In October 2018 I was invited to the World Health Organisation's International Healthy Cities Conference from 1-4 October in Belfast where I showcased the housing and health work that I led:
Context
The Sevenoaks District is the most western district in Kent bordering London, Surrey and East Sussex in the South East of England. It is a large, rural district made up of four main towns and a number of villages.
Sevenoaks is one of the 20% least deprived districts/unitary authorities in England, but these statistics hide serious pockets of deprivation as about 12% (2,500) of children live in low income families where rural deprivation is more isolating than poverty in the towns.
Not surprisingly from an affluent district overall life expectancy is higher than the national average. However, life expectancy is 3.3 years lower for men and 2.2 years lower for women in the most deprived compared to the least deprived areas in the district.
The highest prevalence of long term conditions affecting residents of the Sevenoaks District include: hypertension (14.4%), diabetes (5.7%) and asthma (5.6%). With house prices up to 17 times higher than average wages Sevenoaks suffers from the out-migration of younger people to cheaper areas to live. This contributes to the breaking up of families and communities and results in isolation and loneliness in older people. Many older people are asset rich, but cash poor living in poorly maintained often cold housing that contributes to falls. The district also has about 800 people living in mobile homes – where deterioration is more extreme leading to serious poverty in old age. As a result Sevenoaks has one of the highest rates of falls and hip fractures in the county.
Sevenoaks is an ageing district with the number of people aged 65 set to increase by nearly 37% by 2036, so ageing well is a major priority of the council.
Rationale
Since the Second World War the focus on preventative health has waned in favour of treatment after people fall ill. This has resulted in a continuous increased demand in health and social care over the years; resulting in a re-think that it is better to focus on promoting wellbeing then treatment.
In 2012 the Health and Social Care Act created Clinical Commissioning Groups (CCGs) that brought public health back under the control of local government for the first time in forty years. In two-tier areas that meant giving public health to the upper-tier or county authority because they provide social care. This was an effort to have more synergies between the health service and social care.
County Councils do not have any public health or place-making tools (Planning, Housing, Environmental Health, Licensing, Leisure, Community Safety, Economic Development etc). In order to meet their new public health obligations county councils simply commissioned public health services – some of which were at odds with or duplicating work that district (lower-tier) councils were already doing. Where counties did work with districts it was usually a commissioning arrangement and not a partnership relationship.
Sevenoaks District Council saw very early on that the CCG’s objectives (which later became the STPs) would never be met unless the district councils with their public health and place-making tools became full and equal partners with the County Council as the Public Health authority, and the new CCGs (representing the NHS).
After the district elections in May 2015 Sevenoaks District Council created the new cabinet portfolio of Housing, Health and Leisure and in December that year the council published its ‘Sevenoaks District Health Deal – the future of health at a local level’ which revolved around a ten-point plan.
The health deal gained traction with two neighbouring districts: Tonbridge & Malling Borough Council and Tunbridge Wells Borough Council and soon became the West Kent Health deal. Kent County Council realised it needed to re-focus its efforts on prevention in order to reduce demand on social care. So a new West Kent
partnership was born where districts became full and equal partners with Kent County Council and the CCGs. This resulted in the West Kent Health and Wellbeing Board being replaced by a new Members Forum made up of the CCG, Public Health and crucially the portfolio holders from the district councils and one from the county council.
The three district councils spend approximately £1million on health in West Kent and Kent County Council spends a further £1million on public health. We have pooled all our spending power and tools together to build a partnership that does not duplicate work and aims to achieve the best health outcomes for our residents.
The ten point plan is a two-pronged attack on public health. It involves a health in all policies approach to the district place-making tools so that we build environments conducive to wellbeing; and direct action mainly through social prescribing to tackle the non-medical reasons why people are seeking medical help. The plan has a
particular focus on ageing well, mental wellbeing and tackling obesity as we believe that the districts place-making tools have the biggest impact on those three areas.
Description
Sevenoaks District Council developed a vision where we would use all our tools together, holistically and strategically to create environments conducive to wellbeing.
We believe very much that our home, as our most immediate environment has the biggest impact on our health. If our home is over-crowded, isolated and under-occupied, badly maintained and full of hazards, cold and damp or unaffordable and causing debt - our health will suffer.
We developed a housing strategy: ‘Wellbeing Starts at Home’ that is tackling these issues and will form a major plank of our new local plan which will hopefully be approved next year. For the first time ever health will carry equal weight to the greenbelt and other planning considerations – meaning that once again health will be at the heart of town planning.
We have conducted a number of health-in-all-policies workshops to embed health and wellbeing in all we do as a council, and our new corporate plan is based solely around improving the health and wellbeing of our residents.
Our vision is a back-to- the-future vision – very much inspired by Victorian local government that used their
tools to eradicate Cholera and build healthier towns and cities.
The West Kent ten point enhancement plan
- Debt and housing advice to include healthy lifestyle referrals Sevenoaks District Council has always taken a holistic view of peoples’ problems. In 2009 the council created its HERO (Housing, Energy, Re-training Options) advice service to alleviate homelessness and help people back into work. It is very much a preventative service: advising people on debt and other issues before they are evicted by their landlord solving all the contributing factors threatening homelessness. Recently with more pressures causing homelessness and the Homelessness Reduction Act, the council has upskilled its HERO officers into Super HEROs with a better understanding between the links of debt and health.
- Communications tools The council and our partners have a range of communications tools that we can use to advise on health and wellbeing. These range from traditional communication methods such as our quarterly magazine that is delivered to all residents and social media to less obvious forms of communication such as community awards that are laced with subtle health messages. This year the council’s chairman organised ‘the big sing’ to promote the mental health benefits of singing and joining a choir. The council often supports national awareness campaigns to highlight particular messages such as Rural Housing Day, Supported Housing Day, Health Awareness Week, Dementia Awareness Week etc. We are also exploring digital channels of communication to reach people in our more deprived areas to help close the life expectancy gap. For example, we know that people from deprived areas who are in debt are unlikely to contact the council for help, so we will be advertising on sites where they are likely to go such as Pay Day Loan sites. We are also encouraging people to make small changes to their lifestyle that will make a big difference to their health such as replacing crisps for popcorn or adding peas to their fish fingers and chips.
- Making Every Contact Count The council does not pay lip service to this – we really mean it. It does not matter how we find a resident in need we make sure that all their issues are resolved. They may self-refer to one of our services such as HERO; or they may complain to Environmental Health about a noise nuisance that actually reveals their sensitivity to noise could mean the onset of dementia; or they may be referred to us by a GP or be picked up by our council tax department for missing a payment that could be an early sign of debt. However we find someone we work as a council with Kent County Council, the CCG and the voluntary sector to resolve all their problems.
- Healthy workplaces After the time spent at home, we spend the next amount of time at work and it is important that we support employers to create healthy workplaces. Our economic development team works with local employers to spread good practice and offer support on how to reduce staff sickness and remove the stigma of mental ill health. We have trained a number of employers to be dementia-friends so they can not only better assist customers that maybe living with dementia, but understand the needs of employees that may have caring responsibilities adding to their stress. As one of the largest employers in the district ourselves, we take our responsibility as a community leader very seriously. Our One You advisors are available for our staff to talk to about any health issues that concern them and our Human Resources department was very much part of our health-in-all-policies review. Sevenoaks District Council has signed the employer mental health pledge and we host smoking cessation support in our offices.
- Policy review Our health-in-all-policy review is absolutely essential to make sure that every elected councillor, member of staff, and every department is pulling in the same direction to ensure the council operates as a council to promote health and wellbeing. It will begin with the corporate plan and follow through in every council policy moving forward. It is by having a whole council focus on wellbeing that we are able to build dementia- friendly towns and villages across the district, try to create a district that is conducive to mental wellbeing and to encourage active travel as part of peoples’ daily routine.
- Hub model for integrated health (preventative services) In partnership with Kent County Council and the CCG, West Kent has set up health hubs in each district employing One You advisors to tackle the non-medical reasons why people seek medical help. Examples include asthma caused by damp housing, anxiety caused by debt and a range of issues caused by loneliness, poor diet and lack of exercise. In Sevenoaks the One You advisors work closely with Super HERO when debt is part of a resident’s problem. Often solutions are found in the voluntary sector so we work very closely with organisations such as the Citizens Advice Bureau, West Kent Mind and Age UK. Our Handy HERO service offers home adaptations where necessary. The hubs include the rapid hospital discharge scheme where patient’s homes are prepared while they are in hospital so they can be discharged as soon as they are clinically ready. Remedies can include simple measures such as moving a bed from upstairs to downstairs, fitting a key safe outside the property so carers can gain access to fitting ramps and rails.
- Accessing other external funding In order to provide as holistic a service as possible the council bids for external funding to either completely or partially fund projects. Two of our One You advisors are funded from the Better Care Fund and the council was awarded central government funding to upskill our HERO officers into Super HEROs.
- Assessment of wider determinants of GP surgeries To help tackle the life expectancy gap between the least and most deprived people in the district, we are examining issues based around GP surgeries to identify interventions that could help plug health inequalities. Examples include weight management courses, specialist leisure provision, falls prevention classes, concentrated debt and budgeting classes etc.
- Use of Open Space and Active Travel Health will be a major planning consideration in the council’s new local plan that should be approved in 2019 and that will promote open space and active travel. We are also promoting footpaths as alternative routes to roads and pavements and examining ways that active travel can be made part of peoples’ daily lives.
- GP partnership Partnership with our GPs is essential to making the whole plan work. GPs are experiencing the benefits of what we are doing and are referring more and more people into our services. The new West Kent Members Forum has GP representation on it cementing this partnership.
Achievements:
The housing strategy and ten point plan is already making a big difference to peoples’ health and wellbeing. This was recognised by iESE (The Improvement and Efficiency Social Enterprise) in March this year when they awarded the council the Gold award for Transformation in Health and Social Care.
The hospital discharge scheme won the Kent Housing Group and Kent Joint Policy and Planning Board for the excellent partnership in September 2017, and in December 2016 the Council won the most Dementia-friendly organisation in Kent.
Earlier this year the Council was commended by ‘The MJ’ local government magazine for public health improvement.
Tunbridge Wells acute hospital exceeded its discharge times for the first quarter of this year partly due to the work of the West Kent rapid hospital discharge scheme. The scheme has assessed 288 patients since November 2016.
Since its inception in 2009, HERO has assisted over 1,800 clients where on average they reduce debt or rent arrears by £600 per person. Over 40% are supported onto the correct welfare and benefits payments. The service has reduced housingassociation rent arrears by over £12,000 per annum; and it has supported 13% of clients back into training, work or volunteering.
The new Super HERO service has maximised welfare benefits by an average of £132pp per week; reduced the total amount of debt by over £33,500, prevented people from becoming homeless who were at immediate risk of eviction; and has supported people into employment, training and volunteering.
Conclusion
It is only by placing prevention at the heart of all public services and having a health- in-all-policies approach across the whole public sector can we start making huge in-roads into preventing ill health and keeping people well.
Local government is starting to re-connect with it Victorian roots by using its place-making tools to build
environments that are conducive to wellbeing. Through housing, planning, licensing, environmental health, leisure and economic development we can build communities with good quality homes, which encourage active travel and employment opportunities so that healthy lifestyles automatically become a natural way of life for people.
Sevenoaks District Council has started on this journey and we believe that we are and can continue to make a huge difference to the health and wellbeing of our residents.