The Joint Director of Public Health: Opportunities and challenges in a changing landscape

Jim McManusJoint Director of Public Health, Birmingham City Council

New Species or Oddity?A DPH in Local Government

Wendy thought the new multiple accountabilities for Directors of Public Health could get a bit fraught

Local Government Public Health

IS• A portfolio of activities• part of a Matrix• About doing our Core

Business in a Healthy Way• About complex and

strategic working• About partnership• About People, and Places,

and Exposures

IS NOT• A replacement for the NHS

or good primary care• Going to improve life

expectancy tomorrow• Lacking in Evidence• Lacking in Implementation• Always Short Term• About shifting all energy

from NHS to Local Authority services

Health Improvement

Health Protection

Service Public Health

Commissioning priorities, Evidence, making it work, supporting implementation

Ensuring we have the right frameworks in place

Long term, medium term, short term, matrix

Context

• Birmingham’s support for the White Paper

• Desire to do things differently

• View of members and GPs that public health isn’t working optimally

• PH refreshing and reshaping its vision

Some History• Public Health Acts 1836 and 36 subsequently• Public Health into NHS in 1974• LA Public Health Movement since• Environmental Health• Promotion of Health 1984 Act• Range of Public Health Functions endured in LA:

– Communicable disease– Social care– Housing– Waste disposal, sewage, waste collection

• Marmott !

The Vision as I see it

1. Public health at heart of strategic role for LA

2. JSNA - Commissioning

3. Opportunities for health improvement short, medium and long term

4. The big prize is not the 20%

1. In the LA, but not focused solely on the LA

2. Get this right for primary care

3. Take to heart the NAO criticisms

The new public health duties

Coming into Las where….• Money has been removed

and services cut. Whole landscape changed

• There’s a ring-fenced budget and everybody wants some of it

• Public health is not a known or necessarily trusted quantity (just how joint is your joint DPH?)

Implications

• DsPH need a lot of preparation

• Identify value and priorities with clear business case linked to core authority priorities

• Identify what you can add to LA core agenda and what outcomes

• Identify other outcomes too

So what does it mean?

The Core Business

• Doing the core business of the Local Authority in a way which– improves the health of the

population– Reduces inequalities in

health caused or acted on by social determinants

The Ringfenced Budget

• Opportunities but need to be seen in the context of the core business

• The DPH is “MORETHAN” the 20% of the 4%

Financial Issues for Councils

• Go bust very quickly indeed (tarrif services?)• Create parish/town councils and function transfer • Cut, cut, cut – deny people services – 33% less?• Change your model – targeted services for those

with greatest need, preventive and universal for others– Spread risk and co-produce/outsource

• Ringfencing of public health budgets in this context will be seen as a mixed blessing

The Opportunities

• Public health delivering outcomes• A balanced public health function• Wider networks and systems approaches• Interface between GPs and Social care to

save both sides of the system money• Behavioural solutions to thorny and

expensive problems

Our Burdens of Disease

Primary Secondary Tertiary

The Challenge

• We are doing tertiary prevention first because of where we are epidemiologically

• Understand which levers pull short, medium and long term

Short Term – primary careEXPOSURESLIFESTYLE

Medium to Long Term – LA and other playersEXPOSURES. PLACES. LIVES

Time

Domains of Public Health

Health Improvement

Health Protection

Service Public Health

Where does this go and when will it stop being entirely NHS focused?

Diverse accountabilities

What about the PH role in Commissioning?

So what is our approach since 2008/9?

• Policy Commitment– The Council Plan

• An assessment of work and priorities across the council

• Each service area playing its part

• Corporate areas playing their part

• Scrutiny of Delivery

Each Service Area Playing its Part

• Regulatory services – workplace health and also nutrition through food outlets serving food to people in low paid/deprived areas (the healthy food sales awards)and work on young people and tobacco/alcohol

• Housing and Health• Adult Social Care and Health including our strong work on

prevention and integration between health and social care• Childrens’ JSNA and helping to reshape commissioning and the

work they are doing on emotional development• Worklessness and health, work just starting• The Core Strategy including clear commitments on health

Corporate Area Playing its Part

• Shaping the Place to reduce risk and exposure – Protective Factors (Good Housing, Good

Education, Good Economy, Decent Public Realm)

– Vulnerability Factors • Be Healthy as a Key Priority (for our CORE

business)• Health of our staff as a key part of a corporate

strategy for our human resources

Don’t wait for change or direction…move now

Life Expectancy by WardStill there whatever the back office system

Birmingham Approach to theWhite Paper

• Shadow HWBB• GP Engagement• Public Health

Strategy• Transitional

Programmes• Shared Leadership

across City• develop HWBB

• Public Engagement• Member and GP

shared learning • Prediction &

Prevention– Falls prevention in

social care– Telecare

The Accountability Challenge for the DPH

• Either everyone wants you or you wonder which Lion will bite you first…

• At least some of that is down to the System, and some of it is down to the DPH

The DPH – Focus for Action orPorcupine?

Elected Members

HWBB

SoS / CMO / DH / A-Z

LA CMT

NPHS

Staff Team ?

GP Consortia

PROVIDERS

Issues for us to work out

System

• Clarity of governance• Boundaries• Deliverables• Outcomes Framework• Early Wins with HWBB• Systems Working, Matrix

Working• Pressure Valves• Complexity

Person• Capacity v DASS/DCS• Partnership Oriented• Strengths• Support• Boundaries• Working with elected members• Working with GPs• Resilience• The myth of independence• Political Restriction

Some Golden Rules

• Position – Council Plan, Directorate Plans, HI Plan

• A good time to refresh outcomes, strategies and delivery – keep momentum and morale

• Phased Positions

• Formation/Learning/Preparation

– Members– GPs– DsPH– LA Directors – PH Staff

Birmingham Policy Framework

• Council’s Big Three includes Behaviour Change by Services AND Citizens

• The Council Plan – Be Healthy

• The Prevention Framework and Prevention Strategy for Birmingham

• The Public Health Strategy 2011

Models for new services

• Provide

• Outsource

• Commission

• Matrix

• Network

• Mixed Economy

• Stimulate Social Enterprise

Embrace the vision and the opportunities for Public Health

From “independent” advocate

(was that ever really true) to

Officer working with members

and GPs

Thank you!A copy of a supporting paper “some thoughts on the DPH transition” is in your pack

Jim.mcmanus@birmingham.gov.uk