2015 Review of Public Health in Scotland: Strengthening the Function and re-focusing action for a healthier Scotland

Annex F. Public Health Contribution to Community Planning and Health and Social Care Partnerships

Public Health Function

1. A public Health function needs to work across all structures to successfully support and influence partners to deliver public health outcomes: NHS, local government, private and voluntary sector, Health and Social Care Partnerships and Community Planning Partnerships. In many areas this is already happening. The Public Health Review endorses this approach and seeks increased leadership and visibility of an appropriately resourced public health function within the NHS and across these partnerships.

2. The work by the Royal Society for Public Health (RSPH) has provided a definition of the contemporary public health workforce encompassing consultants and specialists, public health practitioners and a wider workforce across the academic, public and third sectors (Rethinking the Public Health Workforce (Royal Society for Public Health, 2015) and Tackling health inequalities: the case for investment in the wider public health workforce (Royal Society for Public Health (RSPH), 2014)). Within NHS Board and wider Partnership work there are examples where the local public health workforce can work effectively to common goals for population health and wellbeing and for better services, sometimes using the local Director of Public Health annual report or a needs assessment as a stimulus for action. The Public Health Review has the potential to strengthen synergy and collaboration between the work of public health staff in local and national Health Boards, and between Boards and local partnerships and voluntary organisations, in order to improve local services, leading to better outcomes and contribute to reducing inequalities.

3. Public Health can provide oversight, advocacy and facilitation to help reduce duplication across agencies and maximise outcomes. Public Health has expertise in, and responsibilities for, surveillance and assessment of population health and wellbeing; identification of health problems and hazards in the community; and evaluation of the quality and effectiveness of personal and community health services. This role should drive the analysis and mapping of the activity that supports Health and Social Care Partnerships and Community Planning Partnerships, as well as work within NHS Boards and Local Authorities. It should ensure that the collective effort maximises the potential input and positive impact on the population's health.

Context for partnership working

4. The Public Bodies (Joint Working) (Scotland) Act 2014 provides an environment for more consistent and effective application of public health expertise in preventing premature, disabling illness and death and improving services and quality of life for people who are frail or vulnerable across many health and social care functions of Local Authorities and Health Boards.

5. The Public Health etc. (Scotland) Act 2008 requires NHS Boards, in consultation with Local Authorities, to develop a local Joint Health Protection Plan which provides an overview of health protection (communicable disease and environmental health) priorities, provision and preparedness for the NHS Board area. The plan reflects agreed local priorities and supports joint health protection working through maintaining local links and delivering joined up approaches.

6. The reforms to community planning contained in the Community Empowerment (Scotland) Act 2015 specify Local Authorities, Health Boards and Integration Joint Boards (health and social care) and others, as statutory partners in Community Planning.

7. The Community Empowerment Act extends the statutory duty of cooperation beyond health, local authority and education, and places a responsibility on all partners to work collaboratively to carry out community planning and to take account of the local outcome improvement plans in carrying out the partner's own functions and to contribute staff, funds and other resources as appropriate.

8. This provides the opportunity for Health Boards and Public Health Departments to get even more involved in supporting Community Planning Partnerships and Integrated Joint Boards, as well as NHS Board services and Local Authorities, in delivering the stated outcomes and also in working closely with partners to inform strategy and delivery so that they can provide a greater contribution to improving population health, tackling inequalities in health, and improving access to services. This opportunity should be capitalised on now as the intention is that partners should already be supporting community planning consistent with the principles in the Community Empowerment Act leading up to its enactment. Public Health can contribute to a public sector prioritising early intervention and preventive spend as envisaged by the Commission on the Future Delivery of Public Services in 2011.

9. In addition Health Boards and Local Authorities, as governance partners under the Act, become collectively responsible for effective community planning. The Public Health Review recommends that NHS Boards make more explicit their specialist public health contributions to working closely with partners to take forward these efforts. This should include advice and support to improve the health, wellbeing and sustainability of local communities; deliver equitable services that reduce inequalities; and evaluate their impact. This will include providing leadership and skills to help ensure that all areas implement a Health in All Policies approach; undertake integrated impact assessment of strategies, policies and plans, particularly resource allocation; and equity audit service delivery.

10. The expectation that Boards should use this ongoing opportunity, exhibit the behaviours and embrace the principles of community planning is contained in the current Local Delivery Plan guidance for NHS Boards for 2015-16 (December 2014), which asks NHS Boards to "indicate how they will continue to strengthen their approach to community planning during 2015/16, through both their direct contributions and how they demonstrate leadership within the CPP. This should focus on how the CPPs act to improve local priority outcomes which relate to health and wellbeing, and how they shift activity and spend towards tackling inequalities, prevention and community empowerment."

Public Health role in partnerships

11. Public Health's focus includes developing and improving evidence-based health and social care through the careful assessment and planning for health needs, and the inclusion of prevention strategies, quality considerations, efficiency, equity, and ensuring health impact at a population level over the longer term. There is a synergy between the delivery of health improvement interventions that are integral to the provision of effective health care - such as adult immunisations, that are delivered within Health and Social Care Partnerships - and the work at neighbourhood level to improve local outcomes and reduce inequalities within the context of community planning. Public Health teams have the skills required to ensure that these synergies are realised to achieve better population health and wellbeing outcomes.

12. The potential impact of Public Health working with Community Planning Partners is wider still given that community planning involves a broader range of partnership structures and a clearer focus on reducing inequalities and responsibility around wider determinants of health. For example, Public Health can contribute expertise to Local Housing Partnerships to ensure Local Housing Strategies are drafted with population wellbeing across the life course in mind. Public Health can also effectively contribute to Local Authorities and other partnership work covering areas such as Planning, Education, Transport, Employment and Criminal Justice.

13. Integration Joint Boards' remit also includes strategic planning and performance monitoring across a broad range of health and social care services, incorporating the input of the voluntary agencies, independent sector and others. Public Health can provide support for the development of services that reduce health inequalities while delivering improved health and benefit at a population level by preventing disease and improving health-related outcomes through equitable and appropriate access to, and utilisation of, effective health and care interventions. Similarly, Public Health can provide support for effective delivery of Local Authority services to those most in need, including a focus on early intervention and reducing inequalities.

14. There also needs to be strong links to the shape and balance of wider services provided directly by NHS Boards, primarily acute services. To do this they must ensure equity of current provision of prevention, treatment and care, but also need to make a contribution to Community Planning Partnership work on factors affecting the health and wellbeing of the population. The effects of improvements to care and service developments can last for decades, leading to sustained improvement in population health and sustained delivery against organisational goals and priorities.

15. The Director of Public Health Report will continue to provide independent advocacy and a voice for public health actions and responses across the Board's area and reflect the specialty's wider responsibilities for the population's health. The Report should encompass delivery of all of the essential public health operations while highlighting existing strengths and current and emerging challenges to health and wellbeing. The Director of Public Health Report will reflect the priorities for action set by Community Planning Partnerships, Integration Joint Boards, NHS Board services and Local Authorities, and help to inform ongoing activity as part of the collective effort to improving population health and tackling inequalities. It is recommended that Public Health, as a discipline, needs to contribute effectively to the work of senior Community Planning Partnership and Integration Joint Board groups such as the Strategic Planning Group in all local areas.

Summary of Public Health input into Health and Social Care Partnerships and CPPs:

Strategic

• Enable organisations to take a "Health in All Policies" approach at national and local level.
• Provide leadership, advocacy and support to partners to reduce health inequalities, such as by shaping actions to reduce barriers to health and improved living and working conditions.
• Advise on approaches to prioritisation to help ensure that our services focus on areas of greatest population need whilst also ensuring a balanced approach to maintain equitable access to more specialist or intensive services for groups of people who have high or particular needs for which effective intervention exists.
• Provide advice and input on integrated impact assessment, and to help ensure that service evaluation and equity audit are undertaken and that robust prioritisation processes are in place, e.g. that proposals for investment, development and change are assessed for likely effectiveness, opportunity cost (foregone alternative use of resources), affordability and value.
• Embed early intervention, preventive and quality improvement approaches at partnership level.
• Public Health, as a discipline, needs to contribute effectively to senior CPP and IJB groups, such as the Strategic Planning Group, in all local areas and within NHS Boards and Local Authorities.
• Joint planning of health protection to ensure resilience of health protection function through Joint Health Protection Plan.

Health Intelligence and Analysis

• Provide advice and oversight and develop a shared understanding across NHS Board areas; Local Authorities; with the IJB; CPP; and other key partners, on population health and wellbeing including patterns of health and disease and the main determinants of health for defined populations.
• Provide independent interpretation of published evidence; available data or other relevant and important knowledge sources; and inform and support evidence-informed and value-based decision making, with the aim of ensuring equitable access to effective, safe, person-centred and integrated health care services.
• Lead and provide support for Health Needs Assessment to identify need and support service redesign and improved resource allocation through the identification of populations that are most able or most likely to benefit from care.
• Support the use of (integrated) health impact assessment to ensure unintended impacts on people with high levels of need are identified and addressed, and delivery of services tackles health inequalities.
• Support capacity building in HSCPs and Local Authorities through training in epidemiology, demography, data interpretation, and support with more complex analyses (such as health economics) including monitoring and evaluation. This can be facilitated by DPH oversight of allocation of NHS time of academic public health staff, links with academic units and other sources of expert knowledge and skills.

Delivery of services by IJBs/HSCPs, Local Authorities and NHS

• Support the design and delivery of services that meet the needs of all groups, promote accessibility and effective use by the most vulnerable, i.e. proportionate universalism including specific services for vulnerable and marginalised groups, recognising their particular and often greater complexity and level of need, e.g. welfare advice in health settings, inequalities in service access, social support, supported self-management.
• Specialist Public Health directly coordinates and quality assures specific population health programmes such as for screening and immunisation.
• Provide leadership for evidence-based health improvement interventions across Health Board, IJB, Local Authority, third sector and Community Planning, including assets based approaches.
• Maintain local links and delivery of local health protection priorities as identified in the Joint Health Protection Plan.