Jim McManusDirector of Public Health

Working with the new Public HealthArrangements

Chartered Society of Physiotherapy18th September

What’s in a name? “the science and art of preventing disease,

prolonging life and promoting, protecting and improving health through the organised efforts of society” Sir Donald Acheson, 1988

“Decency, Freedom from infection, Labour, Dignity”

Sir Alfred Hill, President of the Society of Medical Officers of Health, 1866-1903

The Public Health Revolutions 1st – Poverty, Living Conditions (Up to 1900)

◦ Improvement in incomes, reduction in deaths

2nd –Communicable Diseases (Up to 1950s)◦ Now on average 6-11% of deaths in UK. Was 85%

of deaths before 1900

3rd – Non-Communicable Diseases (Today)◦ Over 60% of deaths due to lifestyle and behaviour◦ Poorest fare worst (smoking, diabetes, heart

disease)

Contributors to overall health outcomesHave changed over time

Smoking 10%

Diet/Exercise 10%

Alcohol use 5%Poor sexual health

5%

Health Behaviours

30%Education

10%Employment

10%

Income 10%

Family/Social Support 5%Community Safety 5%

Socioeconomic Factors

40%Access to care 10%

Quality of care 10%

Clinical Care 20%

Environmental Quality 5%

Built Environment

5%

Built Environment

10%

Source: Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute. Used in US to rank counties by health status

While this is from a US context it does have significant resonance with UK Evidence, though I would want to increase the contribution of housing to health outcomes from a UK perspective.

Policy History...Zzzzz Chadwick Aneurin Bevan Black Report 1982 (UK) Ottawa Charter 1986 (World) Health of the Nation 1984 (England & Wales) Our Healthier Nation 1998 (England & Wales) Healthier Wales 2000 (Wales) Choosing Health 2005 (England) WHO Commission on Social Determinants 2009 Marmot Review of Health Inequalities 2010

The Technology that is Public Health

Outcomes

Art

Science

The Domains of Public Health

Health Improvement

Health Protection

Service Quality

Then & Now

Sanitation

Housing

NowEnvironment

Then & Now

Smoking

Heart Disease

NowCare which keepsPeople healthy andindependent

Key Point As the factors and services behind health in

the UK improved, key public health contributions became mainstream parts of the local government day job (sanitation, housing, school meals)

How do we work with the new day job?

The Health and Social Care Act 2012 Specialist public health is multidisciplinary

Most public health coming to LAs in 2013 / 2015

Some going to NHS Commissioning Board

National Agency Public Health England

Health and Wellbeing Boards

HW Boards Statute and guidance Boards of commissioners Provider and district engagement left open Roadmap of JSNA to Commissioning Plans Unlikely CSP or Physios will be given

membership per se but each Board is different

Constitutional anomaly – officers as members

Top Tips Influence DPH and lead elected Members Work with CCGs directly Where can you add value?

◦ Prevention◦ Long term conditions◦ Working age adults◦ Frail elderly

Expect JSNA and Strategy and Commissioning Plans to reflect your contribution rather than a seat on the Board

Provider Fora?

Specialist / Wider Public Health Specialist High level of training in

a technical public health function, largely defined by legislation or policy in West

Application of technical and specialist skills to the three domains of public health

Health Improvement

Health Protection

Service Quality

Mechanisms

Policy Mechanisms◦ Marmot, JSNA, Health and Wellbeing Board

Commissioning Mechanisms◦ Applying specialist skills to commissioning◦ Invest in the right things

Delivery Mechanisms◦ Mainstream public health – everyone provider

or citizens understands their contribution

Timeframes of impact/yield

Years

0 1 5 10 15

Planning

Education

Vitamin Supplements

Air Pollution

Decent Homes

Jobs

Primary Care

20

CVD Events

Self Care

Vitamin D and TBRickets

CVD Events

Acute Bronchitis Admissions

RespiratoryMental Health overcrowding educational attainment

Life Expectancy

Healthier space use Changing culture of activity

Life ExpectancyMental Health

Public Health Input into the Commissioning Cycle

Monitor/ Evaluate

Plan

Review Need for Service and

Effectiveness of existing services

Contract/Deliver

Public Health Input into the Commissioning Cycle. Can be

throughout or can be on specific areas playing to the PH strengths

Community Engagement

Support in establishing meaningful indicators of

delivery and outcome

Model whether need willBe met by proposed volume

Check whether plans equateTo evidence and need andTest for equity / inequity

Support and advise onEvaluation and conductBits of it if enough resource

Needs AssessmentsEquity AuditingEvidence of Effectiveness

Health Impact Assessment

Triangle of critical influence – where public health should be most visible

Investing in the Right Things Our Burden of Disease is not the right way round

PrimaryPrevention

SecondaryPrevention

TertiaryPrevention

SystemFailure

Health and Care: Our Burden of Disease is not the right way round

PrimaryPrevention

SecondaryPrevention

TertiaryPrevention

The shift to prevention

The Riches Understanding key drivers of health and

wellbeing, and interventions to improve population health

Structured ways of doing needs analysis Decision analysis and helping with

economic analyses of policy to help setting outcomes

Supporting the understanding of complex variables and their interaction in policy and decision making

The Riches 2 Resource allocation for policy and interventions Understanding targeting action and

interventions to bring most benefit Understanding and manage the conflicts

between population and individual concerns (equity)

Finding, assessing and applying evidence Supporting effective commissioning using 1,2

and 3 above Evaluation of commissioning against desired

outcomes

Seven Principles for a commissioning approach

1. Commission for the whole person’s lived experience (housing, volunteering, leisure, transport,)

2. See Potentials not Problems, assets as well as needs

3. Transformation of current system through staged redesign to preventive and early intervention

4. Subsidiarity and Access5. Co-production6. Behavioural Sciences7. Pathwayed

Making this lot work Burden of avoidable ill-health Demographic and growing demands Benefits to citizens Preventing service use Moves people into self-care We cannot afford the coming time bomb Justice and fairness are public health values

The DPH’s concerns…

https://www.wp.dh.gov.uk/healthandcare/files/2012/06/system-graphic.jpg