Standards for Effective Public Health Teams

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1 Standards for Effective Public Health Teams Issued January 2011 Revision date January Background The publication of the DH England white paper, Equity and excellence: liberating the NHS emphasised the importance of health outcomes and proposed that English health and social services should be assessed on their ability to achieve them. The supporting consultation papers concentrated on clinical services followed by the publication in November 2010 of Healthy Lives, Healthy People: Our Strategy for Public Health in England which set out the Government s vision for how they will respond to the major public health challenges of the 21st century such as smoking, obesity, alcohol through a redefined public health service.. To inform the current discussions around the future of public health this paper describes the various domains of public health practice, proposes related public health outcomes and the characteristics of the public health team and resources required to achieve them. The England Public Health white paper uses a similar approach for public health functions with an emphasis on outcomes, linked to underlying standards. While there is considerable overlap between clinical and public health standards in many areas (e.g. prevention of heart disease) more generic and also more specialised public health standards needs to be developed. To inform this debate the Public Health Knowledge and Standards Committee (PHSKC) of the Faculty of Public Health (FPH) has undertaken an exploration of standards that have already been published and/or used in public health practice in the UK, and have attempted to describe how the various public health functions carried out currently by the teams locally and regionally might be delivered in the future through the public health service, through local authorities and through GP consortia. In the time available it has been possible neither to undertake a full systematic review nor formally to explore the interrelation between these standards and health outcomes. Additionally, although many standards have arisen from published literature or from working documents, some have arisen from suggestions made, from experience, by those who have contributed to this paper. For these reasons the standards have been designated prototype standards. They provide a useful addition to the debate on the role of public health consultants and practitioners in the new health service, and a basis for future work, but they are not definitive. The paper represents Phase One of this work. The paper was developed by Drs Dominique Allwood, Sakthi Karunanithi and Paula Whittaker, three Specialist Registrars in public health appointed by a sub-committee of PHSKC supervised by Dr Steve George (FPH), Dr Frank Atherton (ADPH) and Professor Peter Littlejohns (NICE).

2 2. Objectives 1. To describe the current role of public health professionals at local, regional and national levels 2. To establish the link between the role of public health and various health outcomes 3. To recommend how the various public health functions carried out currently can be sustained in the future. 4. To indicate the resources which are required to achieve the public health outcome, including the composition of public health teams at local, regional and national levels to deliver the public health outcomes in the future. 3. Methods The contents of this paper have been derived from several sources including the following: FPH curriculum for higher specialist training and the Public Health Careers and Skills Framework. Where gaps exist these have been filled by inputs from various public health experts and consultation of professional opinions along with guidance from the project s steering group members. 4. Findings The next section of the paper presents the standards in the main public health domains: health protection, health improvement, healthcare public health, academic public health and public health intelligence. This covers the areas of general public health and mainly describes current PH functions at a local level. It is not able to be exhaustive in terms of public health activity. In addition to describing domain, context and standards it also provides insight into workforce capacity issues and skills. 5. How this paper should be used and future plans This paper is envisaged as a working draft and consultation will continue with the Public Health community in order to establish a definitive document over the coming months. It is will be used by FPH and ADPH to help Government shape the design of the English Public Health Service. RDsPH, DPH s, Public Health Consultants and Specialist Registrars are encouraged to debate the issues raised by this document, use pertinent information to inform local decision making but also to feedback to FPH in order that the paper is a living document, reflective of the challenges of the needs of the population. The Faculty of Public Health is a UK-wide body comprising four nations of England, Scotland, Wales and Northern Ireland. While structures and resourcing are different in the countries of the United Kingdom, FPH and ADPH strongly believe that standards of Public Health must be consistent. FPH and ADPH will be engaging with its country representatives in order that this document is applicable across the nations.

3 Guidance notes i) During the consultation, professionals were able to offer a quantification of their current workforce. However we know from past experience (e.g. Shifting the Balance of Power within the NHS) that a similar size core team is required where the same set of functions is delivered for a smaller population and that a much larger population doesn t really need a proportionately larger team to deliver on some functions (e.g. information and statistical analysis) but does on others (e.g. in relationship building and managing partnerships). Therefore, without detailed foreknowledge of the likely sizes of populations for which public health teams will be required to deliver outcomes, the quantification of capacity required to deliver must wait. Team size is also affected by the complexity of the local community a small highly diverse population with complex health issues may require a larger public health team than a more numerous but simpler population. ii) Although it is possible to separate required competencies across different individuals and agencies, quality cannot always be guaranteed where the overview is lost. This is important as roles and responsibilities will be shared between the NHS and local authorities and the exact profiles of skills will need to be defined. iii) The document describes outcomes of a whole process or care pathway, often involving health service personnel, social service or other local authority personnel, or voluntary sector workers, in addition to the core public health team. The difficulties of attribution of outcomes to an element, or more so to an individual, within that process or care pathway, are likely to be insurmountable given present knowledge. iv) The measurement of outcomes is, in some respects, in its infancy. Even if effective public health action caused cardiovascular mortality to dip by 10% from tomorrow it would take about two years for this to be reflected in the official statistics. v) The standards on workforce capacity and the terminology of specialist in this document is not restricted to the specialist consultant workforce but also refers to the wider public health workforce.

4 5.1 Health Protection Health Protection is one of the three key domains of public health practice This area of practice is concerned with action for the general environment (e.g. clean air, water and food), prevention of the transmission of communicable diseases, and protection against environmental health hazards, through the application of a range of methods including disease monitoring, management of outbreaks and other incidents that threaten the population s health and wellbeing, hazard identification, risk assessment and the promotion and implementation of appropriate interventions. PH Careers and Skills Framework 1 Health Protection Function Proactive prevention functions Outbreak prevention plans e.g. Tuberculosis, sexually transmitted infections, blood-borne viruses. Port health Environmental health liaison Microbiology and tropical diseases medicine liaison PH Team Prototype Quality Standard (based on existing standards 1, 2 ) Programmes to protect population health, wellbeing and safety Lead the development of shared policies for the prevention and control of communicable disease diseases, including, where necessary, disease-specific outbreak control plans Short- and long-term risk analysis in relation to actual or perceived major threats to health and Outcome Prevention of death, disability, healthcare costs and public concern from TB, HIV, E. coli O157, meningitis etc. Reduction from illness associated with environmental hazards and pollutants. Workforce Capacity issues Core team members Consultant of communicable disease control (CCDC), Health Protection Nurses or Specialists Analysts, Surveillance and data handling support staff 1 Skills for Health and PHRU Careers and Skills Framework 2 FPHa - Good Public Health Practice - Standards for Organisations with a Public Health Function [online] Available: Accessed 6th August 2010

5 Emergency preparedness and major incident and business continuity planning wellbeing Capability, contingency planning and resilience. Ability to monitor and respond to an increasing variety of infectious and environmental hazards and risk of deliberate harm to public. Hazards to human health from food or animal sources Effective mitigation of health and societal consequences of public health emergencies and major events. Local authority Environmental Health Officers Emergency planning officer, Executive directors, PH on call staff, data handling support staff. System must be robust enough to function in times of pandemic, major events and natural disaster. Co-ordinate and support planning, training and exercises across the NHS and other responding organisations. Expert advice and assistance to NHS, Local Authorities and others on services to prevent and control of communicable and environmental hazards. Reactive acute functions Proper Officer of local authority (legal duty to remove health risks from the public) Contact tracing Set standards for NHS preparedness Identification of effective interventions and services to control major infections and diseases. Risk communication (particularly with the public) on issues considered or perceived to be major threats to population health, wellbeing or safety Effective prevention and control services that reduce rates of HIV, Chlamydia, TB, MRSA, etc. Prevention of spread of infection from notified cases of TB, meningitis, O157, Legionella etc. Identification of sources of infection and spread. CCDC/CPH Leadership from public health, but delivery reliant on wider workforce e.g.gum/sexual health, TB clinics, health visitors, infection control nurses etc. CCDC, Health Protection Nurses or Specialists, Communication Officer Need to continue consultant peer network to maintain professional standards Identification of outbreaks and

6 Answering specific questions about health risks associated with exposure, identification of causative agent of outbreaks/ incidents and Outbreak and incident control Infection Control- including monitoring and advice on containment of Health Care Acquired Infections (HCAI). Member of hospital infection control committee (HICC) Environmental Health liaison Both proactive and reactive Provide advice on novel threats to health and manage risk Epidemiological investigation of priority problems affecting health, wellbeing and safety Provide an expert 24/7 public health response to incidents and outbreaks arising in local area that place the health of the public at risk. Chairing outbreak/ incident control team Planning, implementation and review of multi-agency or multi sectoral measures to prevent, ameliorate or control risks to population health, wellbeing and safety. Proactive interpreting and using data and information systems to effective incident management Identification of cause of outbreak and incident, population at risk, effective interventions and areas for prevention on future cases Prevention of spread; identification and mitigation/removal of cause; identification of affected groups for treatment; prevention of future outbreaks/incidents. Evaluation of Outbreak /Incident Management (prompt, thorough, investigation to identify cause, stop outbreak quickly and with minimal damage). Reduction in incidence of HCAIs such as MRSA, C.difficile, norovirus etc (lack of advice re: prevention and control associated with increased incidence) Effective control of outbreaks + incidents in hospitals (reduced mortality, reduced cost, less wards closed in hospitals, reduced litigation etc). Identify outbreaks early to allow effective intervention. CCDC, Analysts CCDC, Health Protection Nurses or Specialists Need to continue consultant peer network to maintain professional standards 24 hour access to CCDC expertise to deal with incidents (failure leading to poor handling of incidents) CCDC, Health Protection Nurses or Specialists Commissioning: Director of Infection Prevention and Control, Lead Infection Control Nurse Provider: Infection Control Lead, Infection Control Nurse Analysts, Surveillance and data handling support staff

7 Predict growing and reducing risks Advice on immunisation queries Evidence-based advice on the benefit and risk of implementing new vaccine programmes monitor disease and disease trends and identify current and emerging disease risks in the UK population and the impact of this locally. Implementation and monitoring of immunization and vaccination policies. Identify future risks to public to allow effective planning for prevention and treatment. Reduction in risk to individuals and public eg measles in children or influenza in elderly. % childhood immunisation coverage 3 (failure to reach herd immunity levels= outbreaks including possible mortality, cost of treatment) Systems in place must be sensitive enough to detect problems early to enable a proportionate and effective response CCDC, Health Protection Nurses or Specialists, Analysts, Surveillance and data handling support staff Workforce capacity issues Core team members: CCDC/CiHP Health Protection Nurses or Specialists Analysts Surveillance and data handling support staff Emergency Planning Officer The impending transfer of health protection teams from the HPA needs to recognise and maintain the strengths of the current system. Prior to 2003 CCDCs were working in isolation with associated risk of drift in professional standards. If CCDCs are to be based within local public health teams it is important that CCDCs maintain effective professional networks, such as a managed clinical network model for peer consultant to consultant advice and feedback. 3

8 5.2 Health Improvement Health Improvement is one of the three key domains of public health practice. It is concerned with improving the health and wellbeing of populations and reducing inequalities by using health promotion, prevention and community development approaches to influence the lifestyle and socio-economic, physical and cultural environment of populations, communities and individuals 4, and includes addressing inequalities, education, housing, employment, family/community, lifestyles, and surveillance and monitoring of specific diseases and risk factors 5. This section of the document describes standards for the public health teams to perform the health improvement functions effectively. While it attempts to highlight the key roles needed by the teams the exact number of people will depend upon local team structures, areas of direct responsibility, unitary or two-tier local authorities, and resource availability. Health Improvement Function (Adapted from PH Skills and Careers Framework and FPH nine Key areas of PH practice) PH Team Prototype Quality Standard Indicative Outcomes Workforce required DPH will lead and oversee all the functions Strategically Assess Health and Wellbeing Needs of Communities Lead the joint strategic needs assessment to set strategic direction and vision for health and wellbeing and communicate it effectively to a wide range of stakeholders including the communities. Decrease All age all cause mortality Infant mortality Childhood obesity Consultant in Public Health + Public Health Intelligence officers to analyse and interpret a wide range of NHS and non-nhs data sources as well as local qualitative information Identify where new policies and strategies are needed to improve 4 Skills for Health & PHRU Careers and Skills Framework 5

9 Commission Health and Well Being Initiatives that will achieve better outcomes the population s health and wellbeing and lead on the development and implementation, including the reduction of health inequalities Secure, prioritise and allocate resources to achieve optimal impact on population health and wellbeing outcomes Lead on the development, implementation and evaluation of health improvement programmes across agencies, partnerships and communities to improve population health and wellbeing and reduce inequalities Alcohol-related admissions Health inequalities in Life Expectancy Teenage pregnancy Improve Life expectancy Physical activity and healthy eating Mental well being Healthy Cities Consultant in Public Health + PH Specialists with commissioning skills Health Improvement Specialists Business manager Create and sustain infrastructure and cultures that enable strategic direction and vision to be realised Healthy workplaces Develop Lead on implementation of national public health policy locally, making choices about the pace of implementation and promoting economy of effort Healthy Settings and Cities Capability in HIA, HNA, HEA Building Strategic Partnerships Lead change by building and sustaining strategic alliances and partnerships within a politically Consultant in Public Health Public Health Specialists Senior Health Improvement

10 challenging environment Officers Maximise leadership and partnership working skills to improve population health and wellbeing, balancing the interests of organisational, political and multi-agency agendas and imperatives. Effectively use Health Impact Assessments to shape policies affecting the wider determinants of health Effectively use the powers of the local authority bye-laws in improving health Community Engagement Ensure infrastructure and processes are in place to enable and support communities in the articulation of their views and concerns about health and wellbeing Health improvement specialists and practitioners Campaigns Coordinator Use various techniques including surveys, focus groups, participatory appraisals, and consultation processes to improve health and well being.

11 Advocacy for Health Uses various channels of communications including media to communicate risks to health and well being from lifestyle, physical, social and environmental factors. Consultant in Public Health Health improvement officers Communication Officers Build sustainable capacity and resources for health improvement and the reduction of inequalities Lead local campaigns to improve health Assuring the quality and leading on the communication of key health messages to the public and health professionals Lead on the sustainable development of capacity and capability to improve population health and wellbeing Plan and implement training programmes to build public health capacity in a wide range of professionals and sectors Consultant in Public Health Health Improvement Officers

12 5.3 Healthcare Public Health Healthcare Public Health is one of the three key domains of public health practice. This area of public health covers commissioning of services, planning and evaluation of services, quality improvement, clinical governance, patient safety, equity of service provision and prioritisation of health and social care. This section of the document aims to provide an overview of the role, functions and opportunities of public health within this domain. Primary Care Trusts are currently responsible for purchasing care for a geographically defined population. The White Paper Liberating the NHS, proposes that Primary Care Trusts are replaced with GP Commissioning Consortia which will commission services for their population. The FPH believes that GPs understanding of local populations and experience can bring much to the commissioning process. However, it is imperative that Public Health specialists work alongside GPs, using their expertise to inform GP commissioners about how illnesses and diseases affect their population, what healthcare interventions are effective, analysing outcomes and interpreting information to identify where interventions and services need to improve and be made more efficient. i A GP with a typical list size of 1500 patients will have limited direct experience of relatively common conditions. For example, they may only have one to two patients each year on their list who have a new stroke, one or even zero patients presenting in a year with colorectal cancer (the second most common cancer in the UK after lung cancer), and, in terms of chronic disease, may have one or two ongoing patients with multiple sclerosis at any one time. Public health specialists in the area of Healthcare Public Health have a unique vantage point. They have the skills, the bird s eye view, and the information to look beyond the individual patient to serve a population group of patients. Public Health specialists have a key role in advising GP commissioners on how best evidence based interventions can be offered in primary care. ii Public Health specialists are experienced at working across organisational boundaries and their skills offer an opportunity to ensure that commissioning decisions are made on the basis of getting value for money and getting the most out of a budget for the whole population, while ensuring the highest quality of care. iii By commissioning the right health services and ensuring that they work properly and that they are accessed, this will lead to a gain in quality of life and life added. Health services also have a central role in preventing illness, improving health and supporting patients to make healthier lifestyle choices, as detailed in the previous section. There is a risk that separation of public health from the rest of the NHS, both financially and organisationally, will mean the NHS no longer sees population health as its responsibility, only health care, and that it will focus on treating ill health, not preventing it. Many of the benefits of engaging people in living healthier lives occur in the long term such as reduced severity and chronicity of

13 disease but there are also immediate and short-term benefits. Both will lead to a reduction in demand and workload for health services, especially in those areas such acute primary and secondary care services. iv There are areas where public health has to work with, and within, the NHS in order to deliver prevention services. One example is in the delivery of screening programmes, for breast, bowel and cervical cancer. Such screening services are technically known as secondary prevention, as they aim to catch established disease at an early enough stage to allow effective treatment.. Secondary care accounts for a large proportion of health service spending and secondary prevention depends on involvement of secondary care. Therefore public health also has a key role to play in prevention through secondary care in addition to ensuring quality of health services and patient safety in this setting. However, the NHS also has a critical role to play in primary prevention. A wide range of health professionals have many opportunities to offer brief interventions to support behaviour change, such as smoking cessation or reducing alcohol consumption. However if public health funds are held separately and the responsibility for health improvement and prevention sits with local authorities, it is not clear who will make such investments, particularly at a time when funding will be under pressure. v Public Health involvement in Health and Social Care The following have been identified as public health functions in health and social care. These are discussed below in terms of how they relate to GP commissioning. Detailed standards and outcomes are described in the table below. 1. Effective and cost effective health services commissioning 2. Patient Safety 3. Prioritisation of health and social care services 4. Screening 5. Equity of service provision 6. Clinical Governance and Quality Improvement 7. Healthcare development/planning 8. Healthcare audit, evaluation and research 9. Leadership for Health 10. Capacity Building 11. Value for money 12. Taking difficult decisions about Individual Funding 13. Pathways of care 14. Integration of all health care, including mental health and learning disability

14 The following statements refer specifically to the public health role within commissioning. Public Health specialists should advise GP commissioners on how best to drive up quality of health services. They can advise which indicators of quality are most important in determining good outcomes and select those that can be most easily measured and collated. Public Health specialists should use their expertise to analyse and interpret these quality measures to guide GPs commissioners to where action is most needed. This will allow GP commissioners to use their professional experience combined with rigorous public health analysis to use their time effectively to drive up quality. Public health specialists should also use their expertise to help GP commissioners performance manage and drive up quality of primary care services including GP practices. They will bring their expertise and will provide an objective analysis of primary care performance to help GP commissioners challenge consortia members to improve the quality of care provided Public Health specialists should provide research based evidence that GP commissioners will need to compliment their professional experience in making the best decisions about healthcare services for their population. Public Health Specialists in GP Consortia should also ensure that decisions about healthcare services are integrated with social care services to provide complete care pathways, using their experience and expertise of working with local authorities and the NHS. Public Health should assist GP commissioners to make the best use of the time spent commissioning by providing expert advice. Examples include writing commissioning and prescribing policies and monitoring data to ensure implementation. Public Health specialists have expertise in ethics and evidence based decision making and should use this to help GP commissioners prioritise use of finite resources to achieve the best health care outcomes for the population. Public Health specialists should play key role in advising GP commissioners on how best evidence based interventions can be offered in primary care. GP consortia will need Public Health Specialists to assist them in emergency planning, emergency response and resilience, Public health specialists will be able to advise and support GP commissioners in joint work on emergency planning, emergency response and resilience. Public Health specialists will be able to advise and support GP commissioners in joint work on emergency planning and in emergency situations and advise what their response should be to protect the population from the emergency threat. They will also advise on prioritising health service delivery during emergency situations during which normal service provision cannot be maintained.

15 Health Care Public Health Functions Effective and cost effective health services commissioning PH Team Prototype Quality Standard Compiled from various sources and existing standards vi,vii,viii,ix Support GP consortia to work with the health and Wellbeing Board, NHS Commissioning Board and Local Authority and ensure that GP Consortia are able to contribute to the Joint Strategic Needs Assessment and to the agreement of overall priorities for health, health services, health improvement and social care. Develop care pathways, policies, guidelines to improve health outcomes. Assess health and social care need, utilisation, demand and outcomes Generate and analyse high quality information to support commissioning Influence political and partnership decision-making to maximise the application and use of evidence to improve health outcomes. Outcomes Public Health fully or partially contributes Mortality amenable to healthcare brought down to the level of comparable countries x Improving one and five year survival rates for cancer, so that they are at least in line with EU averages and progressively improve relative to comparators x Reducing premature mortality from stroke, heart disease and lung disease, so that they are at least in line with EU average x Fewer acute episodes/ avoidable admissions to be able to attend work/school e.g. asthma in children xi To increase the proportion of stroke victims who are able to go home and live independently xii Workforce Capacity and skills Core team members Workforce Director of Public Health, Consultant in Public Health, Specialist in Public Health, Public Health Information analysts, Knowledge manager, support staff Skills Organisation and management: Change management, negotiation, leadership, collaboration and partnership working Project management Assessing evidence Literature searching Critical appraisal Clinical and cost effectiveness analysis Health information: Data analysis and Interpretation Needs Assessment, JSNA Technical Financial reporting, budget management statistical analysis

16 Prioritisation of health and social care services (will require DPH to be a Board level appointment) Promote population health prevention approach within health and social care services Decommission where evidence shows interventions or services are not demonstrably cost effective Prioritisation of investments by making explicit evidence-based advice to ensure GP Commissioners are well informed and can make best use of their time in making decisions. xvi Balance needs and resources to make sure that the whole population gets the best value for money. Include stakeholders in a robust process. Evaluate clinical and cost effectiveness of health and social care interventions to inform decisions about overall service provision and make best use of scarce resources. Maintain independence and objectivity so that funding decisions are based on objective evidence and need. xvi Produce high quality evidence NB These are examples and not an exhaustive list of health outcomes Local strategies that accurately reflect need and are influenced by GP Commissioners. Reduction in health inequalities xiii and inequalities in outcomes from NHS care (including primary care) Year-on-year improvement in patients satisfaction with their access to and experiences of healthcare x GP Commissioners are well informed and able to use their time effectively to influence prioritisation of health and social care and to commission services for their patients. Public feel informed in a clear and authoritative manner about decisions made on their behalf and that GP Consortia can be seen to be held to account. Local commissioning decisions taken should be explicitly based on evidence of effectiveness and fairness otherwise they risk challenge by Judicial review and may widen inequalities? Workforce: Director of Public Health, Consultant in Public Health, Specialist in Public Health, Public Health Information analysts, Knowledge manager, PH pharmacist, access to legal advice, support staff Skills: Organisation and management: Change management, negotiation, leadership, collaboration working across multiple clinical areas Project management Assessing evidence Literature searching Critical appraisal Technical Economic evaluation Financial resource mapping Communication Media management Stakeholder engagement

17 Equity of service provision summaries for exceptional treatment requests using ethical and legal principles Critically appraise business cases of proposals for new service developments or configurations based on need and evidence Present decision to the public and the media using skills and experience in media and communication and allow GP Commissioners to make best use their time. Monitor access and use of health and social care services including primary and secondary care by defined groups, including by social deprivation and undertake health equity audit of services and equity impact assessment. Plan services for vulnerable members of society: children, young people, older people, people with mental health and learning disability, BME groups, disabled, offenders using the evidence base about what works in improving access to service for these groups Address access issues and their impact on population health, wellbeing and inequalities Minimising the number of expensive interventions of marginal effectiveness Ensuring equity of access to health care Reduction in health inequalities xiv and addressing the inverse care law Workforce Director of Public Health, Consultant in Public Health, Specialist in Public Health, Information analysts Skills: Organisation and management: Change management, negotiation, leadership, collaboration working across multiple clinical areas Project management Health information Data analysis and Interpretation Health Equity Audit Equity Impact Assessment Communication Engagement with the public and hard to reach groups

18 Monitor access and use of health and social care services including primary and secondary care by defined groups, including by social deprivation and undertake health equity audit of services and equity impact assessments Plan services for vulnerable members of society: children, young people, older people, people with mental health and learning disability, BME groups, disabled, offenders using the evidence base about what works in improving access to service for these groups Address access issues and their impact on population health, wellbeing and inequalities Clinical Governance and Quality Improvement Set and maintain a culture of continuous evidence-based improvement Agree specifications and standards for services which clearly identify the clinical, quality and productivity outcomes which are important for patients and the NHS, and monitoring services to ensure delivery of these outcomes. xvi Generate information to support quality assurance and monitor performance. Year-on-year improvement in patientreported outcomes for patients living with long-term conditions x Reduction in preventable complications e.g. in diabetes xii Improvement in objectively measured clinical outcomes of care GP Commissioners are well informed and able to use their time to greatest effect in driving up the quality of Workforce Director of Public Health, Consultant in Public Health, Specialist in Public Health, Information analysts, support staff Skills: Organisation and management: Change management, negotiation, leadership, collaboration working across multiple clinical areas Project management Assessing evidence Literature searching

19 Healthcare audit, evaluation and research (Links to academic public health) Manage the development of outcomes and quality standards setting across organisations and networks Audit of services and practices to improve outcomes Appraisal of performance and identification of underperforming providers, providing recommendations Benchmarking variations in referrals and surgical procedures against NICE guidance Communication and dissemination of information that improves practices or services Provide impartial interpretation and advice on the performance of primary care and support GP Consortia in driving up quality of primary care. Independent service evaluation against NICE guidance Implement changes based on evaluation of evidence including discontinuation of services which are not cost-effective where appropriate working with stakeholders Service reviews utilising relevant process and outcome data to evaluate health services and public services Critical appraisal Clinical and cost effectiveness analysis Year-on-year improvement in patientreported outcomes for patients living with long-term conditions Improved health outcomes (see commissioning outcomes) Year-on-year improvement in patients satisfaction with their access to and experiences of healthcare x Workforce Director of Public Health, Consultant in Public Health, Specialist in Public Health, Health service Researcher, Knowledge manager. Often links to local academic department Skills: Organisation and management: Change management, negotiation, leadership, collaboration working across

20 Patient Safety health programmes in terms of outcomes Addressing access issues and their impact on population health, wellbeing and inequalities GP Consortia can demonstrate that they have taken account of NICE recommendations and have implemented NICE Guidance Promote research into the gaps in evidence and knowledge Share work and best practice through publication and dissemination. Participate in risk analysis and interpretation of data in incidents and serious untoward events Identify failures and implement procedures to address them. Provide input into management of incidents to reduce risks to the public Learning from events and improve systems to prevent them from occurring in future. Year-on-year reduction in the number of adverse events x (This needs to be interpreted with caution as figures may rise if reporting is encouraged) Minimise avoidable hospital acquired infections xii Reduce costs by reducing adverse events Minimising the number of expensive interventions of marginal effectiveness Ensuring equity of access to health care Reduction in health inequalities xv and addressing the inverse care law multiple clinical areas Project management Assessing evidence Literature searching Critical appraisal Academic skills Research methods Workforce Director of Public Health, Consultant in Public Health, Specialist in Public Health, Public Health Information analysts, statistician Skills Health information: Data analysis and Interpretation Communication Media management, Engagement Health care development/planning Horizon scanning new developments for effectiveness and affordability Year-on-year improvement in patients satisfaction with their Workforce Director of Public Health, Consultant in Public Health, Specialist in Public Health,

21 Engagement and partnership working Analyse costs, benefits and risks of new services/ technology Engage relevant communities to develop services Facilitate strategic and business planning. Support and advise on processes and identify benefits, costs, risks and opportunities Develop service frameworks, specifications and models of care against need and best available evidence. This should include treatment thresholds. xvi Plan and develop services across programme areas and specialities. Input into planning services for vulnerable members of society: children, young people, older people, BME groups, disabled, offenders to improve access and to address inequalities Engagement with patients, public and communities around health and social care. Communicate effectively with the public. Community development approaches should be taken in the development of services and ensuring the public take responsibility for their own health access to and experiences of healthcare x Reduction in health inequalities and addressing the inverse care law Best use made of resources GP Commissioners who are well informed and make best use of their time in planning and setting strategies for health services locally Achievement of health outcomes across organisational boundaries Year-on-year improvement in patients satisfaction with their access to and experiences of healthcare x Year-on-year improvement in patientreported outcomes for patients living with long-term conditions x Skills: Organisation and management: Change management, negotiation, leadership, collaboration working across multiple clinical areas Project management Communication Media management, Engagement with stakeholders Assessing evidence Literature searching Critical appraisal Workforce Director of Public Health, Consultant in Public Health, Specialist in Public Health, support staff Skills Communication Media management, Engagement with stakeholders

22 Leadership for health Know the key contacts within local health economy, local government, the voluntary sector and others for major aspects of work. Develop pro-active and collaborative relationships with clinicians, those in social services, local authority, voluntary sector, private sector. Provide input to teams developing solutions and innovations in the challenges faced by the local health economy. Liaise and provide input to commissioning, prescribing, ad hoc enquiries and working groups on health care. Provide a strategic view of future development in health care. Provide strategic leadership for improving health and tackling health inequalities. Maximise the potential of staff to use their skills and abilities to best effect. Lead and facilitate changes in services Lead across organisations and ensure that they work together to take on the challenge of priorities, applying and sharing good practice. Reduction in health inequalities and addressing the inverse care law Lead teams and individuals, build alliances, develop capacity and capability, work in partnership with other practitioners and agencies to which will contribute to improved health outcomes cited Community development working Organisation and management: Change management, negotiation, leadership, collaboration working across multiple clinical areas Project management Workforce Director of Public Health, Consultant in Public Health, Specialist in Public Health, Organisation and management: Change management, negotiation, leadership, collaboration working across multiple clinical areas

23 Capacity building Ensure access to training and education opportunities in healthcare public health settings Training posts should provide opportunities for acquiring learning outcomes in key areas in health and social services and related areas xvii Increase Public Health skills across the workforce to contribute to outcomes cited Workforce Director of Public Health, Consultant in Public Health, Specialist in Public Health, support staff Skills FPH approved Educational Supervisors and Project supervisors We come now to two areas of public health practice which are not defined as being of the three key domains of public health, but which are essential to supporting it, and without which public health could not function. To some extent they are not separated from the three domains but lie across all of them. All three public health domains require the support of a public health intelligence function, whether that be local, based within the same locality, or at a higher level, like the public health observatories, cancer registries or national agencies. Likewise all specialists working within academic public health will have an honorary NHS contract and a research interest in one or more of the three key domains of public health.

24 5.4 Public Health Intelligence This area of practice focuses on the systems and capacity to deliver intelligence for surveillance, early warning functions, risk to populations, measurement of health and wellbeing and outcomes. Note: these functions relate principally to health intelligence as practised at a local level, not at specialist regional or national level. PH Intelligence Function DPH Annual Report Health Needs Assessments Mapping health indicators PH Careers and Skills Framework 1 PH Team Prototype Quality Outcome Standard (based on existing standards 6, 7 ) Assess the health needs of the local population Describe the results of this assessment Identify the causes and distribution of ill health (i.e. epidemiology) so that these factors can be addressed Interpret the results and report on their implications Disseminate the findings to all Baseline and trend analyses of population health: these are essential for planning appropriate services 8 Benchmark local data on population health against national data 9 Workforce Capacity Issues Core team members DPH PH Consultants PH Specialists PH Analysts Knowledge manager/ information specialist Librarian 6 Skills for Health & PHRU 7 FPHa - Good Public Health Practice - Standards for Organisations with a Public Health Function [online] Available: Accessed 6th August APHO Accessed 14 th September EMPHO Accessed 14th September 2010

25 Interpretation of intelligence about health outcomes Health Equity Audit Health Impact Assessment Access to health intelligence Standardisation of information interpretation Health economic intelligence relevant stakeholders Provide robust, quality assured intelligence about outcomes using quantitative and qualitative data Translate findings of health needs assessment into appropriate (a) recommendations for action, (b) policy decisions and (c) service commissioning and delivery Draw valid inferences from quantitative and qualitative analyses Use these inferences to influence the setting of policy and priorities, and the performance of health systems Manage a document library, accessible across public sector, including national and local sources of policy, advice about behaviours and wider factors Make available best evidence and details about what interventions work for decision makers to use Develop relevant tools and frameworks to help people analysis information robustly and consistently Development and application of prioritisation frameworks Apply health information appropriately according to information limitations Ensure that services are delivered according to need and are configured to reduce health inequalities 3 Ensure that all proposed policies and services are designed for maximum benefit to health and to reduce health inequalities 3 All decisions and actions should be based on up-to-date evidence of effectiveness Analysis of evidence to inform decisions is objective and consistent Informed recommendations to commission/ decommission activities

26 Improving quality of health data Scan published and unpublished literature for evidence or insights related to public health data and the public health intelligence function Use this information to improve intelligence-gathering Evaluate the utility of health data and intelligence systems Use this evaluation to improve their fitness for purpose considered in relation to other proposals which are not readily comparable Production of accurate and timely health data 3 Prediction of emerging health problems 4

27 5.5 Academic Public Health This area of practice focuses on teaching of, and research into, population health and wellbeing. PH Careers and Skills Framework 10 Academic Public PH Health Function Team Prototype Quality Standard (based on existing standards ) Associated Health Outcome Workforce Capacity Issues Core team members Research: Formulate a specific public health research question Define appropriate outcome measures and data requirements for specific research proposals, both quantitative and qualitative Using existing literature Determine priorities for public health research Make recommendations on how the evidence base can be improved through research and development Provide evidence base for effective public health action PH Consultant Lecturer in Public Health Specialist Registrar in Public Health Social scientist Epidemiologist Health service researcher Health economist Medical statistician Information scientist 10 Skills for Health & PHRU Accessed 14 th September FPH Academic Public Health Workshop on Monday 22nd May Accessed 14 th September FPHa - Good Public Health Practice - Standards for Organisations with a Public Health Function [online] Available: Accessed 6th August Health Development Agency, Public Health Skills Audit Accessed 14th September 2010

28 to undertake scoping and gap analysis of topic areas Analysis: Apply and interpret appropriate statistical methods, including meta-analysis Draw appropriate conclusions and make recommendations from own and others research Critically appraise a range of research papers including both quantitative and qualitative, educational and public health practice research Evaluation of health services and PH interventions 15 : Use one or more research methods to support work undertaken in a service or research setting, Translate complex contemporary research results into information and knowledge that can improve population health and wellbeing Carry out original public health and health service research to the highest quality Apply a population perspective to evidence so that issues can be set in a context of incidence, prevalence, and marginal utility Ensure that academic and scientific knowledge leads to appropriate changes in public health practice 15 DH White Paper: Equity and excellence- liberating the NHS Accessed 14th September 2010

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