Directors of Public Health, what is the role in Integrated Care Systems

 

A short note on what it is we might want DsPH to be and do in the context of emerging ICS

a few asking me this q of late 

In no especial order my thoughts on it here

 

1            What IS the DPH role. My working list is as follows  

Orient the conversation around a pop h capability to support the strategy and operations of the ICS.

Given a free hand I would spend most energy on

1. ensuring the right analytic capability and data access to people who know what to do with that data.  
2. be a system leader – help shape and define the purpose. Is it about the service delivery footprint of the NHS vs outcomes delivered by those services vs something bigger than NHS footprint itself (of which the NHS is a part), population health outcomes
3. developing the narrative and story
4. supporting the ICS to develop and implement the right strategy to enable the left shift,
5. enable the focus to be strategy led not data led

the purpose of our input is thus - HCPH / tec / effectiveness and cost eff, use of technical skills to shape commissioning, provision and QI, leadership type role, purpose / left shift, focus on health not health care

Often there is a tendency to focus on specific projects, and be focused on the governance of it all. Sometimes this is appropriate. Often it isnt.

It is probably hard for one person to embody all of the above, never mind having the capacity to do so properly.

2            Don’t expect “the DPH” to be at the beck and call of the ICS

The NHS is but one of the masters the DPH and their team need to serve

The ICS is one bit of the NHS.

Where the ICS covers one upper tier LA it might be a more straightforward relationship, but where ICS spans multiple places the DsPH will need to work out how best to organise themselves.

3            Right capacity and capability at the right level of geography.

There is something in this on geography. Everyone seems to want PH professionals to be everywhere at all time. With available capacity this is simply unrealistic. The NHS might need to make a decision needed around what level of geography to orient ourselves around – region / ICS / ACP / PCN. Each will say “us please”.

If default isn’t place then advice on what we don’t do in place if there is no further investment in staff. The role cant just be “the DPH”. We all know we are only as good as our teams. The need is for the right capacity and capability at multiple levels of NHS geography.

Most DsPH will be oriented around place / local authority boundaries. If ask to operate at multiple levels of geography either we would simply need to give up place or invest in PH team at that level of geography

4            Accountability and governance.

To whom is DPH accountable in this context. SoS / CMO, LA Ch Ex, who in NHS?

For what is DPH accountable? “health”. Clarify who is accountable for healthy life expectancy and the gap. And who has what control over the levers to address this.

There is a view that NHSE should be asking hard questions of ICSs around this – just as hard as they ask about quality, constitutional targets and finance. What Qs need to be built into the NHSE assurance process.

5            Style of working

For me the tole and function should be agnostic of institution and service delivery.

It ought to orient from a place of building from and recognising existing structures and local assets, rather than a model of working based on top down, reaction to instructions from the centre.

6            The left shift

Not just within the “prevention workstream” but central to the whole mission of the whole machine.

This was a prominent theme in the LSE / Lancet Commission on the future of the NHS – for many years the rhetoric has been about moving the focus upstream, for all of those years the investment pattern has been almost entirely the opposite (see specifically the paper on changing health needs). Prevention is always “something someone else can do”.

In any question and in any conversation, how will this help us shift our locus toward a more preventive model and how might this narrow the gap in outcomes.

Financial transparency on prevention spend in ICSs

There needs to be better monitoring of spend on prevention and we would welcome a clear commitment from ICSs to increase spend on prevention (eg by 1% a year up to an aspirational target of 10-20%). One of the functions is to take and find opportunity for a deliberate strategy to reframe the narrative, with as focus on story and why / purpose. This would be an alternative to bowling people over with data and evidence. More often than not it isnt about evidence, it is about belief and the “we need more evidence” line can be used as a tool to delay change. There will never be “enough” evidence (for ANY of the shifts we seek to make) and care re application of evidential double standard to left shift oriented vs any other investment ask

7            Population health management 

Don’t obsess about PHM – yes develop capability for the analytic end of it. Key is ability of users of the intelligence to use the analytics and turn into actionable interventions.

DO obsess about PH (or pop h or whatever you want to call it)

given the things that make up “population health” (basically pretty much everything), build up the population health narrative from all of the aspects of public health - H Imp (lifestyle to SDOH), H protection (vaccines still save lives etc - who does S7a assurance), contribution of NHS and Care to big drivers of demand (individual morbidity through to MM).

make smart use of intel to pull all together.

There will be no single intervention or broad set of interventions to deliver.

There might be influence by proposition. Something to be said in any area in finding the sweet spot in terms of connecting the operational delivery of NHS, social care, LA, VCS services around specific areas – what are various health and care sector contributions to poor quality housing for instance.

Also some investment in QI expertise, people with expertise to support systematic QI across all areas of service delivery. Some of this expertise is there within trusts and CCGs at the moment.

8            Intelligence and outcome framework

Lots will want dashboards and outcome frameworks. The Public Health Outcome Framework is my standard outcome framework – if that isn't good enough outcome framework I don’t know what is

Of course the DPH will need to be the owner of the JSNA, which should remain a high level statement of population need, demographics and should be focused on supporting the setting of strategy.

The JSNA isnt a substitute for detailed and bespoke analysis to answer specific questions. My assumption is made that tools such as Fingertips will remain in place. There is definite merit in developing granular datasets in addition, that should incorporate provider level operational data and primary care data. This may need investment.