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BUILDING CAPACITY FOR HEALTH AND WELLBEING

PROMOTION IN TASMANIA:

A WORKFORCE DEVELOPMENT STRATEGY FOR LOCAL

GOVERNMENT

“Overwhelmed by possibilities, and no one here to accept or consider them. We have too few staff and we are wearing too many hats even in normal times. There are lots of activities that people want to bring to town whether we need them or not. Our own need to raise money by small grants applications is bottle-necking some councils. We just can’t move forward at this time- not enough staff, no identified roles, not enough council funds and a grant system that means we are competing for not so much anyway, with little resources to present good ones”

-Stakeholder feedback (January 2021)

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ACKNOWLEDGEMENTS

Funding

The Tasmanian Local Government Health and Wellbeing Workforce Development Project is part of the Local Government Community Health and Wellbeing (CHW) Project 2020-2022 being implemented by the Local Government Association of Tasmanian (LGAT). This project is funded by the Crown through the Department of Health.

Project Advisory Group

• Lisa Rudd [Glenorchy City Council]

• Suzanne Schulz [Clarence City Council]

• Adam Wilson [Central Highlands Council]

• John Davis [Launceston City Council]

• Jodie Saville [Circular Head Council]

• Amber Power [Circular Head] • Michelle Morgan [Public

Health Services] • Kate Garvey [Public Health

Services] • Katelyn Cragg [LGAT] • Mark Green [Department of

Communities]

Key stakeholders consulted

Appreciated is extended to the following individuals who participated in stakeholder consultations and meetings during this project.

• Sandra Ayton • Richard Muir Wilson • Rebecca Stevenson • Adam Wilson • Deb Mainwaring • Jodie Saville • Glenys Nichols • Heidi Willard

• Jenelle Wells • Michelle Dutton • Rebecca Essex • Tracey Turale • Michelle Morgan • Flora Dean • Julie Williams • Kate Garvey

Sensemaking Group

Appreciation is extended to participants of the April 21 sensemaking workshop that helped interpret preliminary data and fine-tune strategy recommendations.

• Katrina Stephenson • Caroline Davies Choi • Michelle Morgan • Katrina Brazendale • Narelle Synnott • Rebecca Stevenson • Julie Gordon • Ben Morris • Lisa Rudd • Katelyn Cragg

• Leah page • Willie Joseph • Sophie Calic • Trish Jay • Suzanne Schulz • Liz Selkirk • Cathy Starling • Kimbra Parker • Connie Digolis

Suggested citation: Hughes R. Building capacity for health and wellbeing promotion in Tasmania: A workforce development strategy for local government. University of Tasmania, Hobart, 2021.

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CONTEXT Health and wellbeing are the ultimate aspirational outcome of all health systems and a critical determinant of social and economic prosperity. It is therefore a key responsibility of all levels of government.

The capacity of a community to achieve health and wellbeing outcomes is determined by its workforce, leadership, intelligence to inform decision making, community capitol, partnerships and resources1-6.

Public health actions and interventions by definition relies on “organised efforts of society”7. The workforce is a major contributor to this organised effort.

Workforce development that builds the capacity of communities to promote health and wellbeing is context driven. This is particularly the case in Tasmania as summarised in the following box.

The Tasmanian context • Tasmania has a state population health profile that by comparison with other

Australian states is the most unhealthy and unwell in the federation8. • Tasmanians experience high levels of preventable morbidity, hospital admissions

and mortality attributed to the social determinants of health and preventable lifestyle factors such as diet, sedentary lifestyles and substance abuse8, 9.

• There are low levels of health literacy across the Tasmanian population • A state health system is by its own description better described as a “Disease System”,

with a focus on downstream curative services and increasingly under considerable duress10.

• Despite high level recognition by Government of the merits of preventative health services11, health in all policies and the creation of the Premiers Health and Wellbeing Advisory Council12 there appears to have been little progress in advancing investment to build the capacity of the Tasmanian workforce for health promotion.

• Current political leadership in Tasmania emphasises and reinforces a deficit-based disease system. This has been recently demonstrated in the political narrative in the recent state election, that focused on “more hospital beds, Doctors, ambulances, surgery etc” and a focus on inputs (dollars spent) rather than outcomes (health and wellbeing), return on investment and opportunity costs.

• Despite increasing budgets allocated to “health” in Tasmania, the health workforce servicing primary/community health and health promotion is arguably the most under-developed in the federation.

• The proportion of the health budget invested in preventive health services and interventions continues to be disproportionately low relative to need and opportunity (Estimated to be 1.7% of the Tasmanian Health budget in 2017-201811) and difficult to accurately estimate.

• Health budget funding directly to support community-based health and wellbeing interventions and services is approximately 0.05% of the health budget in 2021-2022. Whilst the gross amount allocated to the Healthy Tasmania Strategy and related grants program has increased marginally in the latest budget, this investment is grossly inadequate relative to need.

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• There is an increasing recognition world-wide of the role (and opportunity) of Local Government to address the social determinants of health, promote and protect health and wellbeing of communities13, 14.

• A number of Tasmanian Councils15-20 have taken the lead and developed Health and Wellbeing Plans, employed HWB Officers and continue to lobby for community action, despite inadequate funding and challenges with coordination across the three tiers of government15, 20.

• The COVID pandemic and the resultant disruption has provided a very public demonstration in Tasmania of the benefits of concerted prevention/public health efforts but has also highlighted the lack of preparedness of the state health system (and its workforce). It has also created a range of additional challenges to resourcing and progressing the development of the health and wellbeing promotion system in Tasmania.

• This project has been conducted at a time of significant health system review in Tasmania, including consultation regarding Our Healthcare Future10, the Healthy Tasmania Strategy renewal and the release of the draft National Preventive Health Strategy 2021-203021. This presents a timely opportunity to strategically consider an enhanced future role of local government in public health, including health and wellbeing promotion.

There is a great need for concerted, sustained and evidence-based health promotion investment and workforce development in Tasmania. It is this context that the Local Government Association of Tasmania commissioned this project to consult stakeholders, research aspects of the workforce development challenge and to develop a strategic plan for HWB Workforce Development in Local Government.

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PROJECT SCOPE The Tasmanian Local Government Health and Wellbeing Workforce Development Project is part of the Local Government Community Health and Wellbeing (CHW) Project 2020-2022 being implemented by the Local Government Association of Tasmanian (LGAT). This project is funded by the Crown through the Department of Health.

This project aims to build the capacity of the local government sector to better enable it to improve the health and wellbeing of Tasmanians.

The specific project brief was to conduct a workforce development needs assessment/situational analysis of the Health and Wellbeing Workforce in Local Government in Tasmania. The agreed methodology is described in the Methods section of this report. The scope of work was to:

• Design and conduct an online survey of the Local government workforce in collaboration with the Workforce Project Advisory Group (WFPAG).

• Conduct a literature review. • Design and conduct face to face stakeholder interviews. • Collect and analyze council job descriptions for community development and

health and wellbeing officers. • Develop a final report in collaboration with LGAT that includes consultation through

regional workshops on preliminary findings, consultation with the WFPAG and a communications plan.

• Collaboration with LGAT to develop a workforce development strategy plan.

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METHOD A mixed-method and phased approach to consultation, data collation and analysis has been employed, summarised in Figure 1 and Table 1.

Figure 1: Methods sequence

Strategies developed and suggested in this project have intentionally been aligned with the National Preventive Health Strategy 2021-203021, as this national strategy promises to influence national investment and policy direction regarding the development of preventive health capacity (and in particular workforce development) nation-wide over the next decade.

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Table 1: Methods description summary

Method Description

Project scoping The Project Advisory Group (PAG: see acknowledgements) met over numerous meetings (zoom) to agree on the scope, methods mix, conceptual approach for the project and served as a sounding board for the researcher throughout the project.

Literature Review A review of the grey literature (institutional, non-peer reviewed) relating to HWB workforce development was undertaken using google searches. A non-exhaustive review of the international published literature was undertaken. Both searches informed the development of the stakeholder consultation interviews and the workforce survey study designs.

Key stakeholder consultation

Semi-structured consultative interviews were conducted amongst a purposive sample of HWB workforce development stakeholders including Local Council Directors/Managers, Council Officers and THS Health Promotion Practitioners. A total of 12 interviews (16 stakeholders) were conducted during January-March 2021. Interviews were audio-taped, transcribed verbatim and qualitatively analysed using thematic analysis.

State-wide workforce survey

An on-line survey of the Local Government Officers in Tasmania was conducted during January-April 2021. Professional network contact lists (provided by LGAT) and snow-ball sampling was used to invite Local Government Officers throughout 29 Tasmanian Councils via email to voluntarily participate in the on-line survey. This survey recruited 51 individual Officers from across Tasmania, representing a response rate of over 50%. Data from the survey included workforce size, demography, distribution, attributes, recruitment and retention issues, continuing professional development needs and felt needs regarding workforce development strategies.

Council HWB Strategy Review

Searches of Tasmanian Council (n=29) websites identified 6 HWB Strategic Plans (Clarence, Huon Valley, Central Highlands, Central Coast, Glenorchy and Circular Head-Waratah-Wynyard). Qualitative content analysis was conducted to assess definitions of HWB, approach taken, priorities identified and specific strategies and performance indicators.

Position Description Analysis

Position descriptions were sourced on request by LGAT to all 29 Councils. A total of 43 position descriptions were obtained from 7 Councils (Huon Valley, Georgetown, West Tamar, North Midlands, Hobart, Launceston and

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Kingborough). Most of therse were for positions not specifically focused in HWB roles but contributed to HWB work. An additional 3 position descriptions for Health Promotion Officers in mainland State Health Systems (NSW, WA) was sourced from the internet to enable a comparison and reference point for designated health promotion officers. Qualitative analysis focused on duties/accountabilities as a proxy of the work required and selection criteria as a proxy of the competencies/credentials required.

Data triangulation and sensemaking

Triangulation of data used comparison and interpretation of data from different methods (method triangulation) and by different researchers/collaborators (researcher triangulation). A preliminary summary of the data was presented and workshopped at a sensemaking workshop (See Acknowledgements: Sensemaking Group) of stakeholders (April 21) to help make sense of and contextualise the data.

Strategy Synthesis Strategy recommendations were drafted by the Project Lead and distributed for review and feedback by the Project Advisory Group before finalising.

Ethics approval for key stakeholder consultations and survey data collections was obtained from UTAS Social Science Ethics Committee.

DEFINING HEALTH AND WELL-BEING Developing a strategic plan for the HWB workforce in Local Government in Tasmania requires clarity regarding what is meant by terms health and well-being.

The Health and Wellbeing Workforce Project Advisory Group (hereafter referred to as the Advisory Group) were asked as part of the project scoping stage to define what they meant and how they used the terms in the context of Local Government. Responses aligned with definitions of health and wellbeing used by international agencies such as the World Health Organisation (WHO) and as articulated in Council Health & Wellbeing Plans15-20.

Health A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity7

Health doesn’t just mean being free from sickness and disability. Health is a complete state of physical, mental and social wellbeing. Many of the factors influencing health lie outside the health sector. The social determinants of health are the conditions in which a person lives, that determine their chances of achieving good health. Social, environmental, and economic factors are important determinants of human health and are interrelated. This Plan acknowledges the importance of social position, stress, early life, social exclusion, work, unemployment, social support, addiction, food and transport as contributing to health outcomes. [Clarence City Council15]

Wellbeing is a state of being happy, healthy and prosperous. People cannot fully achieve their potential unless they are able to take control of those things that determine their wellbeing [Glenorchy City Council18] there is no single agreed definition, but a working definition of wellbeing should include the presence of positive emotions and moods, the absence of negative emotions, satisfaction with life, fulfillment and positive functioning[Clarence City Council15]

The disciplinary basis of work required to achieve the outcomes of community health and wellbeing is health promotion (a sub-field of public health).

SITUATING HEALTH AND WELLBEING IN THE CONTEXT OF PUBLIC HEALTH The World Federation of Public Health Associations (WFPHA) in collaboration with the WHO has developed a framework [The Global Charter for the Public’s Health] that describes the structure, role, functions and competencies required of public health systems. This framework aligns with and should be read along-side the UN Sustainable Development Goals1.

This framework helps describe and categorise public health as a field of practice, education, research and service, of relevance to considerations about health and wellbeing promotion in local government.

Figure 2: The Global Charter for Public Health: A Conceptual Framework.

Source: https://www.wfpha.org/the-global-charter-for-the-publics-health/

This framework describes 3 pillars of public health services/action and have relevance to local councils.

The fundamentals of public health as a field of practice (Protect, Prevent, Promote) outlined in the Global Charter is reflected in the Tasmanian Public Health service stated mission2.

1 https://sdgs.un.org/goals 2 https://www.dhhs.tas.gov.au/publichealth

Table 2: The relevance of the global charter to health and wellbeing work22 in local councils

Domain Description/examples/foci Local Council context HEALTH PROTECTION:

• health impact assessment; communicable disease control; emergency preparedness; occupational health; environmental health; climate change and sustainability.

• Primarily the focus of the work of EHOs enforcing elements of the Public Health Act.

• Councils (and the Officers they employ) are the front-line of the State Health Protection System23.

DISEASE PREVENTION

• primary prevention: vaccination; secondary prevention: screening; tertiary prevention: evidence-based, community-based, integrated, person-centred quality healthcare and rehabilitation; healthcare management and planning.

• Councils manage and implement vaccination programs

• Councils link constituents to health service providers

HEALTH PROMOTION:

• Planning, developing, implementing and evaluating interventions that address inequalities; environmental; social and economic determinants, build community capacity and resilience; change behaviours, build health literacy; focus on the life-course; healthy settings.

• The work of Health and Wellbeing Promotion

These services are supported by enabling functions, including: GOVERNANCE • public health legislation; health and cross-sector policy;

strategy; financing; organisation; assurance: transparency, accountability and audit.

• Enforce legislation such as the Public Health Act 1997

• Develop Health and Wellbeing Plans INFORMATION • surveillance, monitoring and evaluation; monitoring of

health determinants; research and evidence; risk and innovation; dissemination and uptake.

• Community needs assessments • Citizen engagement and consultation • Community education

ADVOCACY • leadership and ethics; health equity; social-mobilization and solidarity; education of the public; people-centred approach; voluntary community sector engagement; communications; sustainable development.

• A key role of local government on behalf of constituents

CAPACITY • workforce development for public health, health workers and wider workforce; workforce planning: numbers, resources, infrastructure; standards, curriculum, accreditation; capabilities, teaching and training.

• The focus of this report (workforce development for health and wellbeing promotion)

THE ROLE OF LOCAL GOVERNMENT IN HEALTH AND WELLBEING PROMOTION? In Australia, the responsibility for health is largely the role of national and state tiers of government, both dominated by the biomedical model of healthcare 24.

Strong evidence suggests that to achieve major population health gains, the underlying determinants of health must be addressed25 .

Addressing population health and wellbeing relies on cross-sector collaboration and most often outside of the healthcare system, including investments in education, employment, early years development, housing and transport25.

Coordination and integration of HWB Policy and action between tiers of government has been challenging and inefficient14.

Health and wellbeing is a high priority for Australian local governments, despite lack of funding and limited lobbying and support from other sectors and higher levels of government 26.

Local government has been long proposed as the most feasible level of government to take action on the underlying health determinants because of:

• its close proximity to community27, 28, • a more traditionally social model of health13, 29, and • positioned to take a assets model that creates and maintains health rather than

deficit models that dominate the health sector30.

Local government is also seen as important for interventions to reduce health inequalities, in part because the distribution of the social determinants of health, and the unfair differences in health status, manifest themselves geographically30. Health inequalities are largely the consequence of unequal distribution and access to resources such as housing, income, transport, education, recreational facilities and food31.

In Australia, Victoria has led the way for more than 2 decades of legislation requiring local governments to produce Municipal Public Health Plans. Notably, a social view of health informs its planning framework, Environments for Health, which explicitly references the Ottawa Charter for Health Promotion30.

In 1998, The Victorian government amended the Health Act 1957 giving recognition to the social determinants of health and requiring each of Victoria’s 79 local governments to prepare four yearly evidence-based Municipal Public Health Plans. In 2004-5 a review of the Health Act resulted in the creation of a new Act (the Public Health and Wellbeing Act 2008), that added the requirement for the state to develop a Public Health and Wellbeing Plan14.

General consensus32 and official mandates13 in Tasmania situates local government as having a role in community health and well-being.

• Tasmania’s Local Government Act 1993 requires local governments to provide for the

health, safety and welfare of the community (Section 20). The Act also states that a Council’s major strategies for supporting its public health goals and objectives must be summarised in its annual plan and annual report (Sections 71, 72)33;

• Tasmania’s Public Health Act 1997 requires local government authorities to develop and implement strategies to promote and improve public health (Section 27) 34

Stakeholders consulted in this project report:

▪ Local government best placed to engage with community and promote HWB if resourced to do so.

▪ Local Council HWB workers have a primary role as connectors between constituents and health/community service providers, rather than as providers of HWB services. This is problematic and dysfunctional in councils poorly serviced by health providers.

Existing Council Health and wellbeing related Plans make explicit reference to the scope of health and wellbeing work required (as illustrated in this excerpt from the Central Highlands Council Plan17).

Councils are well placed to promote public health by creating supportive environments to:

▪ reduce Smoking ▪ improve Nutrition ▪ reduce harmful Alcohol use ▪ promote Physical activity ▪ reduce Stress.

Together these five factors are known as SNAPS risk factors. They impact wellbeing but improvements can be achieved through community-led, Council-supported action. By reducing smoking, alcohol and stress, and increasing healthy eating and physical activity, the community will enjoy better health, fewer hospital admissions and longer lives17.

These correspond to the Healthy Tasmania priorities35.

Tasmanian Councils15-20 describe their role in impacting on health and wellbeing to include

▪ Land use and urban planning ▪ Licensing and regulation ▪ Community engagement ▪ Workforce development ▪ Provision of services ▪ Facilitation, advocacy (lobbying) and leadership

The Glenorchy City Council Healthy Communities Plan18 recognises that the role of local government extends beyond direct health services such as early childhood services, immunisation clinics, environmental health and animal management to include place-based actions that impact on the social, cultural and environmental determinants of health, including access to open space, residential design, active transport, sources of healthy food, opportunities for physical activity and social connectedness.

These roles and aspirations of local councils (as expressed in health and wellbeing plans) largely reflect the focus of health promotion as a discipline36.

SITUATIONAL ASSESSMENT Table 3 provides a situational assessment summary of themes derived from data collection in this project relevant to health and wellbeing workforce development in the local government context.

Table 3: Situational assessment summary: HWB Workforce in Local Government in Tasmania

Theme Description

An extreme need for Health Promotion

The relatively poor health profile and inequity in the distribution of health and wellbeing in the Tasmanian populationLR illustrates an urgent and sustained need for investment that builds capacity for effective health promotion actionSC.

Under-resourcing Despite the rhetoric about prevention and health and wellbeing12, the resources allocated to proactively promote health in Tasmania is grossly inadequate relative to need and existing capacity. Health budget papers (2020-2021) reveal less than 0.05% of the $9.8 Billion state health budget is allocated to support community HWB initiatives37. This investment has increased marginally in the 2021-2022 Health Budget but is still at an inadequately low level. Transparency about how much is spent on the prevention system is low.

A health system in crisis

The Tasmanian Health system is not fit for purpose or need10 and has one of the most under-developed health promotion workforces in the federation38 WS,SC.

Funding models are inefficient and undermine capacity

The reliance by Councils on the existing Tasmanian Community Fund which requires competitive grant applications processes for a limited funding pool (~$3.3 M per year in 2021) is inefficient, inequitable and undermines collaborationSC.

Why local government?

Local Government is that level of government closest to the community, best placed to address the social determinants of health and Local Government in Tasmania recognises its role in health promotionLR,SC,PA. Local government is the front-line of public health action, already providing services across health protection and disease preventionLR.

What is health and wellbeing?

Health and wellbeing are aspirational social outcomes that require organised effort across sectors and government jurisdictionsLR. A competent and adequately sized and coordinated workforce is needed for this organised effortLR,WS,SC.

What is the work required?

The work required to promote HWB is health promotionPA,PD, LR, recognised internationally as one of the 3 pillars of public health (alongside health protection and disease prevention)LR. Councils have a strong heritage in community development and capacity building actions at local level, providing an excellent foundation for developing health promotion capacity across Tasmanian communities SC,PD,WS. The existing workforce tends to focus on connecting constituents to healthcare providers (where available) rather than designing, implementing and evaluating place-based

HWB interventions with a primary prevention focusWS,SC,PD. There are some notable exceptions.

Work priorities Mental health, nutrition, physical activity (obesity) and health literacy where commonly expressed priorities for HWB work amongst stakeholders and is consistent with Healthy Tasmania fociLR,SC. This is reinforced in existing Council HWB StrategiesPA. Strategies recognise the importance of addressing the Social Determinants of Health PA, LR.

Leadership and mandates

A small number of Tasmanian Councils have shown leadership by developing Health and Wellbeing Strategic PlansPA,SC. These Plans provide a mandate, direction and prioritise health and wellbeing work. Councils with a HWB Strategy also tend to have designated HWB Officers with a primary purpose of coordinating HWB Plan implementation and coordinationWS,SC.

Workforce composition

This project has recognised the diverse and inter-disciplinary composition of local council workers with roles that potentially promote or impact on HWB. The workforce composition can be categorised as:

1. those primarily responsible for HWB (designated HWB Officers),

2. Officers primarily involved in community development (Community Development Officers),

3. Leadership positions that enable and manage HWB services and functions in Councils, and

4. Officers with roles that have some impact on HWB outcomes.WS,SC,PD,LR

Workforce size The designated HWB workforce in local councils in Tasmania is very small (Between 5-10)SC,WS,PD. Best estimates of the total workforce in Local Government with designated or part-roles relating to HWB is ~100 state-wide (~50 involved primarily in community development)

Workforce attributes

Female, experienced, mostly in permanent roles, relatively low paid, motivated by altruismSC, deeply engaged with their communitySC and with limited turnover intentionsWS.

Competency There are existing strengths in the local government workforce in community development and other aspects of capacity building, but gaps in health promotion intervention practice (design, planning, implementation) and research and evaluation SC,WS,PA.

Recruitment Stakeholders interviewed tended to favour local community knowledge over professional competencies relating to health promotionSC. A lack of awareness of the competencies required for HWB intervention management, research and evaluation is reflected in recruitment instruments (Position descriptions)PD. Most position descriptions have below undergraduate level qualifications as a requirement, few specifically require qualifications specific to health promotion practicePD. This potentially undermines the capacity of the HWB workforce.

Workforce preparation

UTAS as the sole tertiary education provider in Tasmania has limited undergraduate offerings specific to developing health promotion competencies SC,LR. Few of the existing HWB workforce have qualifications specific to HWB practiceWS. Pathways to postgraduate qualifications that recognise prior learning are neededSC.

Continuing Professional development

Stakeholders and the existing workforce recognise the need for upskilling in mental health promotion, capacity building, needs assessment, intervention research (what works, where, when, how, who), intervention design and planning and community development (particularly asset-based community development [ABCD]). Preference strongly favours flexible delivery, low cost but interactive and practice-focused continuing professional developmentWS.

INFORMATION SOURCE (LEGEND):

LR= LITERATURE REVIEW SC= STAKEHOLDER CONSULTATION WS= WORKFORCE SURVEY PA= COUNCIL PLAN AUDIT PD= POSITION DESCRIPTION ANALYSIS

FIGURE 3: SWOT ANALYSIS OF THE HWB WORKFORCE IN LOCAL GOVERNMENT

STRENGTHS

• The existing community development workforce (N~50)

• Councils committed to HWB as a function of local government

• Early signs of development of designated HWB Officer roles in a number of Councils

• A number of exemplar HWB plans across Tasmania

• Pockets of HWB/ Prevention leadership in Local Councils and across jurisdictions in Tasmania.

• Evidence of HWB practice innovation in some Councils.

WEAKNESSES

• Inadequate workforce size and distribution- few designated HWB workers

• Limited state-wide coordination of localised HWB workers

• Limited THS Health Promotion workforce (specialists)

• Limited research and evaluation practice and capacity to inform health promotion interventions.

• Limited targeted tertiary education (workforce preparation and CPD) opportunities relevant to health promotion

OPPORTUNITIES

• It is time to develop an integrated prevention/HWN system for Tasmania.

• Building on the existing community development workforce as a foundation of the HWNB System/workforce.

• Building the evidence-base re: the effectiveness and return on investment of place-based health promotion interventions/services.

• To build more efficient funding mechanisms for community-based interventions.

THREATS

• Lack of an integrated prevention/HWB system in Tasmania

• A lack of investment in health promotion action relative to need

• Health promotion core functions of public health across all jurisdictions get less support in response to prioritising responses to COVID-19.

• A failure to recognise the unsustainability of the bias towards down-stream, curative and politically motivated health system management and financing.

BUILDING AN INTEGRATED HEALTH AND WELL-BEING SYSTEM Recent recognition of the importance of systems thinking as an approach for solving complex problems, that emphasises looking at the whole rather than isolated parts, and highlighting the relationships between parts and their causal linkages and feedback loops3, is particularly relevant to this project.

The complexity of determinants of health and wellbeing require the development of an integrated system (a HWB System/ a Prevention System) with the capacity to sustainably address the social, environmental and economic determinants of health and wellbeing. Developing such a system has been highlighted in the draft National Preventive Health Strategy for Australia (2021-2030)21, distinct from the existing curative healthcare system. The capacity of the Prevention System is largely determined by prevention infrastructure such as workforce (workforce capacity influenced by size, distribution, competencies and practice quality improvement), but it also needs resourcing, intelligence, leadership, organisation, partnerships and community development efforts1-3.

There are numerous limitations associated with considering workforce development of the HWB workforce in local government in isolation of other jurisdictions (workforces, responsibilities, resources etc) and outside of an integrated health and wellbeing system. Whilst it has been outside the scope of this project, it is obvious that a range of HWB relevant professionals/practitioners are employed at State level in the THS (Health Promotion, Community Health), Public Health Services, Health NGO’s and at a national level. The integration and connectedness of workers in different jurisdictions has been difficult to observe or identify in this project. This suggests a need for workforce re-structuring and/or alignment that better integrates and enhances the capacity of the HWB system to achieve HWB outcomes.

This is particularly relevant in a State such as Tasmania that under-invests in prevention, experiences increasing acute healthcare demand pressures associated with preventable chronic lifestyle diseases and has an under-developed HWB system. Table 4 attempts to summarise what a HWB System might look like.

Table 4: Attributes of a Health and Wellbeing System (proposed)

Theme Description

Responsibility Local Government has delegated responsibility as the level of government delivering place-based health promotion services/strategies.

Mandates The Tasmanian Public Health Act (revised) stipulates that a state HWB Plan (Healthy Tasmania Plan) be developed every 5 years mapping evidence-based priorities for Tasmania. The Act also stipulates Councils develop 5-year Municipal HWB Plans that align with the State Plan. PHS and Councils report on progress against Plans on an annual basis.

Investment The State Government allocates $50 Million (equivalent to ~0.5% of the Health budget in 2021) to place-based HWB strategy and services (Health Promotion). This is a 10-fold increase on 2021 (which is ~0.05% Health Budget).

Hypothecated Tax on unhealthy products

The Tasmanian government levies tobacco, alcohol, sugar beverages and gaming to generate an additional $50 Million per annum to specifically fund HWB services/strategy, without having to reduce funding other health services.

Funding Mechanism

Funding for HWB action Local HWB Plans is allocated in a block grant (5 year budget projections) to Councils rather than via competitive grants schemes. This provides budget stability over a 5 year period enabling staff recruitment and retention and reduces inefficiencies with fund administration and application processes. Funding is formula based that factors for needs, population and socio-demographics (Social determinants of Health). Funding includes fixed allocations for staffing and operational budgets. How funding is used is determined by Councils based on 5 year HWB plan implementation. Councils are required to report on budget expenditure and progress against implementation of HWB Plans.

Designated HWB Officers

Councils employ Designated HWB Officers to lead implementation of HWB Plans and build health promotion capacity and intervention activity and outputs. These positions are additional to Community Development Officers. At least 1 FTE HWBO employed per 10,000 population, shared across small Councils as practical (~ 50 FTE HWBO state-wide).

A state-wide Health Promotion Support Unit (HPSU)

Local HWBO’s employed in Councils are supported and networked by a technical support unit located in the PHS that provides research and evaluation, workforce development/training, needs assessment and high level intervention planning expertise (5-10 FTE).

State-wide Coordination, Local action

Located and leading the HPSU, a state-wide Director of Health Promotion (reporting to the Director of Public Health) networks and supports the HWBO workforce and advises Councils on State-wide strategy and policy. This role bridges state and local government jurisdictions on HWB action and policy.

Recruitment aligned to health

Recruitment of staff to HWBO positions in Councils are preferred to hold University qualifications in health promotion or related

promotion competencies

disciplines (such as community development). Position descriptions with key selection criteria are used in recruitment to ensure suitably competent staff are recruited.

Workforce preparation

The University of Tasmania offers a nested graduate program in health promotion as part of its MPH, which can be conducted remotely, part-time and integrated with work. Admission requirements recognise prior learning and provide an efficient and accessible pathway to advanced competencies. Employers assist existing staff upskill via these qualifications.

Continuing Professional Development

The University of Tasmania (and/or other providers) provides an annual schedule of flexibly delivered health promotion short-courses for Tasmanian HWBO’s and community health workers, aligned to competency needs. Short courses accumulate credit to higher degree offerings such as the Master of Public Health.

Practice evaluation and dissemination

In partnership with the HPSU, HWBO in local councils develop evaluation plans as part of intervention planning and routinely report on evaluation findings. Needs assessment and community consultation are core functions of the HWB workforce in collaboration with Community Development Officers. These assessments help inform annual work plans in the implementation of Municipal Health Plans. An annual HWB Conference coordinated by the Health Promotion Support Unit (HPSU) networks the HWB workforce from Councils around Tasmania and provides a forum for peer review, diffusion of innovation and CPD.

Note that aspects of this proposed system exist already.

RECOMMENDATION 1

ADVOCACY

That LGAT advocate for the development of an integrated Health and Wellbeing System for Tasmania that recognises the contribution and integrates the efforts of different jurisdictions, including the funding of an enhanced role for Local Government.

WORKFORCE DEVELOPMENT STRATEGY RECOMMENDATIONS These recommendations fall into 3 categories:

Advocacy Advocacy strategies reflect influence strategies that require change and investment by sectors and organisations outside of Local Government.

Analysis Analysis strategies point to knowledge gaps that require further investigation, debate and/or consensus development.

Action Action strategies are those that can be implemented in the short term to build capacity with existing or minimal extra resources.

Figures 4 and 5 plot a framework and logic model for the workforce development strategy and map some of the components of a HWB System.

Strategies that can be done now

There are a number of strategies recommended that require limited additional resources and can be actioned with intent by key stakeholders in the short-term. These are represented in the top level of the building blocks model in Figure 4, including recommendations relating to:

• Workforce preparation • Continuing Professional development, and • Practice quality improvement.

Strategies that require systems change, investment and leadership

The majority of the strategies outlined in this report require a combination of leadership, investment and vision required to develop a state-wide prevention/health and wellbeing system. LGAT has a role as the organisation representing local government in Tasmania to advocate for change and the development of such a system.

FIGURE 4: BUILDING CAPACITY FOR HEALTH AND WELLBEING PROMOTION IN LOCAL GOVERNMENT

STRUCTURAL

ENABLERS

Hypothecated

HWB Tax

Investment in

community HWB

Delegated

responsibility for HWB

at LG level

Funding

Mechanism

Mandates for

HWB Action

Growth in the

HWBO workforce

State-wide

coordination

A state-wide HWB

support unit

Recruitment

practices

Workforce

Preparation

Cont. Professional

Development

Practice quality

improvement

ENHANCED CAPACITY FOR PLACE-BASED

HWB PROMOTION

INVESTMENT, RECRUITMENT,

COORDINATION

COMPETENCY

HEALTH & WELLBEING SYSTEM

FIGURE 5: LOGIC MODEL

INVESTMENT

INPUTS ACTIONS/STRATEGIES IMPACTS OUTCOMES

MANDATES & COMMITMENT

LEADERSHIP

PARTNERSHIPS

FUNDING MECHANISM

WORKFORCE GROWTH

RECRUITMENT PRACTICES

TECHNICAL SUPPORT

COORDINATION

PRACTICE IMPROVEMENT

WORKFORCE PREPARATION

WORKFORCE CPD

ENHANCED WORKFORCE COMPETENCY

ADEQUATE WORKFORCE DISTRIBUTION

AND COVERAGE

MORE EFFECTIVE

WORKFORCE PRACTICES

ENHANCED WORKFORCE

CAPACITY

ENHANCED COMMUNITY

HWB

RETURN ON INVESTMENT

RESPONSIBILITY FOR DELIVERY OF PLACE-BASED HWB SERVICES (HEALTH AND WELLBEING PROMOTION) RECOMMENDATION 2 : ADVOCACY That LGAT advocate that local government be delegated responsibility for the provision of place-based health and wellbeing services in communities throughout Tasmania, supported by funding allocations from the Health Budget and accountable under a revised Public Health Act (see recommendations 2 and 3)

Rationale There is currently contested responsibility for the provision of health promotion services in Tasmania. The State Government has responsibility for funding health promotion but currently invests little in resourcing community-based health promotion services and interventions (less than 0.05% of the 2020-21 Health Budget) or human resource infrastructure (which is difficult to assess). This is despite great need for services and interventions that address the social determinants of health, health literacy and environments for healthy living. The Tasmanian Health System is not fit for purpose with increasing demand pressure/costs associated with treating preventable illness. The political discourse illustrates that reactive, costly and downstream solutions (more hospitals, ambulances, beds etc) dominate. Advocacy for upstream prevention is needed. Local Government is recognised internationally and interstate as that level of Government best placed to address social determinants of health and promote health and wellbeing.

Costs Minimal (for advocacy)

Responsibility LGAT Public Health Association (Tas)

MANDATES FOR HWB ACTION RECOMMENDATION 3: ADVOCACY That LGAT lobby for, and contribute to a review of the Public Health Act 1997, to strengthen requirements for 5 yearly:

• Health and Wellbeing Plans for Tasmania that provides a mandate and priorities for HWB investment and action, linked to:

• Municipal Health and Wellbeing Plans being developed by Councils (shared between small Councils as per Circular Head-Waratah/Wynyard).

The Act to stipulate that Councils and the Department of Health report on progress against Plans and related investment on an annual basis.

Rationale A Healthy Tasmania 5 Year Plan already exists and has $1.0 Million allocated in the 2021-2022 Health Budget39 for implementation. The Plan includes initiatives to reduce smoking (including support for pregnant women in quitting), promote healthy eating and physical activity (including the student health initiative in Schools) and assist in community connectedness (including health literacy programs and the active ageing plan). Most Tasmanian Councils do not have a Health and Wellbeing Plan (~7/29 do) and those that do are demonstrating investments in workforce (HWBOs) and delivering a limited range of community-based interventions/services, despite inadequate funding. Plans provide a resource allocation, accountability, planning and prioritisation framework and organisational mandates for health promotion action. Communities needs differ across Tasmania and involving community in the co-design of plans is an important principle of community development and good health promotion practice. Experience from Victoria over the past decade where the Public Health Act includes such requirements has enabled Victoria to lead the country in building capacity for localised health promotion work and the workforce to do this work.

Costs Minimal

Responsibility LGAT

INCREASING INVESTMENT IN HEALTH AND WELLBEING PROMOTION CAPACITY AND ACTION

RECOMMENDATION 4: ANALYSIS That LGAT support more detailed analysis of government expenditure on health and wellbeing promotion, as a basis for evidence-based advocacy for enhanced investment in health promotion. RECOMMENDATION 5: ADVOCACY That LGAT advocate for a significant extra investment in public health/prevention and health system reform to address upstream determinants of health and the workforce required to do this. Building a HWB System for Tasmania.

Rationale The current health system in Tasmania is not fit for purpose or need, inefficient and persists with an emphasis on expensive, downstream, curative healthcare. This is exacerbated by a political narrative that promotes hospital building, more hospital beds, more ambulances etc as the solution to the increasing burden of disease, largely attributable to preventable lifestyle and socio-economic risk factors. It is difficult to assess how much or little the Tasmanian government invests in public health services/prevention and even more difficult to assess investment in health promotion at community level. This limits debate and awareness of the incompetence of current health system funding models. The Tasmanian Government reports it will invest $20 Million over the next 5 years to prioritise prevention and early intervention and to empower Tasmanians to improve their own health and wellbeing39. This includes $2 million p.a (less than $4 per Tasmanian) on community grants and $ 1 million p.a on the Healthy Tasmania Strategy implementation. This represents ~0.05% of the annual Health Budget37, 39. When Tasmanians experience some of the worst health status indicators in the nation from preventable lifestyle risk factors and the social determinants of health, this inadequate funding and approach requires concerted advocacy. Given the need and the existing low levels of workforce capacity for health promotion in Tasmania, it is likely that a 10-fold increase in funding to ~$50 Million per annum (0.5% of the Health Budget) to support the development of a state-wide prevention system (+ workforce) with the capacity to develop and implement evidence-based strategies and interventions in local communities. This equates with less than $100 per Tasmanian per year.

Responsibility LGAT Public Health Association (Tasmania) Other prevention stakeholders: Heart Foundation, Royal Flying Doctors Service, Primary Health Tasmania

FUNDING MECHANISM RECOMMENDATION 6: ANALYSIS That LGAT support an analysis of Tasmanian Community Fund/Healthy Tasmania Fund allocations to assess questions of who, where, when, how long, what for, how much, if evaluated, what return on investment?. RECOMMENDATION 7: ADVOCACY That LGAT advocate for changes to the funding mechanism that distributes a small pool of funds for community based projects (Tasmanian Community Fund/Healthy Tasmania Fund) to a block grant/purchasing model via Local Councils. It is recommended funds to be allocated to each Council based on consideration of population size, identified needs and implementation plans aligned with Municipal Health Plans (See Mandates). Rationale The Healthy Tasmania Fund/ Tasmanian Community Fund (TCF)

is a major focus and source of Council resource acquisition to develop HWB interventions/services. There is widespread dissatisfaction with the size and mechanism of the existing Tasmanian Community Fund/Healthy Tasmania grants schemes, viewed by some stakeholders as “more about politician photo opportunities rather than achieving health and wellbeing gains”. Stakeholders report that the cost to Council and low success rates of TCF/HTF applications makes the funding mechanism:

• Inefficient- the cost of applying is high and often unrecoverable if unsuccessful

• Inequitable- Councils with size and expertise are more likely to be successful than Councils with greater needs but no capacity.

Stakeholders report that the TCF application mechanism (upfront cost, low success rate, short-term funding) undermines capacity in Council and pits Councils and community organisations against each other rather than incentivising natural and sustainable collaborations. The current mechanism incurs considerable opportunity costs (forgone opportunity to do other work). Whilst there is an argument that a competitive, grants-based mechanism ensures projects funded are aligned with state priorities and needs, increases quality and accountablility for the investment, there are other more efficient and capacity building mechanisms. Allocating block grants to Local Councils for HWB in a purchaser (DHS) -Provider (Local Councils) model to implement Municipal Health Plans is a mechanism with broad support amongst stakeholders consulted. Budgeting in 5-year cycle helps Councils budget for employing HWBO’s and implementation costs, building capacity within Councils to address local needs and priorities. Councils already

have the administrative infrastructure to ensure budget accountability and human resource management. Accountability for block grant allocations can be annual reports of progress against Municipal Health Plans, intervention evaluations reporting and normal budget accounting/reporting.

Costs A block grant mechanism may reduce costs (actual and opportunity costs) associated with pre-allocation TCF grants applications and the costs and time delays with assessment.

Responsibility LGAT

WORKFORCE GROWTH (DESIGNATED HWB OFFICERS) RECOMMENDATION 8 : ADVOCACY That LGAT advocate for the necessary funding support to enable a staged and substantial growth in the designated HWB Officer workforce situated in Local Councils. RECOMMENDATION 9 : ANALYSIS Further investigation of the HWB workforce within NGO’s, THS, State Health (PHS) and other sectors needs to be conducted to identify the distribution, size, work, competence and functions of the workforce across sectors and jurisdictions (The System). Rationale The existing size of the designated HWB workforce in

Tasmanian Councils (and the THS) is small and inequitably distributed. Without competent and focused HWB practitioners leading evidence-based health promotion in local communities, demonstrable improvements in HWB indicators will be difficult to achieve. Given the scale and nature of health promotion practice (utilising a combination of capacity building, community development, intervention management and analytical functions), it is recommended that 1 FTE HWBO be employed to service per 10,000 population. This would equate with ~50 HWBO distributed across Tasmanian Councils.

Costs ~ $5Million per annum (less than $10 per Tasmanian per year).

Responsibility LGAT Councils

INCREASING WORKFORCE ACCESS TO HEALTH PROMOTION RESEARCH AND EVALUATION EXPERTISE AND RESOURCES RECOMMENDATION 10: ACTION & ANALYSIS That a State-wide Health and Wellbeing Promotion Unit be established to support evidence-based health promotion practice (research, needs assessment, design, implementation science, evaluation) in local Councils. This strategy links with State-Wide Coordination and Mandates. Rationale Stakeholders and the workforce recognise the lack of research

and evaluation expertise as a weakness, often relying on external consultants to conduct needs assessments and develop strategic plans. The Healthy Tasmania website (https://www.health.tas.gov.au/healthytasmania) provides static resources to assist community-based HWB work, but this is a lower level of technical support required to inform quality HWB practice (particularly in areas of intervention research, evaluation, capacity building). Establishing a state-wide unit staffed with relevant expertise will assist the existing (and developing workforce) perform evidence-based practice and provide a platform for knowledge sharing and diffusion of innovation. There are a range of options re-establishing such a Unit, including:

• Establishing a new unit funded and embedded within Public Health Services (note that there appears to be some existing capacity in PHS for this).

• Enhanced resourcing and consolidation of the existing THS Health Promotion teams into a State-wide unit.

• Funding UTAS or PHT to provide such a support role via a partnership agreement or service contract.

Costs $0.5-1.0 Million pa Responsibility Public Health Services

STATE-WIDE COORDINATION, LOCAL ACTION RECOMMENDATION 11: ACTION Retention or employment of a State-wide Health Promotion Coordinator role to connect and account for HWB effort, practice and evaluation across Tasmanian Councils.

Rationale It is not clear if there is a senior health promotion Coordinator at state-wide level in the THS/PHS that provides practice-focused support to Council level HWBOs. Council staff consulted do not report receiving such support. Stakeholders report that current HWB action and effort is sub-optimally coordinated across Tasmania, in part because of limited workforce capacity, but also do to the competitive distributive funding model used by the TCF. The current Health Promotion team in the THS (~5 FTE) plays a coordination and support role for Councils, but existing capacity is limited. A practice-based Health Promotion Coordinator (with a bias to capacity building and supporting action in communities versus bureaucratic functions) would provide a coordination and development function across the HWBO workforce, and could be the conduit for Municipal Plan evaluation and reporting, staff development coordination and PHS liaison. This position could be strategically placed organisationally to ensure local government and state public health coordination.

Costs Probably cost neutral if using existing staff but ~$150,000 pa if new position required.

Responsibility Councils

WORKFORCE RECRUITMENT AND RETENTION RECOMMENDATION 12: ACTION That all recruitment to HWBO positions use position descriptions that require as desirable bachelor level qualifications in health promotion (or related discipline such as community development) and/or demonstrated experience of health promotion practice. A standardised HWBO position description with minimum selection criteria will assist competency-based recruitment.

Rationale There appears to be a general under-estimation of the competency requirements (qualification expectations) for effective HWB work amongst stakeholders consulted. This is reflected somewhat in the position description expectations of HWB positions that tend to be generic and/or open to variable interpretation with qualifications required. A few stakeholders commented that low expectations of the capacity of HWB workers led to a limited capacity to effectively do HWB practice. Others valued local knowledge and contacts over professional competencies and University qualifications. Increasing and standardising the expectations of HWBO’s employed in local councils is a strong recommendation for effective workforce development. Minimum expectations might should include: QUALIFICATIONS -

• Relevant tertiary qualifications in health promotion, public health or related discipline (such as community development)

Selection Criteria • Understanding of health promotion principles and

contemporary health promotion practice including systems thinking, collective impact, capacity building, settings and placed based approaches

• Experience in the planning, implementation and evaluation of best practice health promotion strategies

• data collation, analysis and dissemination competencies • ability to work independently and as a team member • Capacity to facilitate change and be flexible to adapt to

changing roles and relationships • High level of effective written and spoken

communication skills

Costs Limited

Responsibility LGAT Councils

WORKFORCE PREPARATION RECOMMENDATION 13: ACTION That UTAS explore opportunities to provide workforce preparation pathways to prepare graduates for health promotion work relevant to local government practice. Rationale The course offerings at Tasmania’s only university (University of

Tasmania) are as yet not comprehensive across the health professionals, tending to have followed the health systems emphasis on curative services (Medicine, Nursing, Pharmacy etc). With relatively recent changes in leadership and direction at UTAS (i.e. A University for Tasmania), there has been a expansion of health professions aligned to Tasmania’s health and wellbeing workforce needs (e.g. Allied Health, Psychology, Environmental Health, Health Protection etc). UTAS offers an Associate Diploma of Applied Health and Community Support, but this course is unlikely to develop the level of health promotion competencies required for effective HWB work in local councils. There is no specific health promotion undergraduate offering at UTAS although many undergraduate courses (nutrition, nursing, psychology etc) provide some elements of competency development relevant to HWB practice. The Master of Public Health at UTAS provides a postgraduate offering that builds advanced health promotion competencies. Stakeholders consulted support generous recognition of prior learning in admissions requirements to enable under-qualified but practically experienced local council staff access postgraduate coursework options, without having to complete lengthy and costly undergraduate degrees.

Costs Costs borne by students Employers can assist staff by subsiding fees

Responsibility UTAS

CONTINUING PROFESSIONAL DEVELOPMENT RECOMMENDATION 14: ACTION That LGAT collaborate with UTAS and other education providers (e.g. PHT) to develop an annual CPD program targeting the broad HWB workforce. Rationale There is a strong emphasis and existing capacity amongst the

current local council community development workforce (~50 FT) for collective action and building social capitol in communities. This is an important strengths-based foundation for developing a prevention/health and wellbeing system in Tasmania. Stakeholders recognise the need for upskilling of the small existing workforce, including the community development workforce. The workforce identify the following areas as of most interest to personal CPD needs (in descending order):

• Building capacity for health promotion • Planning HWB interventions • Evaluating HWB interventions • Conducting community needs assessments • Leadership • Systems Thinking

These align closely with health promotion core functions and competency needs40. Attributes of CPD offerings need to be:

• Conducted in work-time • Low cost/free • Interactive • Flexibly delivered (on-line, any time) • Practice-focused

Costs Minimal- cost recovery Responsibility LGAT

UTAS

PRACTICE QUALITY IMPROVEMENT: EVALUATION AND DISSEMINATION RECOMMENDATION 15: ACTION That LGAT coordinate an annual State-wide HWB Conference to provide a forum for HWB intervention showcasing, peer review and diffusion of innovation. The target audience to include the workforce across the different sectors and jurisdictions not just those in Local Government. RECOMMENDATION 16: ANALYSIS That LGAT coordinate or commission an evaluative audit (showcasing) of health and wellbeing promotion interventions and activity in local government (as per the 2011 Audit by the NHF)41. Rationale Stakeholders recognise the potential for worker isolation and the

need for professional networking across the HWB space. An annual State-wide Conference is a strategy that works well in other health professional areas (e.g. the annual EHA Conference for EHO’s) and is a mechanism for networking, practice showcasing, dissemination and peer review. There is evidence from stakeholder consultation and in-field observation of innovative place-based HWB interventions across Tasmanian Councils, but little accessible evidence of intervention evaluation and reporting/dissemination. This limits the capacity of the existing workforce to quality improve (build on successful strategies/approaches, learn from failures).

Costs Minimal- cost recovery Responsibility LGAT

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