Public Health Review: Analysis of responses to the engagement paper

6 Strengthening public health partnerships (Q3)

6.1 Question 3 of the engagement paper asked: ‘How do we strengthen and support partnerships to tackle the challenges and add greater value? How do we support the wider public health workforce within those partnerships to continue to develop and sustain their public health roles?’

6.2 One hundred and four (104) respondents made comments at Question 3. It is noted that Question 3 is a two-part question. This chapter considers the first part of the question about the strengthening and supporting of partnerships. The issue of supporting the wider workforce is covered in the discussion of wider workforce development in Chapter 8.

6.3 Respondents confirmed that good partnerships were the key to the public health endeavour and that ‘public health is a partnership issue’. Without effective partnership arrangements the aspiration for improved public health could not be achieved. Thus, a focus on strengthening and supporting partnerships was thought to be vital.

6.4 A wide range of themes were raised in response to this question. In their comments, respondents discussed both what they thought should be done to strengthen and support partnerships, and how it should be done. These aspects (the how and the what) are discussed together in relation to nine (9) key themes. Themes which relate to what needs to be done are: clarify roles and remits; improve understanding of public health; improve data, intelligence and research; and increase resources. The remaining themes relate to how this should be done: by adopting an inclusive approach; building on existing partnership structures; strengthening asset based approaches; developing stronger partnerships with the third sector; and enhancing sharing across boundaries;.

6.5 In addition, respondents commented on the importance of good leadership to support partnerships. These comments have been addressed in the analysis of the material on leadership (see Chapter 5). Finally, respondents provided suggestions in relation to practical steps which could be taken, as well as highlighting examples of good partnership models. These are presented at the end of this chapter.

Clarify roles and remits

6.6 Respondents identified a need to clarify roles and remits. The clarification which respondents wished to see included:

• Who is involved in the public health endeavour and how
• Who the stakeholders are
• The goals which have been set and the outcomes which it is hoped to achieve
• Accountability structures.

6.7 Respondents thought that greater clarity of roles, remits and responsibilities would help in achieving the desired public health outcomes. For example:

If the review clarified roles and responsibilities of IJBs, CPPs, NHS Boards, LAs and Scottish Government with regard to public health it would be helpful. (NHS Board, 73)

6.8 This request for greater clarification was sometimes linked to the preference (see again Chapter 5, paragraphs 5.9-5.10) for a national strategy which would map out the various contributions to the overall public health endeavour.

Irrespective of the final configurations of the public health workforce, such partnerships also require a single, shared vision of what is to be achieved. The creation of a Scottish Public Health Strategy, setting out the outcomes required and recognizing the need for local and regional collaborations and partnerships, may be helpful in creating such a vision. (Public health forums and networks, 62)

Improve understanding of public health

6.9 Respondents thought that, overall, there was a lack of understanding both about the scope of public health and the activities which comprise it. Therefore, respondents thought efforts should be directed towards increasing understanding of public health (and partnerships concerned with improving public health).

6.10 The lack of understanding covers a range of scenarios including:

• The lack of understanding that the specialist public health workforce has about the work of other healthcare professionals
• The lack of understanding between partners within a partnership concerned with public health issues
• The lack of understanding between sectors (e.g. public, third and private sectors)
• The lack of understanding of the different ‘levels’ at which public health operates (national, regional, local)
• The lack of understanding of the issues which impact on public health (including wider social determinants of health)
• The lack of understanding of public health within communities.

6.11 Part of the response to this lack of understanding, is to find ways to improve communication, develop a ‘shared language’, make communications more accessible, and heighten public awareness of public health through education and other channels. For example:

One of the key areas that needs to be developed further is a common understanding of each partner’s role of contributing to tackling improvements in health and reduction in health inequalities. Quite often partners use different language and terminology, but are actually working towards similar outcomes. We need to find a shared vision and objectives in order to get ‘buy-in’ with partners effectively. (NHS Board, 28)

Public health can be seen as distant from local communities and the reports produced are often weighty documents which are difficult for the general public to interpret and understand. (Other organisational respondent, 11)

Improve data and intelligence

6.12 Data, information, intelligence and evidence were all thought to be crucial in supporting partnerships. While some respondents perceived that there were already very good information resources available, others made suggestions about how these could be enhanced and some national organisations set out the programmes that they were currently engaged in to improve the public health intelligence function.

6.13 Respondents commented that having a good understanding of the local context and being able to ‘translate’ complex data and information for local partners were key.

6.14 It was suggested that the Joint Strategic Needs Assessments currently being undertaken by health and social care partnerships provided an opportunity for public health professionals to work closely with local partners.

Increase resources

6.15 Respondents frequently identified a need for increased resources for partnerships. The additional resources which would strengthen partnerships were in the form of: i) increased funding for partnership programmes and initiatives, ii) increased capacity in terms of the public health workforce, and iii) increased time to nurture, build and sustain partnerships (including time to build trust and shared perspectives between diverse partners). Overall, there was a view that successful partnerships needed to be ‘appropriately resourced and supported’. For example:

A successful partnership has the right skill mix, level of influence and leadership and is appropriately resourced and supported. Public health’s effectiveness in partnerships has become restricted as our role has reduced over time due to diminishing resources – this has resulted in the prevention role being limited and eroded over time. Partnership takes time and that may be a luxury because of reporting limits and separate agendas. Partnership-work can take a long time to be established (NHS Board, 74)

This should extend to ensuring local partnerships are appropriately resourced to empower communities at a local level. (Partnership, 56)

6.16 It was noted that at present there was not the capacity for core public health staff to engage with Community Planning processes. Moreover, there was comment from a range of respondents that public resources in general as well as some specific elements of public health resourcing (e.g. resource for health promotion initiatives, resource for the prevention role) had diminished over time; there was a widespread view that reduced resources for the public health effort had resulted in less effective partnerships.

6.17 Partnerships also require additional resources to undertake more effectively their role in dissemination and the sharing of good practice. It was recognised that the wider context of financial pressures has the potential to make partnership working more difficult.

Adopt an inclusive approach

6.18 Respondents highlighted the very wide range of individuals and organisations who have a part to play in (partnerships concerned with) public health. Overwhelmingly, respondents affirmed the importance of adopting an inclusive approach, utilising contributions from the broadest possible array of stakeholders.

6.19 There were many comments from respondents from all sectors, to the effect that including partners beyond health and social care was vital. The list of stakeholders considered to be relevant included the wider public health workforce, the voluntary and third sectors, local authorities, communities and the public. In terms of substantive policy areas, respondents reiterated their views that all areas were relevant.

To effectively strengthen and support partnerships, we need to broaden the definition of the “public health workforce”. This includes not just specialists but all those who work (paid/unpaid) in the areas of health, wellbeing, travel, employment, food, environment, land planning, housing, education, poverty etc. Anyone with a role in improving economic, social and environmental conditions should be viewed as making a contribution towards improving public health. (Third sector, 35)

Public health workers should actively seek to increase the partners they work with and interact cleverly with other agencies and even other sectors to tackle the underlying causes. (Partnership, 26)

6.20 Respondents suggested that one way to cement these relationships across the wide range of stakeholders was to agree shared outcomes, and to promote joint working, shared projects, and joint problem solving. Influence and persuasion were thought to be important ways of working within these contexts.

At local levels Public Health should seek to foster a cohesive collaborative approach with partners across the public sector and the whole of the community to achieve its objectives. It will require being persuasive as its direct authority is limited. (Other organisational respondent, 114)

Build on existing structures (CPPs, HSCPs, IJBs)

6.21 Community Planning Partnerships were seen to be at the heart of the public health endeavour, and the main mechanism by which improvements in public health can be achieved at a local level. Some respondents commented that the public health function would, in many ways, fit better within local community planning arrangements, rather than within health boards alone, since it is community planning partners who have access to many of the levers for tackling health inequalities.

We see Community Planning routes as key to influencing and enacting change to address inequalities. Requiring Local Authorities and others to champion Public Health for example through Community Planning Partnership obligations like the public health aims in the Single Outcome Agreement, Early Years Collaborative champions, etc. There is untapped potential for similar priorities such as tackling poverty. (NHS Board, 81)

We also believe that the reduction of health inequalities should be the main statutory objective of Community Planning Partnerships. (Third Sector, 95)

6.22 In addition, respondents commented that Health and Social Care Partnerships, and Integration Joint Boards offered new opportunities for partnership development. However, there appeared to be some disagreement (or confusion) about whether health and social care partnerships were primarily conceived as public health organisations.

So far the national ambition for HSCP’s has not been to create HSCP’s as overtly public health organisations within the legislation, with only one core outcome related to the wider public health endeavour and no requirement for health improvement or public health to be included in integration schemes. (Partnership, 42)

Strengthen asset-based approaches to working with communities

6.23 Respondents were positive about the ‘direction of travel’ which had been identified by the Christie Commission (and others) which focused on building community empowerment and strengthening asset-based approaches (i.e. building on what people have, rather than focusing on need and deprivation). It was thought that this was an important agenda for partnership development and that partnerships would be improved and strengthened if they engaged more, and more effectively, with communities.

The current direction for supporting community empowerment and co-production is positive. More needs to be done in enabling public sector organisations and staff to work in this way. (Partnership, 47)

Information, resources and training are needed to help public services shift away from a centrally-driven service supply model to an enabling model, supporting and working alongside community organisations, local interest groups and wider communities to create a more participative, empowered and healthier Scotland. This could build on a growing interest amongst public health partners in co-production, asset-based approaches and participative democracy. (Third sector, 34)

6.24 This agenda would involve developing trust and learning across all partners and cultures (including informal and formal sectors); mobilising the public as a resource; increasing public involvement in partnerships; and developing mutual respect and understanding for complementary roles and skills.

6.25 The Community Empowerment Bill was thought to be a helpful lever for giving communities a stronger say in decisions that affect them and, potentially, bringing about better partnership working with communities. Respondents emphasised that public health needs to develop ways of working with communities. This would involve public agencies and partnerships developing better listening skills, and including the public routinely as full partners in public health matters.

Develop stronger partnerships with the third sector / voluntary sector

6.26 There was a concern expressed – mainly, but not exclusively by the third sector – that public agencies and public health leaders did not fully engage with the third sector and did not treat the third sector as an equal partner in relation to the public health agenda. This was expressed in a variety of ways including that:

• Trust in smaller locally based organisations can be lacking
• Voluntary and community organisations are not adequately resourced and this prevents them from fulfilling their potential role in improving public health
• Relationships between the statutory and third sectors needs to change so that there is mutual trust and respect
• Third sector and voluntary groups are able to access marginalised groups in a way which is not always fully recognised
• The contracting arrangements in Scotland inhibit partnership working between the public, private and voluntary sectors.

6.27 For example:

Public Health can learn from third sector partners who have long experience of engagement with ‘targeted’ group, for example CHEX and VHS and it would be important to encourage more cross sectoral dialogue within the extended Public Health community. (Partnership, 94)

Enhance sharing across (organisational and sectoral) boundaries

6.28 Respondents emphasised the importance within a partnership context of sharing across boundaries. It was not enough to have a joint board, a joint strategy, and a shared set of goals. The sharing had to be real and practical. Respondents suggested sharing the following :

• Money and resources
• Data, intelligence, information, evidence, research (including linked data)
• Appropriate ‘tools’ and understanding of ‘what works’
• Assessment, evaluation and interpretation skills
• Ideas and experiences.

6.29 In each case, respondents thought partnership working and partnership effectiveness would be improved by the sharing of assets across organisational and sectoral boundaries. For example:

National agencies could provide greater support to the Community Planning Partnerships by providing appropriate ‘tools’ and support and the evidence of what works. (Partnership, 56)

Public Health has a strong empirical tradition and has many strengths in the assessment and interpretation of evidence. So one way in which the discipline can add value is to share this expertise and help disseminate the messages across a wider range of partners. The work of ScotPHO is an example of an area where Public Health expertise can inform and strengthen the evidence base for wider Partnership work. (Partnership, 71)

6.30 The issues about where to locate expertise (at national, regional or local level) and how to ensure that this expertise was used to best effect across the whole of the Scottish landscape were raised again. However, this was discussed in greater detail in Chapter 3 and is not repeated here.

6.31 A number of quite practical suggestions to improve partnerships were also made. These included the development of guidance on effective partnership working and improving IT. In particular it was thought that there was a lot of published material available on the key elements of partnership working and these could usefully inform the development of public health partnerships. For example:

There is a wide research literature on the composition and effectiveness of partnerships, and it is clear that distilling and translating this into guidance on creating and sustaining partnerships that have as their sole focus the delivery of public health objectives would be a useful start (Public health forums and networks, 62)

There is an extensive literature on the nature of effective partnerships, and applying that knowledge in each instance and context is a founding principle. (National NHS organisation, 79)

Examples of good partnerships

6.32 Finally, respondents highlighted from their own perspectives and experiences, some examples of well-functioning public health partnerships. The Scottish Health Protection Network, the Public Health Observatory and ScotPHN, and the North of Scotland Public Health network were all mentioned in this regard.