Integration – a public health perspective

Written by: Cath Denholm, Director of Strategy, NHS Health Scotland

Published: 17/06/2018

Public health is a big part of health and social care integration.

If the Faculty of Public Health defines public health as “the science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society”, then the aims behind health and social care integration are public health aims.

People’s experience through every public service they receive has an impact on their health and wellbeing.  The more that services are joined up to meet a whole person’s needs the better.  The more that services are measured on how they keep people independent and well (rather than the extent to which ‘beds are blocked’ or ‘waiting times exceeded’) the better.  And, lastly, the more that people’s needs – both at individual and population level – are understood, the easier it is to plan and deliver the most effective kinds of services. So yes, public health is a big part of health and social care integration.

Two years on, does this mean that health and social care integration is providing public health benefits?  Are health and social care services contributing to reducing health inequalities (National Health and Wellbeing Outcome 5)?  Are health and social care services centred on helping to maintain or improve the quality of life of people who use those services (Outcome 4)?

You’ll have your own answers.  From my perspective, which I’m conscious is national rather than local, it would seem that the overriding focus of health and social care services is currently on meeting ill health needs.

Can public health do something about this?  It must.  Some public health and population approaches will never be aimed at health and social care services. However, public health can definitely contribute more to managing demand and delivering the national outcomes of health and social care.

Prevention must become a more integrated part of thinking and practice.  Routine enquiry into gender-based violence during maternity care is an example with some success.  Just as the referral pathway for recurrent urinary tract infection is mainstreamed, we need to make it as easy for primary care practitioners to routinely refer people into practical support to deal with issues like fuel poverty, financial problems, or social isolation – issues that fundamentally affect people’s health and wellbeing.

Public health data, analysis and interpretation offers real impact in planning the wide variety of patient pathways we need to protect and improve health.  To do so, it needs to be accessible and more simply communicated to service planners, providers and people using services.  There are many underlying factors, such as alcohol, deprivation, obesity and people with multiple conditions, which affect Scotland’s health and how long people live.  Providing evidence-based scenarios to help service planners steer resources to where they are most needed will help manage demand and help achieve sustainable services into the future.

But while improving population approaches is extremely important, it is not the whole story.

I believe very passionately that public health also offers a framework to ensure effective inclusion of people, person by person.  For me, any ambition to improve health and eradicate health inequalities is fundamentally underpinned by a human rights based approach.  That means services which involve the person and which are founded on the fact that people have a right, not a privilege, to what sustains their health.  Service transformation, including new digital technology, is currently a big focus of making services more efficient.  That’s fine, but I also want to see more about basic human need.  Take the example of a man in his seventies having multiple falls at home.  Health and social care integration is probably well set up to organise services such as bone scans, home assessments for aids and so on – though there may be waiting times and communication breakdowns between services to contend with along the way.  But what if the primary cause of his falls is that he is drinking too much, which is directly related to his grief and isolation because of the death of his partner?  That’s a broader lens through which to view the pathway of his support and a broader lens for integration of services.

We won’t get services that are based on underlying need, and are sensitive to the points in people’s lives where they are most vulnerable, without the right to health being absolutely core to delivery values.  Some of that is in planning.  Some of that is in workforce development but, crucially, also in the workforce capacity within health and social care to have the time to take that approach and live up to the values in the health and social care legislation outcomes.

At this point, governance and structural issues still seem to dominate health and social care integration.  Once we get beyond this point to a phase of genuine cultural change, public health – in its breadth of what it knows and says about the financial and social determinants of health, power, the health of the workforce, and much more – will be in a better position to help health and social care integration achieve the ambitions of the nine Health and Wellbeing Outcomes set out in legislation.

Public health needs to be ready when health and social care integration is ready.  Scotland’s current public health reform agenda brings an exciting opportunity to reframe the relationship between acute, service-based care and systems that create and sustain a population’s health and wellbeing.  Some of this may mean aspects of public health becoming more integrated into health and social care services in the future.  It is also likely to mean public health’s voice being put to most effective use elsewhere.  It will certainly mean realising the potential of public health leadership, and it will certainly mean broadening out what we mean by the ‘public health workforce’ not just to health and social care, but also very firmly to the third sector.  It is certainly the time to be thinking about this, in order to get it right.

Cath Denholm can be found on Twitter at: @cathdenholm (This link will take you away from our website)

Cath’s Opinion is part of the ALLIANCE’s ‘We Need To Talk About Integration’ anthology which is available at the link below.

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