Healthier Herts - Hertfordshire · 4 Healthier Herts: A Public Health Strategy for Hertfordshire Figure 1: Our public health strategy at a glance OUR PURPOSE: To work together to

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Healthier HertsA Public Health Strategy for Hertfordshire

Hertfordshire

County ofOpportunity

2013 - 2017

Contents

7. The implementation journey

6. Achieving our priorities

5. Public health priorities for our residents

4. Vision into action

3. Conceptual and delivery models for the public health system in Hertfordshire

2. Health in Hertfordshire

1. Why a strategy for public health?page

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2 Healthier Herts: A Public Health Strategy for Hertfordshire

ForewordWe want Hertfordshire residents to have the opportunity to live the healthiest lives possible and to live safely in their communities. Some of the county’s residents are significantly less healthy than others. We recognise the considerable effect that remaining healthy has on the happiness and life chances of our residents. With responsibility for public health returning to local government, we want all services to work together to improve the overall health and wellbeing of people in Hertfordshire, with early measures taken to tackle health inequalities.

Hertfordshire


We have ambitions to improve and protect the health of our residents as part of our vision for Hertfordshire. “We want Hertfordshire to remain a county where people have the opportunity to live healthy, fulfilling lives in thriving, prosperous communities1.”

Healthier Herts: A Public Health Strategy for Hertfordshire 3

This vision is ambitious, and recognises that health, prosperity and fulfilling lives are inter-dependent.

Our ambition for Hertfordshire sets out a common purpose to see:

• Citizens who enjoy life and are healthy • Safe and active communities that get on well • A strong economy where businesses thrive • A high quality environment • People who are able to achieve their potential.

The transfer of statutory responsibilities for public health to the county council on 1 April 2013 gives us a significant opportunity to enhance and further the efforts to achieve this. More than thirty years of scientific evidence on public health underpins the insight that a strong public health system focused on improving and protecting the health of our residents is essential if we are to achieve the vision and ambition we have set2.

This strategy sets out the context in which the county council will discharge its statutory responsibilities for public health, but also recognises that we need to work as a public health system in Hertfordshire, where agencies with statutory responsibilities work together with every agency which can make a contribution to public health. This means local authorities, the Police and Crime Commissioner, police, probation, schools, the NHS, employers, businesses, voluntary and community agencies and others across Hertfordshire, all have a role to play.

No single agency has the answer, and we must all work together, playing our parts and playing to each others’ strengths.

We can either see this as a challenge or anopportunity. We have a strong track record in Hertfordshire of working together.

This is evidenced from the fact that this strategy was written by people from a range of agencies working together.

Achieving this strategy will bring significant benefits to our population in terms of increased quality of life and better health. It will also bring savings to the public purse. Most public health interventions save more than they cost. One case of HIV infection avoided is costed by the Department of Health at £1.25 million saved in treatment and care. Behavioural interventions to keep people at a healthy weight cost less than a fifth of surgery and save up to £250,000 per person in heart disease and diabetes treatment3. Overall, based on research and experience from other areas, public health interventions which are successful could save Hertfordshire up to five times more than we invest. As part of our commitment to demonstrate this, our implementation plans will be accompanied by an analysis of cost-effectiveness wherever possible.

I particularly want to thank our public health team, district and borough councils, Healthwatch Hertfordshire, our NHS partners, the Police and Crime Commissioner, Probation Service and Public Health England for their support and enthusiasm in drawing this strategy together.

Public health is an exciting portfolio because it is something which touches all of us. I am confident that people in Hertfordshire will rise to this opportunity, to the benefit of all of our residents.

Cllr Teresa Heritage


Figure 1: Our public health strategy at a glanceO

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Good health is what we all aspire to for ourselves, families, carers, friends and communities. There are many determinants of health ranging from genetic factors to the impact of where we live and our social and economic circumstances.

1. Why a strategy for public health?


Recent policy and advances in public health science have acknowledged that local government is well placed, in its strategic place-making role, to work on these with partners. Most recently the Health and Social Care Act 2012 gave the county council a duty to improve the health of its residents. The ten district and borough councils in Hertfordshire already have powers to improve health under the 1984 Public Health Act, and these, along with the county council share a general power of competence, enabling them to do what is needed to improve the health of their residents.

National Health Service clinical commissioning groups have a statutory duty to reduce inequalities in health in their patient populations. Many other partners, from the Police and Crime Commissioner to voluntary and community sector bodies, faith communities and business, have a role in making Hertfordshire a healthier county.

The Health and Wellbeing Strategy for Hertfordshire4, sets out the key priorities for the Health and Wellbeing Board (HWBB)5. While there are some priorities within the strategy of common interest to public health and the HWBB (tobacco, healthy weight and alcohol are three of the nine HWBB priorities on which public health take the lead) there are a number of other areas where public

health have responsibilities (sexual health, drugs and alcohol, school nursing, health checks and other areas) which are not within the nine key priorities of the Health and Wellbeing Strategy but which do need to be addressed. This strategy seeks to do that.

This document seeks to outline the vision for public health as part of the vision for Hertfordshire6, and to provide a clear road map for how the work of public health functions in Hertfordshire will ensure all residents will have an “opportunity to live as healthy lives as possible and to live safely in their communities”, which the vision for Hertfordshire commits us all to achieving.

Public health is defined by the Faculty of Public Health (“the Faculty”), the standard setting body7 for public health practice in the UK, as

“the science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society.”


The Faculty’s approach to Public Health:

• is population based • emphasises collective responsibility for health, its protection and disease prevention; across agencies and partners• recognises the key role of the state, linked to a concern for the underlying socio-economic and wider determinants of health, as well as disease• emphasises partnerships with all those who contribute to the health of the population.

A detailed statement of evidence for what this strategy proposes is beyond the scope of this document, because much of it has been stated elsewhere, i.e. The Strategic Review of Health Inequalities in England Post 2010 (the Marmot Review 20108), along with the National Audit Office’s report on Health Inequalities9 and the World Health Organisation report Closing the Gap in a Generation10, all identified that the need for England is to reduce health inequalities in a sustainable way.

Much of this research has identified that the health outcomes (life expectancy, burden of ill-health and disease, avoidable death) which people experience is the result of a complex set of interplaying factors11:

• Our parents health before and during conception and pregnancy• Our start in life (healthy or unhealthy)• The lives we lead (physical, social, psychological and spiritually healthy lives)• The place we live in• The opportunities we have (good education, good employment)• The services we access (high quality, easily accessible, focusing on prevention).

These things are often called determinants of health, and are shown in more detail in figure 2 on page 9. Our experience of education and employment and our built and natural environment are often called wider determinants of health.

The Joint Strategic Needs Assessment (JSNA) for Hertfordshire12 provides an overview of the health of our county, as well as some in-depth analysis on health topics. The JSNA makes it clear that Hertfordshire faces a number of inter-connected public health challenges where we are not performing as well as we could. While in terms of premature death we are twelfth from top of England’s local authorities; when compared against our peer group we are placed twelfth out of fifteen. There is an eleven year gap in life expectancy between the healthiest and the least healthy areas in Hertfordshire.

There are a number of reasons why this is the case:

• Too many people in our county spend the end of their lives in avoidable

disability caused by non-communicable disease as a result of the common risk factors of smoking, obesity, poor diet, physical inactivity and alcohol consumption• Too many people in our county die early of avoidable disease • Smoking remains our biggest cause of avoidable death• Being obese or overweight is reducing the healthy life expectancy of too many of our young people and adults• Preventable mental ill-health is too high; and the burden of mental ill-health across the lifecourse is too high• We need to do more to ensure our children have a healthy start in life and grow up healthy• Avoidable ill-health and the risk factors for these are hindering efforts to reduce poverty and increase prosperity.


These challenges are not something specialist public health functions, wherever they sit, will solve on their own. Everyone must work together. The role of public health is to provide evidence, intelligence and foresight to help those whose key role it is to both deliver the improvements needed and see the interconnectedness of what they do.

But improving health is complex. The NHS has a large part to play in leading health improvement and in securing high quality health care, but local authorities have significant power and influence over many of the medium and longer term inequalities and determinants of health such as environment. These determinants of good health; environmental, economic and social, can only be tackled through good partnership working, and this requires clarity about what we are trying to achieve. Schools and colleges also have a key role to play.

The Marmot Review re-iterated that to improve the health of the whole population and those who are least healthy, “focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage”13. This is called proportionate universalism14. This key principle has been

adopted in the Health and Wellbeing Strategy for Hertfordshire and is adopted here.

The transfer of responsibility for significant areas of public health in April 2013 from the NHS to local government is one of the most significant extensions of local government powers and duties in a generation. It represents a unique opportunity to change the focus from treating sickness to actively promoting health and wellbeing. Equally, as our knowledge on what factors determine our health outcomes grow, we see that improving the health of our residents requires contributions from a wide range of players.

This document seeks to present clarity on what we are trying to achieve. It is intended to focus on priorities and outcomes, and be a brief statement of principles and priorities.

Our implementation plan will focus on identifying the various contributors to good or ill-health, and interventions and roles to improve health. The figure overleaf shows the contribution of various determinants of health to overall health. Many of these are issues which our JSNA and other needs assessment work have identified for Hertfordshire.


Figure 2: Determinants of Health15

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This strategy for public health demonstrates the commitment of the county council to actively improving the health of the people living in Hertfordshire, working with all of its partners. We recognise the commitment of our partners.

The strategy which is shown in summary on Figure 1 (page 4) will:

• Aim to improve health outcomes for all our residents

• Set out our public health priority areas for short, medium and long-term action

• Set the context for implementation plans between 2013 and 2017; these will be

refreshed annually. Within these implementation plans we will use the

tools of proportionate universalism, a lifecourse approach and “Five Ways to Wellbeing”16, along with other tools.


The Lifecourse approach

How long we live, and how much of it we spend in good health or ill-health, is the result of risks we accumulate across our lives. Just as we conceptualise health as outcomes influenced by a range of determinants (see page 9), health outcomes are also the result of a developmental trajectory from before conception (maternal health behaviour and status) to old age. This trajectory is multidimensional; there are biological, psychological, behavioural and social aspects. Figure 3 below conceptualises these influences and dimensions.

The lifecourse perspective will form a key part of our lifecourse model, where we develop health interventions which help people make the best and healthiest start in life, develop through a health promoting school and family environment, work in a health promoting workplace and take steps to keep themselves healthy. We will describe this in more detail in our implementation plan and through our public health skills development programme.

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Figure 3: Influence of health status across the life course


Collectively, people in England are healthier now than at any other point in history. We are living longer and have more years of good health than ever before. In some respects the same can be said of Hertfordshire, and we have seen some significant improvements in health over the last ten years, most notably in life expectancy and reductions in infant mortality.

But some areas of Hertfordshire remain behind England as a whole and the gap for

some of our persistent inequalities in health, between us and England, is not narrowing. There is a higher burden of death and ill-health placed on the poorest areas of Hertfordshire than on England as a whole. The map below shows the Index of Multiple Deprivation (IMD) scores by area. IMD scores provide a useful proxy for health inequalities, because those areas with the highest deprivation (shown in darkest on the map)tend to experience worse health than the rest of Hertfordshire.

2. Health in Hertfordshire

Figure 4: Index of Multiple Deprivation Scores for Hertfordshire


A separate document “Health Challenges for Hertfordshire; Informing the Public Health Strategy17” and the Equality Impact Analysis for this strategy both summarise the issues we have taken into account.

In summary:

• Life expectancy in Hertfordshire as a whole is increasing both for men and for women. But compared with England and with our peer group there are too many

people who still die at a younger age; and too many people who spend much of their life in ill-health or disability.

• There is a marked and real social gradient to this, with people who are most deprived living shortest lives with most ill-health.

Health and economic prosperity are intimately linked. The health of our population is a key asset for our economic prospects, but equally a thriving economy is essential for good health.

Table 1 overleaf summarises some of the successes which have been evidenced in addressing health inequalities in Hertfordshire, and some of the challenges which still remain. The enduring effect of poverty remains a significant challenge18.

The harm from alcohol and tobacco, and the health effects of sedentary lifestyle and being overweight or obese also bring significant avoidable disease burdens to Hertfordshire, and these three areas are Hertfordshire Health and Wellbeing Board priorities. As noted above, public health lead on these.


Successes Challenges• Infant mortality is showing a reduction

in rates over recent years, with recent indications of particular improvement in some of the most deprived areas

• We have seen reductions in all age and all cause mortality; reduction in early death rates from heart disease, stroke and cancer

• We have seen reductions in teenage pregnancy in recent years

• We have seen significant reductions in people smoking and our prevalence of smoking is in line with England. (Reducing the harm from tobacco is a HWBB priority).

• Infant mortality – whilst reducing, we still have disproportionate rates across the county within certain ethnic communities

• Premature death and life expectancy although reducing, remains significantly worse for some cancers and for the poorest areas

• Preventable non-communicable disease, especially diabetes, stroke, cancer and heart disease, remain higher in some areas than in others

• Teenage pregnancy still remains a concern in some areas

• 172,000 people remain smokers and new young people take up smoking every day Smoking prevalence remains very high in the most deprived areas

• Obesity in children, and increasingly in adults, remains a challenge and lies at the root of much other avoidable ill-health. We need to have a co-ordinated and concerted approach to tackle this issue. (Physical activity and maintaining a healthy weight is a HWBB priority)

• The impact of poverty on health remains a significant factor in avoidable mental ill-health, domestic violence, disability and death

• Alcohol remains a high attributable factor in admission to hospital among some late middle age and older people

• The increase in outlets selling alcohol cheaply contributes to a short term rise in emergency hospital admissions and a long term rise in liver disease, mental health problems and avoidable early death. (Reducing the harm from alcohol is a HWBB priority)

• Self harm and preventable mental ill-health in our young people remains high and is increasing.

There remain a range of challenges as shown above which stop us being a healthier county, and which means that the burden of disability, ill-health, disease and death in some parts of Hertfordshire remains higher than it should be if compared to the England and the Hertfordshire average.

Table 1: Successes and challenges in health inequalities


3. Conceptual and delivery models for the public health system in Hertfordshire

The role of every agency and the role of specialist agencies

Sections one and two of this strategy identified that a range of factors mitigate for or against people being healthy across their life (wider determinants of health). This means that we need to build a public health system where a range of agencies understand their role in protecting and promoting the health of our residents, and act to deliver it.

Every agency has a contribution to make to public health in Hertfordshire, and the county council’s Public Health Service will seek to lead and support this through partnership working. In Hertfordshire we believe that no one agency can deliver public health effectively without the others, and this has led us to develop the concept of a public health system where there is:

• A contribution from every agency in Hertfordshire to improve and protect the health of our residents, and• A specialist public health family of agencies each with statutory roles and responsibilities.

The specialist public health family in Hertfordshire

• The county council has statutory responsibilities to improve public health and a statutory duty to lead the

local system through the Director of Public Health.

• District and borough councils have a range of statutory public health duties from the Public Health Act 1984 and other important contributions to public health such as housing, and leisure.

• Public Health England is the lead national body for the public health system in England with a range of

statutory, enabling and supporting roles, including supporting NHS England in its public health commissioning roles.

• NHS clinical commissioning groups have a statutory duty to reduce inequalities in health in their registered populations.

• NHS England has a statutory commissioning role of some public health functions and commissioning of primary care.


There are four key mechanisms which enable this system to work:

• The Health and Wellbeing Board – the key multi-agency board for action on major issues across the health and care system for our residents• The Public Health Board – an officer board

comprising a range of partner agencies, each with a contribution to public health, which develops and supports the public health system in Hertfordshire across all three domains of public health (see page 16)

• The Hertfordshire County Council Cabinet Panel on Public Health and Localism – which oversees the statutory public health portfolio in the county council• District and borough mechanisms – local partnerships and boards which are crucial to local delivery of public health outcomes.

A model for public health in Hertfordshire: conceptual model and delivery

Public health is a discipline practiced by a broad body of people and organisations, not just those who are registered specialists. These include specialist staff (such as consultants in public health in the local

authority and Public Health England, Environmental health and health promotion staff in district and borough councils), clinicians across the NHS, the nurses and doctors in each local practice, as well as a wide range of people who influence our behaviour.

Schools, retailers, employers, sports coaches and police all play a part, together with the planners and providers of quality health and social care, roads, housing, spatial planning, environment and other facilities, which all impact directly or indirectly on our health. The breadth of public health can be described in three domains, although there will always be some overlap. These are the protection of health, the promotion of good health and the delivery of quality health care.

To deliver a robust and sustainable public health service for the county council, and across partners, we will create a public health system and identify a common conceptual model. This model will be based on the scientific principles of public health and recognition that everyone has a role to play in public health in Hertfordshire.


The conceptual model of public health

There are three components to this model:

• The definition of what public health is• The three domains of public health practice• The six levels at which public health action happens.

The definition of public health which has had most support is the definition used by the Faculty of Public Health (the standard setting body for specialist public health practice in the UK). It defines public health as;

“the science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society”19.

This model has been used in the Public Health White Paper20 the Government’s public health strategy21 and in the statutory guidance on public health22. It is illustrated in figure 5 overleaf.

Component 1: The definition of public health

Component 2: The three domains of public health practice


• Health improvement means what we can do to improve health at individual and population level and includes reducing inequalities, improving education, and addressing housing, employment, family / community, lifestyles, surveillance and monitoring of specific diseases and risk factors

• Health services delivery and quality means ensuring services are of consistently high quality and especially that they are evidence based, and address issues of effectiveness, efficiency and equity

• Health protection means we address threats and hazards to human health including infectious diseases, chemicals and poisons, radiation, emergency response and environmental health hazards.

This means that public health is about ensuring everyone has the opportunity to be as healthy as possible, and from that foundational opportunity to be healthy they can grasp the opportunities to be prosperous, to thrive throughout life and to make a contribution to their communities24. This may mean action across a range of levels from individual to social, and this leads us to the third stage of the model, the six levels of public health action.

Demonstrating that public health interventions save money to our residents and the public purse is important to us. Evidence suggests that achieving this strategy will bring significant benefits to our population in terms of increased quality of life and better health. Most public health interventions save more than they cost. As part of our commitment to demonstrate this, our implementation plans will be accompanied by an analysis of cost-effectiveness wherever possible.

Figure 5: Three domains of public health23

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delivery and quality


Component 3: The six levels of public health action

There are six levels at which public health works25. Enabling people to be healthy means acting across all six levels. These levels are needed because most public health challenges have causes or factors across more than one level of people’s lives e.g. social, biological, behavioural, etc.

We need to work at several levels to address change enabling people to be healthy.

Often a change in one level is spurred on by another, for example the legislative ban on smoking in public places has helped create social norms around smoking not being acceptable indoors, leading to a change in personal behaviour by more people giving up smoking.

The table overleaf shows the six levels of public heath action and, as an example, what is happening on tobacco control currently in Hertfordshire.


Table 2: Six levels of public health action

This conceptual model will be used to help us identify for any topic we work on what the role of the county council’s Public Health Service is, what the role of the specialist public health family in Hertfordshire is and what the roles of other, equally important, agencies such as social care, childrens’ centres, schools, employers, voluntary and community agencies are.

Levels Tobacco1. Social – changing social norms about

health, e.g. acceptability of binge drinking, acceptability of taking smoking breaks.

Young people whose peers disapprove ofsmoking and its effects are less likely to start smoking.

Campaigns like Stoptober and other marketing targeted at high risk populations.

Targeted action to enable parents not to smoke around children.

Supporting people in spreading the message that smoking in pregnancy has very high risks to mother and child.

2. Biological – immunisation, vaccinations, treatments.

Nicotine replacement therapy and other drug interventions when appropriate help people reduce the very strong cravings from giving up smoking.

3. Environmental – encouraging green transport, reducing pollution, changing the public realm.

Smokefree playgrounds in several areas in Hertfordshire are encouraging parents not to smoke in front of children and think about giving up.

Making illicit tobacco trading less possible.

Enforcement of stop smoking legislation.

4. Behavioural – helping individuals to stop smoking.

Stop smoking services and individual and group counselling help people give up and stay non-smokers - there are more than 300 of these services in Hertfordshire.

5. Legislative – the smoking ban, legislation on alcohol sales.

The ban on smoking saw heart attacks drop by 14% in England within a year and has encouraged people to give up.

Enforcement of legislation on sales and underage smoking.

6. Structural – policy changes such as workplace health, school health policies.

Workplace policies which make people who take smoking breaks make the time up see more people give up smoking and fewer sickness days from respiratory diseases and colds in winter.

Policy frameworks which support tobacco control.

Tobacco control strategies.


Making the system work: a practical model for delivery

In order to move to a system which will involve every relevant partner and will develop and demonstrate a range of capabilities (skills, knowledge, culture and attitudes) and develop appropriate mechanisms (boards, implementation arrangements, delivery pathways and engagement strategies). Table 3 below lists these capabilities and mechanisms.

We have made specific commitments to these areas across each of our priorities.

We will develop a model of operation which works across partners, starting with understanding what our population needs, moving to identifying what works and then to intervention. We will do this across the three domains of health improvement, health protection and service quality. This latter

domain is sometimes called “healthcare public health”, but because social care, child care, housing, leisure and many other functions are important to public health, good quality services are crucial. This working model for our system is illustrated in the Hertfordshire Public Health Delivery Model©26 shown overleaf. We will use this model to work with partners.

Table 3: Capabilities and mechanisms for public health delivery

Capabilities Mechanisms• Strong Leadership (elected member,

officer, volunteer, resident)• Capable, skilled professional people• Planning and delivery at local levels while

ensuring equity across the county• Whole system approaches.

• Partnerships• County Council Cabinet Panel • Health and Wellbeing Board• Skills Development Programmes• Evidence, Intelligence and Joint Strategic

Needs Association• A multi-agency Public Health Board • Co-production with residents.


Figure 6: The Hertfordshire Public Health Delivery Model©

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Using these insights, we will:

• Deliver a public health system where all skills and contributions are valued and designed around delivering the outcomes and priorities (see section 6 page 26),

with a focus on equity for our diverse population

• Identify for each programme the contributions of the agencies in the specialist public health family, and other agencies

• Develop the skills and capabilities of local authorities, NHS, voluntary and community sector, criminal justice agencies and employers to deliver the public health agenda

• Develop the skills and capabilities of the county council’s public health service to enable others to act on health issues using a public health approach

• Deliver a public health service which uses the best available evidence and information on which to base decisions and recommendations

• Deliver a public health service which advocates successfully for effective prioritisation of resources for key public health priorities

• Deliver a public health service which enables commissioning activity to achieve the population priorities set above. In particular, enable clinical commissioning groups to work effectively on public health issues and priorities

• Develop ways of co-producing better health with residents

• Deliver a public health service which has an effective balance of public health capacity and capability across health improvement, health protection and service quality

• Deliver a public health service which develops the skills of both specialist and generalist stakeholders to be part of the public health agenda for Hertfordshire.


The consensus of stakeholders (county, district and borough council officers, public health lead officers in district and borough councils, Local Strategic Partnerships, NHS clinical commissioning groups, third sector agencies, Healthwatch, Public Health England and community agencies) is that we want our county to be healthy. The consensus of evidence is that to be healthy, Hertfordshire needs to be

prosperous and sustainable. To be prosperous, Hertfordshire needs to be healthy. We have used the vision to action pyramid illustrated below to help explain why we exist, where we want to get to and what we will do. Implementation plans and individual workplans for every public health specialist in Hertfordshire will be needed to deliver this.

Table 4 (overleaf) states Our Mission and Our Vision

The next stage after agreeing this strategy is to produce an implementation plan for the service, which will be refreshed annually.

4. Vision into action

Figure 7: The vision to action pyramid

Individual plans: My personal objectives and must dos

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business and for each topic

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Our Mission Our mission is to work together to improve the health and wellbeing of the people of Hertfordshire, based on best practice and best evidence which means not just looking at effectiveness but also at cost-effectiveness.

Our Vision Healthy and happy Hertfordshire: everyone in Hertfordshire is born as healthy as possible, and lives a full, healthy and happy life.

Hertfordshire’s public health strategy ambitions

Our ambitions within this vision are that:

• Hertfordshire will be among the healthiest counties in England. Our population as a whole will enjoy a life which is better than the England average for life expectancy and disease free years of life

• We will progressively narrow the gap in life expectancy and disease free years of life across the population of Hertfordshire

• Our population has a good understanding of how to be and remain healthy, and puts this into practice

• Everything about our public services and the way our county is organised supports this, from primary care services to quality of education, housing and access to employment.

This strategy is about a whole system approach to opportunities for good health. This approach is underpinned by principles, three of which are, as mentioned above derived from the Review of Health Inequalities for England (2010)2 commonly referred to as the Marmot Review:

1. We will adopt a lifecourse approach to health (pre-conception to death); which seeks to ensure people start life healthy and remain healthy

2. We will adopt a whole system approach; which seeks to identify the components which act to improve and hinder good health, and identify the contribution of public health specialists and partners to addressing them

3. We will adopt the principles of proportionate universalism27 to address inequalities in health while ensuring that the whole population achieves better health

4. We will seek to develop a people centred approach to public health, where we design services working with residents and work to ensure services reflect the needs of our population

5. We will seek to ensure that the environmental sustainability and economic prosperity of our county are improved by what we do, and that we take account of the public health implications of climate change.

Table 4: Our Mission and Our Vision


The public health priorities are about what we need to do in Hertfordshire to achieve:

• The Marmot principles• Better health outcomes for our residents• National public health strategy• Public Health England priorities Our priorities will be tracked by our progress against the Public Health Outcomes Framework (see Section 7 page 36). We will also use the “Five Ways to Wellbeing” to build a resilient and healthy population.

To achieve this set of priorities requires us to act on a range of different factors from the quality of primary care to the life opportunities of our population. Within these factors there are a range of short-term, medium term and longer term dimensions to consider, and the contribution of a range of agencies. The outcomes from the principles will reflect cross cutting themes from Hertfordshire’s Health and Wellbeing Strategy 2013-201628, the Hertfordshire Equality Strategy 2013-201529 and the Hertfordshire Community Safety Strategy.

The public health priorities for Hertfordshire

What we will achieve working for and with our residents

1. Longer, healthier lives.

2. Start healthy and stay healthy.

3. Narrowing the gap between most and least healthy. 4. Protect our communities from harm.

How we will work together

5. Understand what’s needed and we do what works.

6. Make public health everyone’s business.

5. Public health priorities for our residents


6. Achieving our priorities

Working with partners we have developed a set of priorities which are important not just to the agencies in Hertfordshire with statutory public health roles, but to everyone, and to ensuring Hertfordshire remains a county of opportunity. For each priority in table 5 below we have identified what this means, why we have chosen it and what we need to do to achieve it.

A separate implementation plan will identify in greater detail what we will do and how we will do it.

Table 5: Our 6 prioritiesPriority 1 Longer, healthier livesWhat does this mean We will increase life expectancy, especially disease and

disease-related disability free life-expectancy in Hertfordshire and reduce health inequalities in these across the population.

We will reduce the prevalence in our communities of the five common risk factors for early death: smoking, obesity, inactivity, poor diet and excess alcohol consumption.

Why have we chosen this? Hertfordshire has too many people spending a significant part of their lives in avoidable chronic ill health and disease-related disability.


Priority 1 Longer, healthier livesWhat do we need to do? 1. Develop a health improvement programme which identifies

action across the lifecourse.

2. Continue to reduce smoking prevalence (Health and Wellbeing Board Strategy priority).

3. Reduce obesity starting with the areas of highest prevalence (Health and Wellbeing Board Strategy priority):

• Increase and sustain the increase in physical activity uptake across the county

• Develop a lifestyle offer which helps people become and remain physically, psychologically and socially healthy This will engage sport and physical activity agencies and partners and will embed “The Five Ways to Wellbeing”

• Develop an obesity and health behaviour pathway with partners, with tiered weight management services within it.

4. Reduce harmful alcohol consumption (Health and Wellbeing Board Strategy priority).

5. Work with partners to build a culture of healthy living through development of lifestyle offers and health marketing to increase awareness and uptake of healthier lifestyles.

6. Work with partners to ensure that maximum improvement in health is achieved by all services across the county, from NHS commissioners and providers to local authority and voluntary and community sector services.

7. Implement regulatory, policy and population measures to improve health, including spatial planning, licensing and responsibility deals.

8. Strengthen the role of social sciences by embedding behavioural science approaches to public health challenges.

9. Develop public mental health approaches to building resilience and reducing preventable mental ill-health (including self harm and “The Five Ways to Wellbeing”).


Priority 2 Start healthy and stay healthyPublic health definition of this

Ensure we do what we can to improve health across the lifecourse from before conception to death.

Why have we chosen this? We mentioned the importance of a lifecourse approach in our principles above. There is overwhelming evidence that a healthy start for young people is a key public health priority. Giving every child the best start in life (which we do not currently achieve) is crucial for sustaining health throughout life into older age.

What do we need to do? 1. Commission all mandated public health services in a way which underpins a lifecourse approach to health and is personalised.

2. Seek to use local agencies and partners wherever possible to deliver these services.

3. Produce a market position statement which puts prevention and health gain at the heart of everything we commission.

4. Ensure a healthy start for every child through effective coverage of pre-conception, prenatal and perinatal care, health visiting, immunisation and public health nursing.

5. Ensure perinatal mental health work is universally rolled out.

6. Ensure early years services implement key public health interventions for healthy development (from “My Baby’s Brain” to high rates of immunisation).

7. Build the public health role of childrens’ centres and other childrens’ settings.

8. Ensure a whole school day approach to health, starting with nutrition and physical activity.

9. Develop an adolescent public health programme across key services and settings including a focus on mental health, resilience, happiness and self-harm reduction.

10. Work with employers to improve the health of adults of working age, and reap the economic benefits of this.

11. Develop public health approaches for adults with particular and complex needs such as adults with learning disabilities and chronic mental health problems.

12. Roll out NHS health checks for adults and ensure these are part of a universal lifestyle offer, with appropriate targeting for populations who fare less well in health terms.

13. Ensure drug’s and alcohol services are accessible and high performing and help people to reduce harm and recover appropriately.

14. Ensure sexual health services, including contraceptive services, are accessible, personalised and effective.

15. Develop a healthy ageing programme.


Priority 2 Start healthy and stay healthy16. Develop public health approaches for particular

communities: • Serving military personnel, veterans, Territorial Army

and reservists and their families as part of our commitment to the Community Covenant.

• Develop appropriate approaches for traveller communities

• BME communities • LGBT communities • Disabled people (especially access to physical activity) • People with learning disabilities.17. Work to establish healthy living pharmacies and

dental practices.


Priority 3 Narrowing the gap between most and least healthy

Public health definition of this

Reducing inequalities in health outcomes and life expectancy between most and least affluent.

Why have we chosen this? Hertfordshire has too high a disparity in life expectancy and ill-health between the most affluent and least affluent.

What do we need to do? 1. Improve the cycle, granularity and content of the Joint Strategic Needs Assessment to identify inequalities and inequity, including knowledge gathering and equity auditing.

2. Identify particular communities and populations which do less well than the majority of our residents, and identify what specific actions we need to take to improve their health outcomes.

3. Commission and deliver services which consider inequalities and equity and target appropriate areas of worst health whilst delivering a universal offer to everyone using the principles of proportionate universalism.

4. Reduce drug and alcohol related ill-health.5. Improve equity of access and outcomes to services in the

most vulnerable and most disadvantaged populations and those with worst outcomes (ie: children looked after, offenders, families in the ‘thriving families’ programme, people in poverty, disabled people, people with learning disabilities, travellers, LGBT residents, military families and harm from tobacco and alcohol in lowest income groups).

6. Reduce harmful substance misuse, especially tobacco.


Priority 4 Protect our communities from harmPublic health definition of this

Deliver robust and effective health protection arrangements.

Why have we chosen this? Health protection responsibilities sit across a range of agencies and they are crucial to achieving good health for the population. We have a statutory responsibility to deliver and assure a robust health protection system.

What do we need to do? 1. Build a whole system health protection plan and network which harnesses the important roles of county, district/ borough councils, NHS and Public Health England and other partners.

2. Deliver a robust whole system approach to infection control in health and social care settings.

3. Deliver effective public health input to community safety and crime reduction agendas including alcohol, drugs, licensing, tobacco control, causes of domestic violence, offender health and mentally disordered offenders.

4. Support the important role of environmental health in health protection.

5. Develop a public health approach with regulatory services colleagues.

6. Improve take-up and ensure robust and high quality delivery of immunisation, vaccination and screening to our residents.

7. Ensure the public health role in resilience is fully delivered.8. Work with licensing and the local planning authorities

in the county to ensure that the adverse health impacts from licensing and planning are reduced and positive outcomes increased.

9. Continue to work with highways to improve pedestrian and road user safety.

10. Ensure public health skills help make Hertfordshire a more sustainable place.


Priority 5 Understand what is needed and do what works

Public health definition of this

We are driven by robust evidence (epidemiology, needs assessment, evidence of effectiveness) and ensure interventions are evidence-based and appropriately developed. Where evidence is lacking we will ensure we can evaluate interventions for efficacy and effectiveness.

Why have we chosen this? Being evidence and intelligence driven and having the right skills and competencies will deliver better outcomes and better value for money.

What do we need to do? 1. Ensure we have a strong foundation of needs assessment, epidemiology, equity audit and outcome evaluation for programmes and services and work to improve the JSNA as a key source of evidence.

2. Ensure we develop skills and capabilities to understand and apply evidence across interventions, in particular ensuring we develop evidence-based practice and public health skills across the county council and partner agencies.

3. Ensure we develop skills and capabilities to assess and evaluate effectiveness and outcomes.

4. Work with commissioners to develop an integrated commissioning cycle which includes needs assessment, evidence assessment, prioritisation and outcome evaluation.

5. Support NHS commissioners using the Director of Public Health’s statutory duty to advise clinical commissioning groups on how to commission to meet population health need.

6. Support NHS and local authority commissioners as well as criminal justice sectors to commission in a way which develops the health of their population.

7. Innovate to establish best practice where evidence is lacking, conflicting or silent.


Priority 6 Make public health everyone’s businessPublic health definition of this

We want to identify the public health contribution of every partner and stakeholder and build the capacity for them to deliver.

Why have we chosen this? Research demonstrates that public health should be everybody’s business and everyone has a role. District and borough councils, for example, have strong public health potential in their housing, leisure, environmental health and other roles. Voluntary and community sector agencies and faith communities can reach people statutory services may struggle to engage. Ensuring everyone understands their contribution and delivers it will be crucial to making our county and our residents healthier.

What do we need to do? 1. Identify with each stakeholder what their public health impacts are and how they can address them.

2. Continue funding for partnerships and initiatives which deliver on this strategy.

3. Support voluntary and community sector and community agencies in identifying their public health contribution and meeting it.

4. Continue to support local strategies and plans through Local Strategic Partnerships, and the Public Health Board.

5. Commission delivery partners local to Hertfordshire wherever possible.

6. Co-produce services and interventions with stakeholders and residents.

7. Build appropriate capabilities across everyone with an interest in public health through access to learning and skills development (both face to face and online) including development of a route to Public Health Practitioner Registration.

8. Work with academic partners to develop capabilities to deliver effective evaluation and evidence across public health.

9. Develop information systems with partners across NHS and local government and other agencies to deliver information which is easier to use to take public health action.

10. Build a network of health champions across communities and agencies who will work to build a public health and self-care culture.


Priority 6 Make public health everyone’s business11. Work with each of the following priority agencies to develop

public health plans, programmes and strategies across all of their capabilities:

• Hertfordshire County Council departments • NHS and social care commissioners • Police and Crime Commissioner, Probation and

Hertfordshire Constabulary • District/borough councils • Town and parish councils • Voluntary and community agencies and faith communities • NHS and social care providers • Workplaces • Schools, further education colleges and the University of

Hertfordshire.12. In an era when behavioural factors are increasingly

important in primary, secondary and tertiary prevention, enhance and harness the contribution of behavioural sciences.


7. The implementation journey

The Health & Social Care Act 2012 sets out the statutory requirement for local authority leadership of public health from April 2013. Some functions formerly in the NHS, Health Protection Agency or other bodies have transferred to a new body called Public Health England, a new executive body of the Department of Health, while others – screening, immunisation - have gone to NHS England (formerly called the NHS Commissioning Board).

Under the transfer, a public health allocation of £34.2 million was given to the county council by the Secretary of State for the discharge of the public health functions, and a staff team of 46 people transferred from the NHS. Most of the transferred staff work in direct service provision, such as smoking cessation and chlamydia screening. This budget and staff core will be crucial to enabling action by others, both in terms of commissioning and co-commissioning partners, and putting their skills and knowledge at the service of others.

There are a number of statutory functions given to Directors of Public Health (DPH) and the role of the DPH and public health team will work across the NHS, the county council, district/borough councils and other partners. The first step will be to ensure that where necessary, services are commissioned and then to review contracts service by service to ensure they are being delivered in line with the principles in this strategy.

Project and implementation plans will be developed to underpin this strategy and these will include delivering plans for each of the priorities in the next column.

Within this we will ensure we prioritise work on:

• Restructuring the Public Health Service in the county council to align people and financial resources to this strategy• Ensuring mandated services are commissioned and delivered• Developing and start to commission the lifestyle offer• Developing the obesity plan• Developing the sexual health plan• Developing the child and adolescent

public health plan including school health• Recommissioning sexual health services• Delivering a route for public health practitioner registration• Delivering a health protection plan• Delivering a drug and alcohol plan• Delivering a public health and public realm plan• Delivering a public health development plan for skills and capabilities• Recommissioning school nursing services• Assuming statutory responsibility for health visitors.


It is important that we know whether we are succeeding or failing in meeting the ambitions we have set. We will use two sets of indicators to track progress on how we are delivering the strategy:

1. The Health and Wellbeing Strategy indicators

We will also use the local indicators devised for the Health and Wellbeing Strategy priorities on which public health leads.

2. The Public Health Outcomes Framework30

The Public Health Outcomes Framework(PHOF) outlined in figure 8 overleaf is arange of indicators developed nationallyfor use in England, which will help usidentify our progress towards achieving theHertfordshire public health strategy. We will seek to report these indicators in a way which enables us to both look across Hertfordshire and compare areas within Hertfordshire against itself, and against England. The indicators are shown in more detail in Figure 9 (page 38).

The PHOF national data set divides its indicators into four groupings:

• Improving the wider determinants of health• Health improvement• Health protection• Healthcare and premature mortality.

The full set of indicators nationally and for Hertfordshire are available at www.phoutcomes.info


Figure 8: The Public Health Outcomes Framework

All of these indicators will be reported on to the Cabinet Panel for Public Health and Localism, the Public Health Board and the Health and Wellbeing Board.

We will ensure that we benchmark Hertfordshire nationally, against our peer group, and benchmark areas within Hertfordshire against Hertfordshire as a whole so that we identify areas of worse health outcomes and target them effectively.

Vision: To improve and protect the nation’s health and wellbeing, and improve the health of the poorest fastest.

Outcome 1: Increased healthy life expectancy Taking account of the health quality as well as the length of life.

Outcome 2: Reduced differences in life expectancy and healthy life expectancy between communities Through greater improvements in more disadvantaged communities.

(Note: These two measures would work as a package covering both morbidity and mortality, addressing within-area differences and between area differences)

DOMAIN 1:

Improving the wider determinants of health

Objective:Improvements against wider factors that affect health and wellbeing, and health inequalities

DOMAIN 2:

Health improvement

Objective:People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities

DOMAIN 3:

Health protection

Objective:The population’s health is protected from major incidents and other threats, while reducing health inequalities

DOMAIN 4:

Healthcare public health and preventing premature mortality

Objective:Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

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Indicators }Across

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3.1

Fra

ctio

n of

mor

talit

y at

trib

utab

le to

pa

rtic

ulat

e ai

r po

llut

ion

3.2

Chl

amyd

ia d

iagn

osis

(15-

24 y

ear

olds

) 3.

3 P

opul

atio

n va

ccin

atio

n co

vera

ge

3.4

Peo

ple

pres

enti

ng w

ith

HIV

at a

late

sta

ge

of in

fect

ion

3.5

Tre

atm

ent c

ompl

etio

n fo

r Tu

berc

ulos

is (T

B)

3.6

Pub

lic s

ecto

r or

gani

sati

ons

wit

h a

broa

d

app

rove

d su

stai

nabl

e de

velo

pmen

t

m

anag

emen

t pla

n3.

7 C

ompr

ehen

sive

, agr

eed

inte

r-ag

ency

pla

ns

fo

r re

spon

ding

to p

ublic

hea

lth

inci

dent

s an

d

em

erge

ncie

s (P

lace

hold

er)

4.1

Inf

ant m

orta

lity*

(NH

SOF

1.6i

)4.

2 T

ooth

dec

ay in

chi

ldre

n ag

ed 5

4.

3 M

orta

lity

rate

from

cau

ses

cons

ider

ed

pr

even

tabl

e **

(NH

SOF

1a)

4.4

Und

er 7

5 m

orta

lity

rate

from

all

c

ardi

ovas

cula

r di

seas

es (i

nclu

ding

hea

rt

dis

ease

and

str

oke)

* (N

HSO

F 1,

1)4.

5 U

nder

75

mor

talit

y ra

te fr

om c

ance

r*

(N

HSO

F 1.

4)4.

6 U

nder

75

mor

talit

y ra

te fr

om li

ver

dise

ase*

(NH

SOF

1.3)

4.

7 U

nder

75

mor

talit

y ra

te fr

om r

espi

rato

ry

di

seas

es*

(NH

SOF

1.2)

4.8

Mor

talit

y ra

te fr

om in

fect

ious

and

par

asit

ic

di

seas

es4.

9 E

xces

s un

der

75 m

orta

lity

rate

in a

dult

s

w

ith

seri

ous

men

tal i

llne

ss*

(NH

SOF

1.5)

4.10

Sui

cide

rat

e 4.

11 E

mer

genc

y re

adm

issi

ons

wit

hin

30 d

ays

of

di

scha

rge

from

hos

pita

l* (N

HSO

F 3b

) 4.

12 P

reve

ntab

le s

ight

loss

4.

13 H

ealt

h-re

late

d qu

ality

of l

ife fo

r ol

der

peop

le (P

lace

hold

er)

4.14

Hip

frac

ture

s in

peo

ple

aged

65

and

over

4.

15 E

xces

s w

inte

r de

aths

4.

16 E

stim

ated

dia

gnos

is r

ate

for

peop

le w

ith

dem

enti

a* (N

HSO

F 2.

6)

Peo

ple

are

help

ed to

live

hea

lthy

life

styl

es, m

ake

heal

thy

choi

ces

and

redu

ce h

ealt

h in

equa

litie

s.Th

e po

pula

tion

’s h

ealt

h is

pro

tect

ed fr

om m

ajor

in

cide

nts

and

othe

r th

reat

s, w

hils

t red

ucin

g he

alth

ineq

ualit

ies.

Red

uced

num

bers

of p

eopl

e liv

ing

wit

h pr

even

t-ab

le il

l hea

lth

and

peop

le d

ying

pre

mat

urel

y,

whi

lst r

educ

ing

the

gap

betw

een

com

mun

itie

s.


1 Hertfordshire County Council Corporate Plan 2013-2017

http://www.hertsdirect.org/docs/pdf/c/corpplan13-17.pdf

2 Marmot, M (2010) Fair Society, Healthy Lives. Report of the review on health inequalities in England. London: Institute of Health Equity http://www.instituteofhealthequity. org/projects/fair-society-healthy-lives- the-marmot-review

3 Owen L, Morgan A, Fischer A, Ellis S, Hoy A, Kelly MP. The cost-effectiveness of public health interventions. Journal of Public Health, 2012 Mar;34(1):37-45

4 http://www.hertsdirect.org/docs/pdf/h/ hwbstrategy.pdf

5 http://www.hertsdirect.org/your-council/ hcc/partnerwork/hwb/

6 Hertfordshire County Council Corporate Plan 2013-2017

http://www.hertsdirect.org/your-council/ cpdrp/corplan/

7 http://www.fph.org.uk/what_is_ public_health


9 Tackling inequalities in life expectancy in areas with the worst health and deprivation (National Audit Office, 2010) http://www.nao.org.uk/wp-content/ uploads/2010/07/1011186.pdf

10 http://whqlibdoc.who.int/hq/2008/ WHO_IER_CSDH_08.1_eng.pdf

11 Brennan Ramirez LK, B.E., Metzler M., Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health, Centers for Disease Control and Prevention, Editor. 2008, Department of Health and Human Services,: Atlanta, GA

12 http://www.hertslis.org/partners/jsna/


14 http://nccdh.ca/images/uploads/ Approaches_EN_Final.pdf

15 Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute

16 http://neweconomics.org/projects/ five-ways-well-being

17 To be published alongside the Public Health Strategy


19 Department of Health (1998) report of the independent inquiry into inequalities in health. London http://www.fph.org.uk/what_ is_public_health

20 Department of Health (2010) https://www.gov.uk/government/ publications/the-public-health-white- paper-2010

References


21 Department of Health (2011) Healthy Lives, Healthy People https://www.gov.uk/government/ publications/healthy-lives-healthy- people-our-strategy-for-public-health- in-england

22 Department of Health (2012) Directors of Public Health in Local Government https://www.gov.uk/government/ uploads/system/uploads/attachment_ data/file/213007/DsPH-in-local- government-i-roles-and- responsibilities.pdf

23 Griffiths, Jewell and Donnelly (2005) http://www.sciencedirect.com/science/ article/pii/S0033350605000570


25 Beaglehole et al (2004) Public Health at the Crossroads. Oxford: Oxford University Press

26 Copyright, Hertfordshire County Council, 2013

27 http://nccdh.ca/images/uploads/ Approaches_EN_Final.pdf

28 Hertfordshire Health and Wellbeing Strategy 2013-2016 http://www.hertsdirect.org/docs/pdf/h/hwbstrategy.pdf

29 Hertfordshire Equality Strategy 2013-2015 http://www.hertsdirect.org/docs/pdf/e/eqstrat2013.pdf

30 https://www.gov.uk/government/ publications/healthy-lives-healthy- people-improving-outcomes-and- supporting-transparency


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Hertfordshire


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