Getting to know each other
A few weeks ago I started some work with local government and NHS colleagues on the different models which people operate around public health, and what each different field has to offer, and bring to the table. As part of some research, I have been run a few joint NHS-Local Government focus groups on this issue.
I firmly believe that the opportunities for public health specialists in local government are significant, exciting and worthwhile. While some folk might be apprehensive (and fair enough, if you’ve been in the NHS for 5, 10 or 15 years, suddenly to be told you’re moving can be quite daunting), I think there are some real opportunities here. As someone who made the jump into local government, it’s a fantastic place to do public health.
Government’s recognition of the need to continue public health input to NHS commissioning in its response to the Futures Forum actually improves the opportunities within public health to focus not just on the important aspects of ensuring NHS commissioning is supported effectively by public health, but gives us tremendous opportunities to work on integrating health and local government services.
So, what have I heard?
1. It’s about mutual skills, not defecits
This is building on the “find strengths not defecits” approach I have blogged about earlier. The idea is that each side has a range of strengths they bring to the table, and a focus which looks to them initially will get further than one which assumes one side has all the strengths, whereas the other has the defecits in skills/knowledge or expertise.
I’m working this up for publication, but there are some immediate things which have come out of this work, and I’d like to share this in the form of some simple propositions:
2. Pubic Health takes a diversity of forms in the NHS, Local Government and elsewhere
We’re used to this concept when we look at community advocacy for health, so it really shouldn’t be difficult for us to accept that public health in local government is alive and well, albeit in some very different forms than in the NHS. Within local government it takes a variety of forms from very recognisable, regulated and accredited (e.g. chartered and legal regulated environmental health roles) to the less formally regulated but still important (seasonal deaths work, seasonal flu vaccine uptake in social care.)
In 1974 the public health family went in a variety of directions,some of it went into the NHS, but not just into the NHS. It’s almost like a series of branches evolved within the NHS and outwith the NHS, with different concerns and issues. And if we can join up the best of each, we could have a fantastic approach to public health.
3. Recognising different branches of public health focus as they evolved after 1974
You can either say that the public health world actually shows distributed leadership (I believe Paul Corrigan hypothesises most on this in his health policy blog) across systems – NHS public health has led on a number of areas with bits of local government focused public health leading on others. If we take a taxonomy approach, we can and should always be able to fit public health work in local government (and in the NHS) into the “three domains of public health” model we are very used to within the NHS.
Health Improvement. The key features here are that the work is seeking to improve health of a specific population which experiences worse health outcomes or worse inequalities than the general population. There may also be some general population work (e.g. school meals must meet Government standards) because of the legislative and policy context of local government. We need to understand that universal services in local government can and need to be done in a health improving way, just as we would understand that this is the case in the NHS
Health Protection. The key features here are a regulatory or statutory or policy approach to minimising threats to the health of the population. Food hygiene inspections, trading standards work, animal health are all examples of this in local government. (And let’s not forget that Consultants in Communicable Disease Control derive their legal powers as Proper Officers of the Local Authority.)
Service Quality. Key features here are an attempt to use evidence and tools such as decision analysis and prioritisation to improve services and the outcomes of services. So integrated care pathways are an example of this.
Ok, local government could be a bit more rigorous about using this approach, but if we try this taxonomy out, we might find surprising synergies between and across organisational and cultural boundaries.
4. What each brings to the table
The opportunity for us is about taking NHS public health strengths to local government, add these to what is already there, and create a model of public health which works in local government. It’s not that dissimilar to bringing public health into working more closely with GP Consortia. Those of us who worked with Practice Based Commissioning groups will remember the learning process we all went through then.
So, we need to recognise both the local government public health family and the NHS public health family have things to bring to the table, and things they need. I’m not going to talk about the things they need for now, that can be done later. I am going to focus on what we can both bring to the table.
NHS trained public health specialists have a range of domains of competence they can bring to the table. I have deliberately not put these solely in the realms of public health (e.g. immunisation uptake or other functions which might transfer.) I have tried to put them in the sense of how they can impact positively on the business of the whole council, because I think public health skills could impact on the whole work of the local authority. Indeed, the assumption of the Marmot Review (www.marmotreiew.org) is that they need to impact on the totality of local government and public sector to achieve the outcomes Marmot set.
So here is an early take on what public health specialists have to offer local government:
- 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
- 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
Public health specialists, especially those who are registered, should recognise this skill set. These sets of competencies have a wide and strong application across the NHS and they equally can have a wide and strong impact across local government.
Leaving aside the debates about salaries, terms and conditions and risk, those authorities who are having this discussion seem to be developing an ever stronger desire to incorporate public health.
Now , to turn to what local government brings to the table, people already in local government have a range of domains of competence they can bring to the table:
- Working in political systems
- Multiple stakeholder relationship building (good for working with GPs)
- Working with multiple policy frameworks from different government and other influencers and stakeholders who feed into local government (much more than the NHS often does)
- Policy skills (there is usually a policy unit)
- Pragmatic research skills (there is usually a research team)
- Programme management
- Large scale service and intervention delivery
- A strong sense of place and its impact on interventions
5. Look for mutual benefit from each side to the other
Interestingly, much of the work on Intervention Mapping as a set of techniques in delivering public health programmes (see Bartholomew et al, Kok et al) and an increasing amount of the research points to the salience of these local government skills in whether public health programmes are as effective as they could be. So public health could benefit strongly from some of these skills and competencies.
While this list is shorthand,you can see that there are significant opportunities for skills to be used across systems.
In social care, for example, there is a significant range of opportunity to benefit from the kind of approach public health has taken with NHS commissioning, using the domains of skills above.
So, to those of my public health colleagues who might be feeling a little concerned about what skills they bring, and what exists, my message is simply take heart. Up and down the country there are processes of learning going on. Local government doesn’t just want you, it needs you. And that is a potentially very good place to be, without minimising in any way the good of what being in the NHS has brought.
I’ll share more of this work as I write it up.