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Paper 11 - 25 September 1998 Meeting 

ASSOCIATION OF HAMPSHIRE AND ISLE OF WIGHT LOCAL AUTHORITIES

25 September 1998

HEALTH IMPROVEMENT PROGRAMMES A LOCAL AUTHORITY PERSPECTIVE

Joint report by the Chief Executive and Health Policy Manager of

Eastleigh Borough Council

RECOMMENDATIONS

It is recommended that:-

(1) the guiding principles for Health Improvement Programmes set out in paragraph 25 be adopted; and

(2) the Association encourages the sharing of best practice.

SUMMARY

(1) This paper explores the role and some of the issues and challenges facing local authorities in the development of local Health Improvement Programmes and the scope for a coherent approach and sharing of models of good practice.

(2) It suggests that the Government's White Paper, 'Modernising Local Government', and in particular the proposed statutory duty to promote the economic, social and environmental well-being of their area, along with the Health White and Green Papers, provide the framework.

(3) The following sections set out a local authority perspective and some early proposals for a more 'localised' contribution to health improvement as set out in Healthy Cities/Health For All strategies and plans, working with local Primary Care Groups and local communities.

(4) The Association of Hampshire and Isle of Wight Local Authorities is asked to give consideration to the proposed local authority principles for Health Improvement Programmes as set out in paragraph 25.

INTRODUCTION

1. At a meeting of the Association of Hampshire and Isle of Wight Local Authorities on 27th March 1998 the Association gave consideration to a health policy paper titled "Developing Partnerships between Health and Local Government".

2.The purpose of the paper was to raise awareness of the main issues for local authorities arising from the Government's proposals in the White Paper The New NHS - Modern, Dependable and the Green Paper Our Healthier Nation.

3. The pace of change in the health sector in the period March to August has been a challenging one for all concerned, including those with a health policy function in local authorities. Consequently there has been little time to take stock of the role of local authorities in what is one of the Government's top two priorities. This has been made all the more difficult in the absence of any guidance from Government on the partnership role of local authorities in contributing to the development of Health Improvement Programmes and Primary Care Groups, and much less on how this fits with the national and local priorities for local authorities.

4. This paper explores the role and some of the issues and challenges facing local authorities in Hampshire and the Isle of Wight in our role in developing and contributing to Health Improvement Programmes and asks whether there is scope for a coherent approach and sharing of models of good practice.

HEALTH IMPROVEMENT PROGRAMMES

What the Papers Say

5. The NHS White Paper states; "The Health Improvement Programme (HIP) will be the local strategy for improving health and health care. It will be the means to deliver national targets in each Health Authority area. The Health Authority will have lead responsibility for drawing up the HIP in consultation with NHS Trusts, Primary Care Groups, other primary care professionals such as dentists, opticians and pharmacists, the public and other partner organisations" (page 26, paragraph 4.7).

The key components of HIPs as set out in the White Paper will be:

* to assess the health needs of the local population and how these are to be met by the NHS and its partner organisations through broader action on public health.

* to meet the healthcare requirements of local people, and how local services should be developed to meet them either directly by the NHS or where appropriate jointly by social services.

* to manage the investment required in local health services to meet the needs of local people.

6. The Green Paper 'Our Healthier Nation' sets out four key national targets as part of the national contract (or third way) for improving health. These are, by the year 2010:-

* to reduce deaths from heart disease and stroke amongst people under 65 years by a further third

* to reduce accidents by at least a fifth

* to reduce deaths from cancer amongst people under 65 years by at least a further fifth

to reduce the deaths from suicide by at least a sixth.

There is reference here to whether the local authority contribution to Health Improvement Programmes can be brought within the best value regime being developed for local Government. "It is vital that both health and local authorities take responsibility for their part in HIPs" (page 40, paragraph 3.42).

7. "Our Healthier Nation" states that "taken together, the Health Improvement Programmes across the country , combined with the Government's role in the national contracts, will form a concerted national programme to improve health and tackle health inequalities. They will be in place by April 1999. We envisage that they will:

1. give a clear description of how the national aims, priorities, targets and contracts will be tackled locally;

2. set out a range of locally-determined priorities and, targets to address issues and problems which are judged important, with particular emphasis on addressing areas of major health inequality in local communities;

3. specify agreed programmes of action to address these national and local health improvement priorities;

4. show that the action proposed is based on evidence of what is known to work (from research and best practice reports);

5. show what measures of local progress will be used (including those required for national monitoring purposes);

6. indicate which local organisations have been involved in drawing up the plan, what their contributions will be and how they will be held to account for delivering it;

7. ensure that the plan is easy to understand and accessible to the public;

8. be a vehicle for setting strategies for the shaping of local health services." (Page 40, paragraph 3.43).

The initial programmes will cover a three year period with annual reviews and periodic updates.

1. The Green Paper makes a cursory mention of the wider public health contribution of local authorities through Health For All and Local Agenda 21. Responsibilities for education, transport, social services, housing and the environment (page 44) is picked up throughout, although how this is to be implemented or resourced is not clear.

National Guidance

2. In the absence of Government guidance on HImPs generally and more specifically for local authorities, it is difficult to get to grips with our role and function in developing these programmes.

The latest Government guidance, "Better Health and Better Health Care: The Next Steps" (circular HSC 1998/121, 15th July 1998) states that:

"The first round of Health Improvement Programmes will lay important groundwork for collaboration for health improvement between local partners but this will develop further over time".

It concludes by recognising that:

"At this stage the emphasis has necessarily been placed very much on actions for the NHS, given that the Local Government picture is still unfolding, with, in particular, the Social Services White Paper to be published later this summer. NHS bodies are aware that many activities need to be planned jointly with relevant sectors of Local Government, and that working in partnership is the expectation".

8. In the mean time, Health Authorities are in the difficult position of having to lead development of HImPs whilst needing to work towards agreement on local Service and Financial Frameworks (SAFFs) and the establishment of Primary Care Groups (PCGs) to be up and running by 1st April 1999.

LOCAL AUTHORITY CONTRIBUTION TO HImPs

9. The key policy areas for local authorities are much broader than health and social care and any new developments have to be weighed in the balance of the breadth of national and local priorities. Key policies which relate to health improvement for local authorities include:

Nationally

* Modernising Local Government

* Regional Developments

* 'Our Healthier Nation' - in partnership with Health Authorities and others

* Integrated Transport Strategy

* Social Services White Paper

* Air Quality

* Welfare Reform

* Social exclusion

* Welfare to Work

* Lifelong learning

* Crime and Disorder (Community Safety)

* Agenda 21

Locally

*Local implementation of Modernising Local Government and other national policies listed above - including best value and community leadership

* County Structure Plan/Local District plans

* Healthy Cities/Multi-Agency Local Health Strategies/plans

* Corporate/Community Strategies (or equivalent)

* Local Agenda 21 (sustainable development

* Community Safety partnership & plans

* Housing

* Community care plans, including Joint Commissioning of health and social care

* Childrens services plans and young people's strategies

* Anti-Poverty and social exclusion

* Economic development and tourism etc.

* Developing links with Europe

10. Local authority priorities have a local, county/regional and European focus which does not fit comfortably with Health Authority district-wide approaches to Health Improvement Programmes. There are, however, merits in working with local Primary Care Groups (PCGs) to develop local approaches to identifying health needs and enabling them to engage with the community leadership role of local authorities as set out in the Government White Paper 'Modernising Local Government'.

11. This is proving difficult in some areas where HImPs have been developed on primarily disease-based models which do not easily relate to local authority priorities.

12. In the absence of any guidance on the local authority role in health improvement, there is a need to develop a clear understanding of the differing but complementary contributions of Health Authorities and local authorities and what is expected of each.

13. The majority of local authorities in this area have Healthy Cities/Health For All/Local Health Strategies or plans, which provide the local framework for health improvement. These are most often developed by local authorities in partnership with their local health authority. In addition there are joint commissioning strategies and plans which play their part in delivering health and social care services. These local arrangements will increasingly need to work with the emerging Primary Care Groups which are largely following a medical model.

14. It is, therefore, proposed that local authority involvement in HImPs at this time is best focused on local implementation strategies and plans as outlined above, and that the framework of the statutory duty to provide the economic, social and environmental well-being of their area be adopted as the local framework as set out in the following section on Modernising Local Government.

MODERNISING LOCAL GOVERNMENT AND HEALTH IMPROVEMENT

Promoting the well-being of local communities

15. It is recognised that there is a strong health component to all the local authority policies and priorities listed above. The framework which best captures the Local authority role is set out in the recent White Paper 'Modernising Local Government, In Touch with the People', where the Government has stated that local authorities will be charged with a statutory duty;

"....to promote the economic, social and environmental wellbeing of their areas and to strengthen councils' powers to enter into partnerships".

This is also stated in other White and Green Papers including 'The New NHS, Modern and Dependable' and the Green Paper 'Our Healthier Nation'.

16. In the absence of any guidance on the local authority role in health improvement, this duty is all that exists to provide strategic context for the local authority contribution to HImPs.

17. It is important to recognise that the proposed statutory duty falls within the context of local authorities as community leaders. The "Modernising Local Government" White Paper states:

"This new duty will provide an overarching framework for Local Government. It will enshrine in law the role of the council as the elected leader of their local community with a responsibility for the well-being and sustainable development of its area."

18. In the consultation document on 'Local Democracy and Community Leadership' the Government stated that whilst it "...would not extend significantly the scope of what local authorities can do at present, it would go a long way to remove uncertainty within Councils as to the extent of their powers". The Government also stated that; "Councils would be expected to act on the duty from or within their existing financial powers and resources".

Improving Local Services Through Best Value

19. The other area which will impact to some extent on Health Improvement Programmes is the proposed duty to improve local services through Best Value as summarised below.

"Best value will be a duty to deliver services to clear standards - covering both cost and quality..." Local authorities will be expected to set those standards for all the services for which they are responsible. But in those areas such as education and social services where the Government has key responsibilities and commitments, the Government itself will set national standards. Local authorities will need to take the national dimensions into account in setting their own standards.

It is too early to judge the impact that this will have but there will be lessons to be learned from Local pilot Best Value initiatives.

HEALTH IMPROVEMENT PROGRAMME (HImP) INVESTMENT

20. The Government has given Health Authorities the lead in developing HImPs and in the recent Spending Review gave a commitment to an additional 21 billion for the NHS in addition to extra money for winter pressures and waiting lists. With the exception of Social Services Authorities (and to a much lesser extent Education Authorities)within Unitary Councils and County Councils, two-tier local Councils have little access or influence on these resources other than through joint commissioning.

21. Local authorities need the lever of a proportion of resources from Government at a local Health Authority level to pump prime local initiatives. It is proposed that Health Authorities ring-fence a percentage of their total resources for promoting health and preventing disease and that this be primarily allocated to the local authorities. This would enable them to deliver on locally identified needs and to act as a lever for local initiatives working in partnership with the Health Authority, local NHS Trusts and PCGs, within the framework of Healthy Cities, Local Health Strategies and Plans. This would ensure a local focus and ownership to health improvement and directly benefit local communities.

PROPOSED LOCAL AUTHORITY PRINCIPLES FOR HEALTH IMPROVEMENT PROGRAMMES

22. There is much to digest in terms of the local authority role and responsibilities for health improvement. In the absence of any national guidance on the local authority contribution to HImP, it is proposed that our contribution for the present is within the strategic framework provided by Modernising Local Government "to promote the economic, social and environmental well-being of their areas".

23. The following are offered as a set of guiding principles which could be adopted by the Association:

24. that the context of local authorities as 'community leaders' with a responsibility for the well-being and sustainable development of their areas be applied to local health improvement programmes;

25. in the absence of more specific guidance, local authorities in Hampshire and Isle of Wight adopt a set of principles based on those set out in "Our Healthier Nation" (p40, paragraph 3.43) as quoted at paragraph 7 of this report;

* that local authorities in Hampshire and the Isle of Wight give priority to identifying those areas of local authority activities that contribute to health improvement and work towards ensuring that these priorities are incorporated into local Health Improvement Programmes;

* that where these priorities will deliver on the target areas of 'Our Healthier Nation', Health Authorities be requested to ring-fence a percentage of health improvement resources to enable implementation of local initiatives to achieve the health targets set out in local authority led Healthy Cities/Health For All strategies and plans;

* that local authorities take a lead in community involvement for the Health Improvement Programme and Primary Care Groups (PCGs) in their capacity as community leaders;

* that Health Authorities work towards a more comprehensive HImP over the next 3 years with integration of local authority priorities;

* that the Association encourages a coherent approach and the sharing of models of good practice.

CONCLUSION

26. The process for involving local authorities in contributing to the development of Health Improvement Programmes is unclear given the lack of guidance and the fact that the Local Government picture is still unfolding.

27.The White Paper on 'Modernising Local Government - In Touch with the People' provides an overarching framework. It makes explicit the role of local authorities as elected leaders of their community with a responsibility for the well-being and sustainable development of its area.

28. To assist in this process the Government intends to introduce legislation to place on councils a duty to promote the economic, social and environmental well-being of their areas and to strengthen councils' powers to enter into partnerships. This will be within existing resources and (subject to the terms of the new legislation) at local discretion.

29. Whilst there is support for the development of a HImP across the wider Health Authority districts, local authorities are primarily focused on 'localised' districts and wider county, and regional strategies including Regional Development agencies.

30. Local authorities in their community leadership role have taken a lead in developing Local Health Strategies and Healthy Cities Plans which provide a local framework for health improvement. The focus of these local strategies is much more on promoting and protecting the public's health and playing a part in disease prevention. The Health Authority, local NHS Trusts and former GP consortia (emerging PCGs) have in the majority of cases signed up to these local strategies, along with other agencies.

31. The strength of the local authority contributions has to be at this level and at a regional level where economic, social and environmental determinants of health can be more readily addressed. This would enable local authorities and PCGs to work together to gain local ownership of the Health Improvement Programme, whilst delivering on a whole range of priorities set out in para. 11, involving local communities in achieving health improvement.

32. To make the maximum gains in health improvement at a local level, Authorities would need a portion of the resources from Government to be ring-fenced for investment in local implementation of health improving activity aimed at promoting health and prevention of disease as set out in Healthy Cities/Health For All strategies and plans.

33. To assist the local authorities in Hampshire and the Isle of Wight, a draft list of local authority guiding principles for contributions to Health Improvement Programmes has been proposed (see paragraph 25). Members are asked to give consideration to these and whether there is scope for sharing of models of good practice.

DR CHRISTINE JACKSON
 Health Policy Manager - Eastleigh

CHRIS TAPP
 Chief Executives' Group Health Lead

Last update: 20/09/2000
Author: Nick Goulder, Policy Manager

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