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.
Norfolk County Council covers an area of around 2,000 square miles with a population of around 900,000 people. It is largely rural and agricultural with some urban areas, including King’s Lynn, Great Yarmouth, and the city of Norwich. As a low lying coastal area, it is vulnerable to coastal erosion. Norfolk has a strong sense of history, identity and tradition.
The health of people in Norfolk is varied compared to the England average, with life expectancy higher than the average. There are some areas of health inequalities and deprivation and around 15 per cent of children live in low income families. Norfolk’s rurality, dispersed population and extremes of weather are significant issues for public health.
Public health is a team within Norfolk County Council’s Department for Community and Environmental Services. There have been several key changes to how the team operates in recent years. It has taken on council-wide responsibility for resilience, community safety, road safety and the Health and Wellbeing Board (HWB) – extending its reach to new partners. The Intelligence Team has transferred to the council’s Strategy and Delivery Unit to facilitate council-wide use of public health data, analysis, evidence and best practice to inform strategic planning and financial forecasts.
Public health has also developed its commissioning and contracting function and commissions most of its services. To support this, it established:
- a head of delivery and performance to focus on adding value and best use of resources
- a contract management team to lead on relationships with providers and undertake formal contract management functions
- increased skill mix in the department including officers with experience of democratic services, children’s services, and district council functions.
Partnerships and priorities
Working with partners in the seven district, borough and city councils is a priority for Public Health. The Director Public Health (DPH) works with the District Directors Group to support their work on health and wellbeing, aligning county and local priorities.
Public health works closely with the five Norfolk CCGs and with local NHS providers.
The DPH leads the prevention workstream of Norfolk and Waveney sustainability transformation partnership (STP) which has a programme to alleviate winter pressures, as well as longer-term prevention aims focused on the wider determinants of health. These include reducing suicide – the STP has joined the National Suicide Prevention Alliance – scaling up stop-smoking and rolling out social prescribing.
The DPH is the chief officer supporting Norfolk HWB which published a new Joint Health and Wellbeing Strategy (JHWS
Since the transfer to the council, public health has reviewed and redesigned its activities to make sure that services are high quality, accessible to people with the greatest health and wellbeing needs and good value for money. It has also spent time developing relationships with partners within and beyond the council. It is now building on these foundations to deepen the partnerships and networks that together can tackle key public health priorities in Norfolk. These include partnerships around a topic, around a locality and, often, a mix of the two. Another key approach is to maximise the digital offer so that more people receive health and wellbeing support to enable them to self-care, and staff time is targeted at those with higher levels of need. This will be rolled-out through most health and wellbeing services, including through a forthcoming review of healthy lifestyle services.
Challenges and impact of budget reductions
Recruiting skilled staff is very difficult in Norfolk. The council and partners are seeking to improve this by a range of measures including providing additional training to existing staff.
While NHS partners understand the importance of upstream prevention, current pressures are such that it is difficult to do this at scale. Public health will continue to work with the STP to put more focus on sustainable preventative initiatives that are needed to reduce future demand.
Reductions to the public health budget mean that it has become increasingly difficult to find the capacity and resources to take a place-based approach – with additional funding, public health would be able to do more to work with districts and boroughs to deliver health and wellbeing initiatives in local communities.
- Councillor perspective
In Norfolk, commitment to prevention is high, and there is growing good will across the county council, district councils, CCGs and NHS providers to work together. For the first time, Norfolk’s Joint Health and Wellbeing Strategy (JHWS) has been endorsed by all the NHS providers. This brings great opportunities to tackle health and wellbeing together. For example, the Community Health and Care Trust has carried out a survey asking staff what they understand about housing, with a view to NHS staff being aware of patients’ housing needs and able to make appropriate referrals.
In a situation where all organisations are required to make savings and face many pressures, it is not easy to find investment for prevention. As a council, we will keep making the strong case that prevention will reduce demand for expensive health and care services. We are also concerned that the national push to tackle delayed transfers of care has created a narrow focus on hospital discharge, rather than on developing sustainable solutions. We are making good progress, and it would not be helpful if new central diktats or structures were imposed on local partnerships.
The seven district councils in Norfolk are now members of Norfolk Health and Wellbeing Board and also form a HWB sub-committee where they are actively working on health and wellbeing priorities, such as housing. In future, Norfolk HWB will have an increasing role in adding value by ensuring that health and wellbeing interventions, like reducing suicide, are co-ordinated on a system-wide basis.
Councillor Bill Borrett
Chair of Adult Social Care Committee and Chair of Health and Wellbeing Board, Norfolk County Council
Health and wellbeing initiatives – highlights
Resilience and emergency planning
- Resilience and emergency planning
Public health represents the council in the county-wide resilience forum and chairs the local health resilience partnership. The team also hosts a health resilience officer post, jointly funded with Norfolk’s CCGs, which provides co-ordination and a direct link into CCGs to ensure involvement in planning and training. The forum has reviewed its strategy to establish greater involvement of elected members at parish, district and county levels and greater engagement with local communities and volunteers in emergency preparedness, response and recovery.
Norfolk’s geography means it is liable to suffer from heatwaves, water shortages and flooding. An important strand in resilience work is to be prepared for the health implications of climate change and sustainability. Public health won the Sustainable Health and Care Award for ‘Adaptation’ – the best resilience strategy. Key elements of the strategy include the following.
- Identifying solutions for extreme weather preparedness such as:
- auditing a sample of business continuity plans of care homes with commissioned beds
- keeping and sharing risk registers of vulnerable people between services
- making extreme weather preparedness a staff competency.
Developing a self-assessment tool to support the council and partners in considering aspects of preparedness, such as:
- potential for residents with complex needs being left without services
- mitigation, such as video conferencing to reduce travel.
Work on resilience involves many partners which means it is being actively linked with important public health issues such as warm, sustainable homes; fuel poverty; and community support such as social prescribing.
- Road safety
Around 402 people are killed or seriously injured annually on Norfolk roads, many of which are long single-track country roads. Public health’s road safety team and has worked with partners, such as the Police and Crime Commissioner and Highways, to revise the road safety strategy. Partners have made a shift in emphasis from enforcement and individual responsibility to a public health approach which includes:
- systematic collection of information to define the problem
- using research and evidence to design, implement and evaluate interventions, then roll-out what works.
An example of this is an in-depth study of a dangerous stretch of the A1151 which resulted in various improvements including: a safety camera, provision of a passing bay, increasing the size of a speed limit terminal, and standardisation of traffic warning signs and road markings. In 2018, the EuroRaps Conference in the House of Lords identified the A1151 as one of the most improved in the UK.
- Men’s mental wellbeing and suicide reduction
Norfolk’s suicide rate has historically been high, with an average of 75 to 80 suicides a year. A local audit showed a higher proportion were by men of working age. Norfolk partners identified men’s mental wellbeing as a priority and established a suicide reduction group to develop a county-wide strategy. The group made successful bid for NHS England Funding – around £700,000 over two years. Actions include:
A collaboration with Norwich Theatre Royal on a programme of productions, workshops and special events aimed at reducing the stigma surrounding men’s mental health. The work won the silver award (regional) for the best public sector campaign from the Chartered Institute of Public Relations. An annual training and development conference for practitioners, families and individuals. The Menkind mental health campaign which includes work to train barbers to talk with customers about mental wellbeing, and using local figures, such as a former footballer, to talk about mental health. A multi-agency learning event involving experts from across the country.
The strategy started in 2016-17 and, although it is early days, early results are encouraging. In 2017 there was the first reduction in numbers of suicides for four years, dropping from a rate of 12.5 per 100,000 to 10.6.
- Children and young people
Public health redesigned its healthy child programme and commissioned an integrated 0-19 service from a single provider. A significant element of this is to improve the digital offer to make support more accessible to children and young people. This includes podcasts, an interactive and accessible website, and the Just One number which gives access to a trained call handler who can arrange one-to-one support if needed.
This initiative was regional winner in the person-centred care champion award category in the NHS70 parliamentary award. Norfolk is also part of a national evaluation of parenting programmes based on e-learning.
- Sexual health
Public health has redesigned and commissioned an integrated sexual health service which includes prevention, community-based clinics, outreach and, on behalf of NHS England, HIV treatment services. The service continues to develop to meet changing needs and priorities. In 2017 there was a move to online testing for people who are asymptomatic. This proved both popular and cost effective, with around 2,000 more people tested a year and high return rates.
Based on the integrated service, a county-wide sexual health network was established, involving the VCSE, schools, services for children and young people, the NHS, and sexual health providers. The network allows members to address operational issues directly and to share good practice. It has also agreed a sexual heath strategy to work on shared priorities.
Data showed that the previous momentum to reduce teenage pregnancy had stalled and needed to be refreshed. Partners worked with community connectors in children’s services to establish locality based teenage pregnancy groups which have developed projects such as in-reach into targeted schools and improving the effectiveness of outreach services based on local knowledge.
Norwich is a high HIV prevalence area and data showed that late diagnosis was on the increase. Action to address this includes:
- case audits of late diagnoses in clinics, including client interviews and using the data to identify and develop effective interventions
- improvements in health settings, including lab protocols, health professionals spotting non-specific signs and opportunistic testing in A&E
- awareness raising campaigns on local radio, press and social media.
Results for past three years show a significant increase in testing coverage and a 12 per cent reduction in the proportion of people diagnosed late.
- Domestic abuse
As part of its community safety responsibilities, public health leads the multi-agency domestic abuse strategy board which is delivering a comprehensive domestic violence response which includes the following elements.
A communications campaign: #NoToDomesticAbuse and #WalkAway.
A network of domestic abuse change champions now at over 1,000: A recent impact analysis estimated that over 1,500 people were safer than they would have been without the network. The partnership was successful in winning a Home Office grant for three-year and is now rolling out the network and further targeting schools and health settings including hospitals and GPs.
A national beacon project in Norwich using local partnership and national funding, evaluated with the University of Lancaster: The project offers help and support to vulnerable groups including young people, older people and families, with the aim of earlier intervention with medium risk situations, rather than waiting for high-risk crises to develop. Norfolk won the Municipal Journal Innovation in Public Health Award in 2018 for this partnership work.
- Social prescribing
A Norfolk-wide social prescribing service has been set up using funding from the Improved Better Care Fund and Public Health, totalling £950,000 per year for two years.
The service, which will be developed by CCGs on a locality basis working with district councils and the VCSE sector, has the following principles:
- delivered at scale, accessible to patients from all GP practices and takes referrals from the County Council
- one approach to evaluation built in from the start
- asset-based – utilising existing resources from all partners.
- Drugs and alcohol
Public health redesigned the specification for the drug and alcohol service to place a greater focus on accessible community-based recovery programmes while providing specialist health services and rehabilitation for those in most need. The new service, which was commissioned from a new provider, went live in April 2018. Public health is now working with the service to extend the focus on integration, outreach and a digital offer.
- Key messages
- Many public health issues can only be tackled by bringing the right people together to work on shared solutions. A key role for public health is to instigate and support these partnerships.
- A business-like approach to public health spending, based on value for money and quality, is the foundation for partnership working and innovation.
- Digital technology often provides greater reach and improved accessibility and can be more cost effective.
Dr Louise Smith
Director of Public Health
Norfolk County Council