Public Health Reform

Introduction

This is an analysis of public health reform, including the proposals for a new Public Health Body, based on six overarching priorities which have been broadly supported by the voluntary sector:

1. A Scotland where we live in vibrant, healthy and safe places and communities.
2. A Scotland where we flourish in our early years.
3. A Scotland where we have good mental wellbeing.
4. A Scotland where we reduce the use of and harm from alcohol, tobacco and other drugs.
5. A Scotland where we have a sustainable, inclusive economy with equality of outcomes for all.
6. A Scotland where we eat well, have a healthy weight and are physically active.

The wider context for rethinking health and care reform is being assessed on its own wiki page, and based on the following approach:

1. Bring into the light the evidence and data available on the different outcomes achieved when shifting from a medical approach to treating problems to a social approach to healthy and fulfilling living
2. Secure greater participation for people and their carers in decisions on how resources can be better distributed amongst those who require acute care, those who require support and those who can live independently
3. Establish in our sector and campaign in other sectors for clearer lines of accountability for health and care spend, including to people who receive care and support.

The devil of course is in the detail. Will the mechanisms and structure adopted for public health reform, particularly the new Public Health Body deliver against the priorities agreed?

This analysis explores a voluntary sector perspective on this question and offers some proposals emerging from discussions to date, and aims to support voluntary sector responses (including that of SCVO) to the Scottish Government's Public Health Scotland consultation. It draws from the views provided by voluntary organisations in two roundtable events (described below), SCVO's engagement in meetings with the third sector public health stakeholder group plus online discussions facilitated on SCVO's policy networks.

In summary, the following priorities have emerged:

• Governance of the new Public Health Scotland body needs to model a transparent, accountable and participative approach
• Public Health Reform must take a whole systems approach, including the system within which the voluntary sector operates
• The language used within the Public Health system must match the values and principles of people-centred service design
• The Public Health Body should consider hosting a 'wellbeing lab' function which would support innovation, concept development, wider engagement and new ways of working.

Evidence from the third sector

Engagement	When	Nature of event	Outcomes
SCVO and Scottish Government third sector consultation event	14th November 2018	35 people came together from 27 different organisations: including Health Boards, 3rd Sector and Community based organisation Attendees gained an insight to the functioning of the current whole system and opportunities for public health reform to influence Started to develop a shared understanding of areas of focus for whole system working Started to agree criteria to inform prioritisation of areas of focus Scottish Government received constructive feedback on the principles of whole system working	Overall outcomes Everyone recognised that when it comes to healthy life expectancy – the key is quality of life. The significance of that lies within each of the public health reform priorities, and shows we all want a Scotland where everybody thrives. The importance of data and intelligence Data and Intelligence in reference to the 3rd Sector and voluntary organisations was particular important to attendees. They want public health reform to see the importance and value of their data, anecdotal evidence and previous experiences. There is a potential quick win in this area if we open up to areas which can help these organisations with data processing. Its hoped this could mitigate any barriers in capturing data and the perceived disadvantage of not being able to “crunch” data
Scottish Government focus group on the governance arrangements for the new Public Health Body with an SCVO delegation	26th July 2019	Focus group run by Scottish Government Public Health Reform bill team 5 voluntary organisations participated, and based on an open invitation to SCVO's networks. Attendees were expected to bring their experience and insights into good governance based on their organisations, sectors and engagement with public sector partners.	Areas discussed The new Public Health Body needs a clear line of accountability via Scottish ministers to parliament, even if other stakeholders such as COSLA are engaged closely. Joint accountability to local government won’t work in this context. Should Executive accountability be direct to Scottish Parliament or via ministers? There was some uncertainty over how the Chief Executive of the Public Health Body would relate to the Chief Executive of the NHS. As a special health board, more clarity was needed on what role the NHS Chief would have over the new body. Participants were keen secure greater participation in the governance of the public health body, particularly for people with 'lived experience' of the issues being addressed. This however would require information to be presented without jargon and in more engaging and inclusive ways for non-technical audiences. Proposals Scottish ministers should be the ultimate decision-maker for the public health body, and account to the Scottish Parliament for this. Accountability cannot be shared with local government, as this could result in confusion where there was disagreement between central and local government. Publish the papers, minutes and any analysis subject to governance to the general public to improve transparency and trust in the body. Bring some of the governance and decision making out of the board. The board can the smaller and focused on overseeing the structure and finances of the body, with strategy and direction subject to a wider group. Use participatory budgeting with policy panels of people, including those with 'lived experience', for a percentage of the public health budget. Any executives on the board should not have voting rights to avoid conflict of interest

Analysis and recommendations

Objective	Analysis	Recommendations
Governance of the new Public Health Scotland body needs to model a transparent, accountable and participative approach	Voluntary organisations consulted by SCVO believe that the key indicator for public health should be 'quality' of life (see evidence from the third sector above). This is seen as relevant to each of the public health reform priorities and therefore offers a whole-system measure of progress. However, the key to success of the public health reform agenda, will be the trust that Scotland's people have in the new system. This can be enhanced by securing transparency, accountability and participation in the design and delivery of the public health body and its strategy. A practical way to take this forward could be the Scottish approach to service design which has been developed through the approach to its new social security powers.	Work with the Scottish Open Government Action Plan principles and framework to secure transparency and accountability. Engage with the Scottish approach to service design to increase participation. Voluntary organisations also have practical suggestions for the governance arrangements of the new public health body. This includes ensuring a clear and straight line of accountability through Scottish Ministers to the scottish Parliament, an open government approach to governance, and wider participation in governance outwith the Public Health Body board.
Ensuring Public Health Reform takes a whole systems approach, including the system within which the voluntary sector operates	Voluntary organisations with a bearing on public health are diverse and include organisations of different sizes working at national, regional and local level, and sometimes very local level. It's important to reflect this diversity in any engagement strategies to secure a whole system approach. Many voluntary organisations play a key role in public health as part of the wider system, sometimes without realising it. This includes, advice, addiction services, community gardening, befriending, lunch clubs, self-help and hobby groups, community arts and sports and many others. This is the community-based preventative agenda in action, but is not always visible to the NHS system. There is a need to create a space within which innovative, risky and formative ideas can be developed and tested outside the usual NHS parameters or structures that might constrain it. Voluntary organisations consulted by SCVO believe that support to process and share their data and intelligence is of particular importance to bring them in to the public health reform conversation (see above). This is likely based on a perception of what is valued by the NHS.	Don't oversimplify engagement to just one channel e.g. third sector interfaces, a seat on the board for a third sector representative, or a third sector committee, to engage the voluntary sector. National bodies such as CHEX, Voluntary Health Scotland and others are equally important. Proposal for a research and development space hosted by the new Public Health body, a ‘wellbeing lab’ (see below), could help unlock innovation and improvement in a safe space.
Ensuring the language used within the Public Health system matches the values and principles of people-centred service design	There is a lot of NHS jargon in public health reform, including 'whole-system', Scottish approach to 'service design', IJBs, HSCPs, and Interfaces. If participation is central to public health reform, then we need to find a way to de-jargonise. One way to do this is to bring to develop and share real life stories of what successful public health engagement looks like. We should ask people to help rethink how the concepts and language is used.	Use a people panel to de-jargonise public heath reform terms and concepts. There are opportunities to learn from the design of the social security people's panel set up by Inclusion Scotland. Use storytelling techniques to ensure public health reform is more engaging, and not just seen as an NHS clinical intervention.

Wellbeing lab

Introduction

In conversation between third sector public health stakeholders, we identified the need for a more systematic way for non-statutory partners to engage with public health reform, following the formation of the public health body and its functions.

In particular, we felt that a collaborative and open space which would support innovation, concept development, wider engagement and new ways of working would be a useful way to bring the best insights and input from non-state actors into public health reform. The rallying concept around which everyone could agree would be 'wellbeing' which is central to the Scottish National Outcomes Framework, as linked to the Sustainable Development Goals.

Concept

The 'Wellbeing lab' would be a cross-departmental function hosted and resourced by the new Public Health Body.

Its aim would be to provide an open and safe space within which to engage stakeholders, beneficiaries and practitioners with the latest insights and intelligence on public health, in order to experiment, innovate and design the leading edge approaches to supporting wellbeing in Scotland.

It's success would be measured by:

1. the extent to which open, transparent and participative models of service design are mainstreamed into public health functions.
2. the extent to which community-based approaches to public health are aligned with clinical approaches
3. trust in the new public health system by partners across sectors, and the general public.
   

Rationale

• It would be designed as a contained and controlled environment relative to the other functions of the public health body, able to take on a higher level of acceptable risks.
• It would provide an effective and trusted mechanism to support engagement with public health stakeholders
• It would provide the conceptual space within which to co-plan (with partners) the integration of whole-systems approaches with target-based models and the public health principles, as linked to the Scottish National Outcomes
• As a 'wellbeing lab' it would allow the public health function to closely align with scotland's ambitions to be a wellbeing economy.
• It would provide allow the new body to trial more open policy making, participation and Scottish approaches to service design, which might be riskier to advance otherwise.
• There are already precedents set and learning available for working this way within Government and cross-sectorally, such as the Ingage function within Scottish Government, the Joint Improvement team, and the Glasgow Centre for Population Health.