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'This is the NHS having a real go at placed-based working'

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The Long Term Plan’s focus on population health has prompted a reassessment of how the health service interacts with local government.

The panel

  • Lola Abudu, deputy director for health and wellbeing, Public Health England West Midlands
  • Terrie Alafat, chief executive, Chartered Institute of Housing
  • Kate Ardern, director of public health, Wigan MBC
  • Julian Brookes, deputy chief operating officer, Public Health England
  • David Buck, senior fellow, public health and inequalities, The King’s Fund
  • James Bullion, director of adult social services, Norfolk CC
  • Tim Elwell-Sutton, assistant director of strategic partnerships, Health Foundation
  • Stephen Gaskell, head of chief executive office, Southwark LBC
  • Manjeet Gill, policy advisor, Solace
  • Nick Golding, editor, LGC (roundtable chair)
  • Sakthi Karunanithi, director of public health, Lancashire CC
  • Jim McManus, director of public health, Hertfordshire CC
  • John Middleton, president, Faculty of Public Health
  • Maggie Rae, head of school, Health Education England South West and Public Health England
  • Rosie Rowe, healthy place shaping lead, Cherwell DC
  • Tom Stannard, corporate director of regeneration, Wakefield MDC
  • Jacquie White, director of system development, NHS England

No one could accuse Jacquie White of having a straightforward job. As director of service development at NHS England, she is firstly charged with supporting the creation of integrated care systems (ICSs) across all parts of the country. She also leads the organisation’s work on population health management, trying to ensure the broad determinants of health and wellbeing are accounted for in systems, and that data is used to identify specific at-risk groups and ultimately drive improvements in outcomes for local people.

It’s an awful lot to put on the LinkedIn profile. Yet Ms White has a simple, frank summation of her role relating to population health. It is, she says, about helping the NHS “catch up”.

“We know this isn’t a completely new concept,” she told an LGC roundtable on population health, held in association with NHS England. “It builds on some really amazing public health skills and abilities around analytics and data.

“But what we want to do, and what we believe is the true opportunity – particularly through integrated working and through ICSs – is to take the willingness, the enthusiasm, the commitment to want to work together to improve population health, and actually use population health management as the way to do business.”

For many in and around local government, the vocal NHS commitment to this approach will be most welcome. The Long Term Plan confidently proclaims that “local NHS organisations will increasingly focus on population health”, positioning this shift as central to “a new service model for the 21st century”.

“I think we should really clock that this is the NHS having a go at place-based working, which hasn’t happened very often in my career in social services,” said James Bullion, director of adult social services at Norfolk CC.

This was met with murmurs of agreement from fellow panellists. It also underscored a challenge of understanding, definition and perspective. Do the NHS and local authorities have a shared concept and language to describe population health? Many of those at the table suggested not.

David Buck joined the roundtable a day after leading a course on leadership for population health, the issue of a mutual understanding fresh on his mind. “I think what came out was actually people’s ‘populations’ are very different. Everyone’s got their own lens on what the population means,” said Mr Buck, senior fellow, public health and inequalities at The King’s Fund.

Tom Stannard, corporate director of regeneration at Wakefield MDC, said he’d worked in different settings with varying degrees of integration between local government and the health service. “I think one of the things that we often overlook, and it’s partly led by the clinical focus and the Long Term Plan and so on, is that all of those other enablers that we work on in place-shaping are determinants of population health,” he said.

For Jim McManus, director of public health at Hertfordshire CC, it felt like there was “an octagonal prism”. “I’m seeing one side of it and NHS colleagues are seeing another side of it,” he said. “We’re not all seeing the same thing. We might see similar facets, but call them different things.

“I think the role of place and the role of fundamental things like housing and economic development and all those other things needs to be described. How many clinicians really understand the important value of decent housing for mental and physical health?”

As chief executive for the Chartered Institute of Housing, there are perhaps few who have experienced that challenge as often as Terrie Alafat. “Every time I speak to housing audiences we always end up with this thing of the NHS doesn’t understand what we do, we all have a different culture, we all use a different language.”

“Which is true,” she added, chuckling.

Even so, she also expressed delight at the NHS’s desire to “look at this differently and be place-based”. And she argued that it is an “opportunity to challenge ourselves about the way we’re looking at this issue”.

Perhaps the first priority is being clear about the difference between population health management and population health. Some of our panellists feared there was a danger that efforts in this area would be solely focused around data and identifying at risk individuals – the ‘management’ part of population health – rather than the broader issue of understanding a population and the determinants of its wellbeing.

“In the work we’ve set out to do in our patch, the mantra is that population health is 10% data and 90% change,” said Sakthi Karunanithi, director of public health at Lancashire CC. “Population health management is an accessory, but it’s not sufficient to improve population health.”

Mr McManus added: “There’s a real danger we’ll do what we always do in the public sector, which is turn this into a massive great IT programme, and ignore the lessons I think around systematic change.”

So how can such a risk be mitigated? How can a shared focus and understanding of population health be developed? How can obstacles over terminology be circumvented? John Middleton, president at the Faculty of Public Health, advocated a focus on the basics, centering reform on aims which all parts of the system would share.

As he put it: “I want to see people living healthily as long as possible. I want to see the NHS enabling people to recover from treatable illness, and preventing illnesses that can be prevented. I want to see the whole system enabling people with long term conditions not to be disabled by those, so they’re able to live with those problems as long as they can.”

That was, he said, “a health issue and a social care issue and a housing issue – it’s a whole raft of intervention and help”.

“The NHS needs tools to be able to interrogate data, it needs systematic primary care, it needs a whole raft of ways to help it to do what it does. But equally there is a whole housing agenda that supports how people don’t live in hospitals, or how they don’t become ill and need to go back to hospital. It seems to me that spelling out some very simple ideas of what we want actually starts to point you to who’s responsible for what in different parts of an integrated system.”

It was a point reinforced and extended by Julian Brookes deputy chief operating officer of Public Health England. “You can get yourself hung up on a phraseology or words,” he said. “I think some kind of common understanding is useful, but it’s actually about what we do.

“I think there’s a sufficient consensus across the piece, and there has been for a while, about the kinds of things that need to be done. The question often in my mind is that how we do that.”

Ready with an answer was Manjeet Gill. Currently policy advisor at Solace, she was previously a corporate director at Nottingham City Council, among other roles. When she began at Nottingham the place was “gun crime city” she said. “We were in special measures, including the police. So for us it was all about thinking of what’s the new operating model for the public sector rather than separate institutions.

“The biggest risk we had to address was not working in our silos of housing, employment and things like that. It was starting with the person in the neighbourhood. It’s not the neighbourhood as a place, it’s the person. A person is not going to talk to us separately on housing, health and so on. It’s holistically looking at that person.”

The city, she reported, dropped from 13 gun crimes deaths and 14 knife crime deaths a year to zero in two years. “And that was radically rethinking the entire operating model, and it did start from data first.”

A similar story was offered by Kate Ardern, director of public health at Wigan MBC, recently crowned Council of the Year at the LGC Awards. She explained that when she took up her post, 11 years ago, “every single population health indicator was going in the wrong direction”.

“We now have female healthy life expectancy that has achieved the English average. We’ve got the fastest growing healthy life expectancy for men in Greater Manchester. And that isn’t the job that I’ve done, or indeed the council or the NHS has done. That is about 323,000 citizens being engaged.

“It’s about actually working with local people in terms of their aspirations, their hopes, their confidence, their assets, their talent, seeing people as not ‘to be fixed’ but as the co-creators with us of solutions.”

She pointed to the Wigan Deal, an informal agreement between the council and citizens to make Wigan an excellent place to live and work. It means the local authority has promised to support individuals to live well, but at the same time set expectations. On the health front, that means anticipating that residents will stay active, get involved in the community and register with a GP.

Lola Abudu, deputy director for health and wellbeing at Public Health England West Midlands, likewise suggested that when it comes to creating health for a population “the answer is in the people”.

“Most people know what to do [for their wellbeing] if they have the money, a job, a good environment. They don’t need any service from anybody to do that for them. People have the answer. I think we just need to let some of it go, and create the environment that lets it happen for local communities.”

For Rosie Rowe, healthy place shaping lead at Cherwell DC and previously programme director for the Bicester Healthy New Town programme, population health is not about management but about creation.

“The experience that we’ve had in Bicester is about community activation, but in conjunction with a policy environment, a built environment that is supportive and enabling, and a systems approach whereby you’re involving the full range of partners, who come together around a sense of place.”

The theme of citizen engagement was echoed by Mr Karunanithi, who is also senior responsible officer for population health within the Lancashire and South Cumbria ICS.

“What’s emerging in our work on population health is essentially we need a triple lock between a fully engaged population, the ability to deliver person-centred care, and then the policies to shape the place, whether that is housing, economic development, or the wider determinants,” he said. “If you’re really clear on those three big planks then the culture really needs to be [mutual] esteem on what each sector can contribute.”

To find out more about how NHS England is supporting integrated care, visit https://www.england.nhs.uk/integratedcare/ 

So through which mechanism can that sort of mutual esteem and understanding – seemingly crucial to a population health approach – be created? Some felt it might be a role for a much-maligned structure created by the Health and Social Care Act 2012: the health and wellbeing boards.

Steven Gaskell explained that Southwark LBC is working on a governance review of its health and wellbeing board, with a view to making it a more active component in the local system. “I think we’d all probably agree health and wellbeing boards haven’t realised the genuine opportunities open to them in terms of shaping place and shaping change and shaping policy development in order to improve population health,” argued Mr Gaskell, the council’s head of chief executive office.

“I wonder whether there’s an opportunity to use the health and wellbeing boards in a much more real world impact way,” he said. This would move on from joint strategic needs assessments, focusing more on local priorities over the next three to five years and finding ways of working together.

Maggie Rae, head of school at Health Education England South West and Public Health England, offered a telling anecdote. “I met a councillor last week and they said: ‘Tell me about these health and wellbeing boards. I thought they’d be really, really fantastically influential but my experience isn’t that.’ And I said: ‘Well, they were designed to be fantastically influential.’

“What we need, I think, is the kind of spirit of this roundtable today: speaking well of each other, improvising on other people’s points, not arguing, not disagreeing.”

The suggestion that these boards could play a bigger role was one that received support around the room, not least from Tim Elwell-Sutton, assistant director of strategic partnerships at the Health Foundation. He contended that ICSs already constituted an evolution in how population health is approached, and that a similar evolution in health and wellbeing boards would be helpful.

“Certainly my experience of health and wellbeing boards is they’re primarily currently committees of the council, and the NHS are present but not necessarily invested in it, and they don’t feel accountable to it,” said Mr Elwell-Sutton. “I think they could be the forum for bringing together real cross sector partnerships at the level of place. They could bring together public sector, private sector to some extent, but certainly community and voluntary sector could be well represented there.”

How to do it? “They need to be more accountable and need to have more powers,” said Mr Elwell-Sutton. “So they need to probably control real money and they need to be held accountable, I think particularly for health inequality targets.”

That the Long Term Plan wasn’t specific about how such targets are tackled was a possible opportunity, he suggested. “I’d love to see that being a joint accountability, across local government and NHS, rather than it being one or the other. Because I think one of the problems with collaboration is that the NHS responds to national accountable targets while local government is responding to local issues, and you just end up at cross purposes.”

It was a helpful summary of some of the current challenges, but also a sign of how a common understanding on population health might be forged. As LGC editor and roundtable chair Nick Golding brought the event to a close, he suggested the discussion had highlighted “a lot of common ground, and a lot of common optimism”. The challenge now is to retain that as everyday pressures bite, and to turn the planned cross-sector embrace of population health into reality.

This roundtable discussion was sponsored by NHS England. The topic was agreed by LGC and NHS England. The report was commissioned and edited by LGC. See LGCplus.com/Guidelines for more information.

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Readers' comments (1)

  • The NHS isn't used to accountability and public committee meetings so HWBs are not as fantastic as they should be as there always seem to be the need to invent multiple other forums to support them, meeting in private of course.

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