Sector-led improvement

'Sector-led improvement' (SLI) is an approach to organisational and service improvement put in place by councils and the Local Government Association (LGA) following the abolition of the previous national performance framework, in 2011, and the transfer of Public Health from the NHS to within local government, in 2013. It is based on the principles that councils are responsible for their own performance which includes their Public Health functions and being locally accountable (LGA, 2015).

Public Health SLIs are steered locally by the Cumbria and Lancashire Public Health Collaborative, (CLPHC) which aims to continuously improve public health practice and the cost effectiveness of public health commissioned services by driving up the quality of provision and implementing rigorous clinical and non-clinical audits. Support for SLIs is also provided at a national level by the Association of Directors of Public Health (ADPH).

In 2023, the development of the SLI programme is perhaps best understood as a process that has progressed in phases, though this more by necessity than design:

Prior to the covid pandemic (2011-2020): early SLI initiatives at the local, regional and national level were focused across a range of public health needs (on sexual health, and infant mortality in Cumbria and Lancashire) and arguably more on SLI building blocks such as the formation of collaboratives amongst the relevant bodies, baseline needs assessments, related service level audits in order to identify existing gaps and best practice, the development of a number of quality assessing toolkits to support this work, and the development of strategies and implementation plans (LGA, 2018). 

The 2015 LGA (link above) report on SLI initiatives in this phase, noted that such progress was being made and was valuable, but also that, 'external stakeholders and the public still remain to be convinced about the robustness of the sector led approach when there is no national system or obligation to be involved'; and the 2018 LGA report (link above) found that, nationally, the progress of SLI initiatives had been varied.     

SLI during the pandemic (2020-2021): COVID-19 had a significant impact on the population that was unprecedented in recent times, and so of course also on the capacity and resources of Directors of Public Health (DsPH) and their teams, and each had to refocus their activities and priorities to respond effectively to the pandemic. This impacted on the delivery of recently established national and regional programmes and initiatives including those focused on SLIs, which were largely paused or delayed (ADPH, 2021).

Nevertheless, during the pandemic local NHS bodies, Local Government Public Health and others by necessity collaborated and integrated their responses to the pandemic in ways that constituted "improvements in services led from within the sector" though such were not "badged" as SLI's:

the Lancashire Resilience Forum (LRF) coordinated responses to the pandemic across the Health and Public Health (PH) sector drawing on a wide range of organisations, teams, and Public Health (PH) resources, for example LCC's PH Intelligence analysts worked with neighbouring PH analysts in Blackpool, and Blackburn with Darwen, and with analysts in the NHS's Midlands and Lancashire Commissioning Support Unit (CSU) and other bodies in order to secure reliable data flows on covid infection rates and hospitalisations, and later, vaccination rates and the identification of demographic groups and geographic areas where vaccination uptake and coverage were relatively low.  Other services and sources of support from voluntary or charitable community organisations also collaborated in relation to providing support for individuals shielding from potential infection, and other households during periods of self-isolation due to acquired infection.

The LGA continued to provide SLI support (much of this focused on the requirements generated by the pandemic) throughout this period (LGA, 2020), and as we moved out of the pandemic and into recovery, attention was given to both reinstating SLI initiatives and (prompted by the disruption to such brought about by the pandemic) to review their current standing.

In the latter regard the ADPH, for example, noted in its 2022/21 annual report (ADPH, 2021, link above) that:  

'Local Public Health teams … have encountered significant pressures over the past year (2020/21) that, unless addressed, have the potential to impact [Sector Led] improvement work going forward.

In addition, 'funding and capacity continue to be the key issues affecting improvement activity at regional and local level. Three networks lost their SLI Coordinator this year due to funding pressures and the redeployment of personnel towards activities directly related to the pandemic response'.

'Uncertainties brought about by the system reforms [for example the replacement of Clinical Commissioning Groups by Integrated Care Boards and Place Based Partnerships] are also hindering the ability of regional networks to plan for the future. The shape of regional arrangements [which at the time were still to be reconfigured] will have a significant impact on the way that the regional ADPH networks operate, and further clarity is needed to ensure the delivery of effective regional programmes' including SLIs.

SLI into the post-pandemic phase (2021- present): as the pandemic began to recede, and in part reference to both the disruption caused by the pandemic to such initiatives as SLI, and to the pandemic focused service developments such as those noted above, it had become evident to the ADPH and others that, 'regional SLI plans are as much about embedding SLI approaches in to ongoing work as they are about developing specific SLI programmes' (ADPH, 2021, link above) and the associated 'quality assessing toolkits…, strategies and implementation plans' and related, as above. 

In a sense such reinterpretations – from (capitalised) Public Health 'Sector Led Improvements', to (non-capitalised/more routine) "improvements that are led from within the public health sector" – reflects broader concerns relating to higher profile service quality improvement such as 'SLI' that have long been expressed: 'Quality [improvement] is more than a set of tools, to be discussed at meetings. It is a way of looking at the workflows, and it encompasses how managers manage, measure, and react to issues in the workflows…it is not just a bolt on to their current busy roles' (King's Fund, 2017).

The ADPH noted its intentions similarly: 'The networks therefore plan to continue embracing the organic way in which quality improvement activity has been able to take place over the past year and it’s likely that this dynamic will continue to flourish for the foreseeable future' (ADPH, 2021, link above).

The ADPH conducted a review into SLI in 2022, on the basis of which it published it 'SLI Impact Report', in 2023, with its associated 'Summary and Key messages' document noting its aims for the future, featuring both intentions to:

Tackle the now better known barriers to SLIs including addressing both the conceptual issues that have surrounded what SLI means, how improvements are measured, the limitations on resources and capacity, and improving the visibility of improvement works, and;

a continuation with this 'new focus to SLI work resulting from the pandemic, with shorter and sharper work, providing an effective return', the further 'promotion of peer-to-peer working and learning through collaboration, mutual learning and soft-sharing', and 'more effective engagement with local populations' (ADPH, 2023, link above).

LLC Business Intelligence: updated Nov 2023