Effects of local authority expenditure on childhood obesity.

BACKGROUND: Under the 2013 reforms introduced by the Health and Social Care Act (2012), public health responsibilities in England were transferred from the National Health Service to local authorities (LAs). Ring-fenced grants were introduced to support the new responsibilities. The aim of our study was to test whether the level of expenditure in 2013/14 affected the prevalence of childhood obesity in 2016/17. METHODS: We used National Child Measurement Programme definitions of childhood obesity and datasets. We used LA revenue returns data to derive three measures of per capita expenditure: childhood obesity (<19); physical activity (<19) and the Children's 5-19 Public Health Programme. We ran separate negative binomial models for two age groups of children (4-5 year olds; 10-11 year olds) and conducted sensitivity analyses. RESULTS: With few exceptions, the level of spend in 2013/14 was not significantly associated with the level of childhood obesity in 2016/17. We identified some positive associations between spend on physical activity and the Children's Public Health Programme at baseline (2013/14) and the level of childhood obesity in children aged 4-5 in 2016/17, but the effect was not evident in children aged 10-11. In both age groups, LA levels of childhood obesity in 2016/17 were significantly and positively associated with obesity levels in 2013/14. As these four cohorts comprise entirely different pupils, this underlines the importance of local drivers of childhood obesity. CONCLUSIONS: Higher levels of local expenditure are unlikely to be effective in reducing childhood obesity in the short term.

Local authority commissioning of NHS Health Checks: A regression analysis of the first three years.

In April 2013, the public health function was transferred from the NHS to local government, making local authorities (LAs) responsible for commissioning the NHS Health Check programme. The programme aims to reduce preventable mortality and morbidity in people aged 40-74. The national five-year ambition is to invite all eligible individuals and to achieve an uptake of 75%. This study evaluates the effects of LA expenditure on the programme's invitation rates (the proportion of the eligible population invited to a health check), coverage rates (the proportion of the eligible population who received a health check) and uptake rates (attendance by those who received a formal invitation letter) in the first three years of the reforms. We ran negative binomial panel models and controlled for a range of confounders. Over 2013/14-2015/16, the invitation rate, coverage rate and uptake rate averaged 57% 28% and 49% respectively. Higher per capita spend on the programme was associated with increases in both the invitation rate and coverage rate, but had no effect on the uptake rate. When we controlled for the LA invitation rate, the association between spend and coverage rate was smaller but remained statistically significant. This suggests that alternatives to formal invitation, such as opportunistic approaches in work places or sports centres, may be effective in influencing attendance.

Directors of public health as 'a protected species': qualitative study of the changing role of public health professionals in England following the 2013 reforms.

Background: The Health and Social Care Act 2012 gave councils in England responsibility for improving the health of their populations. Public health teams were transferred from the National Health Service (NHS), accompanied by a ring-fenced public health grant. This study examines the changing role of these teams within local government. Methods: In-depth case study research was conducted within 10 heterogeneous councils. Initial interviews (n = 90) were carried out between October 2015 and March 2016, with follow-up interviews (n = 21) 12 months later. Interviewees included elected members, directors of public health (DsPH) and other local authority officers, plus representatives from NHS commissioners, the voluntary sector and Healthwatch. Results: Councils welcomed the contribution of public health professionals, but this was balanced against competing demands for financial resources and democratic leverage. DsPH-seen by some as a 'protected species'-were relying increasingly on negotiating and networking skills to fulfil their role. Both the development of the existing specialist public health workforce and recruitment to, and development of, the future workforce were uncertain. This poses both threats and opportunities. Conclusions: Currently the need for staff to retain specialist skills and maintain UKPH registration is respected. However, action is needed to address how future public health professionals operating within local government will be recruited and developed.

Framing health inequalities for local intervention: comparative case studies.

This article explores how health inequalities are constructed as an object for policy intervention by considering four framings: politics, audit, evidence and treatment. A thematic analysis of 197 interviews conducted with local managers in England, Scotland and Wales is used to explore how these framings emerge from local narratives. The three different national policy regimes create contrasting contexts, especially regarding the different degrees of emphasis in these regimes on audit and performance management. We find that politics dominates how health inequalities are framed for intervention, affecting their prioritisation in practice and how audit, evidence and treatment are described as deployed in local strategies.

Governance for health and wellbeing in the English NHS.

OBJECTIVES: Shifting the focus of health-care systems towards prevention has proved difficult to achieve. Governance structures are complex, incentives may conflict and there are many competing priorities. We explored the influence of governance and incentive arrangements on commissioning for health and well-being in the English National Health Service (NHS) and the governance paradoxes which emerge. METHODS: Qualitative and quantitative methods were employed. We carried out one national and two regional focus groups; a national online survey of primary care trusts (PCTs); and 99 semi-structured interviews in 10 purposively selected case study sites across England. Interviewees included decision-makers in PCTs, practice-based commissioners, Chairs of Local Involvement Networks (LINks) and of Overview and Scrutiny committees (OSCs) and Voluntary and Community Sector (VCS) members of local health and wellbeing partnerships. RESULTS: Case study sites differed in the extent to which they reflected a public health ethos throughout the commissioning cycle, incentivized preventive services through contractual flexibilities or prioritized investment in health and wellbeing. Practice-based commissioners were tangentially involved in the commissioning cycle, public health partnerships or local health needs assessment. While commissioning for health and wellbeing involves working through partnerships, performance management regimes favoured single organizational success. Preventive services were considered at increased risk in times of financial stringency. CONCLUSIONS: As the NHS in England undergoes further reorganization, it is important to ensure that a systematic, strategic and population-based approach to commissioning is not lost. Governance and incentive arrangements should be critically assessed for their impact on population health and wellbeing.

Strengthening public health capacity and services in Europe: a concept paper

This paper, jointly developed by Durham University and WHO Europe, was written to inform ”Strengthening Public Health Capacities and Services in Europe: a Framework for Action”, which will accompany Health2020, the new European Health Strategy. It explores the contested nature of public health and the complexity of contemporary public health challenges. These have implications for the ways in which health systems and public health systems are understood and defined as well as for relationships between them. Stewardship of the health of the population and the values of equity and social justice underpin concepts of ‘good governance’; they are also fundamental to public health practice and public health services are most effective where there is congruence between them. Complex public health challenges, such as persistent health inequalities or rising rates of obesity, require systems thinking, new approaches to knowledge exchange and to coalition building - skills of increasing importance for a 21st century public health workforce. This paper explores the implications of these issues in the context of developing an action framework for public health across Europe.

Fault-lines between policy and practice in local partnerships.

PURPOSE: The purpose of this study is to explore gaps between policy and practice in relation to the involvement of voluntary and community sector (VCS) members in local strategic partnerships (LSPs), using the example of inequalities in health. DESIGN/METHODOLOGY/APPROACH: Documentary analysis; semi-structured interviews with VCS representatives from a sample of LSPs in one region of England; semi-structured interviews with key researchers and national stakeholders. FINDINGS: National policy imperatives to expand the role of the VCS in decision-making and to make LSPs an important avenue for addressing inequalities in health are not always translated into practice. VCS members are at the sharp end of tensions in LSPs between thematic and neighbourhood approaches, local views and strategic priorities and between democratic and participatory approaches to decision-making. Effective engagement in addressing inequalities in health requires a strategic approach across the LSP which is reflected in the priorities of each of the constituent partnerships. RESEARCH LIMITATIONS/IMPLICATIONS: This is a snapshot of LSPs at one point in time and local interviews are restricted to one region of England. PRACTICAL IMPLICATIONS: The article illustrates good practice and barriers to VCS involvement in addressing inequalities in health through LSPs. This is relevant to a range of public health partnerships. ORIGINALITY/VALUE: The views of VCS members on addressing inequalities in health through LSPs have not previously been researched, despite their key role. Lessons are relevant for multi-agency strategic partnerships with a public health focus in England and internationally.

Moving upstream or muddying the waters? Incentives for managing for health.

OBJECTIVES: The objective of this study was to identify factors influencing the capacity of NHS managers to 'manage for health'. STUDY DESIGN: Semi-structured interviews (32) were carried out over the telephone or face to face with national stakeholders (15) and NHS senior managers (17) from four Strategic Health Authorities (SHAs) and five Primary Care Trusts (PCTs) in England. Interviews were transcribed and a qualitative analysis carried out. RESULTS: The current system of targets and incentives prioritised access to acute services, public health skills were too thinly spread, baseline data were inadequate, decision-making for public health investment was fragmented and evidence for effective interventions was scanty. Health improvement targets should be plausible, longer term and locally owned, but key factors in creating a proactive public health organisation were a strong public health ethos, and effective management and leadership skills. Strengthening the NHS's role in managing for health was welcomed, but enthusiasm was tempered by concurrent NHS policy initiatives and incentives pulling in opposing directions. CONCLUSIONS: Key NHS policy initiatives have been developed in isolation from each other. While their combined effect remains unpredictable, they may serve to threaten the welcome shift towards managing for health improvement.