Wigan: Healthy Lives, Healthy People? Making Marmot Real for Real People

1. Wigan: Healthy Lives, Healthy People?Making Marmot Real for Real People Dr. Kate Ardern MBChB MSc FFPH Executive Director of Public Health for the Borough of Wigan

2. Strategic Drivers: Marmot Review The recent Marmot Review Fair Society, Healthy Lives (DH, 2010) identifies 6 key policy areas to tackle Health Inequalities and the priority actions:  Give every child the best start in life Enable all children, young people and adults to maximise their capabilities and have control over their lives Create fair employment and good work for all Ensure healthy standard of living for all Create and develop healthy and sustainable places and communities Strengthen the role and impact of ill health prevention

4. Wigan Health & Well-Being Board Wigan is in the cohort of ‘early implementers’ – aim is to transform the health and social care system with the LA and PBC working together as mutually respecting partners Local Authorities will take on the role of joining up the commissioning of local NHS services, social care and health improvement and will promote integration and partnership working Multi sector stakeholder event held on 2 March 2011 to ‘start the journey’ Aim to have ‘shadow’ Board from April 2011 Organisational development support is needed to capture key learning

5. Health and Well - Being Board Wigan partnership Health and Well- Being Priorities (6 Outcomes) Health and well-being services NHS Local Authority & Partners Social care (children and adults,Third sector Housing, transport, Big Society Leisure, Education, Partnerships, Economy, Social enterprises Primary & Community care Secondary & Tertiary care Specialist & National care Support at home Institutional care Acute care General population Low level advice & support People choosing less dependent more cost-effective options £100 m gap in funding Increasing demand on services NHS “flat cash” funding

6. Evidence, knowledge and skills Toinvest in a balanced economy to focus on wellness determinants of health and high quality health and social care Raising and exceeding public expectations of health and well-being Safeguarding, dignity & respect Respect contributions & perspectives Care closer to home Increase autonomy & perception People centred Co-production Harness local knowledge , skills and leadership Help local people take responsibility for their health To foster the best possible health and well being for every person in Wigan Beliefs Values Outcomes Openness, honesty, integrity H&WBB Best quality & innovation Improve accessibility of services to support independence Target resources correctly Reach out across partnerships Stretching our ambition and performance to achieve world class public health Innovating and implementing best practice to achieve best performance against national standards Reduce social exclusion Ownership & accountability Reduce deaths & disability due to CVD & cancer Productivity and evaluation

7. HEALTH AND WELL-BEING PROGRAMMES FOR CHANGE Localityworking Optimising the role of the Voluntary and Independent sectors Develop the assets based approach to community empowerment Building social capital Developing co-production Public Health capacity and capability building – community health advocates Public Health Annual Report Demand Management System Redesign Stimulating the Market Optimising the role of the Voluntary and Independent sectors Commissioning of Health Improvement Services and Programmes Service re-design to fully incorporate preventative interventions Public Health capacity and capability building Develop & implement a Joint Health & Well-being Strategy. Influencing the wider determinants of health Building the PH capacity of the wider workforce Health promoting settings Corporate social responsibility Social Impact Bonds Screening Programme co-ordination Environmental public health Communicable and Infectious Disease Control Immunisation and Vaccination Safeguarding PH resilience and response to incidents and disasters Research & Development Joint Strategic needs & Assets Assessment Evaluation of services and programmes Health Impact Assessment Health Equity Audits Integrating critically appraised evidence into programmes & services Health Surveillance and Assessment Health Profiling PH expert advice Assurance that commissioning plansincorporate best quality & governance practice Assurance that CQUIN schedules reflect local & national priorities for health improvement, health protection & reducing health inequalities Knowledge Management Unleashing the Talents of Local People System Reform Achieving Best Quality Health &Well-being Policy Health Protection

8. HWBB Launch Event Feedback Liked the 'Big Conversation' style of event - want a follow up and soon! High participation on the day and positive - even though the current economic climate, public sector cuts are challenging. Talked openly about the 'tough stuff' and impacts. Participants want public representation/input into H&WBB - beyond a 'token rep from HealthWatch' A process for gathering public views needs to be formed that feeds into H&WBB and Commissioning priorities and that cuts across LA, PBC, Voluntary and Community Sectors Want to know about level of scrutiny and how this will work - educational opportunities here Creation of a Networked Board - want a diagram of where H&WBB sits 'Root and branch' review of existing groups, terms of reference and how they will fit with H&WBB Communication plan needed for ongoing involvement of stakeholders and influencing of key H&WB priorities

9. What Should a Local Public Health and Wellbeing System Look Like? How to achieve economies of scale for delivering a national public health and wellbeing system Using pooled Information, intelligence and place based solutions to undertake new functions Workforce capacity and capability and resource management to deliver high quality care   Leadership, partnership and vision to successfully deliver population healthcare and wellbeing

10. Workforce Consequences Public health capacity to support the construction of JSNA and the preparation of local health and well being strategies and to support the Health and Wellbeing Boards. Public health capacity to support the oversight of GP and NHS Commissioning board activities. Capacity to ensure local direction and determination of health protection capacity, particularly that associated with existing health protection units. Public Health leadership in informing care pathway development. Capacity to support the commissioning of local health improvement services. Capacity to discharge responsibility for lead commissioner responsibilities.

11. Leadership in GM: The Greater Manchester Strategy The Manchester Independent Economic Review History of collaborative working across GM City Region Pilot status A GM Strategy which stresses the role of health in growth and employment Combined Authority and Local Enterprise Partnership

12. Enablers and Evidence: The case for health collaboration at the GM level. The View from the Moon

13. GM Collaborative Public Health System Understanding the primacy of local working, and the emphasis on JSNA, integrated public sector working, democratic leadership and prioritisation That aggregation to exploit collaborative advantage should only happen from the perspective of local requirement Recognising the potential future role and responsibility of Directors of Public Health in their own local authorities and that in supporting the discharge of this function DPHs may wish to secure specialist skill and technical expertise not likely to be available in each local authority Demonstrating where GM DPH working collectively had already invested resource and capacity , where there was related collaborative activity currently hosted within the GM PCTs and where there were other GM structures providing economies of scale for discharge of regulatory function in Local Authorities. Proposing how to align some functionality to a description of public health function.

14. DPH Leadership Community engagement needs to move beyond consultation into empowerment, which will involve the transfer of power and resources to communities themselves Work towards integration of primary and community care services with statutory, voluntary and independent sector neighbourhood services, providing a more holistic user-centred focus. Public health commissioning mechanisms to drive development of health improvement skills, resilience and leadership within local populations, making the concept of co-production of health between services and communities a reality Making strengthening the core economy of neighbourhood and family the central task of all public services Using the power of Public Health Commissioning, locally coordinated eg through H & WBBs, to explore new models of integrated delivery. For example, develop forms of community-oriented primary care appropriate to underserved communities with poor health outcomes Bottom-up action plans to integrate services as part of the co-production approach with communities, can provide the cornerstones of emerging strategic approaches to Community-based Budgets.

15. Making Health Everyone’s Business: The Approach Staff Health & Wellbeing Developing staff skills & confidence Community Development For Health Maximising Health Gain Investment in health & wellbeing services Developing Public Health Leadership/ Culture change Commissioning levers

16. Local Marmot Action Plan A ‘conscience’ for the new Health & Well-Being Board The 6 Marmot objectives provide the strategic framework Joint Strategic Needs & Assets Assessment highlights the health inequalities Priorities are being set in the context of an emerging policy agenda Plan includes health and well-being challenges throughout life - start well, develop well, live well, work well, age well Engaging local businesses through Food Sector and Well at Work Got cross sector commitment to understand and tackle causes of poor health locally

17. Investment in services Helping people to access the right support Health Trainer service with capacity to work with over (3,500 capacity) Industrial scale weight management programme (11,000 capacity) Stop Smoking services Find & Treat ‘DIY Health Guides’

18. Heart of Wigan CVD prevention partnership was established last year to raise the profile of CVD prevention work and specifically advocate for healthier policy and environments. Over the last 6 months, Heart of Wigan commissioned a piece of work examining the potential impact of local public policy on CVD across the borough based on the national consensus from a range of leading experts on the potential health impact of policy modification and to secure local consensus amongst senior decision makers on how receptive local conditions are to change or introduce related policy. The shortlist of 8 policies which had senior management support is now being taken out to community consultation to gather residents’ views. Heart of Wigan is also developing a CVD commissioning framework to guide future local investment in the area,

19. LifestyleSmoking in the Townships Percentage of adults who smoke across Wigan Borough with areas in Wigan South Township highlighted 26% of the adult population of Wigan borough are smokers compared with 24% in England overall. The Health and Lifestyle Survey (2005/2006) suggests that younger residents are more likely to be current smokers than older residents and men are more likely to have smoked than women. Wigan South Township has one of the highest average smoking estimates of any Wigan’s townships at 34.5% and is higher than both the England and Wigan borough average. Estimates range from 26.4% to 47.4. The majority of areas in Wigan South Township have estimates that are among the highest in the borough. The area in the north of Wigan South Township has the highest smoking estimate of any area in Wigan borough.

20. Smoking (The Reality at RAEI) Reception area at RAEI Smoking litter found beneath this sign below!!! The gutters Standing next to the sign on the left was this guy on the right!!! Visitors Parents/Carers

21. Healthy Hospital Programme This programme contributes towards the QIPP agenda by adding value in a hospital setting through focusing on the prevention of ill health. The programme adopts the framework set out by the World Health Organisations’ Healthy Hospitals initiative by actively supporting and encouraging the health and wellbeing of patients, staff and visitors to ensure that the organization adopts a health promoting culture as routine practice. Good progress has been made in developing and delivering health improvement interventions around smoking, alcohol, healthy eating and breastfeeding as well as working towards improving staff health and wellbeing. A robust smoking cessation brief intervention programme has been rolled out on a trust wide scale and smokers are now actively targeted in the Pre Op Assessment clinic. An innovative training approach is currently being developed to ensure that every opportunity becomes a health improvement opportunity; this will ensure that staff receive the appropriate skills to initiate brief ‘health chats’ that will promote and protect health and wellbeing of patients & staff.

22. Smoke Free Wigan & Leigh Established in May 2010 to reduce tobacco related health inequalities; to reduce smoking prevalence across the borough by developing and delivering a local Tobacco Control Strategy and Action Plan. Locally, the issues include: a high prevalence of smokers, especially within the more deprived areas, illicit tobacco, and underage sales. Specific work streams include: reducing the supply of illicit tobacco, promoting smoke-fee homes and play areas, reducing the number of young people that start smoking, and assisting every smoker to quit smoking, particularly from disadvantaged communities. The objectives are to strategically plan and commission effective, evidenced based interventions for tobacco control. 2 Cabinet members assist in Chairing the Alliance and there is clinical engagement on the Steering Group from the Cardiology Consultant at WWL , the PEC Chairman. Other partners are Public Trading Standards , Ashton, Leigh & Wigan Community Health Care, Wrightington, Wigan & Leigh NHS Foundation Trust, Environmental Health, Greater Manchester Police, Greater Manchester Fire & Rescue Service, Children & Young People’s Service’s, Adult Services , Wigan & Leigh Housing, HMRC, Community Engagement, Wigan & Leigh CVS, 5 Boroughs Partnership NHS Foundation Trust, Wigan Leisure & Culture Trust.

23. Ashton, Leigh & Wigan’s Take 7 Steps Out Roadshow

24. Lose Weight Feel Great The Public Health Directorate leads on commissioning a comprehensive portfolio of services and programmes to promote healthy weight. Our flagship programme is the Lose Weight Feel Great care pathway for managing excess weight in adults that was launched in January 2009. With services for overweight clients right through to bariatric surgery it has capacity to provide treatment for over 10,000 clients per annum across a range of services. It is one of the most comprehensive integrated pathways in the country and has significantly increased access to highly personalised advice and support services focused on achieving long term weight loss and maintenance. In the first 20 months of the programme, approvals for bariatric surgery have been reduced by 73% saving the PCT over £440000. Over 13,500 people have called the access hub for help and advice and nearly 11,000 people have been referred into services. Risk is the fragmentation of the commissioning budget may impact on this type of approach where currently the commissioning for all services related to obesity sits within Public Health.

25. Tanning Wigan Borough has the third highest number of sun bed outlets, per head of population, in England & Wales and a culture of tanning, especially amongst the lower socio-economic groups. There is a particular problem relating to the tanning behaviour of young people related to the junior and senior proms. Usage of sun beds and Melanotan injections separately and in conjunction with each other is currently being assessed through the following means: Research work with post graduate programme at Manchester University. Young people on ‘Future Jobs Fund’ placements, in the borough are undertaking interviews with young people on both attitudes and usage to tanning means. Joint visits to sun bed outlets by Public Health and Trading Standards staff to ascertain level of knowledge of staff manning the salons, and any rules or guidance in place. On the basis of the findings a programme of awareness raising/training will take place in an effort to raise the standards across the borough in an attempt to minimise harm. 

26. Health and Work The ‘What Makes Wigan Work’ Worklessness Strategy for the Borough has seen Wigan be one of the top performing Boroughs in Greater Manchester at supporting people back into work e.g. reduction in Mental Health IB claimants. Achieved through the full allocation of Working Neighbourhoods Funds to the strategy and its implementation, strong partnerships, and responsive commissioning Maximising opportunities within the private sector and building public health capacity within the workforce Key business making huge strides in workplace health e.g. HJ Heinz ‘Full of Beans’ programme

27. Developing Staff Skills & Confidence Use of Yorks & Humber Competency Framework Essential Public Health programme Topic based training where appropriate

28. Local Implementation Model for Skills Development City & Guild HT award Health Trainer Qualification- Health Trainers & Health Trainer Champions Level 3 Topic specific brief intervention Advance behaviour change Thematic training, e.g. smoking, alcohol, mental health. Advanced behaviour change techniques. Target frontline staff Level 2 Practical skills & tools to raise health issues. Delivered to all frontline staff who regularly work with patients/clients on a 1:1 basis Level 1 Essential Public Health (EPH) Develops knowledge & understanding of health improvement. Local health priorities covered. Covers aspects of self care/awareness of own health & well being. Delivered to support cultural change in organisations & as part of staff health & well being programmes. Developing health leadership Level 1 RSPH Level 2 award Self Care. Understanding impact of own behaviours/lifestyle on health & well being. Delivered to local community groups, local people. Supports community Health Advocates. Connecting Communities to Health Level 1

29. Make Every Contact Count This approach of developing the skills of frontline staff in basic behavioural change techniques specifically seeks to provide frontline staff with the skills, tools and confidence to embed prevention in their day-to-day work with clients. Its based on the premise of making the most of the thousands of encounters that public sector, voluntary and community organisations have with people every week and using these contacts as opportunities to raise health issues and signpost people to appropriate support services. Locally, Public Health is working with a wide range of organisations to develop staff skills and confidence in raising health issues and signposting people to appropriate support and advice. Organisations committed to this programme include: Ashton, Leigh & Wigan Community Healthcare NHS Trust; Wrightington, Wigan & Leigh NHS Trust; Wigan Leisure & Culture Trust; Wigan Council; 5 Boroughs NHS Trust; and Groundwork. Essential Public Health is a 2 hour training programme that is being used to provide staff with the practical skills and confidence to deliver ‘health chats’.

30. Leadership & Culture Change RSPH training- voluntary sector leads, Youth Forum members, Teaching Assistants Workplace Health Champions Briefings/ training for elected members Foundation Trust members & governors (proposed) Primary Care Staff

31. RSPH Level 2 in Health Improvement The Royal Society of Public Health (RSPH) level 2 award in Understanding Health Improvement is being utilised in a number of ways: Train the trainer within local public sector, community and voluntary organisations to build local training capacity. Training within local public sector, community and voluntary organisations to ensure that public health is better understood and health messages being given out are as consistent as possible. Current plans include train the trainer for teaching support staff in the level 2 programme so that it can be delivered to all 14+ pupils in the borough .Training for Greater Manchester Fire Service community staff and active fire fighters. Wigan has a large number of amateur sports teams, particularly focused on Rugby League. The volunteers who run these clubs are being trained in RSPH so that holistic messages are given to young people rather than a sole focus on physical activity. This is supporting the borough’s Healthy Stadia programme and has led to Wigan having the first two amateur clubs in Europe to achieve Healthy Stadia status. Supporting staff health & wellbeing - Administrative staff in Public Health and wider PCT have successfully completed the qualification and the qualification is starting to be delivered to staff in primary care settings.

32. Effective Leadership Complex health and well-being challenges Influencing resource decisions across organisations Developing trust across organisational boundaries Harnessing health and well-being leadership skills across local people and all organisational sectors in the Borough.