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Guest blog: A way forward on PrEP

March 1, 2019 in ADPH Updates, President's Blog, Uncategorized by admin

by Professor Jim McManus, ADPH Vice President

As Scotland issues its report into the first year of PrEP for HIV, there is a fair amount of debate going on about where we are in England with PrEP. NHS England announced this week they wanted to roll out more places. I don’t know anyone who doesn’t want the further roll out of PrEP in England – the Local Government Association wants it, the ADPH wants it, community groups want it, even NHS England wants it.

But let’s be clear, this roll out creates an additional and unfunded £7m burden on councils’ sexual health budgets at a time when our budgets are being cut. That’s small change for NHS England. It’s a major problem for local authorities.

Despite NHS England’s press release yesterday[1] the issue of funding remains unresolved. It’s hugely welcome that NHS England will fund new places. However, clinicians tell me regularly, there is a double burden created by the PrEP Trial.

First, not all of the time and admin costs incurred by involvement with the trial are met by NHS England; “additional resources needed to help with data entry are not met by NHS England” said one clinician.

Second, the further associated costs of HIV tests and repeat GUM visits and other tests are paid for by councils through the public health budget. It’s no use saying people eligible for PrEP should be using GUM services more already, this trial is driving people into services (which is great) but creating a major financial burden we could easily solve.

And there is an easy answer. We even proposed it to government. Before Christmas, ADPH and LGA jointly called, with many sexual health and HIV charities, for the increased roll out of PrEP. At the time, ADPH said:

“PrEP is now even more affordable on the NHS. With the NHS saving substantial sums from the drug being cheaper as well as from fewer people needing treatment, we see no reason why NHS England should not extend the roll out of the trial to more people.

“While NHS England pays for the drug, local councils have to meet the costs of extra attendances and tests at sexual health services. These additional costs fall at a time when government is cutting public health budgets.

“The savings made by NHS England switching to generic Truvada would help cover the trial-associated service costs of extending recruitment to the PrEP trial and significantly reduce the burden on local authorities to support this important study.”[2]

The double burden created by the roll out of PrEP could be easily resolved by the Department of Health and Social Care (DHSC) or NHS England spending just 1% of the money DHSC has just found to bail out NHS Acute Trust deficits[3]. The money is clearly there and, in an era when we’re supposed to be moving to prevention, it is an odd policy choice not to find that money.

Getting the double benefit of rolling out PrEP and at the same time getting our residents into more frequent GUM checks would cost just £7m for DHSC or NHS England. That’s the opportunity.

What if we don’t? Well, we create £7m additional demand for sexual health services, and we either cut other public health services further to meet it or we end up with people being displaced from GUM services.

In other words, we end up with the danger of pitting one group experiencing inequalities against one or more others, while NHS England walks through the middle reaping the financial gains of generic Truvada and creating a needless fight between councils and local populations.

That can’t be good. I don’t blame councils for pointing this out. This is a clear example where we could easily work together as a system to solve a problem.





ADPH Press Release: ADPH backs call for a new focus on the first 1000 days of life

February 26, 2019 in ADPH Updates by Ben Wealthy

On Tuesday 26th February 2019, the Health and Social Care Committee published a report on the First 1000 days of life which urges the Government to improve support and services for children and families. 158 KBADPH Press Release – First 1000 days of life

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LGA/ADPH Annual Public Health Conference and Exhibition 2019

February 20, 2019 in ADPH Updates, Headline Events, Upcoming events by admin

Supporting resilient communities: helping people to feel good and function well

Victoria Park Plaza, London, SW1V 1EQ
Thursday 21st March 2019

Our annual flagship conference on public health will explore and build on the challenging, innovative work being undertaken by local authorities, their partners and communities as they continue to make progress on improving the nation’s wellbeing and tackling health inequalities.

This year’s conference will focus on developing and supporting resilient, healthy communities. We will hear from expert speakers, councils and partners on key local and national strategies for promoting health and wellbeing and strengthening resilience to health problems.

Join us at our most popular health conference of the year to hear the very latest thinking on key policy and improvement agendas. This is your opportunity to put your questions and comments to those involved in shaping and implementing them at strategic and community levels, and to network with your peers on the public health issues that matter to you locally.

Confirmed speakers include:

  • Steve Brine MP, Parliamentary Under Secretary for Public Health and Primary Care
  • Jim McManus, Vice-President, ADPH and Director of Public Health, Hertfordshire County Council
  • Ruth Sutherland, Chief Executive, The Samaritans
  • Nathan Dennis, Director and Community Engagement Consultant, First Class Legacy
  • Rob Trimble, Chief Executive, Bromley by Bow Centre
  • Professor Dame Sue Bailey, Consultant Child and Adolescent Forensic Psychiatrist and Professor of Child and Adolescent Mental Health
  • Diane Lee, Head of Public Health, Barnsley Metropolitan Borough Council
  • Andy Bell, Deputy Chief Executive, Centre for Mental Health
  • Professor Jane South, Professor of Healthy Communities, Leeds Beckett University
  • Jude Stansfield, National Adviser – Public Mental Health and Healthy Communities, Public Health England
  • Deborah Harkins, Director of Public Health, Dudley Council
  • Bev Taylor, Social Prescribing Development Manager, NHS England
  • Professor Sian Griffiths OBE, Deputy Chair, Gamble Aware and Associate Non-Executive Board Member, Public Health England
  • Professor Jane South, Professor of Healthy Communities, Leeds Beckett University
  • Cllr Ian Hudspeth, LGA Community Wellbeing Board and Leader, Oxfordshire County Council

Visit the LGA website for further details and to book your place.

Immersive Workshop: Expanded Portfolios

February 19, 2019 in ADPH Updates, Events, Masterclasses and workshops by Teresa Grandi

Tuesday 5th March 2019, St Brides Foundation

The workshop will provide an opportunity to network with and learn from other DsPH with expanded portfolios that have taken on a wide range of responsibilities, from environmental health to road safety; leisure services to licensing. The main purpose of the day will be for the DsPH to problem solve together but we also expect to build in an input on theory of leadership.

DsPH who would like to register for this event or those with a wider portfolio who would like to help us shape this day, should contact Zahra. Please indicate if you have an expanded portfolio and what your additional responsibilities are in the email.

Tackling adverse childhood experiences: new funding to address this vital determinant of health

February 6, 2019 in ADPH Updates, Alcohol and Drugs, Children, Young People and Familes, Mental Health, Policies, Violence by Lucy Sutton

The ADPH is delighted to be partnering with the Institute of Health Visiting (IHV) and the Association of Police and Crime Commissioners (APCC) to tackle the serious consequences of adverse childhood experiences (ACEs), as part of the Health Foundation’s programme on the social determinants of health. 

Please see attached the ADPH press statement following the announcement on Feb 6th 2019.

258 KBTackling adverse childhood experiences – new funding to address this increasingly vital determinant of health

ADPH Press Release: Public health should be a priority in the Spending Review

February 4, 2019 in ADPH Updates by Ben Wealthy

On Monday 4 February 2019 The Times published an open letter organised by the Association of Directors of Public Health, and co-signed by 54 health leaders, calling for public health to be a priority in the Spending Review. The text of the letter and list of signatories is available here.212 KBADPH statement – Public health should be a priority for the Spending Review

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DCLG BRR Consultations: ADPH Response

January 29, 2019 in ADPH Updates, PH Funding, PH System by admin

Attached are the ADPH responses to the Department of Communities and Local Government consultations on: “Self-sufficient local government: 100% Business Rates retention” and “Fair Funding Review: Call for evidence on Needs and Redistribution”.

This was submitted on 19 September 2016.

ADPH Press Release: ADPH welcomes expanded access to PrEP but further work needed to protect existing services

January 23, 2019 in ADPH Updates, Policies, Sexual and Reproductive Health by Lucy Sutton

Attached is the ADPH press release welcoming proposals to expand the PrEP trial in England.

243 KBADPH Press Statement – PrEP (Jan 2019)

The NHS Long Term Plan – let’s stop the ‘us and them’

January 18, 2019 in ADPH Updates, President's Blog by Lucy Sutton

The NHS Long Term Plan has finally arrived. There is much in the plan that Directors of Public Health would support: 

  • The shift in focus to primary and community services
  • Extra funding for those places with the greatest health inequalities
  • Training of medics on nutrition in all hospitals 
  • Action on air pollution within the NHS fleet 
  • Action on screening and vaccination inequalities 
  • £30M for rough sleeping initiatives 
  • Additional NHS gambling clinics 
  • Important focus on children and young people, cardiovascular disease, musculoskeletal disease, mental health and falls prevention.  
  • Alcohol care teams to be developed in collaboration with local authority commissioners. 

We welcome too the strong focus on smoking; but this, and in fact every commitment above, needs to be done in collaboration with LA commissioners.  

Our members are less welcoming of the doubling of the Diabetes Prevention Programme, and I’m sure could have found a more effective use of the £105m already invested in it. 

The press release on the NHS Plan’s commitments on alcohol and tobacco preceded the full plan by two days. We responded positively to this as they heralded the good intention for the NHS to do more to prevent modifiable factors damaging patient’s health. However, we waved three red flags of concern – the plans were ‘undeliverable’ without a good spending review settlement for public health; bold national policy change is needed to address the social determinants of health; and thirdly, the NHS needs the support and contribution of local authorities and the Director of Public Health to deliver the plans efficiently – we need to operate as a public health system.  

Cuts are the issue – more restructuring is not the solution 

But let me turn to some of the disappointing aspects of this plan. Imagine our surprise when the full NHS plan arrived the day after our welcome with the proposal to: ‘consider the potential for a stronger role for the NHS in commissioning sexual health services, health visitors, and school nurses, and what best future commissioning arrangements might therefore be.’ 

Unacceptably, ADPH was neither involved nor informed about the inclusion of a review of our commissioning responsibility – by NHSE, another public sector commissioner. At best this is a well-intentioned but extraordinarily ham-fisted effort to deal with public sector funding cuts – at worst, it is an unwelcome distraction from cross-sector collaboration to manage those cuts to ultimately improve citizen’s health and wellbeing. Cuts are the issue – restructuring is simply not the solution.  

Fighting among ourselves will deliver a worse outcome; how you do things does matter. So in that spirit, and for the NHS’ own good, we’re pushing back and saying there can be no review of the commissioning of public health services without the full involvement of Directors of Public Health. Reviewing what we do can be productive in illuminating areas for improvement – and we would support a review which looked at how public health services could be sustained and improved.  

I have raised our concerns with DHSC and have been reassured that they want to work closely with ADPH and public health stakeholders on this review. 

System challenges 

Austerity has been a major driver of change for over a decade. In part it has driven necessary transformation and efficiencies within public services; but for the most part, it has driven unnecessary demands on those services and arguably is now costing the government more than it is saving – as well as leading to all sorts of distortions within the public sector. Indeed problems which properly funded public health teams could prevent are now being displaced to the NHS, with avoidable extra cost. 

It was within this challenging context that public health moved from the NHS to local government in 2013. The case for the transfer of public health responsibilities remains unchanged – indeed we would argue, it is stronger than ever. Directors of Public Health are providing leadership and expertise to tackle the social determinants of health and deliver strong place-based population health approaches – as well as leading the transformation of those services we’re responsible for commissioning – substance misuse, sexual health, 0-19 year old’s health and wellbeing.  

There is much more to public health than the NHS – the Clean Air Strategy published this week has significant roles for local government and the Serious Violence Strategy advocates a public health approach. We need to challenge this default ‘NHS first’ logic if we are to build a truly preventative system. 

Public health commissioning has delivered improved outcomes 

The completely false presumption in the Long Term Plan is that council commissioning is delivering worse outcomes. This is simply not true. It is not borne out by outcomes data. There are several national reports that show local government has been successful in delivering services under difficult circumstances and has prioritised increasingly scarce resources effectively.  

We’ve brought new energy and rigour to the commissioning of these community services, often transforming who delivers them, where and how, making integration and partnership-working real – and, in the context of rising demand and huge cuts, largely delivering good outcomes. Redesign in many areas has focused on integration – integration with other public services, such as criminal justice, adult services, children and young people services; and integration across the wider health economy. It has also looked to commission the community and voluntary sectors and to increase social value through its contracts.  

‘Be careful what you wish for…’ 

When public health was in the NHS, we know that the funding for prevention was always on a shaky footing – there in good times, the first to go in difficult. This was also true of the funding of many non-acute, preventative community services, including those now commissioned by local government. As Jim McManus has blogged: ‘it was not better in the glory days’. We inherited long-standing challenges – from the underfunding of school nursing and fragmentation in health visiting, including poor links with GPs – to overly medicalised and expensive sexual health services, or drug services focused on clinical treatment and not yet recovery; and Directors of Public Health have worked hard to innovate and introduce new models to deliver improved outcomes for less. Local authorities have also taken some decisions that the NHS could not or would not make.  

In December 2018, our successful ADPH conference focused on ‘disruptive leadership’ – the kind of leadership that understands that improving outcomes often needs challenge and change, that isn’t afraid of challenging ‘the norm’ to enable innovation, and that knows how to be pragmatic and savvy while doing this. This is the kind of leadership that we so desperately need in the public sector – leadership to enable the reforms needed to better serve a population with changing needs and expectations.   

But commissioning can be a thankless task; with a focus on improving population outcomes with efficiency, it’s not often that providers thank commissioners for their efforts. It can lead to experienced professionals being asked to do things differently, or to change a service skill mix or integrate with other providers, or to change the location or mode of the service to make it more accessible for residents and patients. Often, the best innovation comes through commissioners and providers working in creative tension together – and there are very many examples of this leading to fantastic services.  

Joint commissioning of local health and care services in integrated care systems is becoming increasingly important to enable local government and the NHS to shape effective services – and indeed is already happening in many areas. 

It’s time to work as a system. With each part funded appropriately and sustainably. We will focus on articulating that. We all need to join together and end the unhelpful “us and them” discourse. 



ADPH Press Release: Investment in public health is vital to stop the growth of drug resistant sexually transmitted infections

January 10, 2019 in ADPH Updates, Policies, Sexual and Reproductive Health by Lucy Sutton

Attached is a press release from the ADPH in response to the new cases of drug resistant sexually transmitted infections. The statement was published on 10th January 2019.

143 KBThe Association of Directors of Public Health – Response to drug resistant STI cases Jan 2019