Blog by Caroline Tapster, Chief Executive at Hertfordshire County Council
It is very rare that Government reforms are universally welcomed by the local government sector, so when they are I think we know that they are onto something worthwhile. The proposed transfer of local public health leadership and responsibility to local government is one such instance. Whilst there continues to be a debate on the benefits of the Government’s wider approach to health reform, councils of all political persuasions have warmly endorsed the plans, articulated in the recently published Healthy Lives, Healthy People White Paper.
So why have these proposed reforms been so enthusiastically received? I believe it is a reflection of the long and proud tradition local government has of working to improve the health and wellbeing of its local population. Local government’s great municipal heyday was very much built upon the need to improve the health and living conditions of their communities. Councils provided areas with sanitation and clean drinking water, transferred slum dwellers to municipally built housing and created green spaces for sport and recreation.
Despite losing their formal responsibilities for public health in 1974, councils have continued to feel a keen responsibility to promote public health and tackle health inequalities in their local area. As the Government recognises, a key reason for this is the fact that the underlying causes of many of the health issues facing our communities are strongly influenced by the physical, social and economic characteristics of the place in which they live. Councils’ role as the leader and place shaper for their local areas puts them in an ideal position to deliver the Government’s vision for a wellness, rather than illness, service – something successive Governments have struggled to achieve.
Taking my own authority, Hertfordshire County Council, as an example there is an incredible amount of the work being done to improve public health in the county. For example, our schools play a key role in helping to tackle childhood obesity. Through the Healthy Schools programme, children are made aware of the nutritional value and benefit of different foods, with many schools also involving pupils in the growing vegetables to be later used in school meals.
Schools also play a strong role in ensuring that pupils participate in physical exercise not just through Physical Education lessons but also through other curricula or extra curricula activities. As part of the Essentially Dance project, for instance, some schools have held tea dances and invited older members of the community to attend.
Services are also targeted to help improve and maintain the health of our adult population especially those who are more vulnerable. Our Countryside Management Service runs a countywide programme of Health Walks, which not only provide physical health benefits and but also help improve participants’ overall wellbeing.
Our adult social care team has initiated a project with the East of England Ambulance where social care practitioners travel with an emergency care practitioner to attend to older people who have fallen at home. Enabling clinical treatment and social care assessments to take place at the same time, to date this scheme has successfully prevented the unnecessary conveyance to hospital of 87% of patients seen. Having won regional and national health and social care awards, the scheme is being replicated across the East of England.
Moreover, Hertfordshire County Council employs Community Learning Disability Nurses whose role involves raising awareness about the health needs of people with learning disabilities. Work includes supporting individuals to access main stream health services and delivering health promotion initiatives. They have also developed ‘Purple Folders’, which draw together all of an individual’s relevant health information, to help healthcare professionals ensure they receive the appropriate medical attention when they need it.
Similar activities are being undertaken by councils all across the country. In doing so, councils have worked closely and effectively with local health partners, most recently through mechanisms such as local strategic partnerships and local area agreements, to address health outcomes. However, despite this, the challenges we face remain significant and the health inequalities gap in the country has widened. Even in what is seen to be a relatively prosperous county like Hertfordshire, these inequalities are marked. For example, men living in the least deprived areas of Hertfordshire can expect to live more than 5 years longer than those in the most deprived areas of the county. The difference for women is nearly 4 years. Furthermore, levels of smoking, childhood and adult obesity, alcohol misuse and teenage pregnancies in certain parts of county remain too high. It is clear that a different approach to tackling these issues is needed.
The proposed new public health arrangements are an opportunity to do just that. With local Directors of Public Health embedded within the heart of the organisation, councils will be able to more effectively align public health budgets with the work that they are already doing to influence health and wellbeing in their local areas. As such, it should be possible take a more integrated, holistic approach to addressing the public health challenges our communities face.
A more integrated approach will also enable us to make better use of the evidence that both areas currently collect and hold. This will help to strengthen joint strategic needs assessments and develop a greater understanding of how to target services most effectively so that those who are at most need of attention and support receive it as quickly as possible. At the same time, a stronger grip on the evidence available will give us the best possible chance of developing innovative solutions to tackling some of the thorny issues currently hampering our ability to effectively address health inequalities. Almost certainly there are opportunities that we are currently failing to harness and we need to make sure these are identified and exploited.
The new arrangements also provide councils with an opportunity to make healthcare services more responsive to the specific needs of a local area. The transfer of public health staff into local government, along with the creation of Health and Wellbeing Boards, should provide councils with greater influence over local healthcare planning and provision. The greater exposure to the councils’ democratic processes and accountabilities that these new arrangements will bring to these issues will also help to ensure that decisions become more reflective of local community needs, concerns and priorities.
Of course, that is not to say that the new proposed arrangements will be without their challenges. Despite the advantages of what is proposed, there still needs to be a recognition that resource constraints, at a time of budget reductions in local government and of challenging productivity requirements in the NHS, will impact on the capacity to deliver improvements in public health outcomes.
Secondly, the roles and relationships between Public HealthEngland, local councils and local Directors of Public Health still need to be clarified. It is not yet clear, for instance, to what extent spending decisions in relation to the ring-fenced public health budget will be able to be made through normal council decision making processes with elected members ultimately responsible for the decisions taken. In the interests of local democratic accountability, it will be important that elected council members are able to take the lead on these issues in the same way they do with other areas of council responsibility.
Moreover, the transition to the new system is unlikely to be without its issues. The success and failure of this new approach will still largely be determined by how effectively councils work with their local health partners – not least the newly formed GP consortia and the local acute trusts. Councils are already starting to forge stronger links with their relevant health colleagues in preparation for what is to come. Naturally, there will be cultural and political differences to negotiate but the stronger the understanding that can be developed the smoother this process will be.
No doubt these and other issues will need to be ironed out if the potential benefits of the new arrangements are to be fully realised. However, the reasoning behind the transfer of public health responsibilities are strong and the potential benefits high. The health challenges we face as a nation are significant and the approach we are currently employing to tackle these issues is not working. As such, I believe that this return to local government’s historic role in health improvement presents us with a key opportunity to develop a more targeted and effective way of addressing these problems. I’m looking forward to the challenge!