ADPH London ADPH London SLI Review Findings

Transcription

1 ADPH London ADPH London SLI Review Findings ADPH London Business Meeting 21 st June

2 Introduction Sector Led Improvement is an approach to improvement where local authorities help each other to continuously improve. At its best SLI should provide confidence to both internal and external stakeholders and the public as demonstrate continuous improvement to Public Health Practice. In this way it will improve health outcomes and stop top down inspection regimes. It should therefore provide demonstrable evaluation, challenge and measurement of improvement not merely increase learning and knowledge. SLI methods can broadly be characterised into 3 headings: 1) Challenge: Including peer challenge, self assessment and evaluation approaches. 2) Problem Solving: Including collaborative workshops to tackle wicked issues and advice surgeries, 3) Sharing: Best Practice workshops, sharing innovation and learning.

3 Parameters of the review The following lines of enquiry were agreed with the ADPH London SLI Programme Board on : Is the programme meeting its original aims? What lessons have been learnt? How well are teams engaged? What has been the impact of the programme to date? Has challenge been built in to achieve quality assurance? What are the other regions doing and what can be learnt? What are the future aims and ambitions of ADPH London s SLI Programme? What issues are likely to impact on the SLI programme in the future? What is the role of other stakeholders? What is the role of benchmarking? What are future priorities?

4 Methods The methods for the review have involved the following: Desk based review: ADPH London SLI PIDs, Evaluations, Lessons Logs, and Outcomes Documents; Project documentation and evaluations from other regions SLI Programmes. National ADPH SLI framework and notes from meetings with the between the LGA and the London Chief Executive lead for health. A survey was also carried out and analysed to review the impact of the Smoking Cessation and Tobacco Control Thematic Review one year on.19 teams responded. Discussions have also been held with key stakeholders. SLI Programme Board 6 th May Interview with Paul Plant 9 th May Interview with Jeanelle de Gruchy 17 th May London Self Improvement Board 25 th May Interview with LGA staff (Heather Wills and Kate Herbert ) 25 th May Interviews with Vicky Hobart, Julie Billett, Penny Bevan 1 st June

5 Is the programme meeting its original aims? (1/2) The programme has involved two phases: Phase 1 piloted a peer review programme focused on tobacco control and smoking cessation. It sought to develop and test a programme of self assessment and peer review Phase 2 sought to develop and embed SLI practices and cultures within the Local Government Public Health System. Objectives included: a) Implementing and embedding outcomes of the thematic review on tobacco control and Smoking Cessation; b) undertaking a second thematic review on Childhood Obesity; c) To deliver and Implement DPH to DPH/Peer Review Reflective practice process; d) Develop an approach to quality and standards; e) Develop and approach to evaluating impact Both phases have been designed with the following considerations: a) To complement and align with existing approaches; b) To improve health outcomes; c) To ensure our approach worked with and leveraged resources of PHE London.

6 Is the programme meeting its original aims?(2/2) Reflections: Phase 1 The objectives were achieved, and the project was well received, with excellent levels of engagement and participation from teams It is too early to tell if it improved health outcomes The team worked closely with PHE London, and received excellent support from the Knowledge and Intelligent Team Phase 2 The five objectives have been completed or are on track, and the programme has again been well received, with excellent levels of engagement and participation from teams In this phase we have continued our approach to thematic review in a specific outcome area, and also introduced a new process of local reflection across the whole of the public health function. This balance appears to have worked well. The programme had an ambition to develop and embed SLI practices and cultures within the local government public health system. Whilst we have developed our approach, there is a question to which it has been embedded, including across wider teams.

7 What lessons have been learnt? The following are based on reviews of project documentation including lessons logs and minutes of meetings, and interviews: The process we designed benefited from a governance structure, continual DPH leadership, and dedicated project management. Teams see value in learning about the variety of other local authority realities and provision/practice, and sharing learning. Self assessment adds value to the process in that it enables systematic consideration what teams are doing and it initiates conversations with key stakeholders. But boroughs have found it resource intensive to complete. Involving different stakeholders in SLI helps other stakeholders to connect their work to public health. DsPH participation in the thematic review appeared to increase levels of challenge and ensure that discussions are more strategic in nature. DsPH facilitation of the peer review workshops is highly valued. One participant commented that this led to more evidence based discussions. The thematic reviews provide a rich source of information from which to identify areas for collaborative action. Analysing this and developing a pan london improvement plan is a resource intensive activtivity which requires capacity to progress. Good communication is key to the success of the programme and high levels of engagement. At the start of the thematic review positive communication about the purpose of the review ensures buy in from teams. At the end of the programme it is important to communicate outcomes in a timely manner to ensure engagement from stakeholders in next steps. Are there any other lessons or learning points missed not captured above?

8 How well are teams engaged? The following findings relate to the two thematic peer reviews and are based on reviews of project documentation, and analysis of participant surveys: 32 local authorities were represented in the smoking cessation thematic review and 33 local authorities were represented in the Childhood Obesity Thematic review suggesting high levels of engagement of those invited to participate. In the first thematic review at least 3 staff members participated from each team, with 7 teams sending more than 3 team members. 19 Trading standards officers participated. 11 DsPH participated in the process suggesting high levels of senior engagement. In the second thematic review all 33 councils, and 9 DsPH, participated. 30 teams sent 3 or more staff including representatives from other local authority teams. All participating teams returned completed proformas. Lessons learnt show that team resources and capacity may impact level of engagement. The evaluation of the tobacco control and smoking cessation thematic review also suggested that teams who were performing well valued the process less than other teams which may impact on their level of engagement. We do not know how well the process was understood or impacted in wider teams How do we design the programme going forwards to take account of the successful engagement, whilst also recognising the time constraints? How do we continue to ensure DsPH are engaged in the SLI Programme, even if they do not attend a peer challenge workshop? Is there further work to do with the wider public health teams?

9 What has been the impact of the programme to date? The programme as a whole is seen to have clear added value, particularly around developing a culture of working together to challenge each other. The survey on the impact of the Smoking Cessation and Tobacco Control thematic review found that 94.74% of teams completing the survey (N=19) had made changes in-line with their implementation plans. Early indications suggest that several teams reported changes as a result of the tobacco control and smoking cessation thematic review such as: - Greater focus on specific areas such as the creation of smoke free zones and illicit tobacco. - A broadening of the range of stakeholders who are aware of their role in tobacco. - More joined up working. PHE has reported that the priorities highlighted by the Smoking Cessation and tobacco control thematic review have felt very relevant and this has led to high levels of engagement in activities relating to improvement. The Childhood Obesity Thematic Review has also galvanised a more collaborative approach. It has also seen boroughs better prepared to respond to issues such as the National Obesity strategy, and to inform work with the Healthy London Partnership. The programme has been positively received by Chief Executives on the London Self Improvement Board The programme has been positively received by other DPH networks and the ADPH UK SLI Programme Board with recognition that this has required additional investment by London DsPH It is anticipated that undertaking SLI on a systems wide issue will be of future benefit in the context of devolution and other issues requiring whole systems thinking. Do you agree with these? Are there any other impacts of the programme? What kinds of impact would you expect any future phases of work to aim for?

10 Has challenge been built in to achieve quality assurance? Challenge is key to achieving quality assurance and whether it is at the right level of rigour is a central concern of participants and stakeholders. Evaluation of the tobacco control thematic review suggests that the process gave a strong degree of Quality Assurance as it came from more than one source. The evaluation suggested that people need encouragement and example to challenge so that they can see challenge as constructive rather than confrontational. The external evaluation report of the tobacco review identified three possible sources of inhibition to challenge:...the association of challenge with holding to account; a more confrontational performance management view of challenge and potentially at odds with collaboration with peers....a reluctance to appear to pillory obviously poorly-performing local authorities, especially when the professionals had already explained the local context and challenges (e.g. financial, political) that were impacting on this and largely out of their control...the absence of a DPH. One DPH quite specifically felt inhibited about asking challenging questions of a team if their DPH was not present to respond. In the Childhood Obesity review it was suggested that challenge came from completing the self assessment and teams comparing their work to other boroughs work. How can we assure levels of challenge within our SLI Programme? How can we ensure that key issues are addressed?

11 How does SLI fit with the wider ADPH London work programme? As a workstream, SLI is one of eight current priorities for collaboration between London DsPH,: ADPH London Collaborative priorities Jan to July 2016 Best start in life Childhood obesity Devolution Future drivers of public health Public health finance Sector led improvement Sexual health Smoking cessation However, much of the wider joint working, sharing of practice and problem solving between DsPH and their teams relates to improvement and is not necessarily badged as SLI. For example: Best start in Life - recently delivered two London workshops on Service Integration and Transformation for Public Health Services for 0-5 year olds. Sexual health recognising the challenges in this area, one of DsPH early priorities after transition was to invest in a strong commissioners network and support staff. Although not formally part of the ADPH London work programme, the London Sexual Health Transformation Programme, involving most DsPH, is perceived by Chief Executives to show London DsPH and their commissioners as taking a grip on a challenging issue and leading transformation. Workforce and leadership development in partnership with PHE and HEE, DsPH have invested in this to support improvement In other regions and sectors, having a functioning and well-attended officer network is seen as an indication of SLI. London ADASS do not have a dedicated SLI workstream, instead it is built in across all of their joint work.

12 What are other regions doing and what can be learnt? (1/2) In 2015 ADPH UK carried out a review of regional SLI Programmes. This found much variation in regional SLI Programmes. Following this they have challenged regional teams to demonstrate the impact of their SLI Programmes. GMPH network has one of the more advanced SLI programmes. They have carried out 13 thematic reviews over 2 years. Their process includes using benchmarking to support prioritisation of areas for thematic reviews. Unlike the London process, GMPHN involves teams meeting privately with a peer review panel who review their self assessments and advise on an improvement plan. CHAMPS (Cheshire and Merseyside Public Health Network) is initiating an SLI Programme similar to GMPHN, which involves benchmarking to support prioritisation and holding peer review panel meetings. They have carried out a thematic review on suicide, with a collective aspiration to become a zero suicide region.

13 What are other regions doing and what can be learnt? (2/2) North East DsPH have carried out SLI on embedding and maximising opportunities for community centred approaches to improving health. They conducted telephone interviews with all DsPH to identify areas of focus, system led work and areas of interest. They then established a community of practice and held a community based approach conference. Yorkshire and Humber have developed an approach similar to colleagues in adult social care that looks at the Public Health Function as a whole. This is based on the Developing Excellence in Local Public Health (DELPH) Tool which describes standards for good and excellent practice, across the six domains of: health improvement, health protection, healthcare, knowledge and intelligence and capacity building and governance and systems. They have also run half day sharing workshops with DsPH and consultants. East of England identified SLI priorities by running workshops (facilitated by Shared Intelligence) which engaged DsPH, followed by deputy directors and consultants. Current SLI work is focussing on Regional Finance Action Research Learning Sets in response to budget cuts and planning for the end of the ring fence. These are run as telecons. They also have a regional mentoring system, consultant networking, a development group for newly qualified consultants, and have undertaken self assessments/ peer review on prevention and health inequalities.

14 What are other local government professions doing? ADASS (London) has just completed a 3 year SLI Programme where they have run peer challenges of all boroughs. It is based on boroughs completing a self assessment and identifying challenges. Peers then visit the sites for several days and run events to address these challenges. The team are currently refining this process to ensure it focuses on areas of greatest risk. ADASS also uses the Towards Excellence in Adult Social Care (TEASC) risk assessment tool, typically supported by DASS to DASS discussions, which provides a high level check across key domains of risk. London Councils delivers a Treasurer to Treasurer Peer support and challenge programme for the Society of London Treasurers. In this process Treasurers self nominate to participate (it is not mandatory). London Councils then propose pairings in consultation with the SLT president to ensure partnerships bring out relevant issues. The host treasurer sets an agenda for the meeting based on a template developed by London Councils. Following the meeting the visiting treasurer then send the host treasure a letter summing up the discussion. Within other local government professions the SLI programmes have a greater focus on risk areas where failure might lead to harm to residents or where the issue poses a risk to the operational/political or financial stability of a borough or the issue poses a reputational risk. For example the adult social care programme is now focussed Safeguarding and Sustainability.

15 What is the role of stakeholders? Thematic review: A range of stakeholders beyond public health teams have been involved, for example trading standards officers in the tobacco review, the GLA in the childhood obesity review. Feedback from teams in the smoking and tobacco review indicated that involving other stakeholders in the process helped them to better understand the context of the issue. Evaluation suggests that teams who involved wider stakeholders such as environmental health officers in the peer workshops subsequently benefited from their understanding of the improvement needs and increased their buy-in to address. The evaluation of the Manchester SLI programme suggests that stakeholder involvement is important to the success of the SLI Process on broad issues were a range of stakeholders are involved eg childhood obesity. The evaluation also found that stakeholders must want to be involved in the process but they should not feel that the process is imposed on the them. Quality and standards: There is the potential to work with CCGs, NHSE, DASSs, DsCS etc in the quality and standards workstream DPH to DPH reflective practice : The DPH to DPH reflective practice process is primarily focused on DsPH and in some cases their management teams, with DsPH involving their Chief Executive and/or Lead Member as appropriate. Wider stakeholder engagement has not been explored, although issues arising may have implications for stakeholders on a local level e.g. Working with the CCG to develop the Health and Wellbeing Board. Could more value be gained from including other stakeholders in our SLI Programme, in particular thematic reviews? What are the risks and how can these be mitigated? Can we do more to understand the context of other council teams as part of thematic reviews?

16 What is the role of benchmarking? Currently the ADPH London SLI process uses benchmarking to inform discussions at peer review sessions. This has focused on comparing London boroughs with each other and national averages. Benchmarking information such as the Fingertips PHOF at a glance tool is not regularly discussed by London DsPH as a group, nor with PHE London. Other DPH networks have used benchmarking to identify priorities for SLI. Focusing solely on benchmarking to identify priorities may change the nature of the SLI process, for example it could become about ensuring that those boroughs with poorest outcomes improve (so they gain the most). There is a risk that the programme does not set the bar for transformation and world class outcomes. PHE could include in future benchmarking data from other regions and data from areas outside London with similar IMD scores. - Should benchmarking be used as part of criteria to select topics for Sector Led Improvement? - Should we use benchmarking data from outside of London in our SLI process?

17 What factors are likely to influence the future of the programme? (1/3) The following three slides outline some of the external factors that may impact on how London DsPH carry out SLI, including the context for SLI, and national programmes or offers of support: The national programme of ADPH and LGA support for sector led improvement these are outlined on the next two slides. The London approach should avoid duplication. Increasing Sub-regional and/or systems wide working, for example through STPs, and Devolution: for example Manchester is looking to place greater emphasis on stakeholders in the system as a result of devolution Reducing budgets: Levels of team engagement are likely to be effected by reducing capacity and resources, which may affect future SLI work. Reducing budgets may also mean there is a greater focus on statutory services which may influence future priorities for the programme. It also may mean there is a greater focus on a fewer number of priorities. Preparation for the removal of ring fenced budgets. This might affect the programme in two ways: first as it affects how DsPH and their teams ensure public health priorities are supported without a specific grant. Second, how might PHE s assurance role change and how will that affect the context and support for SLI?

18 What factors are likely to influence the future of the programme? (2/3) This diagram shows the national ADPH SLI Framework. ADPH has a national SLI programme board which provides a national focus and leadership for SLI in PH. It also stimulates and supports network activities such as the HIAP SLI Pilot and is setting up a national mentoring programme and the board also provides quality assurance, challenge and feedback to network programmes.

19 What factors are likely to influence the future of the programme? (3/3) The LGA HWB Improvement offer The LGA has recently revised its health and wellbeing improvement offer and includes: Research on the attributes of a successful Health and Wellbeing Board, Health and Wellbeing diagnostic tool, online survey and free facilitated workshop to explore opportunities for what is working and areas for development. Integration Self Assessment LGA is working with ADAS, NHS Clinical Commissioners and the NHS Confederation to develop a vision for what health and social care integration should look like. Workshops to support the building of relationships between CCGs and Local Government; Health In All Policies LGA has developed a set of self assessment questions followed by a workshop which will then explore and support action planning in areas needing further development.

20 Conclusion ADPH London has effectively progressed its SLI programme since Early positive impacts are arising from the tobacco work undertaken last year; the Childhood Obesity Process has helped move boroughs forward and provided greater clarity on this high profile and challenging area. There have been some barriers (particularly capacity) to participation and implementation, but on the whole teams value the process and involving other stakeholders in the process has been very beneficial. DsPH have tested an approach to a more comprehensive review of their local function, which is being rolled out to all DsPH. Work to progress issues identified relating to clinical governance is in train. The public service system, nationally as well as in London, is experiencing unprecedented levels of stress and change, with health and wellbeing in the thick of this. Continuous and self-led improvement must recognise and respond to this changing and challenging context. SLI activities must continue to focus on those issues and priorities that are of greatest importance, and continue to evidence a positive return for public health teams and local authorities more generally, in terms of the time and resources invested.

21 Phase 3 Continue to take forward the outputs of the two thematic reviews, on tobacco ( ) and Childhood Obesity, Roll out the DPH to DPH peer to peer work to all DsPH by the end of 2016/17, Continue work on quality and standards. Consider link up with other system stakeholders such as NHSE and CCGs. Set an ambition for greater AD/Consultant involvement and leadership on SLI to support succession planning and system development, and to release DPH Capacity. Consider a third thematic review to determine where this would be suitable, it is proposed to hold a workshop with ADs/Consultants in autumn 2016, with input from DsPH on the programme board, to review and prioritise London improvement needs, and to propose how these could be delivered. For example if responding to the removal of the ring-fence is seen to be a priority, it may be more appropriate to set up Action-Learning Sets, rather than undertake a thematic review. The workshop would seek to develop and apply a prioritisation approach for SLI topics, as well as brief ADs/Consultants on SLI and explore with them their collective leadership role on this. An approach to benchmarking or outcomes review in partnership with PHE London, should be considered in the next phase. For example one option includes regular meetings with PHE London to review benchmarking data and outliers in PHOF data and identify how these could be addressed. Alternatively this could be a regular item at the SLI programme board, and/or quarterly at existing DPH business meetings. The next phase of work should also play closer attention to how to monitor impact. The programme board established should continue, with new DPH and Consultants identified to participate. As well as this formal or structured approach to SLI, the principles of sector-led improvement should continue to cut across all other ADPH London workstreams.