This is an outline paper which summarises work done for the Association of Directors of Public Health on the Public Health contribution to health and social care integration

1. Public health contribution to health and social care integration
1 © Copyright, 2015, Association of Directors of Public Health UK
What is the public health contribution to integration?
A discussion paper , 2015
Authors:
Anna Middlemiss, Public Health Consultant, Wakefield Council
Sue Matthews, Public Health Consultant, Hertfordshire Council
Jim McManus, Director of Public Health, Hertfordshire Council
Andrew Furber, Director of Public Health, Wakefield Council
Context
The recent King’s Fund paper “Population Health Systems: Going beyond integrated care,” (King’s
Fund, 2015), states in its summary that “the paths of integrated care and public health have rarely
crossed.” However, the authors of this paper, as public health specialists, have all had major
involvement in their local integration programmes. The below paper seeks to share some of the
ways that public health has been involved and asks the question; “What is our contribution to the
integration agenda and how can we demonstrate that we are making it?”
Summary
The integration of health and social care services is currently the dominant narrative in the UK.
Public health practitioners have some essential competencies which will be required if
integration is to be effective. These include our understanding of outcomes, the underpinning
evidence base and the importance of evaluation. Just as important are the leadership skills we
have in working across organisations and our ambition to reduce inequalities. The contribution of
public health to better outcomes from integration should be tangible and recognised.

2. Public health contribution to health and social care integration
2 © Copyright, 2015, Association of Directors of Public Health UK
What outcome does public health seek to deliver? Essentially public health aims to improve the
health of the population using the tools in our tool bag. Not just the technical tools such as data and
epidemiology but the more subtle tools of leadership, partnership building and influencing.
Integrated working is currently “the biggest show in town” for the health and social care sector, with
all three political parties prioritising this approach. The Better Care Fund has mandated health and
social care economies to create a local, single, pooled budget, designed to get people working in an
integrated way and measured by a set of metrics, including one on reducing emergency admissions.
The integrated care pioneers, local areas demonstrating approaches in the delivery of person-
centred care, have been awarded a high national profile and as such are seen as leading the way for
health and social care reform. The pioneers held their “first birthday” event in Leeds in January with
speakers including Norman Lamb, Minister of State for Care and Support.
Public health is sometimes criticised for sitting at the table and “influencing” without providing
obvious deliverables. Therefore, it is important that we as the public health community can answer
the question: “What exactly does public health do?”. The integration agenda is an excellent
opportunity for public health to demonstrate how much they can contribute and the public health
skill set is ideally placed to support the achievement of some of the aspirations of integration.
Where to start?
The integration agenda (rather like public health’s) is huge and it can feel overwhelming for
Directors of Public Health and their teams to know where to start. The best place to start is to
understand what the priorities are for their local integration programme and seek to add value with
the public health offer. For example, using the JSNA as a mechanism to identify priorities, shift the
focus towards prevention and monitor progress.
Another role that public health can have, to add clarity to the integration agenda, is that of
supporting the system to take an outcomes based approach. Much of the literature on integration
comments on the fact that many programmes have no collective understanding of what success
would look like if integration was implemented successfully. Without a system –wide understanding
of outcomes it is very difficult to deliver successful programmes. Conversely, once clear, universally
agreed outcomes are in place everything else can follow, for example, evaluation, resource
allocation and performance monitoring.
The Evidence Base

3. Public health contribution to health and social care integration
3 © Copyright, 2015, Association of Directors of Public Health UK
One of the biggest challenges for integration is the lack of an evidence base. “A fashionable policy in
search of persuasive evidence that it really works”, was how Nigel Hawkes described integration in
the BMJ in 2013, and it is hard not to have sympathy with this view if your definition of integration
“working” is a reduction in demands on the system measured by metrics such as a reduction in non-
elective admissions. This huge chasm between the stated objectives of integration and the reality of
the evidence base can prove a stumbling block for public health but if this is acknowledged and given
perspective then integration can still be used to achieve positive population change. Providing easy
to understand evidence reviews and briefings on topics specific to and which add value to the
integration agenda is an easy way to gain traction with partners and ensure that resources are used
wisely to maximise health gain. For example, telehealth is often viewed as a money saving
intervention whereas in fact the evidence does not support this and sharing this knowledge with
partners via an evidence briefing can support them to shape any technology programmes with an
understanding of realistic benefits.
Reducing admissions and attendances
One of the biggest drivers for integration is the belief that it will reduce attendances and admissions.
The published evidence on this is limited yet local optimism of what can be achieved is high. A
number of high quality studies, such as the RAND evaluation (2012) Evaluating Integrated Care
Pilots, showed not only an increase in non-elective admissions in integration pilot sites, but reported
that patients hadn’t much liked their experience of integration either as, ironically, patients involved
in the pilot reported being listened to less frequently and being less involved in decisions about their
care. The North West London Integrated Care Pilot (2013) reported that there was no significant
reduction in service usage and that 60% of the patients involved in the study noticed no difference in
their care (admittedly this was early days and a small sample). One of the roles of public health is as
the critical friend who provides evidence on what works and what doesn’t and gives a realistic
understanding of what is possible. This approach can be supported by sensible performance
frameworks, which allow boards to keep a good eye on the strategic picture and test some of their
assumptions, for example, having a system wide agreement to not reduce acute beds until
emergency admissions have reduced by a certain percentage.
Evaluation
Integration programmes have traditionally been poorly evaluated for a number of reasons. There is a
wide range of inputs, all of which are interacting within a complex system and a range of incentives
(some of which are perverse, for example, the four hour A&E waiting time target). Additionally

4. Public health contribution to health and social care integration
4 © Copyright, 2015, Association of Directors of Public Health UK
measuring “benefit” (clinically and economically) is complex and difficult, thus not often done well.
This area is replete with examples of poorly evaluated interventions or "policy experiments" that
nobody has the time to evaluate, or have been poorly evaluated, or where political drive to “do
something” takes precedence over good evaluation design.
Public health can make the case that if you are attempting whole scale change to the health and
social care system using public money it is incumbent upon the system to evaluate whether that
change has delivered the outcomes that it set out to. If that argument is made successfully to
partners then the public health skill set can be used to deliver evaluations for local areas or (even
better) make the case to commission independent ones.
The more subtle influencing levers include persuading your partners that if they are the first system
in the world to deliver a measurable change in emergency admissions across a whole population
why would they not want it robustly evaluated?
A new conversation about prevention
Many integration programmes, in an attempt to reduce overall emergency admissions, focus on the
high- risk patients. This is a flawed concept as Roland (Roland and Abel, 2012) proved when he
demonstrated that to have any effect on overall admissions you would have to reduce the top 0.5%
high-risk patients’ admissions by a mathematically impossible 107.5%. When this particular penny
drops with commissioners, it opens up the opportunity to talk about what we do with lower risk
patients to prevent them deteriorating and then, before you know it, the local health and social care
economy are talking about prevention, early intervention, population based approaches and the role
of the voluntary and community sector.
The vision outlined in the Five Year Forward View and the Care Act also strengthens the case.
Partners are looking for public health to provide leadership in the areas of prevention, population
based approaches, using data, self-care and community engagement. With many public health
teams looking at how to demonstrate their value to local authorities, supporting adult social care in
their implementation of the Care Act provides public health with an opportunity to engage,
influence and build stronger relationships. By illustrating how to apply the principle of
proportionate universalism to inform prevention approaches, for example through the development
of population level risk stratification, the contribution of public health expertise becomes evident.
The public health contribution includes demonstrating how best to embed prevention within their
services, recognising that an individual’s level of function is not necessarily static and ensuring our

5. Public health contribution to health and social care integration
5 © Copyright, 2015, Association of Directors of Public Health UK
services are responsive to this. The focus on prevention also enables public health to promote areas
such as self-care, self – management and behaviour change. For example, public health in
Hertfordshire has embedded a health psychology approach into its team to develop psychological
approaches to self-management.
There is also a huge agenda around meaningful engagement with individuals, organisations and
communities. By committing to meaningful engagement public health can support approaches
which reduce social isolation and embed the importance of building personal and community
resilience and promoting interdependence (e.g. Asset Based Community Development).
Inequalities and vulnerable groups
Much of the integration agenda is focused on keeping people out of hospital and in their own
homes. A number of factors are associated with increased risk of admissions (Purdy, 2010; Imison et
al, 2012); these include age, social deprivation and, unsurprisingly, morbidity. This introduces a
number of themes relevant to the inequalities agenda. Firstly, are local programmes providing
proportionately increased support to communities experiencing higher levels of deprivation and
secondly how does the drive to keep people at home disproportionately affect those on lower
incomes? This touches on issues such as having sufficient levels of income to keep your house warm
and pay for other resources, which enable people to feel safe and secure at home, such as shopping
services. It is imperative that if these conversations are not already happening then public health
ensure that they do.
Conclusion
The list of ways in which public health can contribute to the integration agenda is endless and part of
the challenge for public health is defining their contribution, being explicit about this with partner
agencies and then demonstrating the value of their contribution .
Public health has a tendency to observe, stand back, reflect, think and then contribute to the
multiple agendas facing health and social care bodies as a critical friend. Integration approaches will
be different in every area but wherever we are we should be able to answer the question; “what is
the public health contribution to integration?” and more importantly so should our partners.
References

6. Public health contribution to health and social care integration
6 © Copyright, 2015, Association of Directors of Public Health UK
Alderwick H, Ham C, Buck D. (2015) “Population Health Systems: Going beyond integrated care”
King’s Fund. Online at www.kingsfund.org.uk (accessed March, 2015)
Hawkes, N. (2013) “Take me to your leader.” BMJ 2013;346:f2092
House, J.S. et al (1988) Social relationships and health. Science, 241 PP.540-45, quoted in Wilkinson,
R. and Marmot, M. (2003) Social determinants and health: the solid facts. Copenhagen: WHO
Imison, C., Poteliakhoff, E. and Thompson, J. (2012) Older People and Emergency Bed Use. King’s
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RAND Europe and Ernst and Young LLP (2012) National Evaluation of the Department of Health’s
Integrated Care Pilots. Online at www.rand.org (downloaded March, 2015)
Roland, M and Abel, J (2012) Reducing Emergency Admissions: Are we on the Right Track. British
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