Accountable Care Public Health STP

The role of Directors of Public Health in STP. 5 thoughts.

This is niche, and mainly for DPH types. 
Been thinking a lot re the q of what is the role of a DPH in the STP land.
here are some thoughts – as always thanks to others who helped develop these thoughts.

It’s not quite finished yet, and I’d welcome views.

I’ll be clear this isn’t about my local STP, it’s just a set of observations more generally.

1  There seem to be 4 main roles for PH types in STP / ACS etc

  • Health improvement across the board. Strategically and operationally. The left shift.
  • input to individual workstreams – planned care, urgent care etc. Remember why however….to enable the leftward shift.
  • Link to LA – operational, corporate (sometimes this is also done by DASS, Ch Ex, other)
  • Balancing the local v regional agenda

2. How this is operationalised will look different in each area

Different levels of intervention are ok, opportunities may look different with different STP.

Reflects history, dominant agendas

Different shapes are needed to address the different approaches across our areas.

A one size fits all is unlikely to work – must be tailored.


3. Attention is continually needed to ensure weight to local place based answers is not lost

Most accept that 70-80% of the business end of the mission of STP is rooted in place. Thus 70-80% of the attention should be focused there.

If the role of DPH is to be focused on creation of health opportunities (reflecting on fact that c20-30% of opportunities for health gain are within the NHS) and of that 30% of health gain from NHS most of that is locally driven (mostly primary care, mental health?).

Thus it is important it not neglect the local in the balance of time and resource and be mindful we have multiple masters, most of whom inhabit the town hall and will want us to be doing stuff in our own places and focused on things a long way from the NHS.

I’m also mindful that our capacity has been stripped bare over the last 5 or so years through successive cuts to the PH grant, and our (correct imo) attempt to protect frontline services funded through the grant. I reckon I’ve got half the staff I had 5 years ago.

I’m not necessarily whining about that, it’s a statement of fact.

4. We need to be mindful of danger of constant regression back to the 1) hospital model, 2) structural solutions to problems

Often there’s an additional role around ensuring that transformation beyond the workstreams is also on the agenda – culture, value, payment reform, regulatory, the “left shift”, and a focus on population outcomes not service use metrics. 

This will vary from place to place.

all three of the gaps are equally important – not just the money gap.
There are as yet unanswered questions. For eg – What does “addressing health inequalities” mean at STP level. We are trying to answer it in ours. Happy to share the detail
5.  What ARE the high impact actions for STPs to consider? Get them in the discussion

All to consider. My list is as follows

  • Primary care – significant shift of resource base 
  • Mental health and LD parity. Not just the % of £ ( though that would help) but much greater mental health competency amongst generalist workforce and hospital systems
  • PHE menu of preventive stuff – helpful, but also must move towards policy (away from services). Smoking remains, by a margin, the most important.
  • Principle around £ distribution and need. Disproportionate investment for disproportionate need. Unequal offer for unequal need. This is the difference between equal and equitable.
  • Attending to the prevention belief gap might be by far the most important issue,
  • and moving away from the narrative that ROI is all. If we applied this mantra to the current £114bn investment in the NHS we might not fund half the stuff we do!
  •  workforce development  – supporting staff to work in more holistic, reflective, solution-focused & person centred  ways. Also boundary spanning.

Only my thoughts. What are yours. 

Others later had some other additions to this list

start with real (big) needs of ppl and populations!

Creating community alignment on interventions for prevention and wellness . Eg Haltons links with rugby league clubs around their moonshot 

If the battle has been won on the value of community building the next Q is will the system colonise or genuinely share power & resource?

matching effective scale to interventions (one of the reason I am so keen on the primary care home

working to define and legitimize core purpose in terms of health / inequalities i.e. outcomes that matter to citizens

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