Public Health Commissioning Intentions

Purpose

This document sets-out the commissioning intentions for Norfolk County Council (NCC) in relation to its Public Health services for the financial year 2024/2025. 

Context

The Health and Social Care Act 2012 (effective 1 April 2013) gave upper tier local authorities duties both to improve the health of their populations as well to directly deliver, or arrange the provision of, some specialised healthcare services that previously had been the responsibility of the NHS. There is a requirement to appoint a Director of Public Health (DPH), who as a statutory chief officer holds a leadership role spanning health improvement; health protection; and public health support to NHS commissioning bodies.

Through the Department of Health & Social Care (DHSC), LAs receive a ring-fenced public health grant to fulfil these duties, which includes a series of mandated functions:

• Steps must be taken to protect the health of the local population
• Providing NHS commissioners with the specialist public health advice they need
• Providing or arranging the provision of a range of services, namely: 0-5 public health services (Health Visiting), the National Child Measurement Programme (NCMP), open-access sexual & reproductive health services, and NHS Health Checks.

National context

Following publication by government of the public health grant allocation in England in 2023/24 on 14 March 2023, The Health Foundation published the following Public health grant, in which it uses the GDP deflator published by the OBR in March 2023 as its baseline.

• The public health grant has been cut by 26% on a real-terms per person basis since 2015/16
• Additional but time-limited funding for drug and alcohol treatment has been allocated to local authorities. Taking account of this additional spend leaves broader public health funding 21% lower on a real terms per person basis since 2015/16
• Some of the largest reductions in spend over this period were for stop smoking services and tobacco control, falling by 45% in real terms, as well as drug and alcohol services for adults (17%) and sexual health services (29%)
• Poor health is strongly associated with living in socioeconomically deprived areas. A girl born today in the most deprived 10% of local areas is expected to live 19 fewer years in good health than a girl born in the least deprived
• However, real-terms per person cuts to the grant have tended to be greater in more deprived areas. In Blackpool, ranked as the most deprived upper tier local authority in England, the cut to the grant (including new drug and alcohol treatment funding) has been one of the largest - at £33 in real terms per person since 2015/16
• Local authority public health interventions funded by the grant provide excellent value for money, with each additional year of good health achieved in the population by public health interventions costing £3,800. This is three to four times lower than the cost resulting from NHS interventions of £13,500

A number of public health commissioned services are delivered by NHS organisations with their employees paid through the nationally negotiated Agenda for Change mechanism.

With a 2023/24 settlement achieved, consisting of a non-consolidated award for 2022/23 (with national eligibility for staff directly employed by NHS organisations for example permanent and fixed term contracts as of 31 March 2023); and a consolidated pay award for 2023/24 worth an average 5.2% for staff on AfC terms, shortly after publication of the 2023/24 public health grant allocations information was relayed to local authorities that they would need to manage the incremental cost burden of this on NHS delivered services from within their allocations (in previous years additional funds had been provided directly to NHS organisations towards meeting incremental pay costs).

Subsequently, on 28 June 2023, the Department of Health & Social Care wrote to the Chairman of the Local Government Associations Wellbeing Board and the President of the Association of Directors of Public Health to say that an uplift to ICB allocations would be made "to fund the additional cost impact of the AfC pay award", with an expectation that as a result "Local Authorities should not expect additional in-year costs related to the pay award from NHS providers to be passed to them ".

The financial year 2024/25 will mark the third and final year of the governments published spending plans as issued on 27 October 2021 following completion of the Comprehensive Spending Review 2021 (SR21).

Following the publication of SR21, on 1 April 2022, OHID announced that the announced "... additional funding for local authority commissioned adult tier 2 behavioural weight management services... will not be available in the financial year 2022-23". Subsequently these funds were not made available in 2023/24 either.

On 4 October 2023 the Secretary of State for Health and Social Care wrote to Directors of Public Health announcing the "governments historic plan to create a smokefree generation". This includes investment of an "additional £70 million a year over the next five years (2024/25-2028/29) to expand locally delivered and cost-effective services".

Norfolk context

Norfolk Public Health is also responsible for commissioning drug and alcohol services, school-based health provision (excluding vaccination programmes), and lifestyle services such as smoking cessation, weight management, and suicide prevention programmes.

NCCs public health grant for 2023/2024 was £43,639,932, or £46.60 per head of population (estimated at 936,363); an increase in funding of 3.3% in cash terms, but only a 1.9% on a funding per head of population basis.

As of October 2023 it is not possible to state the value of the public health grant to NCC in 2024/2025, however for the first time ever government published indicative figures for the next financial year. For Norfolk these indicative values are a public health grant allocation of £44,214,977, or £46.90 per head of population (estimated at 924,255). Were these figures to be subsequently confirmed, it would make an increase in cash terms of 1.3%, whilst when equated to a per head of population investment the increase would be just 0.6%.

A Commissioning Work Programme for 2024/2025:

Our 2024/25 commissioning intentions reflect the need to further develop the programmes we commission. In relation to investment in public healthcare services, though the national context set-out above has been one of change and uncertainty, locally we continue to be in a position of stability both in terms of our funding levels and commissioning infrastructure.

Indeed, as a result of various additional grant awards and a series of strategic investment decisions, Norfolk County Council will be increasing its public health associated budgets over and above the rise in the allocation values of the core public health grant in 2024/25.

Key to ensuring maximum impact is achieved from public health investment is our part in the emerging Integrated Care System in Norfolk. We have already established a number of joint commissioning approaches to care including aspects of women's health, mental health & wellbeing, and smoking cessation; and we will enter into new initiatives throughout 2024/25.

Norfolk Public Health's Place & Community team will develop and embed a Work and Health Programme, and further their already established work focusing on how Partnerships can support improvements to local populations health, and promotion of and access to our public health commissioned services.

A priority reflected through these commissioning intentions is a desire to gather the views of those eligible to benefit from our commissioned services, but who are not currently engaged; to understand what barriers are being perceived and/ or experienced that may be deterring people from accessing the care and support we are procuring on their behalf.

Finally, we committed in 2023/24 to undertaking a series of strategic reviews; ensuring our future services are designed to best meet the needs of communities, families, and individuals requiring them.

These have been completed and having begun preparations to secure the best placed providers to deliver to the needs of our populations over the years to come, we will see through a programme of procurement activities during 2024/25 and support the associated changes in service offer and entry of new providers to our County.

Though not an exhaustive list, some additional key drivers to our future work are listed here:

• From Harm to Hope: A 10-year drugs plan to cut crime and save lives
• Family Hub and Start for Life Programme
• Towards Zero: the HIV Action Plan for England
• Women's Health Strategy for England
• Suicide Prevention Strategy for England: 2023 to 2028
• Major conditions strategy: case for change and our strategic framework - GOV.UK

Locally there will also be several key initiatives that have a bearing on our priorities and approaches, examples being:

• Ready to Change, Ready to Act: Norfolk County Council Public Health Strategic Plan
• Ready to Change: Your Way to Better Health
• Flourishing in Norfolk (PDF) [4MB]
• Better Together, For Norfolk (PDF) [9MB]
• Transitional Integrated Care and Strategy and Joint Health and Wellbeing Strategy (PDF) [3MB]

Our now established approach to performance management will be utilised in order to:

• Develop further our work to date with providers to embed user voice as part of routine quality and impact monitoring; becoming a key driver of continuous improvement
• Implement our quality assurance framework to further enhance our understanding of service performance
• Review existing practices to ensure compliance with the Commercial Continuous Improvement Assessment Framework (CCIAF).

We will work to consolidate the progress made with provider partners and wider stakeholders in order that we:

• Digitise and modernise our services, including work in recognition that new systems and services are likely to include an element of AI as functionality in the future
• Embed a continuous improvement approach, through an increasing expectation and obligation on our commissioned providers and ourselves towards hearing the voice of service users and Norfolk’s residents; and reflecting back in service design the impact of their views
• Better align the design and targeting of our commissioned service delivery models with the identified public health related priorities of our District Councils.

Norfolk Healthy Child Programme (HCP)

(A combination of services and partnership approaches to improving the health & wellbeing of children and young people) and Healthy Child Service (integrated provision for all 0–19-year-olds, and their families and carers in Norfolk, offering services including health visiting, school nursing, the family nurse partnership and our Just One Norfolk health resource website).

During 2023/24 we worked to review and update our vision for both the Norfolk Health Child Programme (HCP) and the core public health commissioned provisions of the Healthy Child Service.

Following on from this, during 2024/25 we will:

• Work to embed changes to our Healthy Child Service model, following our strategic review, ensuring alignment to the Norfolk family hub approach and school zones. As a result HCS staff will be core to the wider system delivery of meeting the health and care needs of our children and young people
• Enhance and expand the Healthy Start Vitamin provision for mothers and their newborns through our HCS service
• Work to ensure a blended workforce approach is implemented in the delivery of our services, aligning the skill mix of staff with HCS learning from national pilot work and a shared carer pathway
• Work to reshape children’s Tier 2 weight management services, taking a whole pathway approach in partnership with providers, commissioners and other key stakeholders on this
• Lead and learn from the Flourish schools survey about the public health and wellbeing needs of children and young people and use this to help inform and influence the planned work outlined
• Develop our Healthy Child Programme partnership approach, ensuring this aligns with wider children and young people’s partnerships in Norfolk and adds value to this
• Further review and consider, alongside our ICB colleagues, how oral health promotion for children & young people can be enhanced
• Learn from the emerging evidence base in relation to young people’s behaviours in relation to smoking and vaping; working with key strategic partners to ensure that children & young people receive clear guidance and education in relation to the health and other risks.

Young People’s Drug and Alcohol and Affected Others services

Offering specialist support, advice and information for CYP using substances themselves, as well as those affected by someone else's substance misuse).

• Work to implement and embed the revised service model, commissioned in 2023/24 following completion of our strategic review, ensuring effective transition and supporting the enhanced service offer to be realised
• Develop the wider children & young people’s drug and alcohol partnership approach; ensuring a shared system response to the needs of children & young people with drug and alcohol related needs in Norfolk.

Other

We will continue to embed Flourish, Norfolk’s partnership strategy for children and young people based on the Flourish ambition, across our commissioning activities, and provide evidence of impact on related public health outcomes.

NHS health checks

(A health check-up for adults in England aged 40 to 74, designed to spot early signs of Cardiovascular Disease (CVD) stroke, kidney disease, heart disease, type 2 diabetes or dementia).

• Continue to work with Primary Care to support them to deliver NHS Health Checks, including working with the LMC and LPC
• Implement NHS Health Check Training for practitioners in Norfolk, influenced by the outcome of a Training Needs Analysis being completed in 2023/24
• Implement recommendations and findings from our 2023/24 evaluation of the effectiveness and impact of our catch-up and health & wellbeing support programmes
• Continue to deliver on the ambitions set-out in our NHS Health Check Improvement Programme, to increase overall numbers receiving an NHS Health Check, particularly amongst those with the highest need and greatest disparities.

Stop smoking services

(Practical and treatment support to aid quitting smoking through accurate information and advice and through individual support by expert advisers providing a range of proven evidence-based interventions and community pharmacies).

Norfolk County Council public health will continue to invest in stop smoking and tobacco control services, with particular focus on:

Overarching developments

• Commission and embed an increasing range of stop smoking initiatives and interventions in response to evolving national policy, increased government investment, and aligned to local need
• Working with the Norfolk & Waveney NHS ICB to develop a robust system and service offer in Norfolk that includes implementing the commitments of the NHS Long Term Plan, including supporting pregnant women and patients with Serious Mental Illness (SMI)
• Develop a Level 2 Training Programme for smoking advisors.

Specialist stop smoking service

• Mobilise a new specialist stop smoking service following our 2023/24 procurement exercise. The service will have a focus on the Core 20 plus 5 and Inclusion Health groups, and deliver both outreach and in-reach sessions to increase the engagement
• Service will develop a hybrid approach to vape delivery, maintaining existing voucher schemes with direct supply where appropriate.

Community (Level 2) stop smoking service

• Develop, commission and mobilise a new Community Level 2 service, utilising our 2023/24 launched Healthy Lifestyles Framework
• Service will offer community based delivery, in 1-1 and group settings, accepting self-referrals alongside those from specialist services.

Tier 2 weight management services

(Practical support to eligible individuals, helping them to lose weight and decrease the health risks associated with obesity through targeted advice, information and interventions on diet, nutrition, exercise, lifestyle, and behaviour change techniques).

• Fully embed our 2023/24 commissioned Tier 2 Weight Management Services, including promotion of its direct access facility through our Ready to Change platform
• Continue working with NHS ICB commissioning and local acute care partners to develop a robust service offer, and support the mobilisation of the NHS' own Tier 2 digital Weight Management Programme
• Work with ICB colleagues to develop and promote an improved Weight Management System in Norfolk through local communications and/or campaigns. 

Sexual and reproductive health (SRH)

(Offering both contraceptive care and the testing & treatment of sexually transmitted infections, SRH services are available through GPs; Community Pharmacies; and our specialist iCaSH clinics across Norfolk, which are open to anyone present in our county).

Following completion of our 2023/24 strategic review of SRH services in Norfolk, and in-light of government policy announcements, in 2024/25 we will concentrate on:

Addressing Health Inequalities

• Working with our NHS ICB and other partners, to increase awareness of and lowering barriers in access to our Pharmacy, GP, and wider community-based services and our specialist clinical provisions
• Targeted introduction of Level 2 services, based on geographic and demographic need.

Prevention & Behaviour Change

• Raise awareness and provide information about sexual health issues that may impact on individuals and their wider community
• Increasing the knowledge, confidence and skills of our residents so that they can negotiate, build and maintain safe & healthy sexual relationships
• Utilise best practice to engage with high-need groups & vulnerable communities (face to face & digitally), to increase the confidence of individuals at risk of poor SRH outcomes to engage with our services & wider support.

Clinical Services

• Work with our ICB partners to consider opportunities for greater alignment of SRH commissioning in Norfolk
• Scope and introduction of appropriate interventions for the sexual health aspects of psychosexual need
• Support for high need groups and vulnerable communities, including working together across the Norfolk system to implement the governments Women's Health Strategy.

Drug & Alcohol Misuse and Dependence

(Services offering specialist clinical treatment and behaviour change approach to tackling drug and alcohol use across Norfolk, and broader work with system partners to increase success of our interventions and lessen the impact of addiction on our communities).

• Build and develop the work of the Norfolk Drug and Alcohol Partnership, to inform local policy and practice whilst continuing to implement the National Commissioning Quality Standards; and From Harm to Hope (10-year National Drug Strategy 2021)
• Develop Norfolk's drug and alcohol system, including increasing numbers in treatment and achieving national performance outcomes
• Scope and commission, as appropriate, intervention(s) that support those affected by low level alcohol consumption preventing a deterioration in their ability to manage their drinking and increasing the likelihood of their needing specialist, clinical interventions
• Continue to embed practice in the Housing Related Support and Gt Yarmouth Rough Sleeper Drug and Alcohol Services
• Implement a Norfolk Service User/ Experts by Experience service, to ensure the voices of service users, parents, carers and friends are heard and inform future policy and practice
• Continue to jointly lead with the ICB the LTP Joint Forward Plan Priority for Dual Diagnosis to deliver on Year-1 objectives.

(Services funded by Norfolk & Waveney NHS ICB and Norfolk Public Health that seek to improve individuals' wellbeing, reduce the risk of suicide and attempted suicide, and support those who have been affected by someone taking their own life).

• Fully mobilise our 2023/24 commissioned services in Norfolk
• Monitor the reach and impact of our small grants scheme, coordinated by the Norfolk Community Foundation
• Explore joint development and monitoring of progress indicators with mental health commissioners at the Norfolk & Waveney ICB
• Continue to work closely with ICB colleagues to deliver against the NHS Long-Term Plan and Joint Forward Plan priorities, such as mental health literacy/ training and dual diagnosis
• Realise the recommendations of the 2023 National Suicide Prevention Strategy, through implementing our revised Norfolk strategy.

(The provision of education and training across Norfolk's schools, businesses and court diversion schemes as an alternative to prosecution for some driving offences).

Communities

• Embed a train-the-trainer approach to road safety across primary and secondary schools by upskilling teachers, educational workers, and those who home school to deliver road safety learning as part of the curriculum
• Commission increased numbers of Bikeability sessions across Norfolk, so more children and families choose to cycle with the skills and knowledge to do so safely
• Evaluate the impact road safety interventions have on; changing behaviour and reducing risk taking behaviours.

Driver development/skill

• Continue to promote and provide services across the road safety partnership with local communities and stakeholders, as well as NDORS and Norfolk Constabulary
• Share national and develop local driving and riding campaigns to promote positive road safety messages/behaviours
• Expand on our commercial road safety offer and promote this provision to businesses across Norfolk.