Minutes:
JMcManus identified three key points as a Director of Public Health in terms of the current situation, (1) the demography, (2) navigating a system and partnerships that seemed to be perpetually in flux, and (3) issues and potential solutions.
Demography
JMcManus explained that his team ran two websites, hertshealthevidence.org and the JSNA website, with detailed profiles on illicit drug markets, serious violence needs assessments, and an annual Dacorum District profile, which he would send a copy of to JDoe. He noted that profiles were published for all the care partnerships, by district and borough, adding that, by demography, the health issues were quite mixed, and quite stark in some places, with GP practices where outcomes had not changed for ten or eleven years, and others where they had, as well as a life expectancy gap of eight years between the wealthiest and poorest. It was identified that there was a high burden of preventable ill health, with the population in austerity and poverty in worse health than the best off, and that the demography included a higher smoking rate in the manual and routine working, and minority ethnic communities. JMcManus noted that there had been some successes in Hertfordshire and Dacorum, with some practices doing well at getting older people into strength and conditioning exercise, stopping them from needing social care and helping them remain independent, and highlighted the presence of mental health and other voluntary sector organisations. He emphasised the need to configure systems and structures to protect and improve the health of the demography.
Action: JMcManus to send a copy of the annual Dacorum District profile to JDoe.
System and partnerships
JMcManus identified that regardless of what the ICB and the integrated care system were doing, there was a distinct role for local government in regard to public health separate from, and complementary to, the NHS. He highlighted that only 20% of health outcomes could be shifted by NHS clinical care, with 30% a result of jobs, education, and living, meaning that clinical and non-clinical prevention work needed to be balanced, identifying Type 2 Diabetes and Liver Disease as two growing issues. JMcManus suggested that District and Borough Councils had an opportunity to come together and share work, suggesting that GPs should be referring people into leisure and physical activities, giving the example of fatty liver conditions where there was no clinical treatment, but improvements could be seen based on physical activity, diet, and lifestyle. It was noted that there had been an ICS workshop on working together with local government, but stated that local government had been there first, with the 2012 Public Health Partnership money guaranteed until 2025, and suggested that it would be good to see a combined health offer, particularly around physical activity. He gave the example of Stevenage and an exercise suite with assisted exercise machines that GPs were able to refer patients to after leaving hospital, adding that there was work to be done around rebuilding the population psychologically and physically following Covid.
Issues and solutions
JMcManus advised the committee to be informed, recommending independent health experts for consultation on specific topics, and developing interest in patient outcomes and system improvements. He referred to the government ambition of improving life expectancy by five years by 2030, suggesting that it might not be achievable, but that steps towards it could be made by focusing on the people most likely to become seriously unwell, who were currently middle-aged and accumulating risk factors, as well as older people who were beginning to decline. JMcManus reiterated that when looking at the patterns emerging from a population, those at Dacorum level were different to those on a Hertfordshire level, where inequalities were massively masked, so the continuation of Public Health Partnerships was a very good thing, and expressed his scientific opinion that many people would die preventably in the next five years, partly because of austerity.
JMcManus concluded that he had been told to create a public health movement in his first week on the job, with elected members being central, and noted that there was an art and science to the influence and leadership of such a thing, warning that science without art didn't do anything, but that art without science was dangerous. He stated that District and Borough Councils in Hertfordshire could make real differences to health outcomes through things like decent housing standards, funding for mental health interventions etc.
Cllr Pringle noted that people with special educational needs and learning disabilities were another group that needed to be mentioned, as statistically there was a significant difference in life expectancy and suicide rates, adding that there did seem to be an increasingly proactive response from GP surgeries, but that this was not reflected in NHS dentistry. She explained that there had been a government advisory to NHS dentists including the ability to remove patients who had not received a check-up within the last six months from waiting lists, without needing to inform them of the fact, and that it seemed no accommodation had been made for individuals with conditions such as autism, suggesting that it was a situation needing further investigation and potential action. JMcManus stated that dental care nationally was in a crisis, with dentists, like GPs, commissioned by the integrated care board and technically private businesses, and noted that there were good examples of dental care in the country for individuals with autism or learning disabilities but that these were co-funded by the ICB. He agreed that it sounded like there was a point in regard to the potential discrimination, adding that he felt there was an issue about the physical health of those with autism or learning difficulties generally, with the ICS partnership working on a physical health strategy, but that there needed to be something about GPs and dentists providing better care for those individuals, although it was probably an issue for national policy as well as local. It was highlighted that public health didn't have any power over the situation outside of pointing out inequalities through the JSNA, and that if the autism JSNA wasn't up to scratch it could be requested, with the Health and Wellbeing Board, as well as the NHS, having a statutory duty to have regard to a JSNA once published. The Chair clarified that someone with learning disabilities was likely to die twenty years before someone without, due to the level of support needed, and Cllr Pringle added that the statistic for autism was potentially even starker. Cllr Pringle also noted that GPs should be bound by the public sector equalities duty, and requested that the dental care issue be raised for investigation. JMcManus confirmed his understanding that everything under the overarching duty of the Secretary of State to provide a universal health service, as part of the NHS Act 1966, including anything he, GPs, dentists, hospices etc. did under that also was caught by the public sector equalities duty.
Cllr Maddern thanked JMcManus for his work, particularly his updates throughout Covid. She explained that, as a scout leader recently back from a large camp, the mental health of the fourteen to seventeen age group was the lowest she had seen in eighteenyears or her ten years as a guide leader prior to that, and wondered if JMcManus had any advice. JMcManus noted that there were a lot of stresses on children, particularly due to social media, such as body image, relationships, confidence, and resilience, and suggested that there was a need to give them a strong sense of self, followed by the skills to navigate technology, along with psychological, social, and physical toughness, including coping with and assessing adversity. He identified that Covid had given mental health issues a nudge, but had not been the start of their rise, adding that there were issues around ambition and uncertainty, and that young people were prone to pick up on anger and antisocial conduct in society. JMcManus suggested that pro-social behaviour and environments needed to be encouraged, that people needed to be able to acknowledge they were struggling, and that preventative approaches such as Just Talk, mental health advocates, etc, were needed due to the shortage of treatment facilities. It was also noted that there was evidence to show that children who switched off social media, read a book, and talked to other children about it, learned more and avoided negative exposures. Activities outside of school, such as scouts, building reading skills and pro-social skills, were identified as key, including providing role models who had dealt with and recovered from mental health issues and trauma. JMcManus added that an assurance visit from the Department of Health and Social Care had suggested additional spending on public mental health, and highlighted that a volunteer movement focused on young people's resilience would have a series of opportunities.
Cllr Bhinder stated that Dacorum had a good track record of encouraging and developing health and leisure activities for residents, as a local authority, but that a number of life skills not in the curriculum were no longer learned at school, and identified health issues with home working, availability of junk food, and sugar content. He wondered how a local authority could change education, lifestyle, and sugar availability. JMcManus highlighted that the engagement and public health mindset being demonstrated was significant, and crucial to keep sight of, suggesting that regulatory measures were the most effective and cheapest, and it might therefore be worth lobbying at the national level for relevant policy changes. He also suggested that the council lead by example and create a mentally and physically healthy workplace, which could be replicated at other district councils and the biggest employers of the area to change culture by osmosis. JMcManus added that North Herts were about to look at a matrix based on the District Council Network's report on public health in 2015 to identify touchpoints where they could make a difference, such as gambling regulation policies and licensing policies, or Herts catering taking significant amounts of sugar and fat out of 4 million school meals a year as well as adding fresh fruit and vegetables, highlighting that small changes could still add up over time. He stated that there was evidence for a 'social cure', where people finding meaning in adversity became more resilient, with residents' groups, support groups, bereavement support groups, etc, examples of this and should be encouraged to build those skills in people. Cllr Bhinder referred to a BBC programme, Brain Hacks, that had demonstrated physical changes in the reporter's brain along with improvements in focus and other areas, suggesting that it was worth watching.
Cllr Tindall highlighted that Health in Dacorum was being renamed to Health and Wellbeing in Dacorum, with the aim of being proactively involved in making improvements, rather than just holding the health authorities to account. Cllr Bhinder added that the scrutiny committee might not be able to create policy directly, but could investigate ways to be more influential. The Chair noted that plans for the committee's wider approach to health would be made clearer at the full council.
EGlatter wondered what information was actually available about Covid, noting that there was no way to know who had it and didn't when sometimes people had it without realising themselves. JMcManus stated his opinion that it was now endemic and circulating, suggesting a public health approach in terms of getting vaccinations and boosters, taking appropriate precautions if symptomatic, and using measures such as masks, room ventilation, and hand sanitising. He added that it was highly mutable, and that it wasn't going away.
Cllr Pringle suggested that resources could be stretched further by solving multiple problems with the same solution, identifying the growing tendency for generations not to mix as causing or contributing to a lack of inter-generational connection and loneliness. She wondered if there was any research on public health approaches to this, such as pairing up nurseries and care homes. JMcManus agreed that there was a lot of evidence supporting inter-generational contact, and identified the hospice where he was a trustee as having a nursery with a daily walking bus and lunch with patients. He acknowledged that there could be safeguarding concerns, but that done right, it could be highly beneficial, noting that Austria and Germany did a lot of it, and Age UK also had examples, and suggesting infrastructure such as the Scouts and Guides, but noting that the kids and older people might need some training. It was also suggested that cross-generation health walks could be done, as well as other activities in the voluntary sector with the provision of befriending or resilience training. JMcManus emphasised that these sorts of initiatives were something that the borough council was in a unique position to provide, and couldn't be done by the NHS or the County Council.
The Chair noted that there had been reports of the public health nursing services in Hertfordshire no longer meeting needs as they used to and wondered what was happening, from a County Council point of view, to address the issue. JMcManus explained that the public health strategy approved last year stated that public health nursing and family centre services would be re-provided, and that the family service offer would be enhanced, which he believed was a commitment to putting more money in and improving the service. He stated that while he would like a school nurse in every school, it would cost £23 million which they didn't have, and encouraged residents to write to his successor about what was and wasn't working, identifying that there would be a service redesign exercise, including consultation. It was noted that a big issue was the lack of public health nurses, and NHSEngland's programme around graduate mental health trainees sadly hadn't delivered, and that Hertfordshire was lucky to have a public health nursing department. Michael Fallow (ph) was identified as a resource in relation to a national research project on making health visitors research ready, and a new consultant in public health, Adeen (ph), was highlighted as having the goal of landing a new investor for the (ph) public health service, working in partnership with providers and families.
Cllr Pringle suggested that future meetings might benefit from summarised health objectives and asking portfolio holders to reflect on policy changes and how they might feed into that.
Action: JMcManus to raise the issue of dental care for those with autism or learning difficulties to be investigated in regard to the government advisory about removing patients from waiting lists post-Covid.
Due to time constraints, the meeting was ended at 21:30