What does health in all people policies ... - Sheffield DPH



What does health in all people policies really mean The public health strategyThe original ask of the Leader of the Council and Chief Executive was:Describe what SCC as a “public health organization” would look like“transform ‘public health’ please, from an NHS facing model to a local government facing on.“PH” is not “the PH grant”, it is the sum total of all that happens in Sheff that determines how healthy we are. Influence how the city works to achieve the goalThe goal is the 25yr difference in H Life Exp (and the things that lead to this)write a strategy. The aim of the strategy is to describe “SCC as a public health organization” and to enable the public to hold SCC in this. The strategy is now agreed and published: approach taken in the strategyThe approach is, deliberately, tipped away from an NHS centric model of public health, through that model still has significant merit. This is an effort to redress the balance in approach to “public health” a bit, but mindful of the large gravitational pull of the NHS and the potential in terms of the staff that work in it. We have, however, made a concerted effect to shift the balance of the discussion and narrative on health away from the NHS and more towards other issues. What is Health in All Policies / What is the aim of HIAPLarge chunks of NHS and social care resource (about ?180bn nationally) are used “buying back” health that we've already lost via policy choices in other policy spaces. There is renewed interest in the concept of Health in All Policies. A key feature of the strategy is focused on the concept of health in all policies. PHE have written a guide. Its great. LGA have also written a guide, its even better. . The Health Foundation, as part of the work up for their strategy, hosted an excellent seminar. Durham university run an expensive but good looking 3 day course, Im told its good. South Australia Government have published an excellent guide. Health in All Policies is mechanism to 1) make explicit, and 2) increase (rather than describe the current), the health gain from policies and service areas that have not been considered as “health” related. One of the aims is to ensure the health and inequalities impact is on the balance sheet in a visible and tangible way. In this way we will challenge the way the existing resources are committed. The POINT of such approaches is using such frameworks to CHALLENGE EXISTING resource commitments AND DO BETTER with a view to delivering more health return with them than is currently the case.One of the aims is to ensure the health and inequalities impact is on the balance sheet in a visible and tangible way. Many of the processes will happen, the challenge and opportunity is to maximise the well being out of the processes that may otherwise be the case. In this way we can seek to create health & well being, something at least as sensible and as practical as simply avoiding disease. The “public health budget”.Public health is an organisational responsibility not a line in a budget, the “Grant” cannot by itself address the public health challenges of the city. Government have indicated it won’t exist in a few years time, it will be replaced by Business Rate Retention. The grant is currently 80-90% spent on commissioned services (mostly NHS). The ambition in being a public health organisation is to optimize the use of its ?1.4bn budget, and associated purchasing power, to best improve health and address inequality. This is best framed as not about “new resources” but as about maximising benefits from existing commitments, and then changing the nature and shape of those commitments over time to optimise or change the trajectory of outcomes more than would have happened with no intervention. Starting point for implementingThere is no intention to write a detailed action plan. Implementing Health in All Policies will take many forms. There isn’t a single idea or policy option that will achieve the goal. The specific 10 areas highlighted in the strategy are one place to start, and focused on obvious opportunities, easy wins and areas with significant gain potential. These are listed below:best start – pre birth to primary school education. The first 1001 days. comprehensive work and health strategypotential for sustainable economic growth to improve better health outcomes and redresses inequalities. the City for All Ages Strategy and refresh our approach to healthy ageing.optimise the health & well being opportunities around land use planning; population density and mix, transport planning including active travel by adopting a healthy town framework. We will redevelop an Air Quality Strategy for Sheffield. support the NHS with the reform and transformation agenda as articulated in the Sheffield Place Based Plan. review and redevelop the Sheffield strategy for open space and green space, bringing together our approach to the Outdoor City, parks, Move More and other agendasmaximise the health and well being opportunities though the our housing strategy, and development in the housing sector more broadly. develop a strategy for mental well being, building on, and complementing the mental health strategy. Obviously where opportunities naturally arise on account of external or internal events we will take them. We will also seek to engineer opportunities. ‘Policy windows’ may only be open for a short time. They may revolve on an unexpected crisis, budget process, and community demands.What does success in Health in All policies look likeThe acid test of adoption of a principle of Healthy in All Policies will be that all areas of decisions making and resource commitment systematically consider health and well being outcomes, and inequalities across. Success only happens if the approach is institutionalized. To truly deliver a health in all policies approach it will be necessary to change the way the organization thinks and does its business. The expectation would be that transport policy and investments in this area will deliver health gain and that should be led from within that part of the council, for example the licensing or the planning committee. In this way “health” becomes business as usual for the council. This is a long term project and the difficulty shouldn’t be under estimated. Success involves changing cultures, standard operating procedures for a city and challenging the status quo. There are obviously trade offs and compromises are always necessary.Success will involve finding opportunities for change, working with key opinion leaders and other stakeholders, aligning "health" interests with concerns and priorities in that sector that we are trying to influence and being clear what we can do and what others need to do, with measurable goals.Risks and problems in implementation of Health in All PoliciesThe?danger of investments for future health not being made as budgets are skewed (understandably) to demand led services – history has told us a story of consistent demand and cost growth here. Obviously this is the story of the NHS and adult social care, but they are not the only demand led services. “the danger that it’s a framework that’s used for services to describe how what they already did improved health, and how they could do more if they got money (there isn’t any?) so it is not about how they were going to change what they did to better address health”.?Execution of a strategy like this may be been about challenging vested interests and, as ever, the demands of the short term thinking dominates agendas and resources. These are not easy challenges, as history has demonstrated in both the NHS and Social Care. The flash points will become where there are choices to be made about resource commitments (do we protect car drivers in effort to address congestion by building more roads, or do we tackle congestion by proportion modal shift; do we prioritise investment in social care or parks and green space). Success and reasons for failure, as cited in the Health Foundation documentDiagram taken from Hooked on Health. See references. Understanding these and other often cited difficulties with implementing a HiAP approach will help avoid pitfalls. Other cited difficulties include:lack of institutional supportineffective leadership in the bureaucracypoorly planned or unclear objectives and responsibilitiesimpediments of hostile stakeholdersshifting political prioritiesweak enforcementlimited resources and capacityunrealistic time frames.Tendency to focus “health thinking” on care not healthArguments about the role of and relationship between the state and the individual? Misconceptions and misunderstanding of the nature of evidence in complex systemsOften decision makers don’t REALLY got traction to change and shift resource commitments upstream to be more preventive, especially in the context where power is diffuse.The end point is vague and difficult to define, it will not be achieved quickly, not will attribution be easy.Often there is no clear and single definition of “the problem”, or “the solution” – everyone has their own view, sometimes these visions work together, sometimes they are at cross purposes and conflicting.Often there is no clear accountability – nobody REALLY responsible. (Nobody gets the sack if we don’t “improve health”. Even where there IS accountability…. Its mixed across many orgs and agencies and diffuse (nobody has CONTROL of the agenda).There is a tendency to focus on here and now operational detail, often at the expense of long term investments and strategy.LGA / ADPH have suggested an organizational competency framework. language is important. Get it straight.The term “health” takes us down a certain path (NHS), maybe we should just use the word “well being” or something elsePeople get hung up on the word “health” and see it as a bit “narrow” and “medical”…. Perhaps if we substituted the H word for “well being” might make the notion of “well being in all poliices” a bit easier to land. Of note, the Welsh have done it. At policy level, health is largely still seen as?the remit of health care chiefs. We need better?strategies for engaging the broadest set of decision?makers in the consideration of health impact. HIAP being seen as “health imperialism” - HIAP is not a land grab for “health being at the pinnacle of decision making”, but a reflection of the multi faceted nature of things that are risk or protective factors for health. Getting traction. Gaining traction in the way that large resource commitments influence long term well being and inequality outcomes, in the face of immediate demand led pressures, and reconsideration of core statutory duties is the key resource challenge. There is a need to ensure the right machinery to make change happen. Arguably that may become a little bureaucratic but without machinery the strategy may never get beyond bold words.Some ideas to develop implementation are set out below:Build health impact assessment into planning processes and developments in a practical way, based on best practice. This will be prospective and undertaken in a way so as to influence policy at an early stage, not retrospectively measuring when a decision has been made. There is a danger that this becomes a technical diversion away from the real decision making process, we will assess that on a case by case basis. Linked to this, develop common monitoring and evaluation toolsOwnership - it only matters if others share the vision and general approach. Ownership of a large group of stakeholders matters. Persistence and presence across all parts of the organization will be needed.There may be meric in reconsidering the question of the purpose of "commissioning" in some areas, what outcomes do we want to achieve and whether there are more strategic uses of resources to get the outcomes we wantLearning across sectors – there is great, and largely untapped, potential to apply improvement methods from one sector to another to achieve greater value. For example the improvement techniques used in schools to health care, and vice versa.In some areas it may be necessary to change how success is measured in big systems, how ROI is considered and what lessons can be learned from elsewhere in the world or other relevant sectors. An example of this might be reconsidering how “success” is measured in transport policy, and the incorporation of health impact into economic success measures and evaluation models. A second example would be the consideration of the long term health impact of economic policies. The RSA Inclusive Growth report (and many others) have noted that a healthy population is core to economic productivity, but often missed from calculations. Be clear about expectations - should key policy or service areas set and publish health and well being objectives, take reasonable steps to meet objectives, write an annual statement. If we don't meet objectives state why. There is much to learn from the successes or failures of other models of?change at the population level, e.g. recycling, tobacco, climate change??Engaging citizens in this agenda?is important, and we could do better. We need to think through how we can better engage?individuals in the factors that influence their health.?Health is NOT solely the product of our own choices.?But as individuals, we can? influence these decisions as voters, consumers,?employees and shareholders if we understand the? problem. How can?we equip citizens to be just as (or perhaps more?)?prepared to lobby their politicians over the levels of?nitrous oxides on their local streets, or the lack of?street level activity in their housing estates, as the?closure of an A&E??Supporting community based co-design?to define and solve “problems”. Starting with the problems as defined by?communities themselves, rather than the problem? as perceived by the authorities. The five a day message will have little traction in a food desert? Improving access to health?services for depression and anxiety is necessary but?if for instance, the root cause of people’s anxiety is?lack of housing security; a pill or talking therapies?isn’t going to solve it.?Aligning wider policies with improving?health. There is consensus that the?decisions that influence job supply, housing quality,?or our ability to lead active lives are going to have?more impact on our health than whether we fund a?new treatment or build a new hospital.?Engaging local business and employers. The value of health in a local population to business?and employers is one opportunity we tend to?overlook. Mobilizing wider resources and? supporting longer term investment. how might it be possible?to bring together stakeholders to make the longer?term investment in strategies to improve health and?wellbeing.?Obviously this must address the “wrong pocket” problem (where?those that need to make the investment to improve? things are often not those who benefit from the?savings that accrue). There may be potential of “health bonds.”- different from current revenue spending and social?investment, the concept of the health bond would?encourage all stakeholders to put a monetary value?of the benefit to them of a specific dimension of?better health. Then, pooling this value into the?health bonds, it would create a funding stream?for upfront investment in start-up ideas. With?all the investors being part of the governance?arrangements, they would have direct influence?in decisions about which initiatives to support.?Developing an inequality and effiiency narrative. How might we react if we were to start viewing health as a finite asset.?This may be based on analysis identifies those groups that?are achieving sustainable levels of health status as?defined by securing above average life expectancy,?below average resource use and meeting some measure of sustainability. There is a global version of this on the website.Next stepsgive consideration to where energy should be focused first – ie of the 10 areas set out in section 3, where are there obvious opportunities to focus energy first. consider how best to ask other cabinet members or directors to Scrutiny to describe how they are improving health and well being in all SCC processed and policy areas. This may involve working through each portfolio in turn.consider how other scrutiny committees can ask questions about health and well being in their existing processes. Other referencesWhat does excellent look like in a public health strategy thoughts on Health in All Policies in this“Resources within the PH GrantBeyond?the services commissioned (and the ? spend on commissioners, ie many of us)…..Obviously it’s important that the commissioned services are doing what we want and delivering the outcomes we want. This is just as true of services commissioned within the public health grant as ANY other service. This leads me onto the ‘others’……I am one of the ‘others’ – basically the job of others is to engineer change. My chief exec sometimes characterises this as the ‘health strategy’ department, sometimes as the R&D dept. Either way he’s right (he always is). It’s quite a small sum of money spent on strategic leadership, most of it is spent on commissioned services.It’s worth a very careful read of the section in the LGA doc about “backbone staff”. This sort of stuff – changing cultures, SOPs for a city, challenging the status quo etc – isn’t going to happen by itself. It also isn’t easy, nor particularly tangible or quick. So always a danger we cut the backbone to feed the demand led stuff.This will only happen if we make it happen. But if you want”?outcomes based commissioning - we were really outcomes based we’d do something different?when old PH meets new PH from Coventry and Kingstoneveryone talks about in hushed tones about Coventry as a Marmot Citythey are doing some fab stuff.Im not sure it’s any fabber (is that a word) than things going on here. In 2 years time, will people be talking about Sheffield in similar ways. They will be if we make it so.?“some stuff to consider early / my 10 take home lessons.Use of budget and skills1. use your (tiny) budget wisely and strategically2. use your skills and position to influence others (to do what they largely already want to do – prevent stuff). go play with new people and partners3. use your skills and apply them to any problem that you want. Historically our lot have done this in NHS, now do it in jobs, poverty, housing etc4. Really develop new insights into problems and act on those insights. Use the assets you’ve already got to get those insights.5. Use of behavioural economic techniques to achieve behaviour change at scale.6. Health is an asset to the economy and economic growth. View health through this lens and you will make more friends than “banging on about health” all the time7. Doing more of the same will lead to more of the same. Do something different.8. Use the power of social networks to increase reach.9. Use diffuse leadership – don’t “own” things, but inspire others to. Set agenda and create culture.10. Help people – “the system cant make people healthy, people can make people healthy. The system can help the healthy choice be the default or easiest”?targets of early thinking1. The key things that are consistently most important we: – Jobs and employment / Homes / Health and well being2. think through what does “prevention” look like from different lenses – police, social care, housing, health, schools etc etc. Remember “health” and “police” are not homogenous – different messages be pertinent to different chunks of that system.3. Translate stuff between systems. Connect different systems together in ways they may not have been connected.?other stuff1. everyone says getting a shared data function for the whole city, as granular as possible. Critical2. digital by default in the design and implementation of behaviour change services. Web offer. Frees up human time to focus on more vulnerable groups. Of relevance to all behaviour change services?3. Quality of relationships matters – esp q of relationships with local communities. Talk to them, be open and transparent.4. What are the early wins. Go and win them. Develop the business cases for big chunks of work you want to see through”?What skills do we need to doPublic health 3.0Mainly focused on skillset my most read blogWhat is OUR contribution - Data, evidence, perspectives, links, evaluation, economics and value for money.?Six Big Ideas for Health..uk/blog/six-big-ideas-healthExcellent blogPHE - LGA - on Health Care Designing Strategies for Better Health PH strategy Guide LGA guide Foundation Strategy for health Hooked on Health Care Designing Strategies for Better Health Australia - who.int/sdhconference/resources/implementinghiapadel-sahealth-100622.pdf Harry Burns What causes health & ................
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