Linking up Health and Faith: re-learning old lessons

baroque-st-teresa3
The Ecstasy of Saint Teresa by Bernini. Santa Maria della Vittoria, Rome

One of my scientific and theological interests has, for some time, been dialoguing scientific evidence on health and medicine with faith.  I believe dialogue between health and faith needs to be scientifically, theologically and epistemologically rigorous in equal measure.  A growing body of robust scientific research is remembering what people of faith seem to have not quite forgotten, than people mediate their understanding of health, and their coping and living strategies, at least in part through their belief systems. That has profound implications for our health and wellbeing.

 

 

Some practical examples

Less than a month from now, in October 2017 a new series of videos, and in November a website Positive Faith will be launched as one embodiment of this. This will be series of videos and resources by, about and for people living with and affected by HIV. This exercise has been funded by Public Health England, and led by Catholics for AIDS Prevention and Support.  The resource privileges the voices of People with HIV over professionals of any kind. People with HIV explicitly address these issues of health and belief.

The FaithAction health and faith portal remains, for me, one of the great things to come out of Public Health England’s partnerships with the community sector because it works at applying these lessons and collates practical examples.  There are many more. I have been privileged to work with  FaithAction for some time. Their report contextualising the evidence on faith and health for UK commissioners and policymakers is important reading.   Their work on mental health and dementia friendly places of worship has much to offer a prevention and community engagement agenda.  FaithAction have created a series of resources for commissioners, practitioners and faith communities to use together.

A series of Catholic mental health demonstration projects has been delivered.  A mental health access pack for Churches – written by professionals and experts by experience – has been created by a charity whose values commit them to work on disability and health. You can read my invited blog on why I endorse the pack, here.

The University of Leeds with Leeds Public Health team has explored the links and barriers between religion and public health in some really exciting work on mental health.

I don’t claim any of what I say here makes people of faith better or more special than those of no faith in the world of health and care. I merely say that we have legitimate and understandable motivations and values to be in that world, and we have a contribution to make every bit as valuable as anyone else.  And our values inform that. We can no more leave our values or identity at the door that anyone else.

Faith cannot be the one “protected characteristic” that is private when every other one is recognised to be part and parcel of the person. But that’s for another blog.

The scientific evidence behind this

Most of you who know me well know this is an area of interest. I do my job because of my value base.  Early next year my review article on some of the best recent publications in health and faith will make its appearance in Reviews in Religion and Theology

In the process of entertaining this interest I have amassed a smallish library of 200 volumes in several languages, including volumes which stand out like Ellen Idler’s (the polymath Epidemiologist and Sociologist) recent and rather excellent Public Health volume on Religion as a social determinant of public health , the brilliant theological/philosophical work Flourishing by one of my theological heroes Neil Messer  and a range of materials on psychology, psychopathology and religion.  I’m preparing this collection (well the stuff in English anyway) for donation to a library where people will get easier access to it.

Faith still relevant to our population

Some of you may think Faith – especially explicitly religious faith – is a minority interest. Well you may be right, but that minority is still between 37% and 43% of the population depending on who you speak to.  We wouldn’t now be so discriminatory as to dismiss LGBT populations because they’re 2% – 3% of the population depending on who you read, would we?   So let’s recognise that our value bases inform who we are, and most of us are part of some minority. It’s inclusion of every minority’s best offerings which makes social life vibrant.

Prof Stephen Bullivant a sociologist at St Mary’s University has undertaken analysis of ONS data (I believe as yet unpublished) which suggests that, for example, Catholics are present in the health and care field in numbers around eight times more than they would be if they were just present in the same proportion as their presence in the general population.  Incidentally, Stephen Bullivant’s recent report on the “No Religion” population is a good read for anyone in public policy.

People still understand and filter their health experiences, beliefs, behaviours and life choices (including the choice to serve) through their religious belief.  NICE guidance recognises that and has stated there is a strong evidential case for its salience in care.  It is folly not to engage with this. My invited paper to the Equality and Human Rights Commission on what this means for healthcare employers in terms of workforce strategy, service quality and equality and diversity law explores the practical and organisational implications of this further.  The growth of non-religious spiritual and pastoral care in our hospitals, recognising that humanists and others who describe themselves as non-theist and non religious, have spiritual needs too, is welcome and valuable alongside care for those who do have religious faith.

The Guild of Health and St Raphael

A short while ago, I was approached by the Guild of Health and St Raphael to become their president, a role which I shortly take on, after a bit of reflection and dithering on my part. I look forward to this immensely.  It came, to me at any rate, as something of a shock. I did the “why on earth would they want me, couldn’t they find anyone better?” And “why  on earth would they want a Catholic? ”  thing. I then thought of suggesting Archbishop Justin Welby before realising he’s a patron already.  And then I thought of Lord Rowan Williams, who’s a patron of something else they do already. Whoops!

In discussing this with a good colleague , she reminded me that she calls me “the health and faith babel fish”. By which she means I seem to be good at translating the field of health to the field of faith. She asked me “do you think the Guild does important things?” “Yes”, I answered. “Does it have a sound theology?”  “Yes”.  Have they got people who are scientifically credible?”  Again, “yes”. Just for starters, the Director, Gillian Straine is a PhD qualified Scientist and an ordained Anglican priest.  “Does it resonate with your desire to make clear the links between health and faith?” “Yes, vey much so.” “Well, then in your own words -get on with it.”   And so, with that kick up the motivations, here begins a journey.

Formed in 1904 to bring together members of the clergy and medical professions to study and promote the healing ministry of the Church, it claims to be the oldest organisation in the UK working in the field of Christian health.  Anglican in heritage it is now ecumenical in outlook. The two Anglican Archbishops of York and Canterbury are Patrons along with the Methodist Church’s President, and now the Guild has let in a – rather stumbling – Catholic President! (What were they thinking, I hear you ask?)  An academic journal is coming. And practical resources. We have plans!

Academic community of interest

The academic community interested in the crossover between health and faith in the UK is growing. From Professor Chris Cook (psychiatry and psychology) at Durham, to the Guild’s newly launched Raphael Institute collaboration with epidemiologists, scientists, medics and psychologists, through to the work of Professor Michael King at UCL and many others I could mention, a body of work is beginning to be pumped out in a UK context examining the links between health and faith.  Similar communities in German medical schools, Swiss Universities,  Italy and, of course, the United States are creating work of use and value to the public health community.

Putting effort where my mouth is

There are a number of reasons why I am delighted to take on the role of President. First, Health and Faith, and the links between it, are an enduring interest.  My paid professional role as a Director of Public Health seeks to improve and protect the health of a population, something to me which resonates deeply with the call I believe all faiths – including the humanists I am lucky to know and learn from – have to improve human life and hold in good stewardship our earth.  I have written elsewhere, in The Universe about the vocational aspect of this.   And I guess as part of that I need to play my part in dialoguing the health and faith world constructively and rigorously to help us find what mitigates for maximum human flourishing – for those of all faiths and none.  That doesn’t mean those of us of faith leave our values at the door of the office, by the way.

The second is that participation in the work of ensuring people are as healthy as possible, in all dimensions, is a direct participation in one of the ultimate purposes of what most people of faiths do – the cherishing of and service to the human. Visit a Sikh or Jewish social service centre if you haven’t ever done so. You’ll be amazed.

The third is that because of this insight, people of faith have much to offer from “all our best traditions” as the hymn goes to the world of healthcare, and to the whole issue of what health means.  In fact, we were here first. Long before the NHS, before organised health care, we were there.  And people like the Historian of Science Gary Ferngren and others are writing the history of that engagement.

Christian Social Teaching as a Health Inequalities Manifesto

A further reason is that this provides a much needed opportunity to explicitly link Catholic Social Teaching (sometimes called the Catholic Church’s best kept secret) and its seven principles embodying Justice, dignity of the person and so on to issues of health.  Read any book on inequalities in health and a book catholic social teaching side by side and they say very similar things.  People have a right to health, and the means to health including good , healthcare, education and so much else and this is part of doing justice to our world. Good quality healthcare is framed as an exercise in justice and love in such teaching. I can find that link implicitly or explicitly everywhere I look. The founder of the Science of Healthcare Quality and Healthcare Improvement, who was not a Catholic, explicitly defined Quality Improvement in Healthcare as an exercise in love.  The links are significant. For more on the seven principles of Catholic Social Teaching, read here. Recent changes over the past fifteen years in US health care policy have generated a significant body of Catholic thought on Just Health Care policy including a whole body of thought on access. I’ll be discussing my take on what Public Health and Catholic Social Teaching agree on with regard to access, equity, justice and commissioning policy at an International conference on mental health in Oxford in summer 2018.

The fourth reason is that now, explicitly in the policy frameworks of all of the four devolved administrations of the UK, there is the recognition that health has many social dimensions, and needs social actors. This is a Kairos moment – an auspicious time when we can speak into the agenda of what it means to be healthy, and what health and social care is about. We have things to say.  And that means re-energising communities about what they can do on their health.  Faith communities can be a part of this. And examples of good practice here abound, from dementia friendly places of worship to social inclusion programmes and projects for people with long term conditions.

The riches of tradition informs the progress of today

The fifth reason is that while each of us can offer things from our own tradition – I have a particular tradition which feeds my commitment to improve and protect the heath of the population.  I don’t claim it’s better, I just claim it has enduring relevance. Catholics founded religious orders dedicated to health and healing, for example. Countless people we call saints have been engaged in health.  The St Vincent de Paul Society is a Catholic charity providing help from white goods to holiday breaks to clothing to utility crisis payments and has a bigger volunteer workforce than CAB last time I looked.  Entirely funded by Catholics.  Mary Aikenhead, founded the order which created the hospice of which I am a trustee. Her values of advocacy for and inclusion of the most excluded (and said in those words) are a constant reminder to me not to become complacent in a public health system where it would be easy just not to try  to find a way through the cuts being imposed on us.

Those Catholic religious orders still run health and care services across the World and the UK (and over 150 centres from hospices to refuges for victims of human trafficking in England today).  One of those orders is the biggest non-governmental emergency aid agency in the world, among whose volunteers I am proud to count myself. My tradition is supposed to roll up its sleeves, include and serve. (and it often needs a good kick to remind it of that.) Moreover, my tradition attests to the fact that health is social as much as it is individual.  These must go together. No human being is anything other than precious.  Justice, Love and Hope are the hinges on which we embody that insight.

Institutions sometimes get decadent and fail people. That happens in the NHS and public sector as much as it happens in the churches. The point is that continual renewing of our purpose – maximum human flourishing. Every faith which has a sense of the divine is at its best committed to human flourish and justice – even if at its worst we shamefully can and do at times betray and sully that commitment – because we believe that’s what God wants for God’s world.

The whole person

The sixth reason I am keen to do this is because the scientific evidence supports these insights as much as it informs them. We are becoming increasingly aware that health includes the whole person, and especially for those who cannot be cured, health is about making a good response to the realities we face. Like the Guild’s Director, Gillian, I am a cancer survivor, lucky to be alive after a Grade IVB lymphoma. Like Gillian, that experience has shaped how I am rediscovering the riches of the Christian tradition to speak to today’s world on health. Her book Cancer: a pilgrim companion is a brilliant read.

For those with long term conditions or disabilities, those with long term mental health challenges, those who are dying, the World Health Organization’s definition of health as a complete state of psychological, physical, spiritual wellbeing is hopelessly optimistic, and unreal. It implies they are less than fully human, and with that comes the risk they become devalued.  That is not a Christian view. Suffering, limitations and disabilities are not valueless.  It is also not a view that sits with the science of health inequalities, otherwise why bother with the discourse of tertiary prevention?

The World Health Organisation’s vision is valuable, but its valuable because of where it points us. It is future rather than present, a hope for the future. That means we have to revisit what health means here and now. And I would argue that the science and our theology are mutually affirming on this, and the Guild is ideally placed to do that work from the academic work at one end of the spectrum to the work of caring, praying and doing at the other.

Called to serve

Earlier this year, The RC Diocese of Westminster led a season of events entitled Called to Serve the Sick. I hate the term “the sick” but that’s for another time.  The series was intended to be a practical continuation of Catholics being recalled by Pope Francis in 2016 to serve and welcome, when we sometimes exclude too easily.  A series of roadshows, which I was privileged to present at, discussed a Catholic Understanding of Health and Social Care, why Catholics should feel a particular importance of committing to health, social justice and social care, and what local communities can do about it. We had an audience of health and care workers, and people struggling with health issues. And people of all faiths and none. We’ve been asked to do more. There is a demand for this work.

The Bishop who led this season, Bishop Paul McAleenan said that “It is fitting that this season comes as a continuation of the Year of Mercy, giving us the opportunity to practice that most important act of Christian love, care for our neighbour. Good health, poor health, disability and ultimately our death, are integral aspects of what it means to be humans precious to God, and so they are of huge importance to us as people of faith.

On this, I hope, people of all faiths and none can make common cause.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Locating behaviour change in public health practice… some propostions

NICE have recently published their behaviour change guidance http://publications.nice.org.uk/behaviour-change-individual-approaches-ph49 and the British Academy have now released their report on social science interventions in Public Health (press release here http://www.britac.ac.uk/news/news.cfm/newsid/1041  ; report itself here http://www.britac.ac.uk/policy/Health_Inequalities.cfm . )

These two events have come almost simultaneously, and they both highlight the importance contribution of social sciences in health. The British Academy report deliberately focused (as we say in our introduction) on non-individual social science and behavioural science contributions whereas the NICE guidance focuses specifically on behaviour change. These two reports complement each other well and the key issue, as we say in the introduction, is for local areas to find public health strategies which hold population and individual measures, policy/regulatory and behaviour change methods, clinical services and health improvement services in balance. A balanced public health strategy is one which uses appropriate methods and tools for the different facets of the public health challenge we face, especially non-communicable disease.

I’ve read the NICE behaviour change guidance twice now, and I’m using it to bring together our various behaviour change intentions and programmes into a strategy as they recommend. This is a helpful and sane document with wise advice and a good framework for commissioners and providers.

On 28th January Public Health England, NICE and the Local Government Association will be holding Evidence into Practice , the first of a series of events seeking to support the introduction of evidence-based practice.  http://www.local.gov.uk/events/-/journal_content/56/10180/5751863/EVENT

I’m taking part in a panel discussion on the day, and I’ve also recently had colleagues from Public Health England spend a morning with me discusing and sharing how behaviour change approaches fit into a public health strategy.

I believe that there are several big challenges in getting behaviour change working effectively in public health programmes and strategies, and the NICE guidance is an enormous step forward, but we have much more still to do.

1. Having a conceptual framework of where behaviour change fits in public health as part of a strategy is a real challenge and no-one has really articulated this nationally yet in a clear and succinct way.

2. Understanding what method to use- do we target automatic processes or conscious ones, do we do population or individual level?

3. Policymakers often seize on one tool or method because it’s the current buzz topic and attracts a lot of scientific and practitioner interest. That doesn’t always make for  or effective strategy.

4. Many public health departments don’t have expert level behaviour science staff, and often the training we have had relies on models of behaviour change which are no longer used by experts in the field. The field has moved on, our training hasn’t.

4. The field itself is still developing – a bit like public health – and so experts and researchers in the field need to be better at communicating with policymakers

All of this leads me to conclude that we need some propositions about how we as public health practitioners take behaviour change forward.  I intend to share these with participants on 28th January.

Locating behaviour change in public health practice: some propositions

I share this because we ourselves are on the journey of working this out. It needs much more work, but we are already starting to use the framework they help us create.

I: Policymakers and commissioners need a clear Context within which Behaviour Change is used

  • The epidemiology of the UK is such that behavioural sciences can make a significant contribution to primary prevention of non-communicable disease, secondary prevention especially self-management and resilience and tertiary prevention (e.g. coping skills for breathlessness in heart failure.) Behaviour change needs to be seen within this context.
  • This contribution is alongside not instead of policy and population measures (like regulation of tobacco etc). Behaviour change is not the answer to our public health challenges. It is a part of the answer
  • A balanced public health strategy will have interventions at policy, environmental, social, sub-population and individual levels (eg the 6 levels of public health action in the Hertfordshire Public Health Strategy taken from Dettels et al,2009 http://slidesha.re/1e4CVzY ) Another way of looking at this is the Health Impact Pyramid https://www.idph.state.ia.us/adper/common/pdf/healthy_iowans/health_pyramid.pdf

Levels

Example of how they can   be applied –  Tobacco

Social – changing social norms   about health, e.g. acceptability of binge drinking, acceptability of taking   smoking breaks Behavioural economics, social marketing Young people
Biological – immunisation,   vaccinations, treatments Nicotine replacement therapy and cognitive tools for cravings
Environmental – encouraging green   transport, reducing pollution, changing the public realm Environmental cues, display legislationSmokefree playgrounds
Individual Behavioural – helping individuals to   stop smoking Individual and group behavioural change and support
Legislative –  the smoking ban, legislation on alcohol   sales The ban on smokingLegislation on displays
Structural – policy changes such as   workplace health, school health policies Workplace policiesTobacco control partnerships

II: Policymakers need Clarity of the aims and uses for Behaviour Change

  • Behaviour change can be used at population or individual or sub-population levels. Different theories, approaches and methods work for different settings. Policymakers should be aware of this.
  • Including behavioural science skills (e.g. health psychologists) in your service is essential to get it right . They need links with the academics to keep track of the field. We’ve recognised the need for links between public health practice and academic public health starting with our training and running all through our careers. It’s time behaviour sciences had this parity of esteem.
  • Behaviour change can target “automatic” cognitive/emotive processes (e.g. choice architecture and also eye position tracking on cigarette package warnings) or conscious deliberative ones (e.g. behavioural skills to negotiate safer sex.) You need to be clear which you are using for what, and why

III: Policymakers need Clarity of methods, settings and audiences for Behaviour Change

  • The experts in the field need to work with policymakers to create a framework or architecture within which local areas can understand and roll out behaviour change strategies and methods. A preliminary attempt at this is below

IV: A first step at a ready reckoner for behaviour change tools and methods

A   ready reckoner for behaviour change tools and methods

Population   Level

Group   Level

Individual   Levels

“Automatic”

processes

“Conscious” processes

“Automatic”

processes

“Conscious” processes

“Automatic”

processes

“Conscious” processes

Choice Architecture

Advertising e.g. change4 life

Nudge

Groupwork for behaviour

Targeted social marketing

Choice Architecture

Health Trainers

We   still have gaps and weaknesses in science and tools across all of these

(i.e. the science is still developing)

I hope this makes sense, and welcome your comments

What can a Public Health mindset bring to making communities safer?

Hertfordshire’s Police and Crime Commissioner has done something visionary.  He has set up a fund for communities to put together “innovative local schemes which aim to make our communities safer”. This fund is linked to the Police and Crime Plan for Hertfordshire, which takes an “everybody’s business” approach to reducing crime and making communities safer.

Less than an hour later I had tweets and emails asking me what evidence communities could use. Then people started asking me how they could develop and put evaluation frameworks around bids. Then partners asked – can we use the Herts Public Health Partnership Fund given to LSPs and Districts to match fund where there are clear links and overlaps? (The overwhelming view of the Public Health Board was yes.)

This set me thinking, what does Public Health have to bring to the table?  More years ago than I care to remember, I produced briefings on crime and community safety among other work I did in community safety and crime reduction. My public health training helped me find the evidence and organise it into tools which went to statutory crime and disorder reduction partnerships.

I often say one of the ways I describe Public Health  about four Ps:

  • A Perspective (or Mindset) which focuses on
  • Populations and sub-populations; which is
  • Prospective (it looks to what can be improved, prevented or avoided) and goes retrospective to understand where we are today
  • Protective – seeking to protect communities and individuals from risk to health and life

The mindset of Community Safety is very similar. Both Public Health and Community Safety work in similar ways: through communities, through skilling people up, commissioning and using interventions which have evidence of effectiveness and sometimes, when the evidence is silent, going back to good theory to build an intervention and evaluate whether it works.

The Evidence

Crime impacts on Health in a range of ways, and there is a great deal of literature on this. Things like acquisitive crime to feed drug habits, and the devastation of domestic violence and hate crime are perhaps the ones that spring readily to mind. But there are other issues too:

  1. Evidence suggests that ongoing stress from high levels of crime and high fear of crime contributes to a stress pathway that can lead to mental ill-health, poor resilience and even heart disease and stroke.
  2. Victims of crime are more prone to physical and psychological ill-health on an ongoing basis.
  3. Disabled people are typically more victimised for property crime than the general population
  4. Hate Crimes have enduring mental health consequences
  5. Victims of violence often develop adverse coping mechanisms which develop health problems
  6. Ongoing phantom pain and unexplained symptoms among people who are victims are not uncommon

By contrast, communities which have strong self-efficacy (i.e. they believe they can do what they need to) are more resilient (i.e. they can handle challenges and problems more easily and return to a good state of functioning more readily), healthier and more able to address issues of relevance to their communities like crime and disorder. They also have lower fear of crime.

Building resilient communities

So how do we build resilient communities? In essence where people share the same place and public realm we need to support communities find strengths, self-confidence, skills and solutions at individual and interpersonal level, have strong links with each other and develop a sense of affinity for those they live next to and nearby.   Where people share the same identity (sexuality, faith, nationality) finding common ground and sharing common interests are salient. This is neither new nor rocket science.

But often we lack the insight of the behavioural sciences. And it can be quite simple to harness these. We talk about community development in the UK. In the US they talk about Community Advocacy. Community Advocacy has at its hear building capacity in communities to help themselves, to do, to believe in themselves. The approach works in Community Safety as well as Health.  It is particularly effective for marginalised communities and those experiencing hate crimes and has a strong track record in the US. The role of a range of diversity groups  such as Faith Communities in Health Advocacy in the US is particularly striking, working as they do for very marginalised communities. We have much to learn from them.

Building resilient communities is something which public health and community safety could do together, because everyone benefits. Addressing specific types of crime (hate crime, domestic violence) also brings ongoing benefits to both agendas.

The Public Health Contribution

Taking just the range of issues above, Public Health has a lot to bring to the table. The prestigious John Jay College of Criminal Justice actually has a whole programme of courses on health and crime.  I am going to list just some of the things public health can bring to the table:

  1. Sharing epidemiological skills so we can understand better the distribution of crime in time and place
  2. Working together on public resilience and mental health agendas
  3. Finding and appraising evidence for effective interventions (see my next blog post)
  4. Helping NHS commissioners and providers respond early and effectively to victims of crime
  5. Training Police and others in preventing victims of hate crime becoming more traumatised
  6. Providing drug and alcohol services and pathways which cut crime and disorder and help people with problems
  7. Providing training to communities who want to implement and evaluate programmes
  8. Sharing evaluation, evidence appraisal and policy appraisal skills with people in crime reduction
  9. Ensuring services for those likely to become victims of hate crime encourage and support people to report
  10. Ensure the cycle of crime in troubled families is broken by finding effective interventions for people to thrive
  11. Find interventions which help children thrive emotionally and value themselves and others
  12. Using the public health role in licensing to the best good of communities

The new landscape of the NHS means NHS Clinical Commissioning Groups are responsible authorities for Community Safety Partnerships. This could be seen as yet another burden on new CCGs. The challenge is to find ways of integrating the CCG agendas with the community safety agenda, and picking some concrete issues and projects to start with.

My next blog post will do two things: signpost agencies to sources of good evidence in crime reduction, and signpost them to resources to help them evaluate interve

After the disturbances: does public health have a role?

This post also forms the Editorial for Birmingham’s Health Matters, Issue 7, 2011. August/September

As you have all heard over and over again, I love Birmingham. It’s an amazing city of wonderful people, and arguably the most diverse place I have every lived or work, even more so than East London. But we have many challenges, from the ongoing challenge of reducing inequalities in disability, ill-health and death to the more multifacted – the short and long term measures we need to take after the disturbances in our Cities.

I think public health has a role to play in helping our City meet its ongoing ambitions. Lots of people I come across do.

Against this background, work is currently nearing completion to produce a new revised health profile for every electoral ward and every constituency in Birmingham. We will be able to identify a snapshot of the health of our population, across the Lifespan, at electoral levels. These are part of the work of creating the new style JSNA, so that you can look at the City or any part of it and understand the health and social care challenges at a glance.

 Birmingham now has a library of needs assessments (deep dives into health and social care issues) covering 36 different topics. This has been a huge task, but the next task is to bring these together into one summary. That will be done by Christmas.

So why are we renewing the ward and constituency profiles at this point?  Is this not an odd thing to do? Why should this be important when we are in the middle of massive change in health and social care configuration, Dilnot has reported on social care funding, and many are still reeling from the shocking experience of civil disturbance?

I believe the answer to renewing information profiles is that it takes us to the heart of one aspect of what we want Public Health in Birmingham to do. Providing easily accessible, high quality information on the health of our local area is one part of the public health cycle. It enables us to identify what we need to address. In other words it gives us very clearly an overview of what’s not right, or if you want the jargon, areas of inequity and inequality.

The next steps of this cycle are about identifying evidence of what can be effective in addressing inequity and inequality and working with commissioners to implement and deliver this. Public health “science” means we need to know what the problem is and what can be done about it. Public health “art” is about getting it done. In that sense, our elected members and NHS non execs are among our greatest “public health artists”. The “scientists” should support the “artists” in achieving change.

This public health cycle (or one form of it at any rate ) is actually conceptually simple:

  1.  identify need, 
  2.  identify greatest inequality, 
  3.  identify effective interventions, 
  4. agree priorities, 
  5. support commissioning of them and
  6. evaluate what difference it made.

This is what the heart of public health should be about. The specialist training of public health consultants is intended specifically to help us do this. It’s a corny joke, but when we don’t use the public health cycle properly, it’s no surprise that sometimes the wheels come off what we do.

Let’s take an example – stroke. Stroke causes avoidable disability which limits the quality of life of people with stroke and takes a great deal of effort to recover from, and is a substantial avoidable cost on the public purse. We need to adopt a whole system approach. Clinicians and the Cardiac and Stroke Network have done an amazing job of identifying interventions at ambulance, entry to hospital and first 72 hours. What we need to do now is sort out the other ends of the system – stopping people getting strokes in the first place (we know the evidence – addressing Atrial fibrillation, diet, exercise, smoking) and rehabilitation for independence afterwards (social care, recovering activities of daily life.) Unless we know populations at highest risk for stroke, we can’t intervene. These profiles will help us.

But it’s a partnership, and public health works best in this cycle when it knows its role, supports the commissioners in their role, and supports elected members and decision makers in their “art” of public health.

So does public health and its cycle have anything to say about civil disturbance? 

Certainly the City’s formal and informal leaders (from the loving Father preaching peace through searing loss, to the sikhs and muslims who guarded each others places of worship, to those of us who simply took brush and shovel to help with the clean up) have been clear they expect us all to play our part, and follow their lead.

Laying flowers on Dudley Road in memory of Haroon Jahan, Shazad Ali and Abdul Musavir made me wonder what my contribution as a public health specialist might be, in addition to being a (relatively recent) citizen of this city is , both professionally and personally. I believe public health does have a contribution, and it seems to me that this contribution lies across four sets of issues. So here is a starter for ten. Do feel free to disagree with me, and correct me where I am wrong:

    1. Victims of disturbance – the long term effects of being a victim of disturbance in riots is reasonably  well documented. Post traumatic stress (whether short  or long term) is important to look out for, along with  other health effects (stress leading to psychological  or physical health issues like anxiety or heart disease, for example). We need to monitor peoples health and  intervene early.
    2. Communities – identifying how the disturbances  have affected our communities health, confidence and resilience (socially and economically) and then helping identify what can be done, and how to target resources for recovery. Identifying what builds health and social resilience, confidence, and cohesion in our communities can help our colleagues working there. This is in addition to building the healthiest communities we can, and prioritising our communities with the worst burden of ill-health. Health is not “the” answer, but it is a part of it.

    3. Offenders – working to identify effective interventions which rehabilitate and prevent re-offending could be a contribution here alongside criminology.

    4. Root Causes – the method of identifying evidence and analysing root causes is something public health could bring to the table, along with the other disciplines, when we sit down and reflect why this happened.

Ok, so information isn’t everything. But if we believe public health has a role, surely the public health cycle is something we bring to the table, and knowing the situation we face is a part of that.

Ten years ago I worked for a national crime reduction charity applying public health science to crime reduction and community safety.  I still remember the eleven year old boy in a particularly challenging area of South London, who was one of our peer researchers on a research project run by and for young people, to identify their experience of crime and disorder.  He used to go out every night when his dad came home in the taxi with that day’s takings.  He, armed with german shepherd dog and baseball bat, escorted his dad up to the family flat.

That experience – and many others – has stayed with me, not least because he and his mates (the youngest was 9) asked me one night what it was I felt my skills did. He was my first, and most searching “what use are you?” review.

The “big tent” discussion of different disciplines which went on while I worked in that role,  in places as various as the Criminology Journals, the streets and the then Home Secretary’s table helped, I believe, address some issues on drug related crime and on violence against women, and sexual violence. We can and must bring our best expertise from all our disciplines to this challenge. That’s what our citizens – rightfully – expect from us.

So, perhaps we can make a contributon to the recovery from the disturbances, as part of what we can do? My thoughts above are what the discipline of public health can bring.  It is a truism that many social problems have no simple easy solution. Nancy Krieger’s new book Epidemiology and the People’s  Health (Oxford:2011) should tell us that.  But it is equally true that we have to and can start somewhere. The debate about the nature of psychology (is it science, social science, moral science or all three) rages. In public health at least we recognise our work is blend of art and science.

So, can public health find the “start somewhere” evidence and point for the victims, communities, offenders and root causes?  Our predecessors would have sought to do so.  Birmingham will be hosting (as cheaply as possible in these straightened times) a series  debates later this year about what goes into our health and wellbeing strategy. I invite you to come along, take part, or even just email me your views. Jim.McManus @ birmingham.gov.uk  (sorry the email link isn’t fully done. It’s to prevent spam . )

 

 

 

 

 

What public health can bring to local government…getting acquainted

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.

After the listening exercise…the opportunity

As I get ready to speak to a Local Government Association Session on Public Health at their upcoming conference, I find myself trying to distill my thoughts, and looking back on what I learned from the last session I gave at a conference.

I got asked recently by some Public health colleagues and NHS Non Executive Directors (NEDs), somewhere in England, at a conference session I had been asked to lead whether Public Health was safe in Local Government. “How safe do you feel it has been in the NHS?” I asked. Nods.  This wasn’t a hostile exchange, nor an implication that public health is unsafe in the NHS, nor that it will be less safe in local government or public health England. It was trying to identify what our tasks for public health are now. There was some concern among the NEDs partly because they were very committed to public health, and partly because they were wondering what their leadership role was now.  A conversation ensued over coffee among a small group of us. We missed the next session but over the course of the next hour or so we mapped out together some issues, with a small mix of us, NEDs, PCT staff, a journalist, a civil servant or two and a couple of local authority people all sitting round in a group.

The detail of what happens where and with what resources will be worked out in due course (and we should seek to support and influence that so that forms and structures deliver what will benefit our citizens best)  and discussions will be had, but there is a leadership task – I prefer to call it a leadership opportunity –  for all of us who want public health to be core to our future, and deliver its best.

You may think on reading what I am about to say that I am foolishly optimistic, or too hopeful, or haven’t seen the enormous challenges we have to achieve what Government has set out. Fine. I disagree.  Why? Because it is possible to lead public health into a future where the best of what has been and is NHS public health  thrives along with the best of what it has been, is and can be in local government. And no, I’m not going to share what organisational forms I think that could take. Well, not in this bit anyway. I want to talk about our Leadership Opportunity first.

The leadership opportunity

If you take leadership at its very simplest, it is a set of influencing tools and processes, used by people in a position to use them, to get to a desired state. Public Policy increasingly tells us that such a desired state should be shaped by a range of stakeholders: Commissioners, Clinicians, Elected Members, Non-Execs, Citizens (including those who use what we produce),  other agencies such as community groups, think tanks, research experts and so on. One of the things about Public Health is that at its best we have been good at managing and building such relationships and that skill and tool should serve us well now.

But there are three key things we need to do in working our what our respective leadership opportunities are; i) to work out who we need to influence,  ii) what sets of tools and processes to use, and iii) what our desired state is.  And my own listening and learning tells me that these three things need to be different when we look at short, medium and desired future terms.

I know some public health colleagues tell me I am far more optimistic (I prefer to call it hopeful) about the future than they feel. But it seems to me we have a hugely important set of tasks to achieve, and looking around the public sector, private sector and third sector there are a lot of resources we can use to get there. 

 Trying to lead in situations like this is about making sense of the environment,a process of  trying to identify how best to respond to that environment, and from that to decide ideally what environment we need and how to create it for the future.   Yes, it’s much easier said that done. And yes, I am probably sounding  like one of those inferior “how I led Shmoogley Bumpkins Co from one cheese scone bakery in one city to three”  books you find in airport bookshops. (Don’t tell me you haven’t looked!)  But I really believe this.  And when we examine the value base we share in public health (we do, don’t we?) isn’t that what we get out of bed for in the morning? 

Three leadership oportunities for public health then, and I believe there are quite a lot of people who will appreciate us doing it, from Commissioning colleagues to GPs through to those who will be our next generation of public health specialists.  I can name at least fifteen people who inspired me to come into public health even though it was going through massive change. Who will say that of you or me in the future? That’s really up to us.

Yes, it’s a big job, but if you look at the changes wrought to a number of areas of public service and private enterprise over the last ten years, two points emerge. Firstly, this is a massive opportunity for public health. Secondly, other have done things similar and greater, and have gotten there or are well along the road.  It’s no different for us.  It could be a test of our mettle.

Conceptualising and operationalising the leadership opportunity

I once led a workshop on that title to a bunch of leaders in religious organisations who were trying to come to terms with the cultural challenge of responding to child abuse in their midst. Looking back some years later, those participants I’m still in touch with felt this focus was right. I think personally that I can learn from that experience in the situation I am in now. So, here goes:

The  task, I think, breaks down differently for NEDs, elected members and for us in the core of  public health.

Tasks for Core Public Health – cultural agility and customer focus

  • Short term –  ensuring that we understand what we can offer now and for the short term to a range of stakeholders, and that we do this clearly and that we are seen to add value. Who are our top customers, for what, what products are we offering, with what outcomes? Who owns it, and how can we own the short term tasks together?
  • Medium term –  Keeping an eye on the day job and delivering that while building the future, preparing people for it and working through this complexity.
  • Longer term – Engaging stakeholders in building a vision of what public health could be. How do we work with environmental health? How do we work with GPs?  Culture and relationships will be crucial here

Tasks for Elected Members and Local Government Officers

  • Respect the Cluster and its priorities. Respect consortia and their priorities. And dialogue with them
  • Work with your counterpart NEDs to create and lead some cultural agility from the top – try to interpret the ways of local government to the NHS, and vice versa. Local government is complex, and seems very different indeed from the NHS, to many (not all.)
  • Champion the importance of public health in creating a healthier county, city, borough. See the opportunity and work with NHS and local government colleagues to start on it.
  • Be honest that is is not a matter of public health “leaving” the NHS and “coming back” to local government. Public health is a series of systems, or at the very least a complex web of responsibilities. Some bit of public health have never left local government. Some bits of public health (the GP role in health improvement) will never leave the NHS.  That’s fine. The important thing is how we build the coherent systems in a way that they work together.

Tasks for Non Executive Directors

  • Understand, and promote within your agencies understanding of, the complex cultural and priority issues facing local authorities.
  • Work with your counterpart elected members to ensure together you create an understanding of the challenges the public health family in your area (NHS public health, environmental health, regulatory services, health protection agency and so on) have been facing and the opportunities they have
  • Champion the enduring NHS need for public health contributions to health improvement, service commissioning and quality and health protection
  • Interpret and champion to NHS colleagues the important local government contribution
  • Help public health colleagues build the cultural agility needed for the world of local government

Cultural agility

I’m not in any way denying there is a huge amount of transactional stuff in all this – HR structures, pay scales,asset tracking, and all that important stuff. But if we focus too much on this, and don’t turn the leadership opportunity into concrete things to achieve, we might just find we miss that opportunity.

And I think in trying to turn that leadership opportunity into concrete things, there is something we have left out. That’s what I call cultural agility (I’ll track down the source of that term if you want me to.) What do I mean? Well simply this, the ability to work across different cultures, to understand common aims and ends among them, to understand differences and what they mean, to find and respect in those cultures assets for us to work with, and then to work with them to create something. When you look across an average public health function you see people doing this all the time. Working with communities, applying their diversity skills. The reorganisations proposed, on one level, pose the same challenge of us; and ask us to use the same tool chest.

Making cultural agility live is the same task when we come to Local Government, GP Consortia, Clinicians of myriad hue and Citizens, isn’t it? We need to overcome our fears of the “other” (and let’s be honest, there’s a lot of talking about Local Government as the “other” among some public health colleagues currently whish is unhelpful. Yes, there has also been some unhelpful stuff from some local government people but folks, we really need to change the debate.)

When you look at public health, it becomes very clear that it is a series of systems and functions spread out over a range of institutional hosts. Health Protection Agency, NHS, Local Government, and so on. What makes them work is not beautiful system design, it’s cultural agility and goodwill.

We need to think how we build cultural agility together, across the various bits of the system. Public Health should be good at doing this. I’ll write about cultural agility next time, including some tips on acquiring it, from someone who is by no means an expert.

Meantime, some practical tips on cultural agility:

  1. Do some shared problem solving around a public health issue like Obesity and model solutions now, in 18 months time and in 3 years time
  2. Engage in some function design – take the lead in proposing workable solutions which engage everyone following on from the problem solving,

The role of NEDs and Elected Members, and Cluster Directors and Local Authority Directors could coalesce easily around shared problem solving.

 A Guide to Local Government

As an aid to the issue of cultural agility, I have finished the drafting of  an e-book and a learning presentation on understanding and working with local government with some colleagues. We are currently testing this. We hope to post it online shortly.

Public Health in two-tier local government areas: some tips from experience

One of the issues causing concern among Directors of Public Health in England is how, when and if Public Health transfers to Local Government, you configure public health to work in two-tier areas. By that I mean areas where you have both County Councils and District Councils. (All major Councils in Wales and Scotland are unitary, though both Wales and Scotland have a layer of Community Councils underneath the major Councils. So what I say here applies only to England -including Cornwall  and the Isles of Scilly.)

The model of Public Health in Local Government has been written for unitary or all-purpose authorites, and there have been a number of constitutional fudges over the last ten years or so which have put “top-tier” authorities (unitaries or Counties) in charge of some things. The phrase “top-tier” can sometimes feel patronising to District Authorities. But there are ways of making Public Health in two-tier Local Government areas work.

This blog is written from the perspective of someone who has worked in Public Health in the NHS, and has had a range of public health and Public Health roles in and around Local Government. I love Local Government and am passionate about its role, history, potential and significance.

I have worked in a number of two-tier areas, either as an employee or a Consultant, and the key is to understand the respective powers, duties, issues and concerns of each Council, the politics between them and how you can play them in to achieve your objectives. Ok, much more simple than it is, but in eleven years working across multi-tier areas in one capacity or another it has never failed me.

So, here are the things which have worked for me:

Firstly, understand that Local Authorities essentially fall into three Categories 

  •  Principal Councils are those which undertake major functions like Housing or Social Care. In London and many places these are all-purpose unitary councils. But England has a long tradition of two-tier local govermThese are Counties and Districts in County areas. The phrase “two-tier” essentially means you have two types of Authority. Counties cover a whole County such as Warwickshire or Dorset. Districts or Boroughs within the County cover a part of the County, such as Dorchester.
  • Local councils are parish or town councils which are very local. More about these later. In some ways calling an area two-tier is a misnomer when there are Parish councils around. Parish Councils can be significant for public health.
  • Specific purpose authorities are those like the North York Moors National Park Authority, and in some places specific Joint Fire Authorities, which usually exist in places where the Fire Service covers a number of local authorities, such as Tyne and Wear.

Secondly, understand what powers you might want to work with. Principal Authorities in two-tier areas have the following division of functions:

County Councils

  • Social Care for Adults
  • Childrens Care
  • Schools
  • Adult and Child Safeguarding
  • Health and Wellbeing Partnerships (proposed)
  • Category 1 Responder for Civil Contingencies Act
  • Waste disposal
  • Crime and Disorder Reduction Partnerships
  • Consumer Protection and Trading Standards
  • Strategic Planning
  • Libraries
  • Transport
  • Animal Licensing

District Councils (may also be called Borough Councils) 

  • Planning Control and local planning
  • Housing
  • Environmental Health
  • Waste collection
  • Building Regulation
  • Appointment of Proper Officers for Public Health Act purposes
  • Appointment of Proper Officers for Section 47 National Assistance Act
  • Disease Notification
  • Category 1 Responder for Civil Contingencies Act

All councils have different powers on similar issues

  • Leisure services and Culture have duties and powers across Districts, Counties and even Parishes
  • Roads and highways (Counties, Districts and Parishes all have different functions)

Parish Councils (sometimes called Town Councils)

Parish Councils vary enormously in size and functions. We might be tempted to think of the Vicar of Dibley when we look at Parish Councils but some of these very local bodies do struggle while others have functions and budgets not far off several million, often undertaking functions on behalf of their District and County sisters. You can find a really useful guide to the surprising powers of Parish Councils here http://www.townforum.org.uk/servicesstructure/parishcouncilguide2007.pdf. You can also find two very useful quick reads, The Role of Parish Councils http://www.camlink.org.uk/wiki/The_role_of_the_Parish_Council and the National Association of Local Councils, which is the Parish and Town Council answer to the Local Government Association http://www.nalc.gov.uk/Default.aspx

There are a whole host of things which Parish Councils can do you might not know about:

  • The provision of community facilities ranging from allotments to bars, laundrettes and even mortuaries, cycle parks, swimming pools and green spaces.
  • Undertaking functions on behalf of other councils
  • The right to raise a local precept for their parish through council tax collection

But equally importantly, they can help you engage local communities with policy changes, the Joint Strategic Needs Assessment, etc.

What’s in a name?

You  will find some councils in Counties may be called Districts or Boroughs. There is little difference, really just ceremonial and historical. Boroughs are districts which have been granted the title of Borough and can have a Mayor. Technically their councillors can be addressed as Burgesses not Councillors. Districts have a Chairman, not a Mayor.

Parish Councils and Town Councils essentially have the same functions they just exist in a rural or less rural area, or around a market town or historic town respectively.

Some Top Tips for Public Health to Understand

Thirdly, think through these top tips to develop a strategy for influencing and working across:

  1. Bear with me here, I’m going to give you the essence of what Psychology has to say on expert-novice differences and tell you why it’s important to you. The key difference between an expert and a novice in a field, according to psychological research, is that experts not only know the subject (i.e. have domain-specific knowledge of issues like environmental health and housing) but they can relate that knowledge to other areas of knowledge (i.e. how housing and social care interact) and can create mental maps and landscapes of how to work within and across those. What that means for you is get to know the Councils, understand how you can knit things together to create an integrated approach to public health, and understand who can help you.  A friendly local government lawyer is usually a help; while having both a County and a District member as a mentor can help too, especially if the two get on well and will agree to mentor you in joint sessions.
  2. The Elected Member theme here is crucial.  County Members and District Members have both different portfolios (housing, social care) and common concerns (their local area and electorate.) Personally I think elected members are crucial to making public health work and building an effective relationship with them is key. They have a difficult, not very well remunerated and often thankless task which they have to fight to be able to discharge. But they are a rich resource of learning and collaboration. The top tips are to remember – they are elected, you are not; you need to understand with both Chief Officers and Members when to relate to whom; treating them with respect and keeping some clear boundaries between their role and yours and finally staying politically impartial are all important. This comes with practice, hence finding a mentor.
  3. Remember always that Local Government in England has been around for centuries, so historical anomalies are important and you should accept these. The fact that the Common Council of the City of London and the Common Council of the Isles of Scilly have some unique functions is just one of these anomalies, and the fact that the Common Sergeant of the Inner Temple is actually a Local Authority (is He the only Local Authority who goes to bed at night?) is another.  Localism has been around for centuries, and the quirks and quaintnesses of local authorities up and down the land is just one manifestation of this rich heritage.
  4. Even if the public health transition intended in the White Paper is ultimately significantly downplayed or changed, Local Government remains crucial to the achievement of better health for our population. Counties and Districts, and Parish Councils can all have roles and they all have powers and duties you will probably want to tap into.
  5. While you will want to work in a two-tier area with both Districts and Counties (e.g. work with environmental health on food hygiene and education on school health) you need to understand that minimising the role of Parishes could be counter-productive. Make sure you think about Parishes, they can often be very helpful.
  6. Think about options for working together before or even without whatever comes out of the NHS listening exercise. Understand that there are models around for collaboration in two-tier areas already. Despite the political differences and challenges, Councils in two-tier areas often have a history of working together. They may have joint boards constituted between them (e.g. Joint Drainage Boards) which can give you governance models. There is probably a countywide Community Safety Network whose models you can learn from.
  7. Professional bodies often work well across counties. Trading Standards (County) and Environmental Health (District) often come together in networks for regulatory affairs. How can you use these to help? Similarly the lawyers might meet. The Chief Execs almost certainly do and there may be a members’ liaison forum.
  8. Professional groups are important sources of good practice in Local Government. Think about this. Can you work with the local Chartered Institute of Housing branch to help include housing people? Equally, the Chartered Institute of Environmental Health is a crucial body. It has now opened its doors to people from all public health backgrounds, and a good vote of confidence if you really want to be embedded in local government might be to join, and gain value and possibly some respect from your local government peers. I have decided to do this and am putting together my application and portfolio. Let’s hope I make the grade!
  9. Understand that local government thinks it never lost some aspects of public health. The Local Better Regulation Board with the Chartered Institute of Public Health and the LACoRs [Local Authority Co-ordinators of Regulatory Services] put together an excellent paper on the contribution by these bodies to public health. Get and read a copy! http://www.lbro.org.uk/
  10.  Think about whether, in the transition, you might want to set up a Joint Public Health Board, through agreement between the Authorities. Members and Officers can be given appropriate delegated powers within schemes of delegation.  The Council’s Lawyers (sometimes in Counties called The County Secretary) should be someone you want to speak to.  You might even want to consider the use of Agency Powers under the Local Government Act 1972, where one Council can arrange for another to carry out some of its functions as an “agent” on the commissioning Council’s behalf.
  11. Most Counties have shared County Level strategies and will have learning from this experience you can tap into.
  12. Counties and Districts have their own networks within the Local Government Association. These can be rich sources of learning. There is a County or District somewhere that has grappled with the constitutional, administrative or configuration challenge you are facing, so network!
  13. Make sure you are a regular visitor to the Local Government Association Website www.lga.gov.uk and if your Council is a member of the Local Government Information Unit , a Local Government Think Tank, you could benefit from making sure you see their publications. www.lgiu.org.uk

I hope this helps. Working in single tier areas brings is own challenges, but working effectively in two-tier areas can really bring its own rewards.

Further Reading

You can get some basic readings on two-tier local government here

http://www.idea.gov.uk/idk/core/page.do?pageId=1121355

http://www.direct.gov.uk/en/Governmentcitizensandrights/UKgovernment/Localgovernment/DG_073310

Jim McManus (2011) Understanding Local Government – a guide for public health professionals. E Book. Forthcoming