Agenda item

In attendance for this item were:

 

Frances Howie, Interim Director of Public Health at Worcestershire County Council

Cllr John Smith, Cabinet Member for Health and Well-Being

Sue Harris, Director of Strategy and Business Development at Worcestershire Health and Care Trust.

 

In addition to the agenda report, the Interim Director of Public Health gave a presentation to provide further information.

 

From April 2013 the County Council gained new statutory duties on Public Health to improve population health and well-being, which came with a specific ring-fenced grant (PHRFG).  The range of statutory requirements included mandated services (such as sexual health and health checks), specialist staffing, as well as discretionary services (such as drug and alcohol services).

 

In June 2015 the Government announced in-year cuts of 6.2%, which was very unexpected, and strong concern was communicated to the Government.

 

Cabinet gave initial approval of a proposed response to the funding reductions in July 2015, requesting further discussions with providers and review of prevention services over the Summer.

 

Following discussion with Public Health, the Cabinet Member with responsibility (CMR) for Health and Well-being, lead scrutiny members, partners and providers, as well as input from a public survey, revised proposals were approved by the CMR in November 2015. Key themes were the scale of reductions across the system, the potential for cumulative impact, continued uncertainty on funding and unprecedented financial pressures.

 

There was now more certainty, and a national consultation was soon to be announced, as part of the Government's shift from local government funding, to business rates funding.

 

The proposals approved in November prioritised services which the county council was required to deliver (mandatory). Prevention services would be focused on reducing the chances of people coming into high cost social care services.

 

A key decision was to use council reserves to delay reductions, to allow for planned redesign and measured changes to services to take place, which would seek to mitigate the unprecedented financial pressures.

 

For some services, such as drugs and alcohol, it was difficult to measure the impact of what might have been and there was a need for a stronger evidence base.

 

Key messages for HOSC were:

·         Good progress had been made in implementing the November 2015 Cabinet decisions

·         Difficult decisions had been taken but there had also been realism from providers and other partners in accepting them

·         There was now closer partnership working between the Council, commissioning partners and providers – which was a positive base to work with constant changes and challenges ahead

·         The focus was on a careful and measured approach to change allowing opportunities for service redesign, requiring use of reserves

·         Decisions would be reviewed following further announcements on grant funding and further consideration enabled some flexibility

·         It was too soon to measure the impact, and HOSC would be kept informed

 

Updates on reduction decisions

 

Public Health had a very wide remit, and included many non-health areas.

 

Within community safety projects, reductions of 75% in 2015/16 and a further 25% in 2016/17 had been fully achieved, as these had been uncommitted funds.

 

Regarding drug and alcohol services, active discussion was underway around the proposals for a 10% funding reduction from April 2016 and a further 5% from 2017, including changes to prescribing practice. The service performance and positive response from new provider Swanswell, had recently been discussed by the Adult Care and Well-being Overview and Scrutiny Panel.

 

The contract for domestic abuse services would be extended to October 2016, and then reduced by 10% as part of the re-commissioning process. A needs assessment had been completed. Statutory duties sat primarily with the Police, and meetings would take place shortly with the new Police and Crime Commissioner.

 

Funding for primary care mental health would be maintained to October 2016, and the Council would consider the possibility of extending this to the end of 2016/17. The Clinical Commissioning Groups (CCGs) were carrying out a major redesign, focussing on well-being and early and lower level intervention – provider Worcestershire Health and Care Trust would give a further update to HOSC at its July meeting.

 

Funding for adults housing related support and homelessness was an area where it was challenging to measure the impact.  Changes had been implemented for people with acquired brain injury, mental health problems, learning disabilities and the homeless – however the Council would maintain some funding for priority groups, and there would be a change to focus on short-term, lower level prevention and stronger impact data for evaluation.

 

Funding for supported advice and information had been reduced by 10% from April 2016; a new service was in place, which had been redesigned with service users. The service prioritised access for people with protected characteristics, enabling people to access the digital offer, providing face to face service in each of the districts and focusing on enabling people to become more independent in accessing online information - a home service was available for those with greatest need. 

 

Support for advocacy would reduce by 10% from April 2016; commissioning was underway with a focus on the statutory work.

 

Funding for sexual health services would reduce by 12.5% from October 2016, which negotiations were in place to achieve through redesign and reduction in some support costs, such as laboratory costs. A revised service specification had been re-tendered, focusing more on prevention. The outcome of on-going negotiations made further information commercially sensitive at this stage, but recommendations would be made to the CMR in the near future.

 

Smoking cessation services had been discontinued except for pregnant women – a group which the Health and Well Being Board was keen to reach. Consultation had been completed and the focus now was on tobacco control measures.

 

Reductions in funding for health improvement projects had been reduced by £1million in 2015/16 and a further £200,000 in 2016/17, achieved by use of uncommitted funds.

 

Funding of child development services was the second big area where the Council was able to have some flexibility and there had been detailed and energetic conversations with the CCGs. Funding would be maintained until October 2016 and the Council would consider extending this to the end of 2017. A joint service review was underway, with consultation with families and children and young people starting in the next few weeks. Funding would be provided until the end of 2018 to enable service redesign and smooth transition.

 

The decision had been made to maintain funding for families and young people housing related support to April 2017. The PHRFG formed 50% of current contracts and a review of the impact, demand and prevention of looked after children was due for completion by Autumn.

 

For 0-19 services, there would be a 10% reduction in public health nursing from October 2016, and creation of a single integrated 0-19 service, including new investment from the PHRFG into early help. However no compliant bids had been received to provide the service, the decision had been called in and was due to be discussed the following day by the Overview and Scrutiny Performance Board.

 

Funding of the Public Health team had been reduced by 10% from April 2016, and would be reduced by a further 10% from April 2017 – achieved through holding vacancies and a review of functions.

 

In conclusion the Interim Head of Public Health reiterated the key messages. A very clear message from progress so far, was the importance of measuring the impact on individuals.

 

Service provider comments

Comment was invited from the Director of Strategy and Business Development at Worcestershire Health and Care Trust, provider of several services affected by PHRFG reductions.

 

Within primary care mental health, a new 'healthy minds' service had been launched, enabling people to access services such as talking therapies, rather than through mental health crisis. The HOSC was thanked for its continued attention to mental health during the year, and more discussions would follow.

 

Within the health visitor/school nurse service, there were now much smarter and outcome focused performance indicators, and she was very confident in the plan.

 

The Trust was working hard with children with learning disabilities and their families with the aim of managing change in a planned and measured way.

Sexual health was a statutory service, alongside which sat other services. It was a complex area, subject to negotiations with Public Health England. Information was commercially sensitive at this time, but HOSC should be aware that conversations were taking place, including with staff who may be impacted by changes. A briefing note would be circulated as soon as there was more clarity.

 

Overall the process had not been easy, although negotiation had led to closer partner working.

 

Main discussion points

 

During the discussion, two disclosable interests were declared:

 

Cllr Amos – member of the Advisory Committee of Action on Smoking (ASH)

Cllr Cooper – retired General Practitioner (GP)

 

The report made depressing reading, with a member commenting that his fears had been realised - that transfer of public health from the NHS to local authorities, would lead to cuts.  However the Interim Head of Public Health was congratulated on her handling of the situation and her clear report.

 

HOSC members welcomed the new Cabinet Member for Health and Well Being, and looked forward to future discussions with him.

 

It was confirmed that the Director of Public Health was a statutory appointment, required to be a specialist who was registered with the UK Public Health Register. The Cabinet Member explained that the Council intended to put forward Frances Howie as permanent post holder; however the process also required involvement of various external bodies, and it was hoped to finalise the appointment during July.

 

Several members felt that obesity should be a key target. In response, it was explained that although levels were a problem for Worcestershire, it was important to focus on the issues; health problems and cardiovascular risk were easier to address by promoting physical activity, rather than diet. 150 minutes of physical activity a week would halve an individual's risk, even if they remained the same weight. The message about exercise was more positive and therefore an easier and quicker behaviour change to get results – a county-wide campaign was being developed. 

 

Several members were aware of public concern about reductions in mental health facilities - how confident was the provider in plans and how would the impact on individuals' mental health be measured, especially in view of increasing needs? The representative from service provider Worcestershire Health and Care Trust, confirmed that service quality was monitored by a specific group, using a suite of indicators, which would change from April, to bring mental health in line with physical health. Planning had included looking at how people accessed and viewed services, numbers being seen, and making sure that patients with psychosis would be seen within four weeks. The Well-being Hub, launched in May enabled people to access help earlier, and provided a point of referral for GPs. There was also a recognised need to put in more specialist nurses and training to give GPs greater confidence in this area.

 

Based at Wildwood (Worcester), the Well-being Hub service was county-wide and involved the voluntary and community sector. Wildwood was staffed by Community First, working alongside clinicians. People contacting the Hub could be referred directly to talking therapies.

 

The Interim Director of Public Health agreed that prevention was key, and advised that partnership working on sustainable transformation plans would be beneficial. In respect of mental health there were different delivery platforms, including social prescribing (linking people with their community), and the digital inclusion agenda (providing information online, especially for mild-moderate needs). Frontline staff were being trained to identify people who may benefit from early help, and behaviour change could also play a part.

 

A member cautioned the need for realism and was concerned about the reduction in specialist staff, for example health visitors, however the Interim Director of Public Health was impressed by the evidence pointing to the effectiveness of a wider network of help, including peer support, rather than more highly specialist health visitors.

 

Although smoking had dramatically declined in Worcestershire, tobacco control and understanding the implications of e-cigarettes were of interest and the Chairman requested an overview at the next meeting.

 

Public Health clearly had an enormous remit, and whilst the focus of funding was supported, was there a danger of spreading resources too thinly? The Cabinet Member pointed to the need to ensure the right direction for services, along with working differently, better partnership working, removing duplication and repeated assessments; this was not easy but the Council was committed.

 

The Council continued to work hard to minimise the likelihood of the service reductions impacting on service quality, for example as part of the new contract for drugs and alcohol services. Performance indicators were even more focused under the more stringent regime, and largely reflected national targets.

 

The Chairman thanked everyone for their input. It would be important for HOSC to monitor the on-going impact of the PHRFG reductions, and an update would be scheduled within 6-12 months.  In the meantime assurance was given that safety measures were in place in which all staff involved were very mindful.

 

In response to a query about the Health and Well Being Board (HWBB), the Democratic Governance and Scrutiny Manager advised that in his view, the Health Overview and Scrutiny Committee was able to hold to account the HWBB.