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ADPH System Survey 2019 Report

November 22, 2019 in ADPH Updates, PH System, Publications by admin

This summer, we conducted a survey of Directors of Public Health (DsPH) in the UK to gather their thoughts and experiences on a range of challenges and opportunities facing public health.

The survey was open throughout June and July to full members, including DsPH from the devolved nations. A total of 99 responses were received, the vast majority from England (representing 72% of English members). We were pleased to receive some input from the devolved nations and have highlighted responses that include their feedback.

Key findings are presented below. You can also view and/or download the report here: ADPH System Survey 2019 Report (PDF, 236KB)

Key Findings

  • 74% of respondents had substantive appointments (78% in 2017). There were 20% of respondents in an Interim or Acting role. Six said that their LA had not had a substantive DPH for more than a year and a further seven for more than six months, which is unchanged from 2017. 6% responded ‘Other’ due to differing local arrangements.*
  • Asked where they see themselves in 12 months, 80% said they would still be a DPH locally (85% in 2017) with only three saying that they would remain working within Public Health but not locally.*
  • Falling trend of DsPH reporting either directly to their CEO or equivalent or to a super director. This year it was 67%, down from 69% in 2017, and 73% in 2015. However, this masks a web of complex arrangements where line management does not necessarily reflect access, influence or accountability.
  • An increasing number of DsPH are taking on additional responsibilities. 53% manage other council services like adult social care, community development and leisure. Despite the time pressure, these extra roles are overwhelmingly regarded as positive, offering increased influence and credibility.
*includes responses from devolved nations
  • Just 55% of DsPH said they had sufficient access to data, down from 60% in 2017. Ongoing issues with access to NHS data, insufficient data sharing agreements and delays in intelligence sharing were highlighted as particular barriers.
  • DsPH have healthy and increasing levels of influence within local authorities. 97% said they had direct access to their CEO (up from 94% in 2017) and 99% said they had sufficient access to councillors. A greater number of DsPH reported having day-to-day control of the public health budget (96% from 88% in 2017). This likely reflects new arrangements strengthening the role of DsPH in signing off public health budgets.

“I have control of most of the public health grant, although approximately 22% is earmarked for ‘wider determinants’ work. I am working on my influence on this section of the budget.”

  • While the number of DsPH who said they were a standing member of their LA’s most senior corporate management team (CMT) increased slightly (60% from 57% in 2017), it is still low, particularly in comparison to other influencing measures.
  • DsPH have varying levels of satisfaction with key partners in the system. Their most positive relationships are within Local Authorities, with Directors of Adults Social Services (99% positive), Directors of Children’s Services (89% positive) and relationships with other LA directorates (88% positive).
  • Relationships with CCGs are improving: 83% felt positive about it, an increase from 2017 (79%). However, relationships with NHSE continue to be weak – just 27% felt positive about it (no change from 2017) and a greater proportion felt negative (26% from 15% in 2017).
  • Feelings aren’t as strong for the role of PH in their local ICS process (68% positive) and local integration process (65% positive). However, these are an increase from 2017, when 60% felt positive about the role of PH in STPs, and 53% felt positive about their role in the integration process.
  • Relationships with PHE Centres show a significant drop – 76% felt positive about it, compared to 87% in 2017. Comments about the added value of PHE Centres echoed those of the 2017 survey. Relationships with Centres are hugely variable and dependent on local relationships. Issues mentioned continue to be around duplication of work, an imbalance between local and national jurisdiction, and a lack of understanding from PHE Centres of the local government context.
  • Health Protection continued to be the most valued service provided by PHE Centres, closely followed by Knowledge & Intelligence services. Advice and support, including opportunities for professional development were also valued.
  • With respect to the impact of cuts locally to service, the most commonly redesigned service in the last three years was sexual health services. Less than 2% of those that had redesigned their service reported that the change had a negative impact. The other most commonly redesigned services were health visiting and school nursing.
  • Public health advice within councils was the most common function to have increased in provision over the last three years. Looking ahead, the services most commonly reported to be undergoing redesign over the next three years were health visiting and school nursing.
  • 56% negatively regarded the removal of the PH grant ring-fence. This masked a variety of reasons including concern that it could lead to further cuts as funding would be diverted to other competing priorities, and concern that funding may not be made available beyond the spend for statutory services. The impact would largely depend on the status of public health locally. Feelings towards the removal of the ring fence were also largely dependent on whether appropriate assurances (e.g. minimum spend on public health) and monitoring will be in place.
  • With the introduction of Business Rates Retention (BRR), opportunities DsPH highlighted included the potential for greater local flexibility and the potential to influence the wider Council budget and introduce a health in all policies approach within LAs. The main challenges reported, were around the potential for further cuts to public health funding, as well as the potential widening of inequalities.

“Opportunity to reprioritise our spend towards prevention as we shift to stronger local decision making.’’

“Opportunity to build ownership in the authority for health improvement.’’

  • DsPH were asked how they would like to see currently mandated functions changed in the future. Notably, Heath Checks had the least support from DsPH for continued mandation, with 54% of respondents saying they wanted to see no mandation of the function.
  • Health Protection, Sexual Health and 0-5 public health services received positive support for mandation to either stay the same or become more detailed.
  • With the Spending Review due to take place next year, DsPH were asked what their priorities for investment were, aside from public health. Nationally, poverty, early years, and education and skills were the top three priorities for DsPH. Early years, social care and housing emerged as the top three priorities locally.
*Includes responses from devolved nations.
  • Policies that received high levels of support from respondents included:
    • introducing a child poverty strategy with binding national targets to reduce child poverty (86% supported)
    • reducing promotions of foods that are high in fat, sugar and salt (85% supported)
    • introducing of a minimum price of 50p per unit of alcohol (83% supported)
    • prioritising active travel in transport policy and continued investment in infrastructure for active travel (81% supported)
    • amending licensing legislation to empower local authorities to control the total availability of alcohol, gambling, junk food outlets (80% supported)
    • implementing a tax or levy on tobacco manufacturers to help cover the cost of smoking to the NHS and wider society (73% supported)
  • Increasingly DsPH support the use of vaping as an aid to quit smoking with 75% of respondents supporting the use of e-cigarettes in smoking cessation services.
  • DsPH were asked what other policies they thought were needed to promote longer, healthier lives. Key themes that emerged from responses were the adoption of a health in all policies approach; move towards a budget for wellbeing; focus on population level policies which address the root causes of poor health and tackle health inequalities.
*Includes responses from devolved nations.
There is a lot more detail in the survey responses which ADPH will use to both tailor our offer to members and inform our policy and influencing work. We also make the following recommendations and commitments:  
  • Continue developing support for DsPH with expanded portfolios, to include facilitating networking with colleagues with similar portfolios and sharing good practice about matrix working.
  • Improve access to data and data sharing. ADPH will continue to work with partners including the NHS to ease pathways and develop processes that support improved and timely data sharing.
  • DsPH, as frontline leaders of public health should have a place at top level discussions and decision making. We will keep building and promoting strong relationships across the NHS, local government, public health, and voluntary and community sector to facilitate this.
  • Increased local investment in early years, social care and housing. ADPH will work more closely with key partners, including our counterparts in adult social care and children’s services - to make a stronger case collectively for this.
  • Prioritise national investment in early years, education and skills and tackling poverty. We will focus influencing work on making the case and engage with key stakeholders to support this call.
  • Introduce key public health policies supported by DsPH including binding national targets to reduce child poverty, introduction of a 50p minimum unit price for alcohol and taxing tobacco manufacturers to help cover the cost of smoking to the NHS and wider society. Further information about these and other public health topics can be found in ADPH’s policy positions.
  • Continue to promote a health in all policies approach whether from within local authorities, the NHS or across other public health services.
  • Concerted action to address the wider determinants of health and a move towards building wellbeing into the fabric of Government decision making – both in terms of policy development and funding allocation.
Additionally, in England:  
  • Work with PHE and PHE Centres in England to foster stronger and more productive working relationships, understanding of the local government context and avoid duplication of work.
  • Continue to work to improve links with NHS nationally and locally.
  • Engage with Directors Public Health on BRR reform in England to ensure that appropriate assurances are put in place to support local authorities carry out their duty to improve and protect population health.
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A Manifesto for Public Health

November 22, 2019 in ADPH Updates, Publications by admin

The state of health in the UK

The health and wellbeing challenges we face today are clear. While people are living longer, the number of years that they do so in good health is deteriorating, and health inequalities are increasing . People in the wealthiest areas of the country can expect to live 19 more years in good health, compared to those in the poorest.

Although the adage ‘prevention is better than cure’ is once again in ascendency amongst politicians and policy-makers, action and investment consistently fall short of what is needed. For too long, Government spending has focussed on treating illness, rather than keeping people healthy and preventing problems from arising in the first place.

This short-term strategy does little for the health of our nation. The potential of too many people and places is unfulfilled, hindering our economic success and putting a huge strain on our communities and public services.

Our health and wellbeing depends on many different factors.

A small proportion – just 10-20% – is determined by access to traditional health services, like the NHS. The remainder is shaped by the economic, social and environmental conditions of our lives: such as our income, the education we receive, the housing we live in, the transport we use and the air we breathe.

We need a long-term plan to address the root causes of ill health.

The health of the people is the highest good

Creating a society in which we can all be as healthy as possible, for as long as possible must be the fundamental mission of any Government. The Association of Directors of Public Health is calling for health and wellbeing to be the next Government’s top priority.

Below we set out the contribution we will make, as well as our asks of the future UK Government.

The role of Directors of Public Health

Directors of Public Health are ambitious about protecting and improving public health locally and nationally. We believe in the power of a genuine ‘public health partnership’ between the UK Government, the devolved nations, the NHS, local government, charities, professional bodies, businesses and individuals to make this happen.

To achieve this vision, we will:

Provide local place leadership on wellbeing and inequalities.

As independent advocates for public health, with unique knowledge and expertise about our populations, Directors of Public Health will promote health and wellbeing in all policies across local public services, from councils to the NHS to the police.

Deliver efficient and effective services.

Directors of Public Health have reformed services and achieved good outcomes and will continue to do so, despite what is an increasingly unsustainable balancing act. For example, in England, The Public Health Outcomes Framework (PHOF) tracks 112 health indicators. In the last six years, 80 percent of those have been level or improving ; notable, particularly as they have been achieved in a context of year-on-year cuts to the Public Health Grant.

Work collaboratively on joining up services and promoting population health.

Directors of Public Health are committed to working with local and regional NHS and local authority colleagues to ensure integrated pathways between the public health services provided in hospital settings and those offered in the community (e.g. stop smoking and alcohol treatment services); and to ensure that all parts of the health and social care system are focussed on population health outcomes.

Support efforts for healthy public policy at a national level.

As the national voice for Directors of Public Health, the ADPH will play its part in developing and promoting good policies across key agendas like early years, violence prevention, sexual health, alcohol and drug treatment, obesity, smoking cessation, mental health, healthy economic growth and air quality. We will work constructively with Government departments and agencies, professional bodies, commissioners, charities and other partners to implement approaches that work for our communities.

The change we need nationally

Improving the nation’s health requires a bold vision, strong leadership and political will. We ask the next Government to:

Make wellbeing a cross-government ambition.

Wellbeing should be built into the fabric of Government decision-making when it comes to both policy-making and funding allocation. Wales has already made a vital step towards realising this ambition, through the introduction of the Future Generations Wellbeing Act . Similarly, in Scotland, there is now a vision for national wellbeing in the form of the National Performance Framework . These efforts must be matched in England – the proposal to create a ‘health index’, alongside existing wellbeing data collected by the Office for National Statistics, could provide a framework to drive change and embed accountability across Whitehall.

Deliver a multi-year funding settlement for public health.

More investment is urgently needed in public health and prevention. In addition, further investment is needed across a wide range of policy areas including housing, transport and welfare to tackle the root causes of ill health. The ADPH supports the call from the Health Foundation and The King’s Fund for at least £1 billion more a year for the Public Health Grant in England.

Take a whole system and place-based approach to health inequality.

This includes wide-ranging action on the social determinants of health (including housing, the environment and skills), as well as acting on health inequalities caused by the commercial determinants of health such smoking, alcohol use and obesity, expanding the use of the ‘Polluter Pays’ principle.

Set binding national targets to reduce child poverty.

Poverty is the most significant determinant of children and young people’s health in the UK. Currently, 4.1 million children in the UK are living in poverty .

The Association of Directors of Public Health is excited about the opportunity to work with the next Government, other political parties and stakeholders to protect and improve public health in the years ahead.

Email to get in touch with the Policy team

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LGA/ADPH suicide prevention SLI programme

October 9, 2019 in ADPH Updates, Mental Health, Publications, Sector Led Improvement by admin

The LGA and ADPH are pleased bring to your attention the suicide prevention sector led improvement programme prospectus. The following support is available 2019/20:

  • National: a series of tools, products and events designed to provide wider and easier access to the good practice, learning and existing resources. This includes a series of webinars and a masterclass in Spring 2020.
  • Regional: grant funding allocated to ADPH networks to build on and support regional suicide prevention SLI activity
  • Local: bespoke expert support for up to twelve local authorities and partners who self-identify as facing significant delivery challenges locally around suicide prevention.

This prospectus provides more detail on each of the elements.

Expressions of interest in bespoke support are now open, closing 5PM 1st November 2019. The two-page-long submissions should cover the following two areas:

  1. Describe the suicide prevention delivery challenge to be explored by the bespoke support
  2. Provide evidence of local need

If the number of expressions of interest exceed the current level of support, priority will be given to areas whose significant local challenges would not be successfully addressed by other elements of the programme, in conjunction with the two elements set out above. Further details of each aspect can be found in the attached prospectus and on the website:

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What Good Looks Like

June 28, 2019 in ADPH Updates, Children, Young People and Familes, Obesity, nutrition and physical activity, Publications, Sector Led Improvement, Tobacco by admin

The Association of Directors of Public Health (ADPH) and Public Health England (PHE) have co-produced a series of ‘What Good Looks Like’ (WGLL) publications that set out the guiding principles of ‘what good quality looks like’ for population health programmes in local systems.

The WGLL publications are based on the evidence of ‘what works and how it works’ including effectiveness, efficiency, equity, examples of best practices, opinions and viewpoints and, where available a return on investment.

Each publication sets out the guiding principles of what good quality looks like for population health programmes in local systems and aims to be a practical resource for leaders and practitioners in the public health system in England.

The publications are not perfect standards, nor are they intended to be compared against as a performance management tool. They are intended as a tool in assist in the sector-led improvement (SLI) process and to support local resource decisions. Some ADPH networks are developing
specific SLI tools from them and we would encourage others to take up that opportunity.

The WGLL publications will be a repository for evidence and a resource for good quality practice from the essential to the transformational which professionals can dip in to when reviewing their own practice, setting up peer challenge or transforming services.

The initial series will include ten publications covering a range of topics across public health. They will be iterative, with regular reviews and updates when new evidence and insights emerge. The intention is to add to the ten WGLL publications with additional topics to create a rich and good quality resource.

Comments on the publications and particularly any ways in which they could be developed or improved are welcome. Please share them with us, or through the PHE Knowledge Hub.

What Good Looks Like publications

Click to download a PDF of the publication. New publications will be added as they are released.

Visit K-Hub to see publication updates, case studies and view and submit comments.

Annual Review 2018-19

May 28, 2019 in Annual Reviews, Publications by Teresa Grandi

ADPH Policy Positions

December 19, 2018 in Active Travel and Physical Activity, ADPH Updates, Air Pollution and Climate change, Alcohol and Drugs, Built Environment, Children, Young People and Familes, Commercial Determinants of Health, Health and Social Care Services, Housing, Integration & Devolution, Mental Health, Obesity, nutrition and physical activity, PH Funding, PH System, PH Workforce, Policies, Policy Statements, Publications, Sexual and Reproductive Health, Sustainability and Climate Change, Tobacco by Lucy Sutton

In November 2017, ADPH published a series of policy position statements on eight key topics alongside a narrative document exploring roles and enablers within the public health system. These position statements have since been reviewed and updated.

These statements bring together the views and recommendations of our members on eight key public health topics: outdoor air quality, alcohol, tobacco, drugs, obesity, sexual health, housing, and mental health. The narrative is a collation of existing ADPH publications and views from the membership with key recommendations to ensure the public health system is fit for the future.

These statements will help us to drive our policy work forward and push for our members’ recommendations in all the policy work that we do.

If you would like to discuss anything in these documents please do contact the ADPH Policy Team by emailing

424 KBADPH – Narrative on the UK Public Health System (2019)

276 KBADPH Policy Position – Air Quality (2019)

281 KBADPH Policy Position – Alcohol (2019)

299 KBADPH Position Statement – Drugs (2019)

396 KBADPH Policy Position – Housing and Health (2019)

312 KBADPH Policy Position – Mental Health (2019)

287 KBADPH Position Statement – Obesity (2019)

324 KBADPH Policy Position – Sexual Health (2019)

288 KBADPH Policy Position – Tobacco (2019)

Providing A Lifeline: Effective Scrutiny of Local Council Strategies to Prevent or Reduce Suicide

November 2, 2018 in ADPH Updates, Mental Health, Publications by Lucy Sutton

The Centre for Public Scrutiny, the Local Government Association and ADPH have published the report ‘Providing a Lifeline: Effective Scrutiny of Local Council Strategies to Prevent or Reduce Suicide’. The publication looks at effective scrutiny of local strategies to prevent or reduce suicide, focusing on context and relevance for scrutiny, quality improvement and the role of scrutiny and provides 10 questions for scrutiny committees to ask. 

The publication can be viewed here.



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Sector-led improvement in public health: Progress and potential

October 26, 2018 in ADPH Updates, Publications, Sector Led Improvement by admin

Embedding SLI in public health has become a real collaboration between partners. The LGA, ADPH and PHE are working together to support its development at regional, national and local levels. You can view the most recent joint publication here.

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Tackling alcohol, challenging the norm

September 28, 2018 in ADPH Updates, President's Blog, Publications by admin

I remember arriving in the UK as a Junior Doctor to work in the NHS in the mid-90s. The nurses were my new friends, and I used to join them at 9pm post shift for a crawl down the Derby Mile.

The bigger the group, the more the rounds to be gotten through before the 11pm closing hour bell rang. Then curry and Cobra at the end. Not something I had known before, but seemingly commonplace and well, normal.

I jumped into my new social scene with gusto, before long exceeding any recommended unit count, and rapidly putting on weight. A trip back home allowed for a welcome detox and sensible reflection and resolve.

Drinking too much. So easily done when it’s so normal.

The normalisation of harmful heavy drinking

Around that time, there seemed to be an explosion of new product development, new marketing approaches, new ‘normal’ ways of drinking – I remember the bursting onto the stage of alcopops, the surge of stag and hen dos, the creative, free-flowing Happy Hour promotions …

Licensed premises have exploded in numbers since 2005/6 – in my borough, there was a 41% increase. Schools and even hairdressers joined the corner stores and 24 hour pubs.

Since 1970 the amount of alcohol consumed per person has risen by 50% in the UK. Over that period alcohol has become relatively cheaper and more readily available. Alcohol is aggressively and expertly marketed and drinking has become a normal feature of everyday life.

Alcohol can play a positive social and economic role – and the large majority of people enjoy alcohol without harm. However, excessive alcohol use can have a harmful effect on individuals, their families and our community. The number of alcohol-related admissions to hospitals in England has risen yet again, with middle-aged drinkers most likely to be admitted, according to new Public Health England figures. We know we need to do something.

Navigating new approaches to population health

We know that public health issues such as these are too complex for a business as usual approach. We do need to challenge our own thinking and innovate – while developing, and keeping an eye on, the evidence of what works.

Partnering with Drinkaware could be just such a shift. However major changes in approach need careful consideration – a precautionary approach. The Alcohol Leadership Board should have been a place to talk this through with experienced and knowledgeable people.  The ADPH was therefore disappointed at PHE’s independent decision to collaborate with Drinkaware which has led us to a place where we, as a public health system in the broadest sense, have been, in effect, arguing publicly. And sadly, it is likely that this will lead to further confusion for the public around the actual messages about alcohol harm.

The key point is that alcohol is produced for profit. The more that is sold, the greater the profit. The industry spends billions creating new markets, promoting its product and lobbying for favourable business conditions. It spends some on corporate social responsibility (CSR).

A critical review in the latest (Sept) edition of WHO’s Public Health Panorama: Alcohol industry actions to reduce harmful drinking in Europe: public health or public relations? concluded that CSR activities conducted by the alcohol industry in the WHO European Region ‘are unlikely to contribute to WHO targets but may have a public-relations advantage for the alcohol industry’.

And we can all now quote the evidence review produced by PHE (2016) which demonstrated that education campaigns on their own, and particularly those with industry involvement, will not reduce alcohol harm.

These are some of the reasons why the public health community has a healthy scepticism of all things alcohol industry. As we noted in last week’s BriePH (the regular briefing for Directors of Public Health), ADPH has a clear Ethical Collaboration and Sponsorship Policy which sets out that the ADPH ‘will not work with, or accept donations from, organisations whose activities, policies, aims or objectives contradict or are inconsistent with its own’ – this includes partnerships with organisations involved in tobacco or alcohol manufacture. We regard Drinkaware as being too close to the alcohol industry. ADPH remains a member of the Alcohol Leadership Board. But we believe partnering with Drinkaware as they currently stand is unethical.

Missing the value DsPH can bring

I’m sure many of us can tell our own stories of how ‘normalised’ high risk drinking is in our communities and boroughs.

Directors of Public Health recognise that nationally developed social marketing campaigns such as the ‘One You’ have their part to play – and many have adapted these locally. Linking the One You brand with the Drinkaware campaign – without DsPH having any input – may adversely affect these local efforts. And declaring the campaign is ‘where the people are’ forgets that DsPH work closely with elected members and local residents. To some of us, it’s unhelpful and galling.

There is much work to do to reduce the harm. Minimum Unit Pricing, Health as a 5th Licensing Objective, adequate funding of treatment and recovery services and a levy on alcohol driven business to support the cost to councils and police of keeping safe and clean town centres are all part of that. The ADPH is committed to working with, challenging and supporting partners in the public health system – including PHE – to make sure we unite behind efforts known to have impact.

Making measles history together: resource for local government

September 25, 2018 in ADPH Updates, Health Protection, Policies, Publications by Lucia Lucas

ADPH have endorsed PHE’s new measles guidance report for local government which was published on the 11th of September 2018.

Read the report here.