Healthier Herts A Public Health Strategy for Hertfordshire

Transcription

1 Healthier Herts A Public Health Strategy for Hertfordshire Hertfordshire County of Opportunity

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3 Contents page 5 page Why a strategy for public health? 2. Health in Hertfordshire page 14 page 23 page 25 page 26 page Conceptual and delivery models for the public health system in Hertfordshire 4. Vision into action 5. Public health priorities for our residents 6. Achieving our priorities 7. The implementation journey

4 Foreword We want Hertfordshire residents to have the opportunity to live the healthiest lives possible and to live safely in their communities. Some of the county s residents are significantly less healthy than others. We recognise the considerable effect that remaining healthy has on the happiness and life chances of our residents. With responsibility for public health returning to local government, we want all services to work together to improve the overall health and wellbeing of people in Hertfordshire, with early measures taken to tackle health inequalities. Hertfordshire County of Opportunity We have ambitions to improve and protect the health of our residents as part of our vision for Hertfordshire. We want Hertfordshire to remain a county where people have the opportunity to live healthy, fulfilling lives in thriving, prosperous communities 1. 2 Healthier Herts: A Public Health Strategy for Hertfordshire

5 This vision is ambitious, and recognises that health, prosperity and fulfilling lives are inter-dependent. Our ambition for Hertfordshire sets out a common purpose to see: Citizens who enjoy life and are healthy Safe and active communities that get on well A strong economy where businesses thrive A high quality environment People who are able to achieve their potential. The transfer of statutory responsibilities for public health to the county council on 1 April 2013 gives us a significant opportunity to enhance and further the efforts to achieve this. More than thirty years of scientific evidence on public health underpins the insight that a strong public health system focused on improving and protecting the health of our residents is essential if we are to achieve the vision and ambition we have set 2. This strategy sets out the context in which the county council will discharge its statutory responsibilities for public health, but also recognises that we need to work as a public health system in Hertfordshire, where agencies with statutory responsibilities work together with every agency which can make a contribution to public health. This means local authorities, the Police and Crime Commissioner, police, probation, schools, the NHS, employers, businesses, voluntary and community agencies and others across Hertfordshire, all have a role to play. No single agency has the answer, and we must all work together, playing our parts and playing to each others strengths. This is evidenced from the fact that this strategy was written by people from a range of agencies working together. Achieving this strategy will bring significant benefits to our population in terms of increased quality of life and better health. It will also bring savings to the public purse. Most public health interventions save more than they cost. One case of HIV infection avoided is costed by the Department of Health at 1.25 million saved in treatment and care. Behavioural interventions to keep people at a healthy weight cost less than a fifth of surgery and save up to 250,000 per person in heart disease and diabetes treatment 3. Overall, based on research and experience from other areas, public health interventions which are successful could save Hertfordshire up to five times more than we invest. As part of our commitment to demonstrate this, our implementation plans will be accompanied by an analysis of cost-effectiveness wherever possible. I particularly want to thank our public health team, district and borough councils, Healthwatch Hertfordshire, our NHS partners, the Police and Crime Commissioner, Probation Service and Public Health England for their support and enthusiasm in drawing this strategy together. Public health is an exciting portfolio because it is something which touches all of us. I am confident that people in Hertfordshire will rise to this opportunity, to the benefit of all of our residents. Cllr Teresa Heritage We can either see this as a challenge or an opportunity. We have a strong track record in Hertfordshire of working together. Healthier Herts: A Public Health Strategy for Hertfordshire 3

6 Figure 1: Our public health strategy at a glance OUR PURPOSE: To work together to improve the health and wellbeing of the people of Hertfordshire, based on best practice and best evidence. OUR VISION: A healthy happy Hertfordshire: everyone in Hertfordshire is born as healthy as possible, and lives a full, healthy and happy life. We compare well with England and similar counties, and health inequalities across Hertfordshire are reduced. WHAT WE WILL ACHIEVE WORKING FOR AND WITH OUR RESIDENTS HOW WE WILL WORK TOGETHER (our strategic priorities: how we achieve it for our County) The Public Health Outcomes Framework (PHOF) will be used to measure our success Priority 1: Our residents live longer, healthier lives Priority 2: Our residents start life healthy and stay healthy Priority 3: We narrow the gap in life expectancy and health between the most and the least healthy Priority 4: We protect our communities from harm (chemical, biological, radiological and environmental) Priority 5: We understand what is needed and we do what works Priority 6: We make public health everybody s business and work together Building blocks Strong leadership Capable, skilled people Co-production with residents Effective partnerships Evidence and knowledge driven Plan and deliver for localism Whole system approaches For the public health family Making better use of behavioural sciences at individual, interpersonal, community and service levels. 4 Healthier Herts: A Public Health Strategy for Hertfordshire

7 1. Why a strategy for public health? Good health is what we all aspire to for ourselves, families, carers, friends and communities. There are many determinants of health ranging from genetic factors to the impact of where we live and our social and economic circumstances. Healthier Herts: A Public Health Strategy for Hertfordshire 5

8 Recent policy and advances in public health science have acknowledged that local government is well placed, in its strategic place-making role, to work on these with partners. Most recently the Health and Social Care Act 2012 gave the county council a duty to improve the health of its residents. The ten district and borough councils in Hertfordshire already have powers to improve health under the 1984 Public Health Act, and these, along with the county council share a general power of competence, enabling them to do what is needed to improve the health of their residents. National Health Service clinical commissioning groups have a statutory duty to reduce inequalities in health in their patient populations. Many other partners, from the Police and Crime Commissioner to voluntary and community sector bodies, faith communities and business, have a role in making Hertfordshire a healthier county. The Health and Wellbeing Strategy for Hertfordshire 4, sets out the key priorities for the Health and Wellbeing Board (HWBB) 5. While there are some priorities within the strategy of common interest to public health and the HWBB (tobacco, healthy weight and alcohol are three of the nine HWBB priorities on which public health take the lead) there are a number of other areas where public health have responsibilities (sexual health, drugs and alcohol, school nursing, health checks and other areas) which are not within the nine key priorities of the Health and Wellbeing Strategy but which do need to be addressed. This strategy seeks to do that. This document seeks to outline the vision for public health as part of the vision for Hertfordshire 6, and to provide a clear road map for how the work of public health functions in Hertfordshire will ensure all residents will have an opportunity to live as healthy lives as possible and to live safely in their communities, which the vision for Hertfordshire commits us all to achieving. Public health is defined by the Faculty of Public Health ( the Faculty ), the standard setting body 7 for public health practice in the UK, as the science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society. 6 Healthier Herts: A Public Health Strategy for Hertfordshire

9 The Faculty s approach to Public Health: is population based emphasises collective responsibility for health, its protection and disease prevention; across agencies and partners recognises the key role of the state, linked to a concern for the underlying socio-economic and wider determinants of health, as well as disease emphasises partnerships with all those who contribute to the health of the population. A detailed statement of evidence for what this strategy proposes is beyond the scope of this document, because much of it has been stated elsewhere, i.e. The Strategic Review of Health Inequalities in England Post 2010 (the Marmot Review ), along with the National Audit Office s report on Health Inequalities 9 and the World Health Organisation report Closing the Gap in a Generation 10, all identified that the need for England is to reduce health inequalities in a sustainable way. Much of this research has identified that the health outcomes (life expectancy, burden of ill-health and disease, avoidable death) which people experience is the result of a complex set of interplaying factors 11 : Our parents health before and during conception and pregnancy Our start in life (healthy or unhealthy) The lives we lead (physical, social, psychological and spiritually healthy lives) The place we live in The opportunities we have (good education, good employment) The services we access (high quality, easily accessible, focusing on prevention). The Joint Strategic Needs Assessment (JSNA) for Hertfordshire 12 provides an overview of the health of our county, as well as some in-depth analysis on health topics. The JSNA makes it clear that Hertfordshire faces a number of inter-connected public health challenges where we are not performing as well as we could. While in terms of premature death we are twelfth from top of England s local authorities; when compared against our peer group we are placed twelfth out of fifteen. There is an eleven year gap in life expectancy between the healthiest and the least healthy areas in Hertfordshire. There are a number of reasons why this is the case: Too many people in our county spend the end of their lives in avoidable disability caused by non-communicable disease as a result of the common risk factors of smoking, obesity, poor diet, physical inactivity and alcohol consumption Too many people in our county die early of avoidable disease Smoking remains our biggest cause of avoidable death Being obese or overweight is reducing the healthy life expectancy of too many of our young people and adults Preventable mental ill-health is too high; and the burden of mental ill-health across the lifecourse is too high We need to do more to ensure our children have a healthy start in life and grow up healthy Avoidable ill-health and the risk factors for these are hindering efforts to reduce poverty and increase prosperity. These things are often called determinants of health, and are shown in more detail in figure 2 on page 9. Our experience of education and employment and our built and natural environment are often called wider determinants of health. Healthier Herts: A Public Health Strategy for Hertfordshire 7

10 These challenges are not something specialist public health functions, wherever they sit, will solve on their own. Everyone must work together. The role of public health is to provide evidence, intelligence and foresight to help those whose key role it is to both deliver the improvements needed and see the interconnectedness of what they do. But improving health is complex. The NHS has a large part to play in leading health improvement and in securing high quality health care, but local authorities have significant power and influence over many of the medium and longer term inequalities and determinants of health such as environment. These determinants of good health; environmental, economic and social, can only be tackled through good partnership working, and this requires clarity about what we are trying to achieve. Schools and colleges also have a key role to play. The Marmot Review re-iterated that to improve the health of the whole population and those who are least healthy, focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage 13. This is called proportionate universalism 14. This key principle has been adopted in the Health and Wellbeing Strategy for Hertfordshire and is adopted here. The transfer of responsibility for significant areas of public health in April 2013 from the NHS to local government is one of the most significant extensions of local government powers and duties in a generation. It represents a unique opportunity to change the focus from treating sickness to actively promoting health and wellbeing. Equally, as our knowledge on what factors determine our health outcomes grow, we see that improving the health of our residents requires contributions from a wide range of players. This document seeks to present clarity on what we are trying to achieve. It is intended to focus on priorities and outcomes, and be a brief statement of principles and priorities. Our implementation plan will focus on identifying the various contributors to good or ill-health, and interventions and roles to improve health. The figure overleaf shows the contribution of various determinants of health to overall health. Many of these are issues which our JSNA and other needs assessment work have identified for Hertfordshire. 8 Healthier Herts: A Public Health Strategy for Hertfordshire

11 Figure 2: Determinants of Health 15 Health behaviours 30% Socioeconomic factors 40% Clinical care 20% Built environment 10% Smoking 10% Education 10% Access to care 10% Environmental quality 5% Diet/exercise 10% Employment 10% Quality of care 10% Built environment 5% Alcohol use 5% Poor sexual health 5% Income 10% Family/social support 5% Community safety 5% This strategy for public health demonstrates the commitment of the county council to actively improving the health of the people living in Hertfordshire, working with all of its partners. We recognise the commitment of our partners. The strategy which is shown in summary on Figure 1 (page 4) will: Aim to improve health outcomes for all our residents Set out our public health priority areas for short, medium and long-term action Set the context for implementation plans between 2013 and 2017; these will be refreshed annually. Within these implementation plans we will use the tools of proportionate universalism, a lifecourse approach and Five Ways to Wellbeing 16, along with other tools. Healthier Herts: A Public Health Strategy for Hertfordshire 9

12 The Lifecourse approach How long we live, and how much of it we spend in good health or ill-health, is the result of risks we accumulate across our lives. Just as we conceptualise health as outcomes influenced by a range of determinants (see page 9), health outcomes are also the result of a developmental trajectory from before conception (maternal health behaviour and status) to old age. This trajectory is multidimensional; there are biological, psychological, behavioural and social aspects. Figure 3 below conceptualises these influences and dimensions. The lifecourse perspective will form a key part of our lifecourse model, where we develop health interventions which help people make the best and healthiest start in life, develop through a health promoting school and family environment, work in a health promoting workplace and take steps to keep themselves healthy. We will describe this in more detail in our implementation plan and through our public health skills development programme. Figure 3: Influence of health status across the life course Relative Magnitude of Influence Day Care Family School Community Workplace Individual Age (years) 10 Healthier Herts: A Public Health Strategy for Hertfordshire

13 2. Health in Hertfordshire Collectively, people in England are healthier now than at any other point in history. We are living longer and have more years of good health than ever before. In some respects the same can be said of Hertfordshire, and we have seen some significant improvements in health over the last ten years, most notably in life expectancy and reductions in infant mortality. But some areas of Hertfordshire remain behind England as a whole and the gap for some of our persistent inequalities in health, between us and England, is not narrowing. There is a higher burden of death and ill-health placed on the poorest areas of Hertfordshire than on England as a whole. The map below shows the Index of Multiple Deprivation (IMD) scores by area. IMD scores provide a useful proxy for health inequalities, because those areas with the highest deprivation (shown in darkest on the map) tend to experience worse health than the rest of Hertfordshire. Figure 4: Index of Multiple Deprivation Scores for Hertfordshire Healthier Herts: A Public Health Strategy for Hertfordshire 11

14 A separate document Health Challenges for Hertfordshire; Informing the Public Health Strategy 17 and the Equality Impact Analysis for this strategy both summarise the issues we have taken into account. In summary: Life expectancy in Hertfordshire as a whole is increasing both for men and for women. But compared with England and with our peer group there are too many people who still die at a younger age; and too many people who spend much of their life in ill-health or disability. There is a marked and real social gradient to this, with people who are most deprived living shortest lives with most ill-health. Table 1 overleaf summarises some of the successes which have been evidenced in addressing health inequalities in Hertfordshire, and some of the challenges which still remain. The enduring effect of poverty remains a significant challenge 18. The harm from alcohol and tobacco, and the health effects of sedentary lifestyle and being overweight or obese also bring significant avoidable disease burdens to Hertfordshire, and these three areas are Hertfordshire Health and Wellbeing Board priorities. As noted above, public health lead on these. Health and economic prosperity are intimately linked. The health of our population is a key asset for our economic prospects, but equally a thriving economy is essential for good health. 12 Healthier Herts: A Public Health Strategy for Hertfordshire

15 Table 1: Successes and challenges in health inequalities Successes Infant mortality is showing a reduction in rates over recent years, with recent indications of particular improvement in some of the most deprived areas We have seen reductions in all age and all cause mortality; reduction in early death rates from heart disease, stroke and cancer We have seen reductions in teenage pregnancy in recent years We have seen significant reductions in people smoking and our prevalence of smoking is in line with England. (Reducing the harm from tobacco is a HWBB priority). Challenges Infant mortality whilst reducing, we still have disproportionate rates across the county within certain ethnic communities Premature death and life expectancy although reducing, remains significantly worse for some cancers and for the poorest areas Preventable non-communicable disease, especially diabetes, stroke, cancer and heart disease, remain higher in some areas than in others Teenage pregnancy still remains a concern in some areas 172,000 people remain smokers and new young people take up smoking every day Smoking prevalence remains very high in the most deprived areas Obesity in children, and increasingly in adults, remains a challenge and lies at the root of much other avoidable ill-health. We need to have a co-ordinated and concerted approach to tackle this issue. (Physical activity and maintaining a healthy weight is a HWBB priority) The impact of poverty on health remains a significant factor in avoidable mental ill-health, domestic violence, disability and death Alcohol remains a high attributable factor in admission to hospital among some late middle age and older people The increase in outlets selling alcohol cheaply contributes to a short term rise in emergency hospital admissions and a long term rise in liver disease, mental health problems and avoidable early death. (Reducing the harm from alcohol is a HWBB priority) Self harm and preventable mental ill-health in our young people remains high and is increasing. There remain a range of challenges as shown above which stop us being a healthier county, and which means that the burden of disability, ill-health, disease and death in some parts of Hertfordshire remains higher than it should be if compared to the England and the Hertfordshire average. Healthier Herts: A Public Health Strategy for Hertfordshire 13

16 3. Conceptual and delivery models for the public health system in Hertfordshire The role of every agency and the role of specialist agencies Sections one and two of this strategy identified that a range of factors mitigate for or against people being healthy across their life (wider determinants of health). This means that we need to build a public health system where a range of agencies understand their role in protecting and promoting the health of our residents, and act to deliver it. Every agency has a contribution to make to public health in Hertfordshire, and the county council s Public Health Service will seek to lead and support this through partnership working. In Hertfordshire we believe that no one agency can deliver public health effectively without the others, and this has led us to develop the concept of a public health system where there is: A contribution from every agency in Hertfordshire to improve and protect the health of our residents, and A specialist public health family of agencies each with statutory roles and responsibilities. The specialist public health family in Hertfordshire The county council has statutory responsibilities to improve public health and a statutory duty to lead the local system through the Director of Public Health. District and borough councils have a range of statutory public health duties from the Public Health Act 1984 and other important contributions to public health such as housing, and leisure. Public Health England is the lead national body for the public health system in England with a range of statutory, enabling and supporting roles, including supporting NHS England in its public health commissioning roles. NHS clinical commissioning groups have a statutory duty to reduce inequalities in health in their registered populations. NHS England has a statutory commissioning role of some public health functions and commissioning of primary care. 14 Healthier Herts: A Public Health Strategy for Hertfordshire

17 authority and Public Health England, Environmental health and health promotion staff in district and borough councils), clinicians across the NHS, the nurses and doctors in each local practice, as well as a wide range of people who influence our behaviour. There are four key mechanisms which enable this system to work: The Health and Wellbeing Board the key multi-agency board for action on major issues across the health and care system for our residents The Public Health Board an officer board comprising a range of partner agencies, each with a contribution to public health, which develops and supports the public health system in Hertfordshire across all three domains of public health (see page 16) The Hertfordshire County Council Cabinet Panel on Public Health and Localism which oversees the statutory public health portfolio in the county council District and borough mechanisms local partnerships and boards which are crucial to local delivery of public health outcomes. Schools, retailers, employers, sports coaches and police all play a part, together with the planners and providers of quality health and social care, roads, housing, spatial planning, environment and other facilities, which all impact directly or indirectly on our health. The breadth of public health can be described in three domains, although there will always be some overlap. These are the protection of health, the promotion of good health and the delivery of quality health care. To deliver a robust and sustainable public health service for the county council, and across partners, we will create a public health system and identify a common conceptual model. This model will be based on the scientific principles of public health and recognition that everyone has a role to play in public health in Hertfordshire. A model for public health in Hertfordshire: conceptual model and delivery Public health is a discipline practiced by a broad body of people and organisations, not just those who are registered specialists. These include specialist staff (such as consultants in public health in the local Healthier Herts: A Public Health Strategy for Hertfordshire 15

18 The conceptual model of public health There are three components to this model: The definition of what public health is The three domains of public health practice The six levels at which public health action happens. Component 1: The definition of public health The definition of public health which has had most support is the definition used by the Faculty of Public Health (the standard setting body for specialist public health practice in the UK). It defines public health as; the science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society 19. Component 2: The three domains of public health practice This model has been used in the Public Health White Paper 20 the Government s public health strategy 21 and in the statutory guidance on public health 22. It is illustrated in figure 5 overleaf. 16 Healthier Herts: A Public Health Strategy for Hertfordshire

19 Figure 5: Three domains of public health 23 Health protection Director of Public Health Health improvement Health service delivery and quality Health improvement means what we can do to improve health at individual and population level and includes reducing inequalities, improving education, and addressing housing, employment, family / community, lifestyles, surveillance and monitoring of specific diseases and risk factors Health services delivery and quality means ensuring services are of consistently high quality and especially that they are evidence based, and address issues of effectiveness, efficiency and equity Health protection means we address threats and hazards to human health including infectious diseases, chemicals and poisons, radiation, emergency response and environmental health hazards. This means that public health is about ensuring everyone has the opportunity to be as healthy as possible, and from that foundational opportunity to be healthy they can grasp the opportunities to be prosperous, to thrive throughout life and to make a contribution to their communities 24. This may mean action across a range of levels from individual to social, and this leads us to the third stage of the model, the six levels of public health action. Demonstrating that public health interventions save money to our residents and the public purse is important to us. Evidence suggests that achieving this strategy will bring significant benefits to our population in terms of increased quality of life and better health. Most public health interventions save more than they cost. As part of our commitment to demonstrate this, our implementation plans will be accompanied by an analysis of cost-effectiveness wherever possible. Healthier Herts: A Public Health Strategy for Hertfordshire 17

20 Component 3: The six levels of public health action There are six levels at which public health works 25. Enabling people to be healthy means acting across all six levels. These levels are needed because most public health challenges have causes or factors across more than one level of people s lives e.g. social, biological, behavioural, etc. We need to work at several levels to address change enabling people to be healthy. Often a change in one level is spurred on by another, for example the legislative ban on smoking in public places has helped create social norms around smoking not being acceptable indoors, leading to a change in personal behaviour by more people giving up smoking. The table overleaf shows the six levels of public heath action and, as an example, what is happening on tobacco control currently in Hertfordshire. 18 Healthier Herts: A Public Health Strategy for Hertfordshire

21 Table 2: Six levels of public health action Levels 1. Social changing social norms about health, e.g. acceptability of binge drinking, acceptability of taking smoking breaks. 2. Biological immunisation, vaccinations, treatments. 3. Environmental encouraging green transport, reducing pollution, changing the public realm. 4. Behavioural helping individuals to stop smoking. 5. Legislative the smoking ban, legislation on alcohol sales. 6. Structural policy changes such as workplace health, school health policies. Tobacco Young people whose peers disapprove of smoking and its effects are less likely to start smoking. Campaigns like Stoptober and other marketing targeted at high risk populations. Targeted action to enable parents not to smoke around children. Supporting people in spreading the message that smoking in pregnancy has very high risks to mother and child. Nicotine replacement therapy and other drug interventions when appropriate help people reduce the very strong cravings from giving up smoking. Smokefree playgrounds in several areas in Hertfordshire are encouraging parents not to smoke in front of children and think about giving up. Making illicit tobacco trading less possible. Enforcement of stop smoking legislation. Stop smoking services and individual and group counselling help people give up and stay non-smokers - there are more than 300 of these services in Hertfordshire. The ban on smoking saw heart attacks drop by 14% in England within a year and has encouraged people to give up. Enforcement of legislation on sales and underage smoking. Workplace policies which make people who take smoking breaks make the time up see more people give up smoking and fewer sickness days from respiratory diseases and colds in winter. Policy frameworks which support tobacco control. Tobacco control strategies. This conceptual model will be used to help us identify for any topic we work on what the role of the county council s Public Health Service is, what the role of the specialist public health family in Hertfordshire is and what the roles of other, equally important, agencies such as social care, childrens centres, schools, employers, voluntary and community agencies are. Healthier Herts: A Public Health Strategy for Hertfordshire 19

22 Making the system work: a practical model for delivery In order to move to a system which will involve every relevant partner and will develop and demonstrate a range of capabilities (skills, knowledge, culture and attitudes) and develop appropriate mechanisms (boards, implementation arrangements, delivery pathways and engagement strategies). Table 3 below lists these capabilities and mechanisms. Table 3: Capabilities and mechanisms for public health delivery Capabilities Strong Leadership (elected member, officer, volunteer, resident) Capable, skilled professional people Planning and delivery at local levels while ensuring equity across the county Whole system approaches. Mechanisms Partnerships County Council Cabinet Panel Health and Wellbeing Board Skills Development Programmes Evidence, Intelligence and Joint Strategic Needs Association A multi-agency Public Health Board Co-production with residents. We have made specific commitments to these areas across each of our priorities. We will develop a model of operation which works across partners, starting with understanding what our population needs, moving to identifying what works and then to intervention. We will do this across the three domains of health improvement, health protection and service quality. This latter domain is sometimes called healthcare public health, but because social care, child care, housing, leisure and many other functions are important to public health, good quality services are crucial. This working model for our system is illustrated in the Hertfordshire Public Health Delivery Model 26 shown overleaf. We will use this model to work with partners. 20 Healthier Herts: A Public Health Strategy for Hertfordshire

23 Figure 6: The Hertfordshire Public Health Delivery Model Identify What Works Understand What s Needed Health Improvement Hertfordshire Residents Service Quality Health Protection Understand Roles, Players and Contributions Good Implementation Evaluate Outcomes Right Intervention, Right Delivery Mechanisms Right Population Healthier Herts: A Public Health Strategy for Hertfordshire 21

24 Using these insights, we will: Deliver a public health system where all skills and contributions are valued and designed around delivering the outcomes and priorities (see section 6 page 26), with a focus on equity for our diverse population Identify for each programme the contributions of the agencies in the specialist public health family, and other agencies Develop the skills and capabilities of local authorities, NHS, voluntary and community sector, criminal justice agencies and employers to deliver the public health agenda Develop the skills and capabilities of the county council s public health service to enable others to act on health issues using a public health approach Deliver a public health service which advocates successfully for effective prioritisation of resources for key public health priorities Deliver a public health service which enables commissioning activity to achieve the population priorities set above. In particular, enable clinical commissioning groups to work effectively on public health issues and priorities Develop ways of co-producing better health with residents Deliver a public health service which has an effective balance of public health capacity and capability across health improvement, health protection and service quality Deliver a public health service which develops the skills of both specialist and generalist stakeholders to be part of the public health agenda for Hertfordshire. Deliver a public health service which uses the best available evidence and information on which to base decisions and recommendations 22 Healthier Herts: A Public Health Strategy for Hertfordshire

25 4. Vision into action The consensus of stakeholders (county, district and borough council officers, public health lead officers in district and borough councils, Local Strategic Partnerships, NHS clinical commissioning groups, third sector agencies, Healthwatch, Public Health England and community agencies) is that we want our county to be healthy. The consensus of evidence is that to be healthy, Hertfordshire needs to be prosperous and sustainable. To be prosperous, Hertfordshire needs to be healthy. We have used the vision to action pyramid illustrated below to help explain why we exist, where we want to get to and what we will do. Implementation plans and individual workplans for every public health specialist in Hertfordshire will be needed to deliver this. Figure 7: The vision to action pyramid Values, what s important to us? Mission: Why? Vision: Where we want to get to Strategy: How we want to get to the vision Why are we doing this? Implementation plans : What we need to do in each area of the business and for each topic Individual plans: My personal objectives and must dos Where/what do we want to be? How we want to get there? What we need to do! What I need to do! Table 4 (overleaf) states Our Mission and Our Vision The next stage after agreeing this strategy is to produce an implementation plan for the service, which will be refreshed annually. Healthier Herts: A Public Health Strategy for Hertfordshire 23

26 Table 4: Our Mission and Our Vision Our Mission Our Vision Our mission is to work together to improve the health and wellbeing of the people of Hertfordshire, based on best practice and best evidence which means not just looking at effectiveness but also at cost-effectiveness. Healthy and happy Hertfordshire: everyone in Hertfordshire is born as healthy as possible, and lives a full, healthy and happy life. Hertfordshire s public health strategy ambitions Our ambitions within this vision are that: Hertfordshire will be among the healthiest counties in England. Our population as a whole will enjoy a life which is better than the England average for life expectancy and disease free years of life We will progressively narrow the gap in life expectancy and disease free years of life across the population of Hertfordshire Our population has a good understanding of how to be and remain healthy, and puts this into practice Everything about our public services and the way our county is organised supports this, from primary care services to quality of education, housing and access to employment. This strategy is about a whole system approach to opportunities for good health. This approach is underpinned by principles, three of which are, as mentioned above derived from the Review of Health Inequalities for England (2010) 2 commonly referred to as the Marmot Review: 1. We will adopt a lifecourse approach to health (pre-conception to death); which seeks to ensure people start life healthy and remain healthy 2. We will adopt a whole system approach; which seeks to identify the components which act to improve and hinder good health, and identify the contribution of public health specialists and partners to addressing them 3. We will adopt the principles of proportionate universalism 27 to address inequalities in health while ensuring that the whole population achieves better health 4. We will seek to develop a people centred approach to public health, where we design services working with residents and work to ensure services reflect the needs of our population 24 Healthier Herts: A Public Health Strategy for Hertfordshire 5. We will seek to ensure that the environmental sustainability and economic prosperity of our county are improved by what we do, and that we take account of the public health implications of climate change.

27 5. Public health priorities for our residents The public health priorities are about what we need to do in Hertfordshire to achieve: The Marmot principles Better health outcomes for our residents National public health strategy Public Health England priorities How we will work together 5. Understand what s needed and we do what works. 6. Make public health everyone s business. Our priorities will be tracked by our progress against the Public Health Outcomes Framework (see Section 7 page 36). We will also use the Five Ways to Wellbeing to build a resilient and healthy population. To achieve this set of priorities requires us to act on a range of different factors from the quality of primary care to the life opportunities of our population. Within these factors there are a range of short-term, medium term and longer term dimensions to consider, and the contribution of a range of agencies. The outcomes from the principles will reflect cross cutting themes from Hertfordshire s Health and Wellbeing Strategy , the Hertfordshire Equality Strategy and the Hertfordshire Community Safety Strategy. The public health priorities for Hertfordshire What we will achieve working for and with our residents 1. Longer, healthier lives. 2. Start healthy and stay healthy. 3. Narrowing the gap between most and least healthy. 4. Protect our communities from harm. Healthier Herts: A Public Health Strategy for Hertfordshire 25

28 6. Achieving our priorities Working with partners we have developed a set of priorities which are important not just to the agencies in Hertfordshire with statutory public health roles, but to everyone, and to ensuring Hertfordshire remains a county of opportunity. For each priority in table 5 below we have identified what this means, why we have chosen it and what we need to do to achieve it. A separate implementation plan will identify in greater detail what we will do and how we will do it. Table 5: Our 6 priorities Priority 1 Longer, healthier lives What does this mean We will increase life expectancy, especially disease and disease-related disability free life-expectancy in Hertfordshire and reduce health inequalities in these across the population. Why have we chosen this? We will reduce the prevalence in our communities of the five common risk factors for early death: smoking, obesity, inactivity, poor diet and excess alcohol consumption. Hertfordshire has too many people spending a significant part of their lives in avoidable chronic ill health and disease-related disability. 26 Healthier Herts: A Public Health Strategy for Hertfordshire

29 Priority 1 What do we need to do? Longer, healthier lives 1. Develop a health improvement programme which identifies action across the lifecourse. 2. Continue to reduce smoking prevalence (Health and Wellbeing Board Strategy priority). 3. Reduce obesity starting with the areas of highest prevalence (Health and Wellbeing Board Strategy priority): Increase and sustain the increase in physical activity uptake across the county Develop a lifestyle offer which helps people become and remain physically, psychologically and socially healthy This will engage sport and physical activity agencies and partners and will embed The Five Ways to Wellbeing Develop an obesity and health behaviour pathway with partners, with tiered weight management services within it. 4. Reduce harmful alcohol consumption (Health and Wellbeing Board Strategy priority). 5. Work with partners to build a culture of healthy living through development of lifestyle offers and health marketing to increase awareness and uptake of healthier lifestyles. 6. Work with partners to ensure that maximum improvement in health is achieved by all services across the county, from NHS commissioners and providers to local authority and voluntary and community sector services. 7. Implement regulatory, policy and population measures to improve health, including spatial planning, licensing and responsibility deals. 8. Strengthen the role of social sciences by embedding behavioural science approaches to public health challenges. 9. Develop public mental health approaches to building resilience and reducing preventable mental ill-health (including self harm and The Five Ways to Wellbeing ). Healthier Herts: A Public Health Strategy for Hertfordshire 27

30 Priority 2 Public health definition of this Why have we chosen this? What do we need to do? Start healthy and stay healthy Ensure we do what we can to improve health across the lifecourse from before conception to death. We mentioned the importance of a lifecourse approach in our principles above. There is overwhelming evidence that a healthy start for young people is a key public health priority. Giving every child the best start in life (which we do not currently achieve) is crucial for sustaining health throughout life into older age. 1. Commission all mandated public health services in a way which underpins a lifecourse approach to health and is personalised. 2. Seek to use local agencies and partners wherever possible to deliver these services. 3. Produce a market position statement which puts prevention and health gain at the heart of everything we commission. 4. Ensure a healthy start for every child through effective coverage of pre-conception, prenatal and perinatal care, health visiting, immunisation and public health nursing. 5. Ensure perinatal mental health work is universally rolled out. 6. Ensure early years services implement key public health interventions for healthy development (from My Baby s Brain to high rates of immunisation). 7. Build the public health role of childrens centres and other childrens settings. 8. Ensure a whole school day approach to health, starting with nutrition and physical activity. 9. Develop an adolescent public health programme across key services and settings including a focus on mental health, resilience, happiness and self-harm reduction. 10. Work with employers to improve the health of adults of working age, and reap the economic benefits of this. 11. Develop public health approaches for adults with particular and complex needs such as adults with learning disabilities and chronic mental health problems. 12. Roll out NHS health checks for adults and ensure these are part of a universal lifestyle offer, with appropriate targeting for populations who fare less well in health terms. 13. Ensure drug s and alcohol services are accessible and high performing and help people to reduce harm and recover appropriately. 14. Ensure sexual health services, including contraceptive services, are accessible, personalised and effective. 15. Develop a healthy ageing programme. 28 Healthier Herts: A Public Health Strategy for Hertfordshire

31 Priority 2 Start healthy and stay healthy 16. Develop public health approaches for particular communities: Serving military personnel, veterans, Territorial Army and reservists and their families as part of our commitment to the Community Covenant. Develop appropriate approaches for traveller communities BME communities LGBT communities Disabled people (especially access to physical activity) People with learning disabilities. 17. Work to establish healthy living pharmacies and dental practices. Healthier Herts: A Public Health Strategy for Hertfordshire 29

32 Priority 3 Public health definition of this Why have we chosen this? What do we need to do? Narrowing the gap between most and least healthy Reducing inequalities in health outcomes and life expectancy between most and least affluent. Hertfordshire has too high a disparity in life expectancy and ill-health between the most affluent and least affluent. 1. Improve the cycle, granularity and content of the Joint Strategic Needs Assessment to identify inequalities and inequity, including knowledge gathering and equity auditing. 2. Identify particular communities and populations which do less well than the majority of our residents, and identify what specific actions we need to take to improve their health outcomes. 3. Commission and deliver services which consider inequalities and equity and target appropriate areas of worst health whilst delivering a universal offer to everyone using the principles of proportionate universalism. 4. Reduce drug and alcohol related ill-health. 5. Improve equity of access and outcomes to services in the most vulnerable and most disadvantaged populations and those with worst outcomes (ie: children looked after, offenders, families in the thriving families programme, people in poverty, disabled people, people with learning disabilities, travellers, LGBT residents, military families and harm from tobacco and alcohol in lowest income groups). 6. Reduce harmful substance misuse, especially tobacco. 30 Healthier Herts: A Public Health Strategy for Hertfordshire

33 Priority 4 Public health definition of this Why have we chosen this? What do we need to do? Protect our communities from harm Deliver robust and effective health protection arrangements. Health protection responsibilities sit across a range of agencies and they are crucial to achieving good health for the population. We have a statutory responsibility to deliver and assure a robust health protection system. 1. Build a whole system health protection plan and network which harnesses the important roles of county, district/ borough councils, NHS and Public Health England and other partners. 2. Deliver a robust whole system approach to infection control in health and social care settings. 3. Deliver effective public health input to community safety and crime reduction agendas including alcohol, drugs, licensing, tobacco control, causes of domestic violence, offender health and mentally disordered offenders. 4. Support the important role of environmental health in health protection. 5. Develop a public health approach with regulatory services colleagues. 6. Improve take-up and ensure robust and high quality delivery of immunisation, vaccination and screening to our residents. 7. Ensure the public health role in resilience is fully delivered. 8. Work with licensing and the local planning authorities in the county to ensure that the adverse health impacts from licensing and planning are reduced and positive outcomes increased. 9. Continue to work with highways to improve pedestrian and road user safety. 10. Ensure public health skills help make Hertfordshire a more sustainable place. Healthier Herts: A Public Health Strategy for Hertfordshire 31

34 Priority 5 Public health definition of this Why have we chosen this? What do we need to do? Understand what is needed and do what works We are driven by robust evidence (epidemiology, needs assessment, evidence of effectiveness) and ensure interventions are evidence-based and appropriately developed. Where evidence is lacking we will ensure we can evaluate interventions for efficacy and effectiveness. Being evidence and intelligence driven and having the right skills and competencies will deliver better outcomes and better value for money. 1. Ensure we have a strong foundation of needs assessment, epidemiology, equity audit and outcome evaluation for programmes and services and work to improve the JSNA as a key source of evidence. 2. Ensure we develop skills and capabilities to understand and apply evidence across interventions, in particular ensuring we develop evidence-based practice and public health skills across the county council and partner agencies. 3. Ensure we develop skills and capabilities to assess and evaluate effectiveness and outcomes. 4. Work with commissioners to develop an integrated commissioning cycle which includes needs assessment, evidence assessment, prioritisation and outcome evaluation. 5. Support NHS commissioners using the Director of Public Health s statutory duty to advise clinical commissioning groups on how to commission to meet population health need. 6. Support NHS and local authority commissioners as well as criminal justice sectors to commission in a way which develops the health of their population. 7. Innovate to establish best practice where evidence is lacking, conflicting or silent. 32 Healthier Herts: A Public Health Strategy for Hertfordshire

35 Priority 6 Public health definition of this Why have we chosen this? What do we need to do? Make public health everyone s business We want to identify the public health contribution of every partner and stakeholder and build the capacity for them to deliver. Research demonstrates that public health should be everybody s business and everyone has a role. District and borough councils, for example, have strong public health potential in their housing, leisure, environmental health and other roles. Voluntary and community sector agencies and faith communities can reach people statutory services may struggle to engage. Ensuring everyone understands their contribution and delivers it will be crucial to making our county and our residents healthier. 1. Identify with each stakeholder what their public health impacts are and how they can address them. 2. Continue funding for partnerships and initiatives which deliver on this strategy. 3. Support voluntary and community sector and community agencies in identifying their public health contribution and meeting it. 4. Continue to support local strategies and plans through Local Strategic Partnerships, and the Public Health Board. 5. Commission delivery partners local to Hertfordshire wherever possible. 6. Co-produce services and interventions with stakeholders and residents. 7. Build appropriate capabilities across everyone with an interest in public health through access to learning and skills development (both face to face and online) including development of a route to Public Health Practitioner Registration. 8. Work with academic partners to develop capabilities to deliver effective evaluation and evidence across public health. 9. Develop information systems with partners across NHS and local government and other agencies to deliver information which is easier to use to take public health action. 10. Build a network of health champions across communities and agencies who will work to build a public health and self-care culture. Healthier Herts: A Public Health Strategy for Hertfordshire 33

36 Priority 6 Make public health everyone s business 11. Work with each of the following priority agencies to develop public health plans, programmes and strategies across all of their capabilities: Hertfordshire County Council departments NHS and social care commissioners Police and Crime Commissioner, Probation and Hertfordshire Constabulary District/borough councils Town and parish councils Voluntary and community agencies and faith communities NHS and social care providers Workplaces Schools, further education colleges and the University of Hertfordshire. 12. In an era when behavioural factors are increasingly important in primary, secondary and tertiary prevention, enhance and harness the contribution of behavioural sciences. 34 Healthier Herts: A Public Health Strategy for Hertfordshire

37 7. The implementation journey The Health & Social Care Act 2012 sets out the statutory requirement for local authority leadership of public health from April Some functions formerly in the NHS, Health Protection Agency or other bodies have transferred to a new body called Public Health England, a new executive body of the Department of Health, while others screening, immunisation - have gone to NHS England (formerly called the NHS Commissioning Board). Under the transfer, a public health allocation of 34.2 million was given to the county council by the Secretary of State for the discharge of the public health functions, and a staff team of 46 people transferred from the NHS. Most of the transferred staff work in direct service provision, such as smoking cessation and chlamydia screening. This budget and staff core will be crucial to enabling action by others, both in terms of commissioning and co-commissioning partners, and putting their skills and knowledge at the service of others. There are a number of statutory functions given to Directors of Public Health (DPH) and the role of the DPH and public health team will work across the NHS, the county council, district/borough councils and other partners. The first step will be to ensure that where necessary, services are commissioned and then to review contracts service by service to ensure they are being delivered in line with the principles in this strategy. Within this we will ensure we prioritise work on: Restructuring the Public Health Service in the county council to align people and financial resources to this strategy Ensuring mandated services are commissioned and delivered Developing and start to commission the lifestyle offer Developing the obesity plan Developing the sexual health plan Developing the child and adolescent public health plan including school health Recommissioning sexual health services Delivering a route for public health practitioner registration Delivering a health protection plan Delivering a drug and alcohol plan Delivering a public health and public realm plan Delivering a public health development plan for skills and capabilities Recommissioning school nursing services Assuming statutory responsibility for health visitors. Project and implementation plans will be developed to underpin this strategy and these will include delivering plans for each of the priorities in the next column. Healthier Herts: A Public Health Strategy for Hertfordshire 35

38 2. The Public Health Outcomes Framework 30 The Public Health Outcomes Framework (PHOF) outlined in figure 8 overleaf is a range of indicators developed nationally for use in England, which will help us identify our progress towards achieving the Hertfordshire public health strategy. We will seek to report these indicators in a way which enables us to both look across Hertfordshire and compare areas within Hertfordshire against itself, and against England. The indicators are shown in more detail in Figure 9 (page 38). The PHOF national data set divides its indicators into four groupings: Improving the wider determinants of health Health improvement Health protection Healthcare and premature mortality. The full set of indicators nationally and for Hertfordshire are available at It is important that we know whether we are succeeding or failing in meeting the ambitions we have set. We will use two sets of indicators to track progress on how we are delivering the strategy: 1. The Health and Wellbeing Strategy indicators We will also use the local indicators devised for the Health and Wellbeing Strategy priorities on which public health leads. 36 Healthier Herts: A Public Health Strategy for Hertfordshire

39 Figure 8: The Public Health Outcomes Framework Vision: To improve and protect the nation s health and wellbeing, and improve the health of the poorest fastest. Outcome 1: Increased healthy life expectancy Taking account of the health quality as well as the length of life. Outcome 2: Reduced differences in life expectancy and healthy life expectancy between communities Through greater improvements in more disadvantaged communities. (Note: These two measures would work as a package covering both morbidity and mortality, addressing within-area differences and between area differences) DOMAIN 1: DOMAIN 2: DOMAIN 3: DOMAIN 4: Improving the wider determinants of health Health improvement Health protection Healthcare public health and preventing premature mortality Objective: Improvements against wider factors that affect health and wellbeing, and health inequalities Objective: People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities Objective: The population s health is protected from major incidents and other threats, while reducing health inequalities Objective: Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities }Across Indicators the life course }Across Indicators the life course }Across Indicators the life course }Across Indicators the life course All of these indicators will be reported on to the Cabinet Panel for Public Health and Localism, the Public Health Board and the Health and Wellbeing Board. We will ensure that we benchmark Hertfordshire nationally, against our peer group, and benchmark areas within Hertfordshire against Hertfordshire as a whole so that we identify areas of worse health outcomes and target them effectively. Healthier Herts: A Public Health Strategy for Hertfordshire 37

40 Figure 9: Public Health Outcomes Framework Indicators VISION To improve and protect the nation s health and well being and improve the health of the poorest fastest Outcome measures Outcome 1) Increased healthy life expectancy, i.e. taking account of the health quality as well as the length of life Outcome 2) Reduced differences in life expectancy and healthy life expectancy between communities (through greater improvements in more disadvantaged communities) Alignment across the Health and Care System Indicator shared with the NHS Outcomes Framework. Complimentary to indicators in the NHS Outcomes Framework. Indicator shared with the Adult Social Care Outcomes Frameworks. Complimentary to indicators in the Adult Social Care Outcomes Framework Indicators in italics are placeholders, pending development or identification Public Health Outcomes Framework At a glance (Autumn 2012) Improving the wider determinants 1 2 Health Improvement 3 Health Protection 4 of health Objective Improvements against wider factors which effect health and well being and health inequalities. Objective Objective Objective People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities. The population s health is protected from major incidents and other threats, whilst reducing health inequalities. Indicators Indicators Indicators Indicators Healthcare public health and preventing premature mortality Reduced numbers of people living with preventable ill health and people dying prematurely, whilst reducing the gap between communities. 1.1 Children in poverty 1.2 School readiness (Placeholder) 1.3 Pupil absence 1.4 First time entrants to the youth justice system year olds not in education, employment or training 1.6 Adults with a learning disability/in contact with secondary mental health services who live in stable and appropriate accommodation (ASCOF 1G and 1H) 1.7 People in prison who have a mental illness or a significant mental illness (Placeholder) 1.8 Employment for those with long-term health conditions including adults with a learning disability or who are in contact with secondary mental health services *(i-nhsof 2.2) (ii-ascof 1E) ** (iii-nhsof 2.5) (iii-ascof 1F) 1.9 Sickness absence rate 1.10 Killed and seriously injured casualties on England s roads 1.11 Domestic abuse (Placeholder) 1.12 Violent crime (including sexual violence) 1.13 Re-offering levels 1.14 The percentage of the population affected by noise 1.15 Statutory homelessness 1.16 Utilisation of outdoor space for exercise/ health reasons 1.17 Fuel poverty (Placeholder) 1.18 Social Isolation (Placeholder) (ASCOF 1I) 1.19 Older people s perception of community safety (Placeholder) (ASCOF 4A) 2.1 Low birth weight of term babies 2.2 Breastfeeding 2.3 Smoking status at time of delivery 2.4 Under 18 conceptions 2.5 Child development at 2-2 1/2 years (Placeholder) 2.6 Excess weight in 4-5 and year olds 2.7 Hospital admissions caused by unintentional and deliberate injuries in under 18s 2.8 Emotional well-being of looked after children 2.9 Smoking prevalence - 15 year olds (Placeholder) 2.10 Self-harm (Placeholder) 2.11 Diet 2.12 Excess weight in adults 2.13 Proportion of physically active and inactive adults 2.14 Smoking prevalence - adults (over 18s) 2.15 Successful completion of drug treatment 2.16 People entering prison with substance dependence issues who are previously not known to community treatment 2.17 Recorded diabetes 2.18 Alchol-related admittance to hospital (Placeholders) 2.19 Cancer diagnosed at stage 1 and Cancer screening coverage 2.21 Access to non-cancer screening programmes 2.22 Take up of the NHS Health Check programme - by those eligible 2.23 Self-reported well being 2.24 Injuries due to falls in people aged 65 and over 3.1 Fraction of mortality attributable to particulate air pollution 3.2 Chlamydia diagnosis (15-24 year olds) 3.3 Population vaccination coverage 3.4 People presenting with HIV at a late stage of infection 3.5 Treatment completion for Tuberculosis (TB) 3.6 Public sector organisations with a broad approved sustainable development management plan 3.7 Comprehensive, agreed inter-agency plans for responding to public health incidents and emergencies (Placeholder) 4.1 Infant mortality* (NHSOF 1.6i) 4.2 Tooth decay in children aged Mortality rate from causes considered preventable ** (NHSOF 1a) 4.4 Under 75 mortality rate from all cardiovascular diseases (including heart disease and stroke)* (NHSOF 1,1) 4.5 Under 75 mortality rate from cancer* (NHSOF 1.4) 4.6 Under 75 mortality rate from liver disease* (NHSOF 1.3) 4.7 Under 75 mortality rate from respiratory diseases* (NHSOF 1.2) 4.8 Mortality rate from infectious and parasitic diseases 4.9 Excess under 75 mortality rate in adults with serious mental illness* (NHSOF 1.5) 4.10 Suicide rate 4.11 Emergency readmissions within 30 days of discharge from hospital* (NHSOF 3b) 4.12 Preventable sight loss 4.13 Health-related quality of life for older people (Placeholder) 4.14 Hip fractures in people aged 65 and over 4.15 Excess winter deaths 4.16 Estimated diagnosis rate for people with dementia* (NHSOF 2.6) 38 Healthier Herts: A Public Health Strategy for Hertfordshire

41 References 1 Hertfordshire County Council Corporate Plan corpplan13-17.pdf 2 Marmot, M (2010) Fair Society, Healthy Lives. Report of the review on health inequalities in England. London: Institute of Health Equity org/projects/fair-society-healthy-livesthe-marmot-review 3 Owen L, Morgan A, Fischer A, Ellis S, Hoy A, Kelly MP. The cost-effectiveness of public health interventions. Journal of Public Health, 2012 Mar;34(1): hwbstrategy.pdf 5 hcc/partnerwork/hwb/ 6 Hertfordshire County Council Corporate Plan cpdrp/corplan/ 7 public_health 8 Marmot, M (2010) Fair Society, Healthy Lives. Report of the review on health inequalities in England. London: Institute of Health Equity org/projects/fair-society-healthy-livesthe-marmot-review 9 Tackling inequalities in life expectancy in areas with the worst health and deprivation (National Audit Office, 2010) uploads/2010/07/ pdf 10 WHO_IER_CSDH_08.1_eng.pdf 11 Brennan Ramirez LK, B.E., Metzler M., Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health, Centers for Disease Control and Prevention, Editor. 2008, Department of Health and Human Services,: Atlanta, GA Marmot, M (2010) Fair Society, Healthy Lives. Report of the review on health inequalities in England. London: Institute of Health Equity org/projects/fair-society-healthy-livesthe-marmot-review 14 Approaches_EN_Final.pdf 15 Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute 16 five-ways-well-being 17 To be published alongside the Public Health Strategy 18 Marmot, M (2010) Fair Society, Healthy Lives. Report of the review on health inequalities in England. London: Institute of Health Equity org/projects/fair-society-healthy-livesthe-marmot-review 19 Department of Health (1998) report of the independent inquiry into inequalities in health. London is_public_health 20 Department of Health (2010) publications/the-public-health-whitepaper-2010 Healthier Herts: A Public Health Strategy for Hertfordshire 39

42 21 Department of Health (2011) Healthy Lives, Healthy People publications/healthy-lives-healthypeople-our-strategy-for-public-healthin-england 30 publications/healthy-lives-healthypeople-improving-outcomes-andsupporting-transparency 22 Department of Health (2012) Directors of Public Health in Local Government uploads/system/uploads/attachment_ data/file/213007/dsph-in-localgovernment-i-roles-andresponsibilities.pdf 23 Griffiths, Jewell and Donnelly (2005) article/pii/s Marmot, M (2010) Fair Society, Healthy Lives. Report of the review on health inequalities in England. London: Institute of Health Equity org/projects/fair-society-healthy-livesthe-marmot-review 25 Beaglehole et al (2004) Public Health at the Crossroads. Oxford: Oxford University Press 26 Copyright, Hertfordshire County Council, Approaches_EN_Final.pdf 28 Hertfordshire Health and Wellbeing Strategy hwbstrategy.pdf 29 Hertfordshire Equality Strategy eqstrat2013.pdf 40 Healthier Herts: A Public Health Strategy for Hertfordshire

43 Healthier Herts: A Public Health Strategy for Hertfordshire 41

44 Hertfordshire County of Opportunity Design ref: Hertfordshire County Council County Hall Hertford SG13 8DE