Healthier Herts

A Public Health Strategy

for Hertfordshire
2013 - 2017

Hertfordshire
County of
Opportunity

0300 123 4040

www.hertsdirect.org/countyofopportunity
Contents
page 1. Why a strategy for public health?

5
page 2. Health in Hertfordshire

11
3. Conceptual and delivery models for the
page public health system in Hertfordshire

14
page 4. Vision into action

23
page 5. Public health priorities for our residents

25
page 6. Achieving our priorities

26
page 7. The implementation journey

35
Foreword
We want Hertfordshire residents
to have the opportunity to live the
healthiest lives possible and to
live safely in their communities.
Some of the county’s residents
are significantly less healthy
than others. We recognise the
considerable effect that remaining
healthy has on the happiness and
life chances of our residents.
With responsibility for public
health returning to local
government, we want all services
to work together to improve the
overall health and wellbeing of
people in Hertfordshire, with
early measures taken to tackle
health inequalities.

We have ambitions to improve

and protect the health of our
residents as part of our
Hertfordshire vision for Hertfordshire.
County of “We want Hertfordshire
to remain a county where
Opportunity people have the opportunity
to live healthy, fulfilling
lives in thriving, prosperous
communities1.”

2 Healthier Herts: A Public Health Strategy for Hertfordshire

This vision is ambitious, and recognises
that health, prosperity and fulfilling lives
are inter-dependent.
Our ambition for Hertfordshire sets out a
common purpose to see:
• Citizens who enjoy life and are healthy
• Safe and active communities that get
on well
• A strong economy where
businesses thrive
• A high quality environment
• People who are able to achieve
their potential.
The transfer of statutory responsibilities for
public health to the county council on 1 April
2013 gives us a significant opportunity to
enhance and further the efforts to achieve
this. More than thirty years of scientific
evidence on public health underpins the
insight that a strong public health system
focused on improving and protecting the
health of our residents is essential if we are
to achieve the vision and ambition we have set2.
This strategy sets out the context in which
the county council will discharge its
statutory responsibilities for public
health, but also recognises that we need
to work as a public health system in
Hertfordshire, where agencies with statutory
responsibilities work together with every
agency which can make a contribution to
public health. This means local authorities,
the Police and Crime Commissioner, police,
probation, schools, the NHS, employers,
businesses, voluntary and community
agencies and others across Hertfordshire, all
have a role to play.
No single agency has the answer, and we
must all work together, playing our parts
and playing to each others’ strengths.
We can either see this as a challenge or an
opportunity. We have a strong track record
in Hertfordshire of working together.
Healthier Herts: A Public Health Strategy for Hertfordshire 3
This is evidenced from the fact that this
strategy was written by people from a
range of agencies working together.
Achieving this strategy will bring significant
benefits to our population in terms of
increased quality of life and better health.
It will also bring savings to the public purse.
Most public health interventions save more
than they cost. One case of HIV infection
avoided is costed by the Department of
Health at £1.25 million saved in treatment
and care. Behavioural interventions to keep
people at a healthy weight cost less than
a fifth of surgery and save up to £250,000
per person in heart disease and diabetes
treatment3. Overall, based on research and
experience from other areas, public health
interventions which are successful could
save Hertfordshire up to five times more
than we invest. As part of our commitment to
demonstrate this, our implementation plans
will be accompanied by an analysis of
cost-effectiveness wherever possible.
I particularly want to thank our public
health team, district and borough
councils, Healthwatch Hertfordshire,
our NHS partners, the Police and Crime
Commissioner, Probation Service and
Public Health England for their support
and enthusiasm in drawing this
strategy together.
Public health is an exciting portfolio
because it is something which touches
all of us. I am confident that people in
Hertfordshire will rise to this opportunity,
to the benefit of all of our residents.
Cllr Teresa Heritage
 OUR PURPOSE:
To work together to improve the health and wellbeing of the people of Hertfordshire,
based on best practice and best evidence.

OUR VISION:
A healthy happy Hertfordshire: everyone in Hertfordshire is born as healthy as possible, and lives a full,
healthy and happy life. We compare well with England and similar counties, and health inequalities
across Hertfordshire are reduced.

HOW WE WILL WORK TOGETHER

WHAT WE WILL ACHIEVE WORKING
(our strategic priorities: how we
FOR AND WITH OUR RESIDENTS
achieve it for our County)

The Public Priority 1: Priority 2: Priority 3: Priority 4: Priority 5: Priority 6:

Health Our residents Our residents We narrow We protect our We understand We make
Outcomes live longer, start life the gap in life communities what is needed public health
Framework healthier lives healthy and expectancy and from harm and we do everybody’s
(PHOF) will stay healthy health between (chemical, what works business and
be used to the most biological, work together
measure

4 Healthier Herts: A Public Health Strategy for Hertfordshire

and the least radiological and
our success healthy environmental)
Figure 1: Our public health strategy at a glance

Building Strong Capable, Co-production Effective Evidence and Plan and Whole
blocks leadership skilled with residents partnerships knowledge deliver for system
people driven localism approaches

For the Making better use of behavioural sciences at individual, interpersonal, community and service levels.
public
health
family
1. Why a strategy for public health?
Good health is what we all
aspire to for ourselves,
families, carers, friends and
communities. There are many
determinants of health
ranging from genetic factors
to the impact of where we live
and our social and economic
circumstances.

Healthier Herts: A Public Health Strategy for Hertfordshire 5

Recent policy and advances in public health
science have acknowledged that local
government is well placed, in its strategic
place-making role, to work on these with
partners. Most recently the Health and Social
Care Act 2012 gave the county council a duty
to improve the health of its residents.
The ten district and borough councils in
Hertfordshire already have powers to
improve health under the 1984 Public Health
Act, and these, along with the county council
share a general power of competence,
enabling them to do what is needed to
improve the health of their residents.
National Health Service clinical
commissioning groups have a statutory
duty to reduce inequalities in health in their
patient populations. Many other partners,
from the Police and Crime Commissioner to
voluntary and community sector bodies, faith
communities and business, have a role in
making Hertfordshire a healthier county.
The Health and Wellbeing Strategy for
Hertfordshire4, sets out the key priorities for
the Health and Wellbeing Board (HWBB)5.
While there are some priorities within the
strategy of common interest to public health
and the HWBB (tobacco, healthy weight and
alcohol are three of the nine HWBB priorities
on which public health take the lead) there
are a number of other areas where public
6 Healthier Herts: A Public Health Strategy for Hertfordshire
health have responsibilities (sexual health,
drugs and alcohol, school nursing, health
checks and other areas) which are not within
the nine key priorities of the Health and
Wellbeing Strategy but which do need to be
addressed. This strategy seeks to do that.
This document seeks to outline the vision
for public health as part of the vision for
Hertfordshire6, and to provide a clear road
map for how the work of public health
functions in Hertfordshire will ensure all
residents will have an “opportunity to live
as healthy lives as possible and to live safely
in their communities”, which the vision for
Hertfordshire commits us all to achieving.
Public health is defined by the Faculty
of Public Health (“the Faculty”), the standard
setting body7 for public health practice in
the UK, 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.”
The Faculty’s approach to
Public Health:
• is population based
• emphasises collective responsibility for faces a number of inter-connected public
health, its protection and disease
prevention; across agencies and partners
• recognises the key role of the state,
linked to a concern for the underlying from top of England’s local authorities;
socio-economic and wider determinants
of health, as well as disease
• emphasises partnerships with all
those who contribute to the health of
the population.
A detailed statement of evidence for what
this strategy proposes is beyond the scope of
this document, because much of it has been
stated elsewhere, i.e. The Strategic Review
of Health Inequalities in England Post 2010
(the Marmot Review 20108), along with the
National Audit Office’s report on Health
Inequalities9 and the World Health
Organisation report Closing the Gap in a
Generation10, all identified that the need for
England is to reduce health inequalities in a
sustainable way.
Much of this research has identified that the
health outcomes (life expectancy, burden
of ill-health and disease, avoidable death)
which people experience is the result of a
complex set of interplaying factors11:
• Our parents health before and during
conception and pregnancy
• Our start in life (healthy or unhealthy)
• The lives we lead (physical, social,
psychological and spiritually healthy lives)
• The place we live in
• The opportunities we have
(good education, good employment)
• The services we access (high quality,
easily accessible, focusing on prevention).
These things are often called determinants
of health, and are shown in more detail in
figure 2 on page 9. Our experience of
education and employment and our built and
natural environment are often called wider
determinants of health.
Healthier Herts: A Public Health Strategy for Hertfordshire 7
The Joint Strategic Needs Assessment
(JSNA) for Hertfordshire12 provides an
overview of the health of our county, as well
as some in-depth analysis on health topics.
The JSNA makes it clear that Hertfordshire
health challenges where we are not
performing as well as we could. While in
terms of premature death we are twelfth
when compared against our peer group we
are placed twelfth out of fifteen. There is an
eleven year gap in life expectancy between
the healthiest and the least healthy areas in
Hertfordshire.
There are a number
of reasons why this is
the case:
• Too many people in our county spend
the end of their lives in avoidable
disability caused by non-communicable
disease as a result of the common risk
factors of smoking, obesity, poor diet,
physical inactivity and alcohol consumption
• Too many people in our county die early of
avoidable disease
• Smoking remains our biggest cause of
avoidable death
• Being obese or overweight is reducing the
healthy life expectancy of too many of our
young people and adults
• Preventable mental ill-health is too high;
and the burden of mental ill-health across
the lifecourse is too high
• We need to do more to ensure our
children have a healthy start in life and
grow up healthy
• Avoidable ill-health and the risk factors
for these are hindering efforts to reduce
poverty and increase prosperity.
These challenges are not something
specialist public health functions, wherever
they sit, will solve on their own. Everyone
must work together. The role of public health
is to provide evidence, intelligence and
foresight to help those whose key role it is to
both deliver the improvements needed and
see the interconnectedness of what they do.
But improving health is complex. The NHS
has a large part to play in leading health
improvement and in securing high quality
health care, but local authorities have
significant power and influence over many
of the medium and longer term inequalities
and determinants of health such as
environment. These determinants of good
health; environmental, economic and social,
can only be tackled through good partnership
working, and this requires clarity about
what we are trying to achieve. Schools and
colleges also have a key role to play.
The Marmot Review re-iterated that to
improve the health of the whole population
and those who are least healthy, “focusing
solely on the most disadvantaged will not
reduce health inequalities sufficiently.
To reduce the steepness of the social
gradient in health, actions must be
universal, but with a scale and intensity
that is proportionate to the level of
disadvantage”13. This is called proportionate
universalism14. This key principle has been
8 Healthier Herts: A Public Health Strategy for Hertfordshire
adopted in the Health and Wellbeing Strategy
for Hertfordshire and is adopted here.
The transfer of responsibility for significant
areas of public health in April 2013 from
the NHS to local government is one of the
most significant extensions of local
government powers and duties in a
generation. It represents a unique
opportunity to change the focus from
treating sickness to actively promoting
health and wellbeing. Equally, as our
knowledge on what factors determine
our health outcomes grow, we see that
improving the health of our residents
requires contributions from a wide range
of players.
This document seeks to present clarity on
what we are trying to achieve. It is intended
to focus on priorities and outcomes, and be a
brief statement of principles and priorities.
Our implementation plan will focus on
identifying the various contributors to good
or ill-health, and interventions and roles
to improve health. The figure overleaf shows
the contribution of various determinants
of health to overall health. Many of these
are issues which our JSNA and other
needs assessment work have identified
for Hertfordshire.
Figure 2: Determinants of Health15

Health Socioeconomic Clinical Built

behaviours factors care environment

30% 40% 20% 10%

Smoking Education Access to care Environmental

quality
10% 10% 10%
5%
Diet/exercise Employment Quality of care Built
environment
10% 10% 10%
5%
Alcohol use Income

5% 10%
This strategy for public health demonstrates the
commitment of the county council to actively
Poor sexual Family/social improving the health of the people living in
health support Hertfordshire, working with all of its partners.
We recognise the commitment of our partners.
5% 5%
The strategy which is shown in
Community summary on Figure 1 (page 4) will:
safety
• Aim to improve health outcomes for all
5% our residents
• Set out our public health priority areas for
short, medium and long-term action
• Set the context for implementation plans
between 2013 and 2017; these will be
refreshed annually. Within these
implementation plans we will use the
tools of proportionate universalism, a
lifecourse approach and “Five Ways to
Wellbeing”16, along with other tools.

Healthier Herts: A Public Health Strategy for Hertfordshire 9

 The Lifecourse approach
How long we live, and how much of it we
spend in good health or ill-health, is the
result of risks we accumulate across our
lives. Just as we conceptualise health as
outcomes influenced by a range of
determinants (see page 9), health outcomes
are also the result of a developmental
trajectory from before conception (maternal
health behaviour and status) to old age.
This trajectory is multidimensional;
there are biological, psychological,
behavioural and social aspects. Figure 3
below conceptualises these influences
and dimensions.
The lifecourse perspective will form a
key part of our lifecourse model, where
we develop health interventions which help
people make the best and healthiest start
in life, develop through a health promoting
school and family environment, work in a
health promoting workplace and take
steps to keep themselves healthy.
We will describe this in more detail in
our implementation plan and through our
public health skills development programme.

Figure 3: Influence of health status across the life course

Day
Relative Magnitude of Influence

Care Community
School
Workplace

Family

Individual

5 10 15 20 30 40 50 60 70 80
Age (years)

10 Healthier Herts: A Public Health Strategy for Hertfordshire

2. Health in Hertfordshire

Collectively, people in England are some of our persistent inequalities in health,

healthier now than at any other point in
history. We are living longer and have more
years of good health than ever before.
In some respects the same can be said of
Hertfordshire, and we have seen some
significant improvements in health over the
last ten years, most notably in life expectancy
and reductions in infant mortality.
But some areas of Hertfordshire remain
behind England as a whole and the gap for
between us and England, is not narrowing.
There is a higher burden of death and
ill-health placed on the poorest areas of
Hertfordshire than on England as a whole.
The map below shows the Index of Multiple
Deprivation (IMD) scores by area. IMD scores
provide a useful proxy for health inequalities,
because those areas with the highest
deprivation (shown in darkest on the map)
tend to experience worse health than the
rest of Hertfordshire.

Figure 4: I ndex of Multiple Deprivation Scores for Hertfordshire

Healthier Herts: A Public Health Strategy for Hertfordshire 11

A separate document “Health Challenges for Table 1 overleaf summarises some of
Hertfordshire; Informing the Public Health the successes which have been evidenced
Strategy17” and the Equality Impact Analysis in addressing health inequalities in
for this strategy both summarise the issues Hertfordshire, and some of the challenges
we have taken into account. which still remain. The enduring effect of
poverty remains a significant challenge18.
In summary: The harm from alcohol and tobacco, and
the health effects of sedentary lifestyle and
• Life expectancy in Hertfordshire as a
being overweight or obese also bring
whole is increasing both for men and for
significant avoidable disease burdens to
women. But compared with England and
Hertfordshire, and these three areas are
with our peer group there are too many
Hertfordshire Health and Wellbeing Board
people who still die at a younger age; and
priorities. As noted above, public health lead
too many people who spend much of their
on these.
life in ill-health or disability.
• There is a marked and real social gradient
to this, with people who are most deprived
living shortest lives with most ill-health.

Health and economic prosperity are

intimately linked. The health of our
population is a key asset for our economic
prospects, but equally a thriving economy
is essential for good health.

12 Healthier Herts: A Public Health Strategy for Hertfordshire

Table 1: S
 uccesses and challenges in health inequalities

Successes
• Infant mortality is showing a reduction
in rates over recent years, with recent
indications of particular improvement in some
of the most deprived areas
• We have seen reductions in all age and all
cause mortality; reduction in early death rates
from heart disease, stroke and cancer
• We have seen reductions in teenage
pregnancy in recent years
• We have seen significant reductions in people
smoking and our prevalence of smoking is in
line with England. (Reducing the harm from
tobacco is a HWBB priority).
Challenges
• Infant mortality – whilst reducing, we still
have disproportionate rates across the county
within certain ethnic communities
• Premature death and life expectancy although
reducing, remains significantly worse for some
cancers and for the poorest areas
• Preventable non-communicable disease,
especially diabetes, stroke, cancer and
heart disease, remain higher in some areas
than in others
• Teenage pregnancy still remains a concern in
some areas
• 172,000 people remain smokers and new
young people take up smoking every day
Smoking prevalence remains very high in the
most deprived areas
• Obesity in children, and increasingly in adults,
remains a challenge and lies at the root of
much other avoidable ill-health. We need to
have a co-ordinated and concerted approach
to tackle this issue. (Physical activity and
maintaining a healthy weight is a HWBB
priority)
• The impact of poverty on health remains a
significant factor in avoidable mental
ill-health, domestic violence, disability
and death
• Alcohol remains a high attributable factor in
admission to hospital among some late middle
age and older people
• The increase in outlets selling alcohol cheaply
contributes to a short term rise in emergency
hospital admissions and a long term rise in
liver disease, mental health problems and
avoidable early death. (Reducing the harm
from alcohol is a HWBB priority)
• Self harm and preventable mental
ill-health in our young people remains high
and is increasing.

There remain a range of challenges as shown above which stop us being a healthier county,
and which means that the burden of disability, ill-health, disease and death in some parts
of Hertfordshire remains higher than it should be if compared to the England and the
Hertfordshire average.

Healthier Herts: A Public Health Strategy for Hertfordshire 13

3. Conceptual and delivery models
for the public health system
in Hertfordshire
The role of every agency
and the role of specialist
agencies
Sections one and two of this strategy
identified that a range of factors mitigate
for or against people being healthy across
their life (wider determinants of health).
This means that we need to build a public
health system where a range of agencies
understand their role in protecting and
promoting the health of our residents, and
act to deliver it.
Every agency has a contribution to make
to public health in Hertfordshire, and the
county council’s Public Health Service
will seek to lead and support this through
partnership working. In Hertfordshire we
believe that no one agency can deliver public
health effectively without the others, and this
has led us to develop the concept of a public
health system where there is:
• A contribution from every agency in
Hertfordshire to improve and protect the
health of our residents, and
• A specialist public health family of
agencies each with statutory roles
and responsibilities.
14 Healthier Herts: A Public Health Strategy for Hertfordshire
The specialist public health family in
Hertfordshire
• The county council has statutory
responsibilities to improve public
health and a statutory duty to lead the
local system through the Director of
Public Health.
• D
 istrict and borough councils have a
range of statutory public health duties
from the Public Health Act 1984 and
other important contributions to public
health such as housing, and leisure.
• Public Health England is the lead
national body for the public health
system in England with a range of
statutory, enabling and supporting roles,
including supporting NHS England in its
public health commissioning roles.
• NHS clinical commissioning groups
have a statutory duty to reduce
inequalities in health in their
registered populations.
• NHS England has a statutory
commissioning role of some public
health functions and commissioning of
primary care.
 authority and Public Health England,
Environmental health and health promotion
staff in district and borough councils),
clinicians across the NHS, the nurses
and doctors in each local practice, as well
as a wide range of people who influence
our behaviour.

Schools, retailers, employers, sports

coaches and police all play a part, together
with the planners and providers of quality
health and social care, roads, housing,
spatial planning, environment and other
facilities, which all impact directly or
indirectly on our health. The breadth of
public health can be described in three
domains, although there will always be some
There are four key overlap. These are the protection of health,
mechanisms which enable the promotion of good health and the delivery
of quality health care.
this system to work:
To deliver a robust and sustainable public
• The Health and Wellbeing Board – the key health service for the county council, and
multi-agency board for action on major across partners, we will create a public
issues across the health and care system health system and identify a common
for our residents conceptual model. This model will be based
• The Public Health Board – an officer board on the scientific principles of public health
comprising a range of partner agencies, and recognition that everyone has a role to
each with a contribution to public health, play in public health in Hertfordshire.
which develops and supports the public
health system in Hertfordshire across all
three domains of public health (see page 16)
• The Hertfordshire County Council Cabinet
Panel on Public Health and Localism –
which oversees the statutory public
health portfolio in the county council
• District and borough mechanisms –
local partnerships and boards which
are crucial to local delivery of public
health outcomes.

A model for public health in

Hertfordshire: conceptual
model and delivery
Public health is a discipline practiced by a
broad body of people and organisations, not
just those who are registered specialists.
These include specialist staff (such as
consultants in public health in the local

Healthier Herts: A Public Health Strategy for Hertfordshire 15

The conceptual model of public health
There are three components to this model:

• The definition of what public health is

• The three domains of public health practice
• The six levels at which public health action happens.

Component 1: The definition of public health

The definition of public health which has had most support is the definition used by the Faculty
of Public Health (the standard setting body for specialist public health practice in the UK).
It 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”19.

Component 2: T
 he three domains of public health practice

This model has been used in the Public Health White Paper20 the Government’s public health
strategy21 and in the statutory guidance on public health22. It is illustrated in figure 5 overleaf.

16 Healthier Herts: A Public Health Strategy for Hertfordshire

Figure 5: Three domains of public health23

Health Health
protection improvement
Director
of Public
Health

Health
service
delivery and
quality

• Health improvement means what we can do to improve health at individual and population
level and includes reducing inequalities, improving education, and addressing housing,
employment, family / community, lifestyles, surveillance and monitoring of specific diseases
and risk factors

• Health services delivery and quality means ensuring services are of consistently high quality
and especially that they are evidence based, and address issues of effectiveness, efficiency
and equity

• Health protection means we address threats and hazards to human health including
infectious diseases, chemicals and poisons, radiation, emergency response and
environmental health hazards.

This means that public health is about ensuring everyone has the opportunity to be as healthy
as possible, and from that foundational opportunity to be healthy they can grasp the
opportunities to be prosperous, to thrive throughout life and to make a contribution to their
communities24. This may mean action across a range of levels from individual to social, and this
leads us to the third stage of the model, the six levels of public health action.

Demonstrating that public health interventions save money to our residents and the public
purse is important to us. Evidence suggests that achieving this strategy will bring significant
benefits to our population in terms of increased quality of life and better health. Most public
health interventions save more than they cost. As part of our commitment to demonstrate this,
our implementation plans will be accompanied by an analysis of cost-effectiveness
wherever possible.

Healthier Herts: A Public Health Strategy for Hertfordshire 17

Component 3: The six levels of public health action

There are six levels at which public health
works25. Enabling people to be healthy
means acting across all six levels. These
levels are needed because most public
health challenges have causes or factors
across more than one level of people’s lives
e.g. social, biological, behavioural, etc.
Often a change in one level is spurred on by
another, for example the legislative ban on
smoking in public places has helped create
social norms around smoking not being
acceptable indoors, leading to a change in
personal behaviour by more people giving
up smoking.

We need to work at several levels to address The table overleaf shows the six levels of
change enabling people to be healthy. public heath action and, as an example,
what is happening on tobacco control
currently in Hertfordshire.

18 Healthier Herts: A Public Health Strategy for Hertfordshire

Table 2: Six levels of public health action

Levels
1. Social – changing social norms about
health, e.g. acceptability of binge drinking,
acceptability of taking smoking breaks.
2. Biological – immunisation, vaccinations,
treatments.
3. Environmental – encouraging green
transport, reducing pollution, changing
the public realm.
4. Behavioural – helping individuals to
stop smoking.
5. Legislative – the smoking ban, legislation
on alcohol sales.
6. Structural – policy changes such as
workplace health, school health policies.
Tobacco
Young people whose peers disapprove of
smoking and its effects are less likely to
start smoking.
Campaigns like Stoptober and other
marketing targeted at high risk populations.
Targeted action to enable parents not to
smoke around children.
Supporting people in spreading the message
that smoking in pregnancy has very high risks
to mother and child.
Nicotine replacement therapy and other drug
interventions when appropriate help people
reduce the very strong cravings from giving
up smoking.
Smokefree playgrounds in several areas in
Hertfordshire are encouraging parents not
to smoke in front of children and think about
giving up.
Making illicit tobacco trading less possible.
Enforcement of stop smoking legislation.
Stop smoking services and individual and
group counselling help people give up and stay
non-smokers - there are more than 300 of
these services in Hertfordshire.
The ban on smoking saw heart attacks drop by
14% in England within a year and has
encouraged people to give up.
Enforcement of legislation on sales and
underage smoking.
Workplace policies which make people who
take smoking breaks make the time up see
more people give up smoking and fewer
sickness days from respiratory diseases and
colds in winter.
Policy frameworks which support tobacco
control.
Tobacco control strategies.

This conceptual model will be used to help us identify for any topic we work on what the role of
the county council’s Public Health Service is, what the role of the specialist public health
family in Hertfordshire is and what the roles of other, equally important, agencies such as
social care, childrens’ centres, schools, employers, voluntary and community agencies are.

Healthier Herts: A Public Health Strategy for Hertfordshire 19

Making the system work: a practical model for delivery
In order to move to a system which will involve every relevant partner and will develop and
demonstrate a range of capabilities (skills, knowledge, culture and attitudes) and develop
appropriate mechanisms (boards, implementation arrangements, delivery pathways and
engagement strategies). Table 3 below lists these capabilities and mechanisms.

Table 3: Capabilities and mechanisms for public

health delivery

Capabilities
• Strong Leadership (elected member,
officer, volunteer, resident)
• Capable, skilled professional people
• Planning and delivery at local levels while
ensuring equity across the county
• Whole system approaches.
Mechanisms
• Partnerships
• County Council Cabinet Panel
• Health and Wellbeing Board
• Skills Development Programmes
• Evidence, Intelligence and Joint Strategic
Needs Association
• A multi-agency Public Health Board
• Co-production with residents.

We have made specific commitments to domain is sometimes called “healthcare

these areas across each of our priorities.
We will develop a model of operation
which works across partners, starting with
understanding what our population needs,
moving to identifying what works and then to
intervention. We will do this across the three
domains of health improvement, health
protection and service quality. This latter
public health”, but because social care,
child care, housing, leisure and many
other functions are important to public
health, good quality services are crucial.
This working model for our system is
illustrated in the Hertfordshire Public
Health Delivery Model©26 shown overleaf.
We will use this model to work with partners.

20 Healthier Herts: A Public Health Strategy for Hertfordshire

Figure 6: T
 he Hertfordshire Public Health Delivery Model©

orks
ify What W
nt
Ide

nt

He Understand
me

Understand alt
Roles, Players
ve

What’s Needed
hP
and Contributions
ro

ro
mp

tec
hI

tio
alt

n
He

Hertfordshire

l e m e n t a ti o n
Residents

Service Quality

Im p
od
Ev

Go
alu
at

Ou Right Intervention,
e

tco Right Delivery Mechanisms

me
s Right Population

Healthier Herts: A Public Health Strategy for Hertfordshire 21

Using these insights, • Deliver a public health service which
advocates successfully for effective
we will: prioritisation of resources for key public
health priorities
• Deliver a public health system where all
skills and contributions are valued and • Deliver a public health service which
designed around delivering the outcomes enables commissioning activity to achieve
and priorities (see section 6 page 26), the population priorities set above.
with a focus on equity for our In particular, enable clinical
diverse population commissioning groups to work effectively
on public health issues and priorities
• Identify for each programme the
contributions of the agencies in the • Develop ways of co-producing better
specialist public health family, and health with residents
other agencies
• Deliver a public health service which has
• Develop the skills and capabilities of an effective balance of public health
local authorities, NHS, voluntary and capacity and capability across health
community sector, criminal justice improvement, health protection and
agencies and employers to deliver the service quality
public health agenda
• Deliver a public health service which
• Develop the skills and capabilities of the develops the skills of both specialist and
county council’s public health service to generalist stakeholders to be part of the
enable others to act on health issues public health agenda for Hertfordshire.
using a public health approach

• Deliver a public health service which

uses the best available evidence and
information on which to base decisions
and recommendations

22 Healthier Herts: A Public Health Strategy for Hertfordshire

4. Vision into action

The consensus of stakeholders (county, prosperous and sustainable. To be

district and borough council officers, public prosperous, Hertfordshire needs to
health lead officers in district and borough be healthy.
councils, Local Strategic Partnerships, NHS We have used the vision to action
clinical commissioning groups, third sector pyramid illustrated below to help explain why
agencies, Healthwatch, Public Health we exist, where we want to get to and what
England and community agencies) is that we will do. Implementation plans and
we want our county to be healthy. individual workplans for every public health
The consensus of evidence is that to be specialist in Hertfordshire will be needed
healthy, Hertfordshire needs to be to deliver this.

Figure 7: The vision to action pyramid

oing
ed
ew
ar
hy ?
W is
th
Mission: do
Why? h at e?
Values, what’s /w b
e re nt to
important to us? h
W wa
we
Vision:
Where we want to get to o
ntt
e wa
w ?
w ere
Ho t th
ge
Strategy:
How we want to get to the vision d
nee
we
t
ha
W do!
Implementation plans : to
What we need to do in each area of the
business and for each topic ee
d
n
tI
ha !
W do
to
Individual plans:
My personal objectives and must dos

Table 4 (overleaf) states Our Mission and Our Vision

The next stage after agreeing this strategy is to produce an implementation plan for the service,
which will be refreshed annually.

Healthier Herts: A Public Health Strategy for Hertfordshire 23

Table 4: Our Mission and Our Vision
Our Mission
Our mission is to work together to improve the health
and wellbeing of the people of Hertfordshire, based on
best practice and best evidence which means not just
looking at effectiveness but also at cost-effectiveness.

Our Vision Healthy and happy Hertfordshire: everyone in

Hertfordshire is born as healthy as possible, and lives a
full, healthy and happy life.

Hertfordshire’s public health This strategy is about a whole system

strategy ambitions
Our ambitions within this vision are that:
• Hertfordshire will be among the healthiest
counties in England. Our population as a
whole will enjoy a life which is better than
the England average for life expectancy
and disease free years of life
• We will progressively narrow the gap
in life expectancy and disease free
years of life across the population
of Hertfordshire
• Our population has a good understanding
of how to be and remain healthy, and puts
this into practice
approach to opportunities for good health.
This approach is underpinned by principles,
three of which are, as mentioned above
derived from the Review of Health
Inequalities for England (2010)2 commonly
referred to as the Marmot Review:
1. We will adopt a lifecourse approach
to health (pre-conception to death);
which seeks to ensure people start life
healthy and remain healthy
2. We will adopt a whole system approach;
which seeks to identify the components
which act to improve and hinder good
health, and identify the contribution of
public health specialists and partners to
addressing them

• Everything about our public services and

the way our county is organised supports 3. We will adopt the principles of
this, from primary care services to proportionate universalism27 to address
quality of education, housing and access inequalities in health while ensuring that
to employment. the whole population achieves better health

4. We will seek to develop a people centred

approach to public health, where we
design services working with residents
and work to ensure services reflect the
needs of our population

5. We will seek to ensure that the

environmental sustainability and
economic prosperity of our county are
improved by what we do, and that we take
account of the public health implications
of climate change.

24 Healthier Herts: A Public Health Strategy for Hertfordshire

5. Public health priorities for
our residents
The public health priorities are about what How we will work together
we need to do in Hertfordshire to achieve:
5. Understand what’s needed and we do
what works.
• The Marmot principles
• Better health outcomes for our residents
• National public health strategy 6. Make public health everyone’s business.
• Public Health England priorities

Our priorities will be tracked by our progress

against the Public Health Outcomes
Framework (see Section 7 page 36). We will
also use the “Five Ways to Wellbeing” to
build a resilient and healthy population.

To achieve this set of priorities requires us

to act on a range of different factors from
the quality of primary care to the life
opportunities of our population. Within these
factors there are a range of short-term,
medium term and longer term dimensions
to consider, and the contribution of a
range of agencies. The outcomes from the
principles will reflect cross cutting themes
from Hertfordshire’s Health and Wellbeing
Strategy 2013-201628, the Hertfordshire
Equality Strategy 2013-201529 and the
Hertfordshire Community Safety Strategy.

The public health priorities

for Hertfordshire
What we will achieve working for and with
our residents
1. Longer, healthier lives.

2. Start healthy and stay healthy.

3. Narrowing the gap between most and

least healthy.

4. Protect our communities from harm.

Healthier Herts: A Public Health Strategy for Hertfordshire 25
6. Achieving our priorities

Working with partners we have developed a set of priorities which are important not just to the
agencies in Hertfordshire with statutory public health roles, but to everyone, and to ensuring
Hertfordshire remains a county of opportunity. For each priority in table 5 below we have
identified what this means, why we have chosen it and what we need to do to achieve it.

A separate implementation plan will identify in greater detail what we will do and how we
will do it.

Table 5: Our 6 priorities

Priority 1 Longer, healthier lives
What does this mean We will increase life expectancy, especially disease and
disease-related disability free life-expectancy in Hertfordshire
and reduce health inequalities in these across the population.

We will reduce the prevalence in our communities of the five

common risk factors for early death: smoking, obesity,
inactivity, poor diet and excess alcohol consumption.
Why have we chosen this? Hertfordshire has too many people spending a significant part
of their lives in avoidable chronic ill health and disease-related
disability.

26 Healthier Herts: A Public Health Strategy for Hertfordshire

Priority 1 Longer, healthier lives
What do we need to do? 1. Develop a health improvement programme which identifies
action across the lifecourse.

2. Continue to reduce smoking prevalence (Health and

Wellbeing Board Strategy priority).

3. Reduce obesity starting with the areas of highest prevalence

(Health and Wellbeing Board Strategy priority):
• Increase and sustain the increase in physical activity
uptake across the county
• Develop a lifestyle offer which helps people become and
remain physically, psychologically and socially healthy
This will engage sport and physical activity agencies and
partners and will embed “The Five Ways to Wellbeing”
• Develop an obesity and health behaviour pathway with
partners, with tiered weight management services
within it.

4. Reduce harmful alcohol consumption (Health and

Wellbeing Board Strategy priority).

5. Work with partners to build a culture of healthy living through

development of lifestyle offers and health marketing to
increase awareness and uptake of healthier lifestyles.

6. Work with partners to ensure that maximum improvement

in health is achieved by all services across the county, from
NHS commissioners and providers to local authority and
voluntary and community sector services.

7. Implement regulatory, policy and population measures to

improve health, including spatial planning, licensing and
responsibility deals.

8. Strengthen the role of social sciences by embedding

behavioural science approaches to public health challenges.

9. Develop public mental health approaches to building

resilience and reducing preventable mental ill-health
(including self harm and “The Five Ways to Wellbeing”).

Healthier Herts: A Public Health Strategy for Hertfordshire 27

 Priority 2
Public health definition of
this
Why have we chosen this?
What do we need to do?
28 Healthier Herts: A Public Health Strategy for Hertfordshire
Start healthy and stay healthy
Ensure we do what we can to improve health across the
lifecourse from before conception to death.
We mentioned the importance of a lifecourse approach in
our principles above. There is overwhelming evidence that a
healthy start for young people is a key public health priority.
Giving every child the best start in life (which we do not
currently achieve) is crucial for sustaining health throughout life
into older age.
1. Commission all mandated public health services in a
way which underpins a lifecourse approach to health and
is personalised.
2. Seek to use local agencies and partners wherever possible
to deliver these services.
3. Produce a market position statement which puts prevention
and health gain at the heart of everything we commission.
4. Ensure a healthy start for every child through effective
coverage of pre-conception, prenatal and perinatal care,
health visiting, immunisation and public health nursing.
5. Ensure perinatal mental health work is universally
rolled out.
6. Ensure early years services implement key public health
interventions for healthy development (from “My Baby’s
Brain” to high rates of immunisation).
7. Build the public health role of childrens’ centres and other
childrens’ settings.
8. Ensure a whole school day approach to health, starting with
nutrition and physical activity.
9. Develop an adolescent public health programme across key
services and settings including a focus on mental health,
resilience, happiness and self-harm reduction.
10. Work with employers to improve the health of adults of
working age, and reap the economic benefits of this.
11. Develop public health approaches for adults with particular
and complex needs such as adults with learning disabilities
and chronic mental health problems.
12. Roll out NHS health checks for adults and ensure these are
part of a universal lifestyle offer, with appropriate targeting
for populations who fare less well in health terms.
13. Ensure drug’s and alcohol services are accessible and high
performing and help people to reduce harm and recover
appropriately.
14. Ensure sexual health services, including contraceptive
services, are accessible, personalised and effective.
15. Develop a healthy ageing programme.
Priority 2 Start healthy and stay healthy
16. Develop public health approaches for particular
communities:
• Serving military personnel, veterans, Territorial Army
and reservists and their families as part of our
commitment to the Community Covenant.
• Develop appropriate approaches for traveller
communities
• BME communities
• LGBT communities
• Disabled people (especially access to physical activity)
• People with learning disabilities.
17. Work to establish healthy living pharmacies and
dental practices.

Healthier Herts: A Public Health Strategy for Hertfordshire 29

 Priority 3 Narrowing the gap between most and
least healthy
Public health definition Reducing inequalities in health outcomes and life expectancy
of this between most and least affluent.
Why have we chosen this? Hertfordshire has too high a disparity in life expectancy and
ill-health between the most affluent and least affluent.
What do we need to do? 1. Improve the cycle, granularity and content of the Joint
Strategic Needs Assessment to identify inequalities and
inequity, including knowledge gathering and equity auditing.
2. Identify particular communities and populations which do
less well than the majority of our residents, and identify
what specific actions we need to take to improve their
health outcomes.
3. Commission and deliver services which consider inequalities
and equity and target appropriate areas of worst health whilst
delivering a universal offer to everyone using the principles of
proportionate universalism.
4. Reduce drug and alcohol related ill-health.
5. Improve equity of access and outcomes to services in the
most vulnerable and most disadvantaged populations
and those with worst outcomes (ie: children looked after,
offenders, families in the ‘thriving families’ programme,
people in poverty, disabled people, people with learning
disabilities, travellers, LGBT residents, military families and
harm from tobacco and alcohol in lowest income groups).
6. Reduce harmful substance misuse, especially tobacco.

30 Healthier Herts: A Public Health Strategy for Hertfordshire

Priority 4 Protect our communities from harm
Public health definition Deliver robust and effective health protection arrangements.
of this
Why have we chosen this? Health protection responsibilities sit across a range of agencies
and they are crucial to achieving good health for the population.
We have a statutory responsibility to deliver and assure a robust
health protection system.
What do we need to do? 1. Build a whole system health protection plan and network
which harnesses the important roles of county, district/
borough councils, NHS and Public Health England and
other partners.
2. Deliver a robust whole system approach to infection control
in health and social care settings.
3. Deliver effective public health input to community safety
and crime reduction agendas including alcohol, drugs,
licensing, tobacco control, causes of domestic violence,
offender health and mentally disordered offenders.
4. Support the important role of environmental health in
health protection.
5. Develop a public health approach with regulatory
services colleagues.
6. Improve take-up and ensure robust and high quality delivery
of immunisation, vaccination and screening to our residents.
7. Ensure the public health role in resilience is fully delivered.
8. Work with licensing and the local planning authorities
in the county to ensure that the adverse health impacts from
licensing and planning are reduced and positive
outcomes increased.
9. Continue to work with highways to improve pedestrian and
road user safety.
10. Ensure public health skills help make Hertfordshire a more
sustainable place.

Healthier Herts: A Public Health Strategy for Hertfordshire 31

 Priority 5 Understand what is needed and do
what works
Public health definition We are driven by robust evidence (epidemiology, needs
of this assessment, evidence of effectiveness) and ensure
interventions are evidence-based and appropriately developed.
Where evidence is lacking we will ensure we can evaluate
interventions for efficacy and effectiveness.
Why have we chosen this? Being evidence and intelligence driven and having the right
skills and competencies will deliver better outcomes and better
value for money.
What do we need to do? 1. Ensure we have a strong foundation of needs assessment,
epidemiology, equity audit and outcome evaluation for
programmes and services and work to improve the JSNA as
a key source of evidence.
2. Ensure we develop skills and capabilities to understand and
apply evidence across interventions, in particular ensuring
we develop evidence-based practice and public health skills
across the county council and partner agencies.
3. Ensure we develop skills and capabilities to assess and
evaluate effectiveness and outcomes.
4. Work with commissioners to develop an integrated
commissioning cycle which includes needs assessment,
evidence assessment, prioritisation and outcome evaluation.
5. Support NHS commissioners using the Director of Public
Health’s statutory duty to advise clinical commissioning
groups on how to commission to meet population
health need.
6. Support NHS and local authority commissioners as well as
criminal justice sectors to commission in a way which
develops the health of their population.
7. Innovate to establish best practice where evidence is
lacking, conflicting or silent.

32 Healthier Herts: A Public Health Strategy for Hertfordshire

Priority 6 Make public health everyone’s business
Public health definition We want to identify the public health contribution of every partner
of this and stakeholder and build the capacity for them to deliver.
Why have we chosen this? Research demonstrates that public health should be everybody’s
business and everyone has a role. District and borough councils,
for example, have strong public health potential in their housing,
leisure, environmental health and other roles. Voluntary and
community sector agencies and faith communities can reach
people statutory services may struggle to engage. Ensuring
everyone understands their contribution and delivers it will be
crucial to making our county and our residents healthier.
What do we need to do? 1. Identify with each stakeholder what their public health
impacts are and how they can address them.
2. Continue funding for partnerships and initiatives which
deliver on this strategy.
3. Support voluntary and community sector and community
agencies in identifying their public health contribution and
meeting it.
4. Continue to support local strategies and plans through Local
Strategic Partnerships, and the Public Health Board.
5. Commission delivery partners local to Hertfordshire
wherever possible.
6. Co-produce services and interventions with stakeholders
and residents.
7. Build appropriate capabilities across everyone with an
interest in public health through access to learning and
skills development (both face to face and online) including
development of a route to Public Health Practitioner
Registration.
8. Work with academic partners to develop capabilities to
deliver effective evaluation and evidence across public health.
9. Develop information systems with partners across NHS and
local government and other agencies to deliver information
which is easier to use to take public health action.
10. Build a network of health champions across communities and
agencies who will work to build a public health and
self-care culture.

Healthier Herts: A Public Health Strategy for Hertfordshire 33

 Priority 6 Make public health everyone’s business
11. Work with each of the following priority agencies to develop
public health plans, programmes and strategies across all
of their capabilities:
• Hertfordshire County Council departments
• NHS and social care commissioners
• Police and Crime Commissioner, Probation and
Hertfordshire Constabulary
• District/borough councils
• Town and parish councils
• Voluntary and community agencies and faith communities
• NHS and social care providers
• Workplaces
• Schools, further education colleges and the University of
Hertfordshire.
12. In an era when behavioural factors are increasingly
important in primary, secondary and tertiary prevention,
enhance and harness the contribution of behavioural sciences.

34 Healthier Herts: A Public Health Strategy for Hertfordshire

7. The implementation journey
The Health & Social Care Act 2012 sets
out the statutory requirement for local
authority leadership of public health from
April 2013. Some functions formerly in the
NHS, Health Protection Agency or other
bodies have transferred to a new body called
Public Health England, a new executive body
of the Department of Health, while others –
screening, immunisation - have gone to
NHS England (formerly called the NHS
Commissioning Board).
Under the transfer, a public health
allocation of £34.2 million was given to the
county council by the Secretary of State for
the discharge of the public health functions,
and a staff team of 46 people transferred
from the NHS. Most of the transferred staff
work in direct service provision, such as
smoking cessation and chlamydia screening.
This budget and staff core will be crucial to
enabling action by others, both in terms of
commissioning and co-commissioning
partners, and putting their skills and
knowledge at the service of others.
There are a number of statutory functions
given to Directors of Public Health (DPH)
and the role of the DPH and public health
team will work across the NHS, the county
council, district/borough councils and other
partners. The first step will be to ensure
that where necessary, services are
commissioned and then to review contracts
service by service to ensure they are being
delivered in line with the principles in
this strategy.
Project and implementation plans will be
developed to underpin this strategy and
these will include delivering plans for each of
the priorities in the next column.
Healthier Herts: A Public Health Strategy for Hertfordshire 35
Within this we will ensure we
prioritise work on:
• Restructuring the Public Health Service
in the county council to align people and
financial resources to this strategy
• Ensuring mandated services are
commissioned and delivered
• Developing and start to commission the
lifestyle offer
• Developing the obesity plan
• Developing the sexual health plan
• Developing the child and adolescent
public health plan including school health
• Recommissioning sexual health
services
• Delivering a route for public health
practitioner registration
• Delivering a health protection plan
• Delivering a drug and alcohol plan
• Delivering a public health and public
realm plan
• Delivering a public health development
plan for skills and capabilities
• Recommissioning school nursing
services
• Assuming statutory responsibility
for health visitors.
 2. The Public Health
Outcomes Framework30
The Public Health Outcomes Framework
(PHOF) outlined in figure 8 overleaf is a
range of indicators developed nationally
for use in England, which will help us
identify our progress towards achieving the
Hertfordshire public health strategy. We
will seek to report these indicators in a
way which enables us to both look across
Hertfordshire and compare areas within
Hertfordshire against itself, and against
England. The indicators are shown in more
detail in Figure 9 (page 38).

The PHOF national data set divides its

indicators into four groupings:

• Improving the wider determinants

of health
• Health improvement
• Health protection
• Healthcare and premature mortality.

The full set of indicators nationally and

for Hertfordshire are available at
www.phoutcomes.info

It is important that we know whether we

are succeeding or failing in meeting the
ambitions we have set. We will use two sets
of indicators to track progress on how we are
delivering the strategy:

1. The Health and

Wellbeing Strategy
indicators
We will also use the local indicators
devised for the Health and Wellbeing
Strategy priorities on which public
health leads.

36 Healthier Herts: A Public Health Strategy for Hertfordshire

Figure 8: T
 he Public Health Outcomes Framework

Vision: To improve and protect the nation’s health and wellbeing, and improve the health of
the poorest fastest.

Outcome 1: Increased healthy life expectancy

Taking account of the health quality as well as the length of life.

Outcome 2: Reduced differences in life expectancy and healthy life

expectancy between communities
Through greater improvements in more disadvantaged communities.

(Note: These two measures would work as a package covering both

morbidity and mortality, addressing within-area differences and between
area differences)

DOMAIN 1: DOMAIN 2: DOMAIN 3: DOMAIN 4:

Improving the wider Health improvement Health protection Healthcare public

determinants of health health and preventing
premature mortality

Objective: Objective: Objective: Objective:

Improvements against People are helped to The population’s health Reduced numbers of
wider factors that affect live healthy lifestyles, is protected from major people living with
health and wellbeing, make healthy choices incidents and other preventable ill health
and health inequalities and reduce health threats, while reducing and people dying
inequalities health inequalities prematurely, while
reducing the gap
between communities

}
Indicators
Across
the life
course
Indicators
} Across
the life
course
Indicators
} Across
the life
course
Indicators
} Across
the life
course

All of these indicators will be reported on to the Cabinet Panel for Public Health and Localism,
the Public Health Board and the Health and Wellbeing Board.

We will ensure that we benchmark Hertfordshire nationally, against our peer group,
and benchmark areas within Hertfordshire against Hertfordshire as a whole so that we identify
areas of worse health outcomes and target them effectively.

Healthier Herts: A Public Health Strategy for Hertfordshire 37

 Figure 9: Public Health Outcomes Framework Indicators
VISION Alignment across the Health and Care System
• Indicator shared with the NHS Outcomes
To improve and protect the nation’s health and well being and improve
Framework. Public Health
the health of the poorest fastest
• Complimentary to indicators in the NHS Outcomes
Outcome measures Framework. Outcomes
Outcome 1) Increased healthy life expectancy, i.e. taking account of the health † Indicator shared with the Adult Social Care Framework
quality as well as the length of life Outcomes Frameworks.
Outcome 2) Reduced differences in life expectancy and healthy life expectancy †† Complimentary to indicators in the Adult Social 2013-2016
between communities (through greater improvements in more disadvantaged Care Outcomes Framework
Indicators in italics are placeholders, pending
At a glance (Autumn 2012)
communities)
development or identification
Improving the wider determinants Healthcare public health and
1 2 Health Improvement 3 Health Protection 4
of health preventing premature mortality
Objective Objective Objective Objective
Improvements against wider factors which effect People are helped to live healthy lifestyles, make The population’s health is protected from major Reduced numbers of people living with prevent-
health and well being and health inequalities. healthy choices and reduce health inequalities. incidents and other threats, whilst reducing able ill health and people dying prematurely,
health inequalities. whilst reducing the gap between communities.

Indicators Indicators Indicators Indicators

1.1 Children in poverty 2.1 Low birth weight of term babies 3.1 Fraction of mortality attributable to 4.1 Infant mortality* (NHSOF 1.6i)
1.2 School readiness (Placeholder) 2.2 Breastfeeding particulate air pollution 4.2 Tooth decay in children aged 5
1.3 Pupil absence 2.3 Smoking status at time of delivery
3.2 Chlamydia diagnosis (15-24 year olds) 4.3 Mortality rate from causes considered
1.4 First time entrants to the youth justice 2.4 Under 18 conceptions
3.3 Population vaccination coverage preventable ** (NHSOF 1a)
system 2.5 Child development at 2-2 1/2 years
1.5 16-18 year olds not in education, employment (Placeholder) 3.4 People presenting with HIV at a late stage 4.4 Under 75 mortality rate from all
or training 2.6 Excess weight in 4-5 and 10-11 year olds of infection cardiovascular diseases (including heart
1.6 Adults with a learning disability/in contact 2.7 Hospital admissions caused by unintentional 3.5 Treatment completion for Tuberculosis (TB) disease and stroke)* (NHSOF 1,1)
with secondary mental health services who and deliberate injuries in under 18s 3.6 Public sector organisations with a broad 4.5 Under 75 mortality rate from cancer*
live in stable and appropriate 2.8 Emotional well-being of looked after children
approved sustainable development (NHSOF 1.4)
accommodation† (ASCOF 1G and 1H) 2.9 Smoking prevalence - 15 year olds

38 Healthier Herts: A Public Health Strategy for Hertfordshire

1.7 People in prison who have a mental illness (Placeholder) management plan 4.6 Under 75 mortality rate from liver disease*
or a significant mental illness (Placeholder) 2.10 Self-harm (Placeholder) 3.7 Comprehensive, agreed inter-agency plans (NHSOF 1.3)
1.8 Employment for those with long-term health 2.11 Diet for responding to public health incidents and 4.7 Under 75 mortality rate from respiratory
conditions including adults with a learning 2.12 Excess weight in adults
emergencies (Placeholder) diseases* (NHSOF 1.2)
disability or who are in contact with 2.13 Proportion of physically active and inactive
secondary mental health services *(i-NHSOF adults 4.8 Mortality rate from infectious and parasitic
2.2) †† (ii-ASCOF 1E) ** (iii-NHSOF 2.5) †† 2.14 Smoking prevalence - adults (over 18s) diseases
(iii-ASCOF 1F) 2.15 Successful completion of drug treatment 4.9 Excess under 75 mortality rate in adults
1.9 Sickness absence rate 2.16 People entering prison with substance with serious mental illness* (NHSOF 1.5)
1.10 Killed and seriously injured casualties on dependence issues who are previously not 4.10 Suicide rate
England’s roads known to community treatment
4.11 Emergency readmissions within 30 days of
1.11 Domestic abuse (Placeholder) 2.17 Recorded diabetes
1.12 Violent crime (including sexual violence) 2.18 A lchol-related admittance to hospital discharge from hospital* (NHSOF 3b)
1.13 Re-offering levels (Placeholders) 4.12 Preventable sight loss
1.14 The percentage of the population affected 2.19 Cancer diagnosed at stage 1 and 2 4.13 Health-related quality of life for older
by noise 2.20 Cancer screening coverage
people (Placeholder)
1.15 Statutory homelessness 2.21 Access to non-cancer screening
1.16 Utilisation of outdoor space for exercise/ programmes 4.14 Hip fractures in people aged 65 and over
health reasons 2.22 Take up of the NHS Health Check 4.15 Excess winter deaths
1.17 Fuel poverty (Placeholder) programme - by those eligible 4.16 Estimated diagnosis rate for people with
1.18 Social Isolation (Placeholder) † (ASCOF 1I) 2.23 Self-reported well being dementia* (NHSOF 2.6)
1.19 Older people’s perception of community 2.24 Injuries due to falls in people aged 65 and
safety (Placeholder) †† (ASCOF 4A) over
References
1 Hertfordshire County Council Corporate
Plan 2013-2017
http://www.hertsdirect.org/docs/pdf/c/
corpplan13-17.pdf
2 Marmot, M (2010) Fair Society, Healthy
Lives. Report of the review on health
inequalities in England. London: Institute
of Health Equity
http://www.instituteofhealthequity.
org/projects/fair-society-healthy-lives- 13 Marmot, M (2010) Fair Society, Healthy
the-marmot-review
3 Owen L, Morgan A, Fischer A, Ellis S,
Hoy A, Kelly MP. The cost-effectiveness
of public health interventions. Journal of
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11 Brennan Ramirez LK, B.E., Metzler M.,
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Help Communities Address Social
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2008, Department of Health and Human
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12 http://www.hertslis.org/partners/jsna/
Lives. Report of the review on health
inequalities in England. London: Institute
of Health Equity
http://www.instituteofhealthequity.
org/projects/fair-society-healthy-lives-
the-marmot-review

4 http://www.hertsdirect.org/docs/pdf/h/ 14 http://nccdh.ca/images/uploads/
hwbstrategy.pdf Approaches_EN_Final.pdf

5 http://www.hertsdirect.org/your-council/ 15 Robert Wood Johnson Foundation and

hcc/partnerwork/hwb/ University of Wisconsin Population
Health Institute
6 Hertfordshire County Council
Corporate Plan 2013-2017 16 http://neweconomics.org/projects/
http://www.hertsdirect.org/your-council/ five-ways-well-being
cpdrp/corplan/
17 To be published alongside the Public
7 http://www.fph.org.uk/what_is_ Health Strategy
public_health
18 Marmot, M (2010) Fair Society, Healthy
8 Marmot, M (2010) Fair Society, Healthy Lives. Report of the review on health
Lives. Report of the review on health inequalities in England. London: Institute
inequalities in England. London: Institute of Health Equity
of Health Equity http://www.instituteofhealthequity.
http://www.instituteofhealthequity. org/projects/fair-society-healthy-lives-
org/projects/fair-society-healthy-lives- the-marmot-review
the-marmot-review
19 Department of Health (1998) report of
9 Tackling inequalities in life the independent inquiry into inequalities
expectancy in areas with the worst in health. London
health and deprivation (National http://www.fph.org.uk/what_
Audit Office, 2010) is_public_health
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uploads/2010/07/1011186.pdf 20 Department of Health (2010)
https://www.gov.uk/government/
10 http://whqlibdoc.who.int/hq/2008/ publications/the-public-health-white-
WHO_IER_CSDH_08.1_eng.pdf paper-2010

Healthier Herts: A Public Health Strategy for Hertfordshire 39

21 Department of Health (2011) Healthy 30 https://www.gov.uk/government/
Lives, Healthy People publications/healthy-lives-healthy-
https://www.gov.uk/government/ people-improving-outcomes-and-
publications/healthy-lives-healthy- supporting-transparency
people-our-strategy-for-public-health-
in-england

22 Department of Health (2012) Directors of

Public Health in Local Government
https://www.gov.uk/government/
uploads/system/uploads/attachment_
data/file/213007/DsPH-in-local-
government-i-roles-and-
responsibilities.pdf

23 Griffiths, Jewell and Donnelly (2005)

http://www.sciencedirect.com/science/
article/pii/S0033350605000570

24 M
 armot, M (2010) Fair Society, Healthy
Lives. Report of the review on health
inequalities in England. London: Institute
of Health Equity
http://www.instituteofhealthequity.
org/projects/fair-society-healthy-lives-
the-marmot-review

25 Beaglehole et al (2004) Public Health

at the Crossroads. Oxford:
Oxford University Press

26 Copyright, Hertfordshire County

Council, 2013

27 http://nccdh.ca/images/uploads/
Approaches_EN_Final.pdf

28 Hertfordshire Health and Wellbeing

Strategy 2013-2016
http://www.hertsdirect.org/docs/pdf/h/
hwbstrategy.pdf

29 Hertfordshire Equality Strategy

2013-2015
http://www.hertsdirect.org/docs/pdf/e/
eqstrat2013.pdf

40 Healthier Herts: A Public Health Strategy for Hertfordshire

Healthier Herts: A Public Health Strategy for Hertfordshire 41
 Hertfordshire
County of
Opportunity

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