived communities are targeted by engaging with key organisations and partners such as Supporting Leicestershire Families, working with children’s centres, midwifery and public health nursing services and workplaces with large representation of routine and manual workers.

Staff have high visibility in deprived wards attending many health and other events and have targeted marketing and communications activity within these areas to help further increase foothold into the service.

Routine and manual workers make up the largest proportion of smokers that set a quit date with the service as compared to other social-economic classifications.

The service has good links within the Leicestershire Partnership NHS Trust and contributes to the in-house training programme for staff and in-patients. It also hosts brief advice training sessions with the recovery colleges for carers of people with mental ill health and service users. There are good referral pathways in place between the community teams, GP practices and QuitReady.

In the first six months since the service was launched in January 2017, QuitReady helped more than 600 people to give up smoking.

In addition, the cost of the service was reduced by two thirds compared to the predecessor smoking cessation service model.

Health in All Policies – joint work with planning

Leicestershire’s public health team has taken a strategic approach to enabling physical activity in the county. Its brief is to facilitate developers and council planning teams to design enhanced physical activity opportunities into new housing developments, leading to improved health outcomes, ultimately resulting in savings to the public purse. Taking a Health in All Policies approach, the public health team has piloted working closely with the planning department at Hinckley and Bosworth Borough Council on an ‘Active By Design’ programme based on the 10 Principles of Active Design developed by Sport England (supported by Public Health England).

Hinckley and Bosworth district was chosen as a launching pad for this approach because 27 per cent of residents were inactive, an increase from previous years and 28.9 per cent of adults were classified as obese, worse than the England average. There was a lack of awareness in the planning sector of the Active Design Principles, so Leicestershire Public Health set itself the challenge of first raising awareness among staff and elected members; and then ensuring that the principles were embedded long term into future policy. The action plan includes the following stages:

• develop high level service level agreement between public health and district planning teams
• develop staff training package
• design healthy communities policy for Leicestershire review
• cascade to fellow East Midland local authorities.

To date, a checklist has been developed to help planners assess whether new planning applications have taken account of the 10 Active Design Principles. Information materials have also been developed for elected members to help them understand the importance of active design principles. Future action will include:

• information sessions for members
• working with Hinckley and Bosworth Borough Council to implement and test the feasibility and effectiveness of the Active Design checklist
• assessing the feasibility of undertaking health impact assessments on large housing development
• proposals in the borough evaluating the impact of all of the above in embedding Active Design Principles into planning decisions.

Mental health

Leicestershire County Council, along with NHS and voluntary sector partners, has prioritised improving mental health in the county. The ‘recovery college’ model has been developed, with investment from public health to recruit a two year fixed term post of Recovery College Engagement Officer.

The college offers a range of recovery focused educational courses and resources for people with live mental health experience, their friends, carers and families.

The engagement officer has been working to bring the Recovery College from its main site into satellite venues across the county. The college now delivers classes in four additional venues and further venues are currently being sourced. Leicestershire Partnership NHS (mental health) Trust leads on delivery of the courses and with support from public health has forged important partnerships with wider NHS and local authority departments, voluntary organisations and the private sector (including Leicester City Football Club).

Alongside the work of the college, concern about the numbers of people with serious mental illness requiring ongoing support to aid their recovery has led to the development of the Leicester, Leicestershire and Rutland (LLR) locality mental health, wellbeing and recovery services which were rolled out in October 2017. The hubs are jointly funded by the city, county and Rutland councils, and the three local clinical commissioning groups (CCGs). Public health has been instrumental in supporting the development of the business case to give these patients equal access to high quality mental health services across ten sites in LLR, in buildings that are already well-used by local people. There they can get advice and support on a range of council and health services in additional to the statutory mental health services provided by health and social care.

Public health also commissions services aimed at wider mental health and wellbeing including a teenage mediation service and Mental Health First Aid Training for front line staff. Public health has also played a pivotal role in delivering the LLR Future in Mind Transformation plan, including establishment of a school based resilience service across LLR-‘Route to Resilience’ and an early intervention service for children with emotional and mental health issues.

Overall, services that support emotional wellbeing were considered so essential to the public health and prevention agenda that spending on this area from public health budgets has been protected despite the national cuts to the public health budget. Priority has also been given to supporting joint approaches with NHS and other partners to strengthen emotional health and wellbeing across the life course.

Warm Homes project

In addition to the issues discussed above, two indicators in the Public Health Outcome Framework (PHOF) stood out in Leicestershire: fuel poverty and excess winter deaths. With elected member support, public health led the development of a sustainable approach to tackling fuel poverty in the county. External funding sources had come to an end so £100,000 of public health funding was identified to support the programme, from efficiencies in service provision elsewhere. The public health team worked with colleagues in adult social care and with housing colleagues in district councils to develop a healthy housing referral service. The service was put out to tender and awarded to the Papworth Trust in partnership with National Energy Action (NEA), the national fuel poverty charity. The initial programme provided a range of routes of referral into the service, including via First Contact Plus. Basic energy advice was available and more complex cases referred to a caseworker. The scheme has now been embedded into First Contact Plus and the caseworker employed by the council. It is separately funded by Disabled Facilities Grant (DFG) funding and has been integrated with the various housing support services provided by the county and the seven district councils, making services easier for residents to understand. For more detail on the Warm Homes initiative, see the publication in the documents and links section below.

Future plans and challenges

The number of local area coordinators is being expanded across the county up to 24. The ongoing challenge of maintaining services at a time when the public health grant continues to reduce, and the uncertainty around future funding arrangements, will drive further service transformation. Learning from the experience of Quit Ready, services such as weight management and alcohol brief advice will be brought in house and integrated with the remaining lifestyle services, delivered using technological solutions.

Key messages

• Mutual learning between public health and the rest of the county council has led to the development of a broad social model of public health.
• Asset based community capacity building is a key element of a public health approach to prevention, particularly in light of cutbacks in public spending.
• In two-tier areas, good relationships with district council departments such as planning and housing are vital to a Health in All Policies approach.
• The council has not been afraid of taking services back in-house which has led to significant improvement in its smoking cessation services and an integrated approach to lifestyle services.
• The emotional wellbeing of the community is such a high priority that it merits public health investment.

Contact

Mike Sandys, Director of Public Health

Email: [email protected]

Documents and links

Information on Leicestershire’s Warm Homes scheme is given in the LGA’s Commissioning for Better Health Outcomes

During production of this publication we heard the sad news that Councillor Ernie White, Cabinet Member for Health at Leicestershire County Council had passed away. The longest serving politician at Leicestershire County Council, we’ve kept his words in this report in tribute to his work for Leicestershire and the sector.