| 6. | PARTNERSHIPS FOR HEALTH
This chapter draws together some unifying themes to identify levels at which action needs to be taken. |
6.1. Action is needed across a broad front extending well beyond the NHS to tackle the inequalities in health and poorer health experienced by Wales relative to the best in Europe. This will require a long-term strategy and a structured approach to decide what needs to be done and who should do it. Some aspects will be addressed more appropriately by central Government, some at the all-Wales level, and some at local level.
6.2. Developing appropriate policies and tackling the problems will not be easy. Everyone will have a contribution to make particularly to encourage individuals to take action to promote their own health and well-being. Forging new effective partnerships across a wide range of agencies, including central and local Government, commerce, industry and voluntary organisations will be essential.
| How should responsibilities for identifying and acting upon inequalities in health status be shared by different agencies?
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Individuals
6.3. Each of us has a responsibility to maintain our health and avoid factors which cause illness. Avoidable ill-health wastes lives, squanders NHS resources and reduces our economic prosperity and well-being. The Welsh Office believes that individuals and families should have ready access to good information on healthy lifestyles and should be supported in communities, in the workplace, in schools and in public settings of all kinds to make the best of the opportunities for health and well-being.
| How best can individuals be encouraged to look after their own health within communities, workplaces, schools and other environments?
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Community and Voluntary Organisations
6.4. The role of the churches, women's, youth and children's groups, sports and activity groups, and voluntary organisations (in which women are particularly active) will be important to the success of the new framework for health and well-being. Social relationships and support are key to ensuring that everyone is able to enjoy an active life.
6.5. In the spirit of the compact which is being developed between the Welsh Office and the voluntary sector in Wales, productive partnerships between statutory services and community and voluntary organisations should maximise all the resources in a community. The Welsh Office is interested in innovative volunteering schemes which provide help to local people when they need it. Such schemes must be properly monitored and evaluated and participants must be trained and have the support of appropriate professionals.
| How can voluntary organisations play a full part in improving the health and well-being of their communities, in partnership with professionals and other services?
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Local Authorities
6.6. Local Authorities are responsible for major services such as social services, housing, transport and planning. They also exercise important public health functions. These include controls on occupational and environmental health, food hygiene and infectious disease. Maritime districts also have port health responsibilities. Local Authorities are also a major employers.
6.7. Local Authorities have a community governance role, often through the funding of voluntary organisations and the development of corporate strategies. The role of elected members is important, both because of their local knowledge of their ward community, their specific expertise e.g. Chairs of Environmental Health/Public Protection Committees, and their contribution to corporate strategic agendas.
6.8. To help the development of shared responsibility for broad improvements to people's health, and the well-being of local communities, a new duty to engage in partnerships will be introduced for both Local Authorities and the NHS. Local Authorities will be significant partners in the development and delivery of health improvement programmes.
6.9. The Government is considering the introduction of a requirement for Health Impact Assessment to be conducted for major new service developments, including those which are the responsibility of local government. It also intends to review the present allocation of functions between Health Authorities and Local Authorities for the control of communicable disease.
6.10. Local Authorities play an extremely important part in the lives of a wide range of people. Social Services Departments can make an important contribution to supporting people at home and promoting their independence, frequently through partnership with health services.
6.11. Effective joint working at this level can achieve substantial benefits for individuals and ensure the efficient use of all the available resources, for example, by preventing the need for admission to hospital and by supporting patients on their discharge from hospital. Through their day to day contact with many of the most vulnerable people, social services can play an important part in identifying problems early. They can help people to access the appropriate services and find their way round the system. They can:
- assist with access to health services;
- ensure people receive benefits and services for which they are eligible;
- work with education services and the NHS to promote the well-being of children and families;
- support people to live independently as far as possible in their own homes in the community;
- recognise the value of carers and promote services to support them.
6.12. The Welsh Office will consider what changes are necessary to planning guidance to ensure that health impact is taken account of in local social and economic development plans.
6.13. Other forms of collaboration which could be considered include:
- formal joint bodies structured on existing models, including representatives of the voluntary sector;
- more effective joint working both to define and to deliver statutory social care plans in each Local Authority area, for example by ensuring an interchange of Health and Local Authority staff;
- joint consultation with local communities to involve local people with the development of plans of both Health and Local Authorities, including the wide-ranging community plans which Councils are likely to be empowered to prepare;
- Local Authority Public Protection and Environmental Health Officers to advise Health Authorities and Local Health Groups;
- Directors of Public Health to develop their role in providing independent advice to both Health Authorities and Local Authorities;
- Health Impact Assessment of major developments to have input from a range of professionals;
- joint appointments by Health and Local Authorities, including recruitment of public health specialists to work with Local Authorities.
| How best can Local Authorities play a full part in improving the health and well-being of their populations, in particular responsibilities for identifying and acting upon health determinants, such as housing, which impact on health?
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The NHS
6.14. Putting Patients First (1998)cm sets out a framework for replacing the internal market in NHS Wales with a system of integrated care. The new structure is intended to concentrate resources on direct patient care and enable each professional to contribute to cohesive services. Local doctors, nurses and other healthcare professionals will take the lead in shaping local services to meet patients' needs.
6.15. The new focus of NHS Wales will be on collaboration rather than competition and on improving health as well as treating sickness. Sustainable health requires integrated services involving a range of health professionals including nurses, doctors, pharmacists, school health services, dentists, opticians and a range of specialist services.
6.16. The public health role of NHS Wales needs to be strengthened to ensure that all parts of the health service become more focused on preventing ill-health by:
- tackling inequality by ensuring that services reach areas of greatest need and that the services available are of a better quality;
- ensuring the right mix of local services;
- ensuring the NHS sets an example as a good employer, showing that it is serious about environmental health and occupational health and safety.
| How should these duties be carried out, in particular responsibilities for identifying and acting upon inequalities in access to acute services and differing outcomes for patients?
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Health Authorities
6.17. Health Authorities have a major role in preventing disease and health improvement, and holding hospitals and other health care providers to account for their contribution to making people healthier. Directors of Public Health are responsible for communicable disease control, effective immunisation, vaccination and screening programmes, and for independent reports on the health of their populations. Expertise in public health needs to be strengthened in all sectors. It is fundamental to the new approach to promote an increased awareness of public health issues so that they permeate health professionals' and non-professionals' understanding and culture.
6.18. Public Health Professionals have a key role in facilitating new relationships with local government and local agencies. In order to strengthen our existing knowledge base, the Government will exempt public health professionals from the definition of Health Authority management costs, so that efforts to curb bureaucracy in the NHS do not create a perverse incentive to weaken public health expertise at local level. Public health is a long-term investment, not an administrative overhead.
6.19. Health Authorities will have new duties of partnership, particularly with Local Authorities and the voluntary sector, to improve the health of their populations. The Welsh Office, in consultation with service managers, will develop frameworks for collaboration and mechanisms for identifying and requiring action on health inequalities. In particular, the framework for allocating resources between Health Authorities and within areas served by the Health Authority, will need to take account of work to tackle inequalities in health status and access to services. The particular needs of women and of special groups within the community must be separately identified and addressed.
6.20. The new priorities for Health Authorities will require them to become more strategic and more focused on improving health. They will retain many of their existing responsibilities which were not associated with the internal market. Unless otherwise revised, these include agreeing to what needs to be done to improve the health and health care of local people, the measurement and public reporting of health status and epidemiology, the provision of independent medical, dental, pharmaceutical and nursing advice and a range of functions to protect public health and to respond to outbreaks of disease.
Local Health Groups
6.21. Implementation of Putting Patients First (1998) will lead to the setting up of Local Health Groups, based upon Local Authority boundaries. Local Health Groups will be the vehicle for local collaboration between services affecting public health. The Groups will have representation from public services outside health and will provide real leverage on services and resources for a wide range of services. It will be important that the Local Health Group has access to information about health status, particularly where this is below the national average, and the resources to make a real difference over time.
6.22. Although Local Health Groups will bring decision-making closer to local people, they will be too large to represent small-area health issues. It is intended to use the experience of the Sustainable Health Action Research Programmes to develop ways of effectively under-pinning the planning and decision-making powers of Local Health Groups.
| How best can Local Health Groups be equipped to undertake this work, in particular responsibilities for identifying and acting upon inequalities in health status and actively promoting health improvements?
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NHS Trusts
6.23. NHS Trusts as the main employers of NHS staff have a particular responsibility for setting an example as good employers and ensuring high quality occupational health services (both as employers of staff and as providers of occupational health services for others). They also have responsibility for ensuring hospitals are healthy places, through rigorous measures to prevent cross-infection.
Primary Care
6.24. 90% of contacts with the NHS are made with primary care services such as general practitioners, community nurses, health visitors and midwives. GPs, practice nurses and other members of the primary care team, are in an ideal position to act as the patients' advocate, helping them through the system, pointing them in the right direction, making the right contacts. The co-location of health and other community services can provide easy access and 'one stop shops' so that people can discuss issues such as benefits with social security representatives, social care for vulnerable children and adults with social service staff, and seek advice on other issues from Citizen's Advice Bureaux personnel, as part of wider health care.
6.25. GPs also provide specific information on the health status of patients for the purposes of access to housing, transport (DVLA), insurance, and benefits (e.g. Incapacity Benefit and Disablement Allowance). They play a particularly significant role in relation to Statutory Sick Pay and short-term state Incapacity Benefit since the medical evidence they provide to their patients usually acts as the initial entry route to benefit. They also play an important role in the assessment of patients for placement in long-term care (particularly older people) and the identification of the needs of carers along with other local health services. Joint management of services to patients between health and social services, such as integrated support for patients leaving hospital, is crucial both to sustaining health and well-being and to the effective use of resources. The Welsh Office intends to consult Health Authorities, NHS Trusts, Local Authorities, other interested bodies and individuals on ways of achieving greater support and integration.
| Crosshands Surgery Healthy Community Project |
The Crosshands Surgery Healthy Community Project was set up to address community needs in the Upper Gwendraeth Valley using a community co-ordinator model. The identification of local health needs and the development of inter-agency alliances to meet those needs are key features of the project.
The initiative involved the appointment of a health community co-ordinator based at one of the local GP practices. The role of the co-ordinator is to identify the needs of local communities and address the needs by working in partnership with members of local communities, health and other professionals and voluntary agencies.
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6.26. GPs, nurses, health visitors, midwives, dentists and pharmacists also provide patient education on lifestyle matters that has as much to do with disease prevention as disease management. Advice on exercise, safe sex, diet, smoking, safety and food preparation are relevant here. There is strong evidence (e.g. smoking cessation) that advice and health promotion interventions given by health professionals are well received and effective.
| Healthy Living Centres |
Wales will receive nearly £20 million for the establishment of a network of healthy living centres spread over the years to 2001-02. £300 million will be provided across the UK for Healthy Living Centres from Lottery Funding via the New Opportunities Fund. (The establishment of the Fund was set out in the White Paper The People's Lottery, published in July 1997.) The funding for Healthy Living Centres is a massive opportunity to improve the health of the people of Wales. Healthy Living Centres will be aimed at those communities, both urban and rural, which experience the poorest health.
Healthy Living Centres will help people to maximise their health and well-being whatever their capacity for Ôfitness' in the traditional sense. But Healthy Living Centres will not just be fitness centres. Their focus will be on health as a positive attribute which helps people to get the most out of life, embracing both physical and mental well-being. They will be relevant to people of all ages: a healthy start in life for children, a healthy life for adults of working age, and a healthy retirement for others. There are already many examples of innovative local initiatives designed to improve people's health across Wales and they provide a solid platform for the development of a network of Healthy Living Centres.
Healthy Living Centres will need to create partnerships between local communities, voluntary organisations, and statutory bodies such as Health Authorities and Trusts, Local Authorities, including their social services and education departments. They may also need to involve, health promotion specialists, GPs and primary care services, universities, schools and private sector organisations.
Healthy Living Centres will be locally based, aimed at meeting specific local circumstances. Active local participation through volunteer effort, and a sense of ownership by local people will be essential to make Healthy Living Centres a valued community resource which can attract people who may not be accessing existing services.
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Health Promotion
6.27. Effective health promotion at every level is another key element of the new approach. Many agencies have a role to play in providing information, advice and cultural change programmes aimed at improving health. Health Authorities and NHS Trusts provide specialist health promotion units. Health professionals in many settings are important sources of advice and support on aspects of a healthy lifestyle. Local Government has a strong health promotion role. In future, local health promotion initiatives should be co-ordinated across a range of services, within a national strategy.
6.28. Parents, with the support of schools, have the major role in educating children about healthy living, avoidance of harm and dangerous substances, and living safely. A review of the Personal, Social and Health Education curriculum is underway to consider how children can be educated for health and well-being.
6.29. In addition to Education, many other aspects of local authority services promote health and well-being through their work on food safety, road safety, trading standards, environmental protection and personal social services.
6.30. The Health Promotion Authority for Wales (HPAW) runs national programmes and works in partnership with other organisations in the health service and elsewhere to further the promotion of health and well-being. The Secretary of State has asked the Health Promotion Authority for Wales, under the guidance of a multi-agency steering group, to review existing health promotion activity in Wales in preparation for a national strategy to be taken forward by the National Assembly. The review and strategy will take into account the role of local government, the voluntary sector and others involved in health promotion and the need for greater collaboration:
- developing the contribution of health promotion to health improvement and tackling inequalities in health status through:
- relating public policy towards improving health;
- enhancing people's skills to improve their health and well-being;
- strengthening the capacity of communities to achieve health gains;
- maintaining living and working conditions which promote health;
- orientating health and social care services towards enhancing health and well-being.
6.31. The review will be subject to wide consultation, leading to an agreed strategy to be published as part of the Better Health - Better Wales Action Plan in September 1998.
Research and Development
6.32. Sustainable health and well-being for individuals and communities, alongside the provision of appropriate health and social care, must be based on the best available evidence of effective public policy and practice. To do this, the strategy must be informed by best practice elsewhere in the UK and internationally through strong academic and research links with Europe.
6.33. Following the establishment in 1995 of the Wales Office for R&D (WORD), Wales is developing standards and evidence-based practice designed to underpin health and social care. Refocusing research on public health issues will be important to achieving improvements in health. The Secretary of State has asked WORD, under the guidance of a multi-agency steering group, to develop a strategic framework for promoting high quality research and development to support evidence-based approaches to health improvement. The framework will include recommendations for priority-setting and a support programme to be taken forward by the National Assembly. The strategic framework and support programme will consider the contribution research and development can make to health improvement and tackling inequalities in health status, and effective health and social care, through evidence-based support for:
- refocusing public policy towards improving health;
- providing appropriate and effective management and treatment of ill-health and disability;
- enhancing people's skills to improve their own health and well-being;
- strengthening the capacity of communities to achieve health gains;
- maintaining living and working conditions which promote health;
- orientating health and social care services towards enhancing health and well-being;
- identifying the separate health needs of women.
6.34. This agenda for the review reflects unique arrangements in Wales which bring health and social care research closely together. The review will be subject to wide consultation, leading to an agreed strategy to be published as part of the Better Health - Better Wales Action Plan in September 1998.
Collaborative Networks
6.35. A new agenda for Better Health - Better Wales needs collaborative action across a broad front. Collaboration already exists in a wide variety of settings; examples of networking are:
- inter-sectoral and interdisciplinary groups such as the Welsh Public Health Network, Welsh Collaboration for Health and Environment, Welsh Food Microbiological Forum and the Welsh Air Quality Forum; and
- professional groups such as the Society of Directors of Public Protection in Wales, Directors of Public Health Medicine, Designated Doctors (Child Protection), Designated Nurses and Midwives (Child Protection), Immunisation Co-ordinators, All-Wales Chief Housing Officers' Panel, Association of Directors of Social Services, Society of Local Authority Chief Executives.
6.36. The Welsh Office is considering the need for a collaborative network at National Assembly level to which all stakeholders would be expected to contribute. In addition to those listed at 6.35 there are a number of educational establishments, research networks and voluntary organisations who have much to contribute to the debate, the development of policy and its implementation. The National Assembly for Wales could benefit from an arrangement which facilitated the active collaboration of all these groups, underpinned by a comprehensive health information system such as HOWIS. Discussions are at an early stage and suggestions of how such a network might be developed and possible membership are welcome.
| How can professional groups play a full part in meaningful collaboration which will improve the health and well-being of communities, in partnership with voluntary and community groups?
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The National Assembly for Wales
6.37. Subject to Parliamentary approval, the establishment of the National Assembly for Wales in 1999 will transform public life in Wales and introduce for the first time democratic control of the resources for health. The White Paper, A Voice for Wales, outlined the Assembly's intended health functions:
- to monitor the health and well-being of the Welsh population and respond with policies to promote health and tackle ill-health;
- to decide the scale of financial resources for health within its overall budget;
- to identify and promote good practice in health services and hold NHS bodies in Wales to account for their performance;
- to canvass and act upon the views of patients, staff and carers on the quality of NHS services;
- to ensure that NHS Wales has a workforce of well-trained staff.
6.38. In setting the strategic framework for the improvement of health in Wales, the Assembly will require the following:
- information about the health of people in Wales at a national, regional and local authority level;
- guidance and directions to set standards for housing, transport networks, environmental controls, health care and health promotion, and access to health services;
- feedback on the level and achievements of public services in terms of health gains;
- all-Wales services such as research and development for health and social care; and health promotion.
6.39. The objective will be to improve health across Wales and tackle inequalities in health status and in access to appropriate services. The Government believes that this can be achieved by ensuring that health effects are taken into account in other agendas, and by new forms of collaboration. This is not a new idea and we all know how difficult it is in practice. What is new is the encouragement of inclusive policies which operate with the active participation of individuals, local agencies and Government.
6.40. To start to break down the barriers to collaboration at the heart of Government, the Prime Minister has appointed a new Minister for Public Health and appointed a senior Cabinet Committee for Public Health with representatives of 12 Departments. The Welsh Office health minister takes forward this work in Wales. The Social Exclusion Unit is charged with taking action to address inequalities affecting the most vulnerable groups in our society.
6.41. The Welsh Office, in preparation for the National Assembly, is undertaking a fundamental review of the structure of the Health Group, looking specifically at the Assembly's remit for health improvement and tackling inequalities. Mechanisms for cross-departmental working are being developed with the absorption of Tai Cymru Housing for Wales into a new Housing Department and parts of the Welsh Health Common Services Authority and the Health Promotion Authority for Wales coming into the Assembly.
| How should collaboration in the context of the National Assembly for Wales be strengthened to ensure that better health drives major policies?
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