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.
Liverpool is a city in the North West of England with a population of around 491,000. It is governed by the directly elected Mayor of Liverpool with Liverpool City Council and is one of six local authorities that make up Liverpool City Region (LCR). LCR is a combined authority in which six Merseyside councils share strategic decision making for areas such as economic development, transport, employment, skills, tourism, culture, housing and physical infrastructure.
The health of people in Liverpool is generally worse than the England average. It is one of the 20 per cent most deprived council areas in England and some areas of the city are among the most deprived, and have the greatest health inequalities, in the country.
Liverpool has a young population and a rich maritime and cultural history. Since being European Capital of Culture in 2008, global tourism has grown significantly, and the city provides a unique destination with a diverse range of leisure and cultural activities.
Organisation and partnerships
Liverpool Public Health is a department in the directorate of Adult Services and Health and works closely with partners at several levels.
- With health colleagues in Liverpool CCG and local NHS providers – many of the initiatives in this case study involve the CCG and NHS partners.
- With public health colleagues across Cheshire and Merseyside in the Champs Collaborative which supports joint work on health and wellbeing issues best tackled at scale, such as suicide prevention. Champs coordinate the public health input into Cheshire and Merseyside Health Care Partnership.
- Collaboration with other public health teams and partners across LCR.
The city council has embraced health and wellbeing across all its functions and services and works on major themed interventions to improve health. It seeks to be at the forefront of public health advances both in the UK and internationally.
A big push to tackle deprivation and reduce health inequalities is taking place through the Mayor’s Inclusive Growth Plan which has a vision for Liverpool as ‘a strong and growing city, built on fairness’. The Plan embraces a health in all policies (HIAP) approach but goes further with the concept of ‘health in all policies and places’ – HIAPP. The joint strategic needs assessment is being revised to provide the road map to inclusive growth.
Challenges and impact of budget reductions
Because health outcomes from public health interventions can often be long-term, it can be difficult to secure funding for prevention at a time of financial cut backs. Since budget reductions started in 2015, through national in-year and year-on cuts to the budget, Liverpool Public Health has lost a number of posts, but has managed to continue to deliver its responsibilities through combining roles across the team. It has also looked at opportunities to generate income through the potential to license campaign materials and will continue to do so where this can support future developments.
Public health achieves a lot through partnership working, but funding cuts to the wider council are having an impact on achieving health outcomes. Public health would like to do much more work with communities on tackling the social determinants of health, and without additional funding will look for innovative ways in which this can be achieved.
- Councillor perspective
The public health remit in local government has been a great opportunity to use all the functions that have an impact on health, like housing and open spaces. The growing pressures in population health, such as the obesity crisis and the rise in mental health problems, are best tackled through a social model of health and wellbeing which can focus on deprivation and accompanying health inequalities.
Liverpool City Council and its partners have made a concerted effort to improve health and wellbeing, as shown in this case study. We have taken a health in all policies and places approach, and interventions such as the landlord licensing scheme, accessible community-based sexual health services, social prescribing, targeted cancer screening, a bed for every rough sleeper and campaigns like ‘Save Kids from Sugar’ have all had an impact.
However, we can only go so far, and funding cuts to public health and councils means that we cannot make progress at the speed and reach we would like. Unless funding is increased, very difficult choices will need to be made, and the prevention work which supports the sustainability of joined-up health and care will be limited.
Also, society is being delivered in a way which makes poor health choices too easy. Local government and its partners can only go so far – some changes are needed at national level. Local government is well placed to campaign for national change, such as increased health-related powers in licensing, planning, and local taxation. Liverpool is regularly involved in making such representation.
Councillor Paul Brant
Cabinet Member Adults and Health
Liverpool City Council
- Air quality
Public health is part of a task group convened by the Mayor to improve air quality across the city with a view to developing a city where walking, cycling and clean transport will dominate by 2025. As part of this, the Director of Public Health (DPH) contributed to a scrutiny panel on air quality for Liverpool City Region. Work is also taking place to explore links with children’s lung health, led by a consultant at Alder Hey hospital, and future plans include working with schools to change drop-off and pick-up behaviours.
A major piece of work on air quality is the campaign Let’s Clear the Air Liverpool, which was co-created by public health’s Behavioural Insight and Change Team, with local communities, to motivate people to take action. The campaign has a bespoke website with news and updates and large-scale outdoor, digital and social media activity with infographics and animations as well as radio, newspaper and face to face community events. In first six weeks of the campaign the website received almost 5,000 hits.
- Licensing and planning
Liverpool currently applies a special cumulative impact policy (SCI) to five areas of the city with large clusters of alcohol premises and risk of alcohol harm. Four areas are in the city centre, and one is in a residential area where people face inequalities.
Liverpool already has recommendations relating to hot fast food takeaway clusters in the Local Plan and supplementary planning directions (SPD). As part of HIAPP it is looking to strengthen guidance to maximise the health gains of spatial development, perhaps through a pre-application advice service, design and access statements, and a wellbeing SPD to the Local Plan.
- Making every contact count (MECC)
Liverpool is currently working with partners on extending MECC at scale across all Liverpool NHS trusts and in some cancer pathways in Merseyside and Cheshire. For example, MECC is included in NHS trusts’ standard contracts, and Liverpool CCG is working with public health so that training is being provided to all relevant trust staff to deliver brief advice to patients. Trusts are engaged in a range of MECC activity, including having a dedicated MECC lead, recruiting departmental champions, reporting on performance and developing IT infrastructure.
The next stage will be to roll MECC out across other organisations such as housing associations, Merseyside Police and Fire services, social workers and the universities, and to widen it to include brief advice on mental wellbeing.
- HIV Fast-Track Cities – signing the Paris Declaration
Liverpool has joined London, Manchester, Brighton and 250 countries around the world in signing up to become part of the Fast Track Cities network. This involves committing to accelerate and scale-up local HIV responses. Liverpool’s ultimate aim is to eradicate new cases of HIV and end AIDS as a public health threat by 2030. Pledges include:
- 90 per cent of people with HIV to know their status
- increased percentage of diagnosed people receive treatment
- reduce the negative impact of stigma and discrimination.
Liverpool set up a multiagency Fast Track steering group of clinicians, academics, public health leads and service providers to oversee preparation for the bid, including a city-wide HIV symposium to review services, pathways for patients, and access to testing.
- New model of delivery – pre-birth to age-19
Liverpool has developed an integrated model for delivering the healthy child programme – health visiting, school nursing and the family nurse partnership – shaped through consultation with families and professional stakeholders. At its heart is a seamless, universal, child and family centred service which responds consistently to issues such as mental health and emotional wellbeing, and which collaborates with the broader system of supporting children and families in Liverpool
The model is being rolled-out as part of a two-year transformation programme involving service and workforce development. Collaborative working is already increasing, with health visitors participating in multi-agency working with both children’s centres and early help hubs for children and families with complex needs. The performance of the health visiting service is the highest of the English Core Cities.
- First 1001 days
A 1001 Critical Days Strategic Network has been established to oversee three thematic areas, with the aim of improving the life chances for children, particularly those facing inequalities:
- improving infant nutrition and health including breastfeeding rates
- protection – better identification and targeted interventions at those exposed to adverse childhood experiences
- parent and infant wellbeing and development – improving readiness to learn at age two and school readiness at five.
The Liverpool 1001 Critical Days Programme was recently selected as a pilot area by the LGA and the Design Council. It will work with parents to generate ideas to reduce modifiable risks associated with infant mortality through developing healthy, happy families.
- A focus on breastfeeding
Public Health commissions the Babies and Mothers Breastfeeding Information Service (BAMBIS), a breastfeeding peer support service, at home and in the community. The council also delivers the Mayoral Breastfeeding Friendly Charter Mark which awards organisations for providing a supportive environment to encourage and normalise breastfeeding. Liverpool’s breastfeeding prevalence is below the England average of 42.7 per cent but has risen steadily from 27.6 per cent in 2010 to 35 per cent in 2017 – higher than other Merseyside authorities.
A multi-agency programme of work is being planned to strengthen links between midwifery, health visiting and peer support to further improve support for families around infant feeding and family nutrition.
- Healthy lifestyles
Liverpool commissions large-scale health and wellbeing services which operate in communities to tackle health inequalities. A programme commissioning manager helps co-ordinate shared approaches. For example, all are trained in brief mental health interventions and suicide prevention. A Live Well Directory with public-facing information operates across the LCR.
Public health runs regular multi-media and high-profile health campaigns across the city (see graphics). These include:
- Save Kids from Sugar – Liverpool was the first council to name and shame manufacturers of fizzy drinks, yogurts and cereals that have high sugar content.
- Drink Less Enjoy More and Drink Less Feel Good which involved simulation training to help bar staff with ways of not serving people when drunk.
Campaigns are evidence-based, often co-produced with stakeholders, linked to support from lifestyle services and measured for impact by public health or a local university.
- Global Active City
Liverpool is one of the first six cities in the world to be designated a Global Active City. To achieve this label, it had to pass an independent audit with a tough review of physical activity strategies and working practices. The flagship programme for partners in Liverpool (the council, CCG, Liverpool John Moores University and others) is their advanced work in delivering Liverpool Active City Strategy. Liverpool’s aim is to become the most active city in England by 2021. Some recent developments in physical activity are described below.
- Local Government Declaration on Healthy Weight
In November 2018, Liverpool became the 15th council to sign up to this declaration, confirming the council’s commitment to promoting healthy weight in all policies. It was the first council to be supported in this by the local NHS – Liverpool CCG and seven NHS trusts across the city pledged to support the council’s declaration through involvement in a whole-systems approach.
- Fit for me
Fit for me is a research and insight based physical activity campaign launched by Liverpool Council and Liverpool CCG as part of the ambition to become the most active city in England by 2021. The campaign targets adults 16-64, particularly those who are inactive – 40-60-year-olds, women, people with long-term conditions, pregnant women and young families. The campaign launch featured films of local people as ambassadors, describing how they became active and the benefits this brought. The films have received over 100,000 views to date.
Multi-media follow-up campaigns have asked people to walk more and build ten minutes more activity into their daily routine. Support was provided through hundreds of free activity taster sessions across the city. Five months after launch, a representative survey of 532 adults found half were aware of the campaign and 18 per cent had taken action as a result of seeing it. The survey also showed a six per cent reduction in the number of people who were inactive in the target audience. The campaign website has received over 161,874 visits, while 8770 people have completed an online activity quiz.
Fit for Me is underpinned by several community asset-based initiatives.
Volunteer-led behaviour change: A group of 11 women in a low activity neighbourhood were supported to produce a community asset map, which identified 119 different opportunities for activity. Using a bespoke social network analysis tool developed for the project the women identified 24 people with whom to have a conversation about being more active. Fifteen people were followed-up after three months. Eleven showed some evidence of improved activity and four had made significant changes. There were also improvements in self-esteem and resilience. The project will be built-on and tested at greater scale.
Recovery runners – this pilot programme is for people recovering from drug and alcohol problems and involves a 12 week ‘couch to 5K’ training programme. The programme has peer support through social media and programme graduate peer mentors. It has been linked with free Liverpool Park Runs to provide opportunities for continuing exercise.
A plan under development is to increase physical activity in children and young people with cross-council, NHS and community support. A public health consultant and an epidemiologist are working on the details of this.
- Key messages
- Although the financial position is very difficult, there are many opportunities and successes that provide encouragement.
- It is important to frame discussions around what outcomes investment in health and wellbeing can achieve.
- Highlighting success stories, so that councillors, other senior decision makers, and the public know what is being achieved is very important.
- Making the case for ‘big hit’ programmes that will make a significant impact across all partners is essential.
Dr Sandra Davies
Director of Public Health
Liverpool City Council