This document provides an overview of public health services in Hertfordshire and discusses approaches to improving population health from a systems perspective. It outlines the various workstreams, budgets, and services provided by public health including health protection, improvement, screening programs, and sexual health services. It emphasizes the need to address the social determinants of health and take a systemic approach that considers health equity, prevention, and improving systems to better support overall wellness. The document advocates for public health leaders and elected members to think systematically and consider the health impacts of all policies across economic, effectiveness, efficiency, and equity domains to ultimately reverse trends of avoidable disease burden.

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Ten Minutes...
on system leadership and public health
Workshop for elected members
Jim McManus
Director of Public Health
Jim.mcmanus@hertfordshire.gov.uk

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Some of what we do for Hertfordshire
• 142 workstreams ranging from health protection to
health improvement
• 40 staff on commissioning and technical/specialist side
• £52m budget reducing to £46m
• 35,000 hours of school nursing a year
• 8000 hours of health visiting a week
• 60,000 people using sexual health services
• 15,000 children weight measured every year
• 96% of children get hearing and eye screening
• Immunising children and young people

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Protection
• Medical examiners for new death certification
• Infectious Disease Outbreaks
• Assurance on vaccs, imms, screening
• Advice – contaminants and environment
• Statutory consultee
• Mentally disordered offenders
• Child Death Overview Panel

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But
• This is not the whole story
• What would we do if someone else
commissioned all this?
• How do we make use of core PH services to
impact on the rest of the system?
• How do we use core PH Skills to impact on the
rest of the system?
– Equity, service redesign,
• What is the role of each bit of the system on
Public Health?

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The 3 Domains of Public Health
Health
Improvement
Health
Protection
Service Quality
This area much
underutilised by
commissioner across the
system

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We have built a culture where being healthy is not
the default option for many
Only acting as a system will turn it round
And it will take phases of work across time, and
work at different levels
If focusing on individuals really worked that
well, why are we still in this mess?

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The History, and the Future..waves of
Public Health
Adapted from Davies et al, 2014 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62341-7/abstract
Infectious Diseases
Lifestyle Diseases
Culturally
Reinforced Diseases

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Big Ticket Issues
• Systematic approach to prevention
• Systematic approach to health inequalities
• Systematic approach to making systems better
at keeping people at optimum wellness
• Cultural and social norms reinforcing that
• Making health the default and easy option

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Can elected members think system in all they do on
health? If not, we won’t reverse the wave of avoidable
disability and disease
Smoking 10%
Diet/Exercise 10%
Alcohol use 5%
Poor sexual health
5%
Health
Behaviours 30%
Education 10%
Employment
10%
Income 10%
Family/Social
Support 5%
Community
Safety 5%
Socioeconomic
Factors 40%
Access to care
10%
Quality of care
10%
Clinical Care
20%
Environmental
Quality 5%
Built
Environment 5%
Built Environment
10%
Source: Robert Wood Johnson Foundation and
University of Wisconsin Population Health Institute.
Used in US to rank counties by health status
While this is from a US context it does have significant
resonance with UK Evidence, though I would want to
increase the contribution of housing to health outcomes
from a UK perspective.

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Ambitions
• Protect and promote the health of the population
• Look across the system and get the system to
improve health
• Think Systems
• Think 4 Es
– Economy
– Effectiveness
– Efficiency
– EQUITY

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The System in England
National Leadership
Evidence, Local centres ,health protection
Imunisation and screening
Dental PH
JSNA, Evidence, Advice esp CCGs
Commissions pile of stuff
(eg school nurses)
Sits on HWBB
Vital to public health: communicable disease
Food safety, range of EH Services
Counties and
Unitaries
Unitaries and
Districts
Counties and
Unitaries
Trading Standards (esp tobacco control
and public safety)

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A man called Wanless
• Worksheet in front of you we will be using later

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We cannot afford to be where we are
anymore.
All the primary prevention in the world
will not be the answer..need 2ndary
and 3ary too. Especially system
improvement

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System Leadership when the system
is in crisis – need to speak in one
voice not four
Authoritative
(the law, policy)
Formal
(what policy wonks and thought
leaders say)
“Prevention core to future of NHS” “How will we get there, what’s
happening, big buzz word....”
Professed
(what we say we do)
Operant
(what we actually do)
“We believe in prevention and co-
production”
“Here’s our plan. 97% of money stays
where it is We’ll take comments by
tomorrow.”
The Four Voices of Commissioning and Policy

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The voice we need
• The system despite valiant efforts from many
needs to be re thought. We have short term,
medium term and long term challenges.
• Let’s agree what they are and then agree how
we get there
• Elected members need to push this discussion
right across the system

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The avoidable spend areas in the health
system, with poor health/quality of life
Crisis pathways
And repeat
Admissions, dual
diagnoses
People with long term mental ill health
Whose physical health deteriorates due to
Sub-optimal management
Prescribing practice where
IAPT or CBT could resolve issues
Volume of
spend
Severity of condition
Existing curve

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Key actions to reduce spend curve
Clinical + Lifestyle + Behavioural
Recovery focused
care
Channel shift:
Greater use of
online and
community groups;
less prescribing
Optimum
physical health
(eg quitting
smoking
reduces cost to
MH services)
Volume of
spend
Severity
Existing curve
The Achievable

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That evidence question again...when the
desire for evidence is an attempt to ward off more work....
The question
1. What evidence have you
got?
2. What ROI have you got?
3. Have you done a Health
Impact Assessment?
4. What specific evidence
have you got?
What they mean
1. What have you read that
I haven’t? (AoMRC
report)
2. That’ll fox you...
3. We never have, I’d love
to know what one looks
like
4. Ok, you’ve done your
homework but I’m still
resistant...

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Building a public health mindset.
What
population?
What issue/need?
(Needs Assessment)
What outcomes
do we want?
(Strategy)
What
interventions fit
best?
(Prioritising,
Planning)How do we know
it’s working?
(Evaluation)
Where are we?
Intelligence,
JSNA
Where do we
want to be?
How do we get
there?
Are we there yet?