National Assembly for Wales Developing Local Health Alliances July 1999 BetterHealth BetterWales
PREFACE BETTER HEALTH - BETTER WALES DEVELOPING LOCAL HEALTH ALLIANCES We are committed to raising levels of health in Wales to the best in Europe and, in particular to improve the levels of those with the worst health. These aims were set out in the Green Paper Better Health-Better Wales and its Strategic Framework. Substantial measures to cut smoking outlined in the White Paper Smoking Kills are being implemented. Wales has a dreadful legacy of ill-health and improving health will require maximum effort from everyone - individuals, communities, public bodies, voluntary organisations and businesses. A partnership of interests and strong leadership are needed at every level, but it is crucial that this agenda is supported by our largest organisations - the local authorities and the NHS. Local Health Alliances will bring together all these interests in targeted action backed by close involvement of local people. We commit ourselves to these aims and commend this guidance. Signed Alun Michael Harry Jones D. Hugh Thomas Secretary of State Leader WLGA Lead Chairman Health Authorities i
CONTENTS Preface...i Page Introduction... 1 Context...1 National Structure for Improving Health... 2 Local Health Alliances... 3 Partners in Local Health Alliances...4 Principles...4 Steps in establishing a Local Health Alliance...5 Programmes of Action for Sustainable Health and Well-being...5 Contributing to Strategic Plans...6 Further Guidance...6 Annex 1 - Examples of Initiatives which may be undertaken by a Local Health Alliance...8 Annex 2 - Potential Roles of Partners in a Local Health Alliance...9 ii
BETTER HEALTH - BETTER WALES DEVELOPING LOCAL HEALTH ALLIANCES Introduction 1. This document sets out a best practice framework for Local Health Alliances. Alliances are part of the new public health strategy and have been developed from ideas put forward by local government and the NHS during the consultation on the Green Paper Better Health-Better Wales. This guidance sets out the core principles under-pinning the establishment of Local Health Alliances in the context of Government policies for public health, local government and the NHS. It is intended to provide a framework within which each area will develop an Alliance which best meets the needs of the area as defined by local partners. 2. Local Authorities have a key role in influencing the determinants of health. Through the mechanism of establishing a Local Health Alliance, the local authority could focus action to improve the social, environmental and economic determinants of health, as distinct from Local Health Groups which are concerned with ensuring an equitable delivery of high quality health care. Examples of the kinds of actions which might be undertaken by an Alliance are given in Annex 1. Context 3. The Government set out its policy for improving health and reducing inequalities in health status in Better Health-Better Wales (May 1998 Cm 3922) and the Tobacco White Paper Smoking Kills (Cm 4177). Following widespread consultation on the Green Paper, the actions required to realise health gain in Wales were set out in a Strategic Framework (October 1998). The Strategic Framework proposed to support the development of a Local Health Alliance, in each local authority area, to bring together multi-sector agencies to protect and improve health. Such partnerships are already in place in some parts of Wales, usually led by local authorities and health authorities and with a range of other partners such as GPs, voluntary and community groups and businesses. In principle, a Local Health Alliance should broadly engage local partners to: gain a wider understanding of how health gain can be achieved; ensure better co-ordination between local health and environment services; increase local capacity and abilities in public health skills; develop local health promotion capacity in conjunction with local health promotion specialists; facilitate a network for sharing health and environment information; and 1
support communities in action to improve health, living conditions and life chances. 4. The Government's proposals for modernising the NHS were set out in the White Paper Putting Patients First (January 1998 Cm 3841) and other consultation papers emanating from the White Paper. The guidelines for setting up Local Health Groups in each local authority area and the guidelines for Health Improvement Programmes are particularly relevant to Local Health Alliances and should be read alongside this guidance. The Social Services White Paper for Wales Building the Future (April 1999) should also be taken into account. The White Paper highlights key aims for social services including contributing towards securing an inclusive society, supporting individuals and families towards greater independence, and providing services which are responsive to individual needs and choices. 5. The Government's proposals for modernising local government are set out in the White Paper Local Voices: Modernising Local Government in Wales. The White Paper proposes that local government in Wales should be more community focused and that councils should be given the power to promote the economic, social and environmental well-being of their areas. It also proposes to strengthen councils' powers to enter into partnerships and joint arrangements with other bodies, including the NHS. 6. The proposals for "Best Value" are also relevant. They provide a framework by which local authorities can assess whether the type and quality of services they provide match their communities' expectations and needs. The principles for Local Health Alliances include sustainability and other issues covered in a series of consultation papers, including Opportunities for Change (1998). These, in turn, link with Local Agenda 21 initiatives and Environmental Health Action Plans. This framework is also within the World Health Organisation WHO Health 21 (Health for All) targets. 7. In addition to the proposal to give local authorities the power to promote the well-being of their areas, the Government intends to place a duty on councils to prepare overarching strategies (community plans). These plans should be based on an analysis of their areas' needs and future potential. Consideration is being given, in consultation with local government, to the ways in which these plans might be prepared in Wales. The partnership arrangements described in this framework for Local Health Alliances will make a significant input to the strategies in the community plans and to the provision of services contributing to community well-being. 8. Local Authorities, with the police, now have a legal responsibility to lead a local partnership to cut crime and disorder. NHS bodies, voluntary organisations and others have a legal obligation to be involved. The Secretary of State has written to all NHS bodies in Wales to encourage joint approaches to reducing violent crime, for instance. These are good examples of "joined up Government". National Structure for Improving Health 9. The Strategic Framework proposed a new structure to support the National Assembly for Wales in its responsibilities for protecting and improving the health and well-being of the people of Wales and, in particular, for taking action to reduce inequalities in health. 2
10. It is intended to establish, in conjunction with academic and public sector partners, a Wales Centre for Health as the all-wales body with a remit for public health. The Centre will be the national focus for multi-disciplinary advice, debate and professional development in public health. Its functions will include: providing a forum for multi-disciplinary advice on health hazards; risk assessment of threats to health; advice on risk management; and on cost-effective interventions to improve determinants of health and reduce health inequalities; disseminating research and other evidence to support decisionmaking; support for multi-professional development and training in sustainable health; and liaison with national and international multi-professional groups. 11. The Wales Centre for Health is to be supported by a new National Network for Health drawn from representatives of local government, the NHS and other key all- Wales organisations and professionals. Together, the Wales Centre for Health and the National Network for Health will provide a focus for advice on public health at the all-wales level. 12. The establishment of the Wales Centre for Health, supported by the National Network, will provide the national focus for strategic co-ordination of public health skills such as epidemiology, micro-biology, environmental health and personal social services. However, to be effective in raising the level of health and in tackling health inequalities, the new national structure will need to be supported by a local delivery structure which delivers action to improve the social, environmental and economic determinants of health. 13. In addition, the New Opportunities Fund will invest 19.5 million over the next 3 years in a range of Healthy Living Centres which will help some of the most deprived communities across Wales to improve health levels. There is no blueprint for what should be included in a Healthy Living Centre or how a bid should be presented. Local Health Alliances 14. Each local authority should urgently consider the case for establishing a Local Health Alliance. This would contribute a public health and health promotion dimension to the statutory and other responsibilities which local authorities already carry for community planning and for the planning and delivery of a wide range of services to the public. It will be for the Local Authority to convene a partnership of local interests, to be drawn from the various local authority departments, from the health service and from the voluntary and private sectors including local businesses and employers. 3
15. A Local Health Alliance will commit partner agencies to working together to take stock of local circumstances and to audit the factors which contribute to health and to health gain; will identify areas for action and the priorities within them; and will map out a programme of action which the Alliance itself, or its constituent partners acting independently, would take forward. 16. Successful Alliances will be characterised by evidence that members enter them voluntarily, negotiate the nature of the relationships and commitments upon which they are based, and thereby legitimise and give their authority to the actions of the Alliance as a co-operative venture. 17. The task for each Alliance will be to draw up a clear statement of outcomes and targets for improving social, economic and environmental influences on health, against which their performance could be measured and targets progressed. Partners in Local Health Alliances 18. The partners in each Local Health Alliance will be for local determination in the light of the issues to be addressed under the wider public health agenda. Such issues may include: poverty; employment; education; housing; transport services; crime prevention; environmental hazards; leisure and recreation. These should be identified with reference to objective factors - including the Crime and Disorder Audit undertaken by the police and local authority in each part of Wales recently. That audit should include socio-economic and other factors as well as crime figures. 19. Best practice indicates that establishing a core membership and a steering group can provide a strong focus for planning and consultation, ensure the momentum to achieve health gain and eliminate inequality is maintained, and monitor and report on results. A description of potential roles for key services who may be invited to join an Alliance is given in Annex 2. 20. A Local Health Alliance may need to appoint staff to carry out projects or for core administration. Such posts may be co-funded by the partners. Each partner in an Alliance will want to act within their own accountability, financial and legal powers. It would normally be for the local authority to act as lead partner for the employment of staff or for managing external contracts. Principles 21. Successful Local Health Alliances are expected to engage a range of local partners to work together to produce some, or all, of the following outcomes: a wider understanding of how the determinants of health and wellbeing can be influenced; increased co-ordination between local health and environmental services; increased local capacity and abilities in public health skills; increased local health promotion capacity in conjunction with local health promotion specialists; 4
a network for sharing information leading to health gain and better access to services; and community action which improves health, living conditions and/or life chances. Steps in establishing a Local Health Alliance 22. Experience from Alliances and similar partnerships suggests that development should follow a pattern of action including: identifying key players; setting up a steering group; canvassing other public, voluntary, private, academic and community sectors for support; ensuring top level support in each partner organisation; bringing existing partnerships into the Alliance; training to understand each other and the influences on health; developing a vision of what the Alliance could achieve; undertaking a review or "audit" of health indicators and existing provision; defining respective roles and responsibilities; drawing up a strategy and plan for implementation; and setting up monitoring and evaluation mechanisms. The WLGA and Health Authorities have produced guidance on the practical issues to be addressed in establishing an Alliance. The need to work with objective criteria and to define intended outcomes cannot be stressed too strongly. Programmes of Action for Sustainable Health and Well-being 23. Each Local Health Alliance will want to determine its own priorities to influence other programmes and to develop its own programme of action to improve public health (see Annex 2 for examples). These priorities are expected to cover some or all of the following criteria: identifying activities that involve agencies working together; improving these activities by: 5
* providing training so that each relevant agency is aware of each others' work, * involving partners in the planning, delivery and monitoring, and * seeking the highest quality action, based on evidence of what works, promoting activities to combat poverty, unemployment, lack of access to education and training, and poor living conditions lead to demonstrable health gain; prioritising activities to improve the health determinants of the poorest communities and, in particular, to address the needs of ethnic minorities and socially excluded groups; seeking sustainable health gains; implementing sustainable health action research; and monitoring and evaluating, including the development of innovative ways of measuring health improvement through social, economic and environmental improvements. 24. In some programmes, activities may build on the work of Local Agenda 21 initiatives working to improve the environment in sustainable ways. Some programmes may achieve sustainability by training community volunteers to maintain improvements or continue services initially provided by professionals. 25. Guidance in developing community programmes of this kind is available from organisations which are skilled in community development, the voluntary movement and consumer groups. By working for sustainable health and well-being, the Alliance can help to ensure that improvements continue after the programme. Contributing to Strategic Plans 26. A Health Improvement Programme (HIP) will be drawn up by each Health Authority in consultation with its Local Health Groups. The HIP will be the main planning mechanism for addressing health improvement. When fully established, Local Health Alliances will be expected to contribute to local health needs assessment and to help the Local Health Group in contributing to the component parts of the HIP. In particular, the Alliance will be well placed to share data on social, environmental and economic determinants of health, especially for areas with the worst health status. 6
27. The local authority has responsibility for leading on a number of significant strategic areas for health improvement. Included among these are corporate strategies, such as those on Social Inclusion and Environmental Health, and others which are more service specific, such as the Social Care Plan, the Children's Services Plan and the Housing Strategy and Operational Plan. The Alliance and the local authority will wish to consider how the Alliance can appropriately contribute to the further development of these strategies. These plans will also provide a useful framework within which the Local Health Alliance can determine how best to target its activities. Further Guidance 28. The National Assembly for Wales and the WLGA intend to hold seminars to share experience of working in Alliances to develop best practice. Additions to this best practice framework may be issued as Alliances progress. 7
ANNEX 1 EXAMPLES OF INITIATIVES WHICH MAY BE UNDERTAKEN BY A LOCAL HEALTH ALLIANCE Action to reduce children's access to age-restricted products - promoting 'proof of age' cards through local schools to prevent agerestricted products being sold to children, involving collaboration and commitment by the local business community, trading standards and schools. Action to provide cheap healthy choices of food - schemes designed to provide cheap fruit and vegetables together with local cooking sessions to encourage nutritious and healthy diets. The scheme could involve local retailers and suppliers, community leaders and the local college. Action to target the worst off communities - shared economic and health data for small community areas collected by local government services, health authorities and GPs could be made available to strategic planning groups and to support proposals for regeneration, including lotteries and EU funds. Action to reduce accidents in the home, workplace and travelling - could involve health promotion for accident awareness, housing/ workplace/ highways design and data on vulnerable groups through a partnership of local authority departments, HSE, NHS trusts, health promotion, employers and the media. Action to encourage healthy lifestyles - such as 'exercise on prescription schemes' where local GPs issue vouchers for community education classes and activities at local leisure centres. In some areas, employers promote schemes to encourage exercise by employees and their families. 8
ANNEX 2 Potential Roles of Partners in a Local Health Alliance 1. This annex describes a range of possible partners to a Local Health Alliance and their potential contribution to improving health and well-being. It is not expected that an Alliance would enlist a large group of organisations at the outset. Best practice suggests that it would be best to start with a core group (who would probably form the Steering Committee in due course) and to build up. The core partners would probably include: the Local Authority, the Local Health Group, the Health Authority, the local council for voluntary action and appropriate specialised voluntary sector representation. Local Authority 2. Local authorities already provide comprehensive community services which protect health, prevent disease and combat poverty, poor living conditions and poor life prospects. Personal and social services provide safeguards for people in time of vulnerability or need. To strengthen and reinforce community leadership, the Government will provide a framework within which councils will work for the wellbeing of their areas. A focus for a council's role in community leadership could be through the Local Health Alliance. 3. It is reasonable therefore for an Alliance to be led by the local authority with its corporate responsibility for the cohesion of services such as public protection, environmental health, community safety, education, leisure and recreation, housing and personal social services. 4. All Councils have appointed a lead Member and a lead Officer for initiatives within Better Health-Better Wales and may consider there are advantages in linking these roles with Member direction and support for the Local Health Alliance. 5. An Alliance could also expect to receive strong support from the Chief Executive and Members of the Council to demonstrate the local authority's commitment to the full integration of its services which contribute to health and well-being. 6. The Local Health Alliance will also find it beneficial if other Chief Officers are actively involved. The Directors of Public Protection (along with Directors of Public Health) will be invited to contribute to, and participate in, the National Network for Health and could provide an important link. Where an Authority has a People in Communities programme, the senior officer identified as Social Exclusion Champion could be a key member of the Alliance. 9
NHS Action for Health 7. The NHS has a vital role in protecting and improving health, in addition to its prime responsibility for treating illness. The NHS can: support community action to improve health; provide equitable access to health care; act as an advocate for health gain; protect and promote the health of its own staff; provide specialist prevention, screening and immunisation programmes; provide health checks, surveillance and records of health status; analyse and report on the epidemiology of health and disease; and manage risk and seek to identify preventable illness etc. 8. The Health Authority is well placed to provide support for the Local Health Alliance through services such as independent reports of health status and threats to health; commissioning health care; advocacy for health and health promotion; and monitoring health gain. An Alliance might therefore want to seek the support of the Chief Executive and the Director for Public Health. Local Health Groups 9. From April 1999, a Local Health Group will operate in each local authority area as a sub-committee of the Health Authority. Its membership includes the NHS contractor services whose significant contact with the public will be of importance to Local Health Alliances. The Local Health Group will be responsible for contributing to the Health Improvement Programme and for commissioning health care for the local population after taking account of local views. It will be essential for both bodies to appreciate that, while Local Health Alliances will be a valuable source of information and action in respect of the determinants of health, the direct provision of health services is solely the responsibility of Health Authorities, NHS trusts and the Local Health Groups. A link between the organisations is already provided by local authority officer representation on the Local Health Group, but the Local Health Alliance may, in addition, wish to consider Local Health Group participation in the Alliance itself. Cross representation is essential. Health Promotion Units 10. Local health promotion specialists are expected to give support to the work of the Local Health Alliance, particularly in providing evidence for what works effectively in promoting health. The roles of specialist health promotion units are described more fully in the Review of Health Promotion Arrangements in Wales 10
published by the Welsh Office in September 1998. From 1 April 1999, specialist health promotion units will come under Public Health Departments of Health Authorities and will be well placed to support both Alliances and Local Health Groups. Other proposals from the Review, including the development of a national strategy for health promotion, will be taken forward by Health Promotion Wales as part of the National Assembly for Wales from June 1999. Voluntary sector and Community groups 11. Voluntary and community groups have a vital role in promoting health through social and economic development and through health and community care services. Church and other community groups are often well placed to understand the aspirations of local people for improved services and the barriers to change. The County Voluntary Council or Council for Voluntary Action should be considered as a core member of the Alliance. It will normally be appropriate to extend membership to other community groups, and other organisations which represent local interests. The Local Health Alliance should involve such groups in local projects and to seek their views when drawing up programmes of action. Crime Prevention and Community Safety Teams 12. Police, probation, ambulance and fire services have important roles in public protection and social cohesion. It will be preferable for the statutory partnership to be represented on the Local Health Alliance. Local community safety groups, voluntary organisations and tenants' associations may also make an important contribution to the Alliance, depending on the programme of local action to be undertaken. 13. Local Drug and Alcohol Teams (DAAT) already work closely with local authorities, health authorities and voluntary groups. Representatives of the DAAT and the Local Advisory Team (LAT) are therefore other candidates for inclusion in the core membership of the Alliance. Education and Training Services 14. Local providers of adult and further education, community education groups and providers of skills training have responsibilities for informing, educating and training in community settings. Health promotion in schools is a key way of influencing children and their families to make choices which encourage health and well-being and avoid ill-health and social dysfunction. These agencies therefore, could all have a role within a Local Health Alliance. These functions may include: assisting in public education campaigns; providing specialist services in basic skills; providing settings for learning community action skills; providing skills and qualifications for employability; and drawing the wider community into programmes which support healthy living. 11
Business Sector 15. Local businesses provide employment which is a significant determinant of individual health and of community vitality. Many employers' organisations and individual businesses contribute to local communities through sponsorship and the support of professional advisers. The workplace is also a significant setting for health promotion and employers and unions/staff representatives can strongly influence the health and well-being of their workforce. Local businesses could be encouraged to work in partnership with the Local Health Alliance in community action programmes. 12