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.
The London boroughs of Camden and Islington have shared a joint Director of Public Health (DPH) and a single public health team since the transfer from the NHS to local government. Team members are employed by Islington but work equally as officers of both councils. Both boroughs are inner London councils with broadly similar population profiles, levels of health inequalities and size of public health grant. Camden has a population of around 240,000 and Islington around 230,000. Both boroughs have a strong sense of community and a distinct borough identity.
Most health and wellbeing work is borough-facing and each borough has a health and Wellbeing Board (HWB) and a joint health and wellbeing strategy (JHWS). However, the shared public health function affords the opportunity to align work across the two councils where this makes sense, and the boroughs share good practice and learn from each other.
Partnerships and priorities
A strong focus on tackling inequalities, and on prevention and early intervention is shared across both councils, not just in public health but across each council’s broader agenda and as the ‘leader of place’ in each borough. Within the context of these shared values, the boroughs have slightly different HWB priorities:
- ensuring every child has the best start in life
- preventing and managing long term conditions to enhance both the length and quality of life and reduce health inequalities
- improving mental health and wellbeing.
- healthy weight, healthy lives
- reducing alcohol-related harm
- resilient families
- the first 1,001 days
- ensuring good mental health for all.
Islington and Camden are part of North London Partners sustainability transformation partnership (STP) which covers the five boroughs of Barnet, Camden, Enfield, Haringey and Islington and their NHS partners.
The five boroughs collaborate with each other and their wider system partners to take forward the prevention workstream of the STP, as well as seeking to embed a focus on prevention and earlier intervention across all STP work programmes. The framework for prevention to date includes: creating healthy environments; developing a workforce for prevention; and supporting healthy choices. The five boroughs have resourced some programme capacity for joint work on prevention.
Both boroughs are also part of collaborations to tackle city-wide public health priorities at a London level. The Joint DPH for Camden and Islington is currently Chair of the Association of Directors of Public Health (ADPH) London. Key developments and achievements in recent years include:
- the London-wide HIV prevention programme and London Sexual Health Transformation Programme
- improvement work focused on tackling childhood obesity, including peer reviews, master classes and 19 London boroughs signing up to the Local Government Declaration on Sugar Reduction
- the development of a London Smoking Cessation Transformation Programme.
Challenges and impact of budget reductions
The greatest challenge is the overall funding situation, for Public health specifically and for the wider councils more generally. Public health continually endeavours to ensure it is making the best use of resources by working collaboratively across the two boroughs, and beyond, where this makes sense in order to commission and transform services. It also seeks to attract alternative funding, such as academic grants.
Additional resources would enable key public health approaches and interventions to be delivered systematically and at the scale necessary to impact on population outcomes.
Another key challenge working in a shared service, and in the wider STP context, is the volume and complexity of the partnership landscape and the time and resources required to maintain vital relationships across the system.
- Lead councillor’s perspective – Camden
Improving health and tackling health inequalities runs through everything we do. For example, poor mental health and problems with drugs and alcohol cannot be addressed in isolation – proper housing is vital. If people don’t have somewhere to live it is practically impossible to help them to tackle their problems – any interventions are likely to be money wasted. Good health starts from an early age and the council needs to take every opportunity to help families make healthier choices, as in our Best Start work.
Austerity has resulted in major cuts to the prevention budget and has had a significant impact on our ability to help people to improve their health and wellbeing. We will continue to do as much as we can, but real funding is needed to make a difference to people facing problems of deprivation, particularly in light of developments in Camden that will impact on health, like HS2.
Maintaining a ring-fence on public health funding is important – without this there is a danger that vital specialist services, like stop smoking, could be lost.
Councillor Patricia Callahan
Deputy Leader and Cabinet Member for Tackling Health Inequality and Promoting Independence
- Lead councillor’s perspective – Islington
Public Health is now an integral part of the council and there is a widespread understanding that health and wellbeing are related to every part of its work. Islington has made a great deal of progress and has done so in a way which makes best use of resources. An example of this is the reformed drug and alcohol service which has managed to make efficiencies while providing a better integrated service.
There is huge potential for doing more to promote health and wellbeing. For example, Islington has a large number of community centres which could be further involved as a focus for engaging with local communities and building on assets. There are also opportunities to join up more with leisure services and to embed prevention in the locality-based health and care teams that are being established.
The rate of our progress will depend on future funding. We have laid good foundations by carrying out internal efficiencies and renewing all our contracts to make efficiencies and also, in many instances, creating a better service, but now there is little wriggle room to save more money without serious impact on services.
Cllr Janet Burgess MBE
Executive Member for Health and Social Care and Deputy Leader
- Tackling illicit tobacco
In Camden and Islington, Trading Standards work in partnership with Environmental Health, HMRC, Police, Licensing, Education and Public Health, both locally and across North and East London local authorities. The purpose of this joint work is to raise public awareness and change attitudes about illegal tobacco, increase reporting and deliver effective enforcement of illegal tobacco sales. Camden and Islington Smokefree Alliance was formed in 2014 to drive the joint tobacco control strategy ‘Smokefree Camden and Islington 2016-21’. Examples of recent outcomes include:
- In Camden, inspections of business premises led to the seizure of illicit products including 58,000 cigarettes, 22kg of rolling tobacco,16.5kg of shisha tobacco and 50kg of oral tobacco and snuff.
- In Islington, 53 test purchase attempts for illicit tobacco led to two sales and two small seizures of illicit products. This resulted in two formal written warnings and a requirement to attend a licensing officer panel, where additional conditions were added to alcohol licences.
- Alcohol licensing in Islington
In Islington, analysis by public health of the distribution of licensed premises, alcohol-related ambulance callouts and alcohol-related crime identified correlations between these factors in particular areas and at certain times. This led to the establishment of cumulative impact zones within the council’s licensing policy, which require new licence applicants to demonstrate they will not add to alcohol-related harm, and a borough framework to control sales at times when harm is most prevalent. Public health has also created a ‘licensing premises tool’ to screen new applications and licence reviews in areas of higher alcohol-related harm and submits a representation to the Licensing Committee when it has concerns.
- Spatial planning in Camden
Camden’s Local Plan was refreshed and adopted in 2017, with public health working closely with planning colleagues on its development. This resulted in a strengthened requirement for developers to undertake health impact assessments at an earlier stage and a stronger focus on health promoting environments. This has led to recent major developments in Camden featuring greater connectivity and design features to encourage active travel, outdoor toilets as part of Camden’s Community Toilet Scheme, and increased provision of outdoor space, community gardens and play areas. Public health has also contributed to a review of all the Council’s supplementary planning documents to ensure that a HIAP approach is embedded.
Islington’s 60 betting shops and four adult gaming centres are geographically concentrated in areas of greatest deprivation in the borough. Public health has calculated a local gambling risk index, based on Geofutures, to help inform local planning decisions. Public health contributes to the Local Plan and the ‘Location and Concentration of Uses’ supplementary planning document which is intended to resist clustering of unhealthy premises. A new betting shop application has been refused due to its proposed location being near sensitive users (substance misuse service clients) and to an existing cluster of seven betting shops.
- School superzones
As part of a programme of city-wide prevention work being progressed under London’s Health and Care Devolution Memorandum of Understanding, Camden and Islington are working with the North London Commissioning Support Unit (CSU) on a project to use data and geographical analysis (GIS) to better understand the wider environmental determinants of health and health inequalities to inform place-based action. The school superzones pilot is looking at features of the local environment within 400 metres walking distance from schools, in terms of food, advertising, alcohol, smoking, gambling and vehicle emissions, and working with local communities to then explore and use locally available levers to tackle these.
- Working with communities
Both boroughs undertake resident engagement and insight work with communities and neighbourhoods, seeking to work with local people to better understand needs and assets and to co-produce solutions to improve health and reduce inequality.
For example, in Camden the St Pancras and Somers Town Partnership was formed to bring residents and a broad range of stakeholders together to identify the barriers to eating healthily and being active. Insights from this work are being used to drive collaborative action. One issue to emerge was poor availability of affordable healthy produce. Subsequently, a local organisation was supported through the Camden Can Innovation Fund to set up ‘the people’s fruit and veg stall’. This provides fresh, affordable fruit and veg for the local population, accepts healthy start vouchers, and has links to wider work on health improvement through the School Health Champions programme. Further plans for the stall include a travelling fruit and veg stall campaign across all primary schools in the ward. A project evaluation will be completed in October 2019.
- Health scrutiny driving a “health in all polices” approach
Camden undertook extensive resident and stakeholder engagement to help develop a new vision for the borough – Camden 2025. The vision is that Camden becomes ‘a better borough – a place where everyone has a chance to succeed and where nobody gets left behind’. This community strategy is a call to action for a new way of working in which the council and communities develop solutions together to tackle long-standing community challenges.
Camden’s Health and Adult Social Care Scrutiny Committee used the scrutiny process to consider how the council could embed a HIAP approach for one of these key community challenges – social isolation. It found many examples of existing activities that were supporting individuals and communities to be more connected, such as green space volunteering projects and caretakers proactively engaging with isolated residents. It also identified new opportunities, including the use of social value to drive a greater focus on social isolation through procurement and contracts.
- Behaviour change services
Most behaviour change services are commissioned across the two boroughs, providing residents with greater choice of where to access support. The services are commissioned as separate contracts, but a provider alliance forum has been established to bring the providers together to identify opportunities for joint work. Both boroughs have developed One You portals, based on the national Public Health England (PHE) One You model. One You Camden and One You Islington both provide comprehensive information and access to support and services for local residents.
- Breathe stop smoking service
A new stop smoking offer, ‘Breathe – it’s about living’ was launched by Camden and Islington in 2017 following an intensive process of co-design with local stakeholders and residents. It aims to reach groups who have traditionally not used stop smoking services and help tackle smoking-related inequalities. The service is organised in three tiers dependent on the levels of support people require to help them quit. This ranges from online or app-based information or support, through to specialist advisors based in community or health settings, to more intensive support for people with complex needs, such as those with respiratory disease or mental health problems.
In the first year of activity, in Camden 1,208 people set a quit date and 54 percent (650 people) had stopped smoking at four weeks. In Islington, 1,460 people set a quit date and 51 percent (744 people) had stopped smoking at four weeks.
An important part of the Breathe stop smoking service model is to work with the local voluntary, community and social enterprise (VCSE) sector to recruit and train local people to become stop smoking practitioners. So far 12 people have been trained to become specialist advisors. The advisors offer tier 2 support, targeting smokers in the most deprived communities in each borough and some BME populations. Advisors receive ongoing support and supervision from experienced stop smoking practitioners. The target is for these VCSE practitioners to achieve 50 four-week quitters within six months of operation.
- Better Lives drug and alcohol service in Islington
In developing its new integrated drug and alcohol service, Better Lives drug and alcohol service in Islington carried out extensive engagement, involving service users as experts by experience. Feedback highlighted that treatment options were only one part of ensuring that people have the tools to achieve and maintain their recovery. Support with housing, employment and establishing positive social networks were regarded as essential elements in a comprehensive package of support. A new service specification was co-produced with the local substance misuse user forum, shaped around a holistic model and simplifying routes into and through the service for both users and referrers.
The new service, which was launched in April 2018, is provided by a local NHS provider in partnership with VCSE organisations. Interventions range from residential detoxification and rehabilitation to self-help groups, aftercare services, specialist women’s groups, debt and housing advice, and support for families to tackle familial patterns of abuse.
Since its launch, there has been a significant increase in the number of new service users entering treatment compared to the same period in the previous year:
- 42 per cent increase in the number of opiate users accessing treatment
- 78 per cent increase in the number accessing treatment for alcohol.
The number of families supported for drug and alcohol needs has also increased – from 39 families in the first quarter of 201/18 to 59 in the same period in 2018/19.
- Children and young people 0-19
Both boroughs have put significant focus on developing integrated 0-5 early years services with the aim of providing support which is family-centred, community-based and oriented towards the social determinants of health and wellbeing as well as clinical and developmental needs.
Health visitors are co-located in children’s centres with other early years services, such as family support, parenting programmes and employment support, as part of each borough’s integrated offer – Sure Start (Camden) and Bright Start (Islington). Health visitors are managed by locality managers as part of integrated teams, while professional supervision remains in NHS clinical structures.
School nursing services have also developed in recent years to work more closely with the wider health offer in schools and provide significant input into areas such as mental health, emotional resilience and obesity. Local school nursing services operate a successful Healthy Living Practitioner service providing one-to-one support to children who are overweight/very overweight from a nutritionist attached to school nursing teams. The two boroughs are also piloting an Enhanced Healthy Living Practitioner Service for very overweight children with complex needs and their families.
Both boroughs also offer universal, group-based activities and programmes for children and families focused on healthy eating, cooking and increasing physical activity.
When National Childhood Measurement Programme results are sent out to families, both councils are trialling a new approach in which trained volunteers and staff are based at the school gate in a selection of schools to answer parents’ questions, provide advice, and signpost or refer to support.
- Integrating health and care – analytics and intelligence
Public health has a leading role in the implementation of a population health management system in North Central London which will enable the use of ‘real time’ data to improve population and individual health and wellbeing outcomes. This is intended to deliver a step change in shifting towards more proactive management of health and wellbeing and more efficient use of data and system resources. The next step is to develop and test the new system in one or two neighbourhood level health and care integrated networks (CHINS) with a population of approximately 50,000 people and use the learning to roll the model out across North London.
Public health is also working with North London partners, the London School of Economics and University College London (UCL) to develop an innovative, predictive model for people at risk of needing adult social care services so that prevention and early intervention efforts can be better targeted.
Islington Council is working with Islington CCG, North East London CSU and UCL in a project funded by the Health Foundation’s Advancing Applied Analytics programme. This project will link council and health data to better understand the social determinants of health for households in the borough by creating and analysing a one-off linked dataset and producing analysis and intelligence to inform future planning and locality working.
- Key messages
- Driving transformation and fundamental changes to services is hard and takes time to engage all partners. A focus on outcomes and on listening to and working with residents helps with the navigation of some of these challenges, and the end result can bring many benefits.
- The fundamental alignment of public health with the core values and approaches of each council, namely a focus on tackling inequality, and prevention and early intervention, has enabled public health to embed itself and demonstrate its value in both councils. Recognition and support for public health continues to develop and grow.
- When working to engage with partners, success often comes when we find a ‘sweet-spot’ of added value which meets everyone’s priorities and ambitions.
Joint Director of Public Health,
Camden and Islington Councils