Patrick Libbey Q&A: Sharing Across Public Health Department Jurisdictions
Across the nation, health departments are exploring ways to share services, resources and functions across multiple public health agencies and jurisdictions. Often motivated by the need to do more with fewer resources, many health departments and elected officials are approaching cross-jurisdictional sharing as a way to improve efficiency as well as strategy to improve the quality of the services provided and, hopefully, the health of the affected communities and residents.
With support from the Robert Wood Johnson Foundation, the Kansas Health Institute (KHI) has been selected to form the Center for Sharing Public Health Services to assist public health agencies across the country that are considering or implementing cross-jurisdictional sharing. The team will include a national learning community of up to 18 competitively selected and funded sites. The Foundation has issued a call for proposals from health departments considering or working on shared relationships to join the new project. The members of the new learning community will help identify successful, innovative regional and shared approaches to help improve the quality, efficiency and impact of public health services.
Patrick Libbey, former executive director of the National Association of County and City Health Officials and a national expert on the issue of cross-jurisdictional sharing, will serve with Gianfranco Pezzino, MD, MPH, KHI senior fellow, as co-director of the project. Libbey also co-authored the first major environmental scan on the state of cross-jurisdictional sharing arrangements among U.S. public health agencies. NewPublicHealth spoke with Patrick Libbey about the new project.
NPH: What are some of the key reasons that health departments are exploring or entering into shared service arrangements?
Patrick Libbey: There are several reasons but the key ones are to improve their service capabilities and capacities and to be able to do things together that individually they might not have been able to do. This has been accelerated in some respects by the emergence of performance standards, notably, voluntary national accreditation of public health departments.
There is an increasing concern about being as efficient as possible in costs and other resources. And given the economy and the effect on local and state budgets, there’s an increased attention on how can we do well at lesser costs or at least without increasing costs. In public administration circles of all kinds, regionalization and shared services is one method being looked at and increasingly being used as a means of being more effective and efficient. Examples of different public sectors that have looked at or implemented shared services include schools, traditional government service areas such as fire and police, library services and parks and recreation. It’s not a question that’s emerging exclusively in public health.
NPH: What types of sharing relationships currently exist between local health departments, and how common are they?
Patrick Libbey: In every state we interviewed we saw evidence of shared arrangements. We need to think of shared services as a spectrum or a range of options. It can be as informal as almost a handshake agreement to share resources and equipment. In many places we saw service agreements, where a department might purchase a service they didn’t provide—more of a transactional arrangement. Particularly in the last decade there has been an emphasis on preparedness, and that has led to mutual aid agreements. We see arrangements where an official for one department on, say, Women, Infants and Children, might direct that service for a neighboring department but still remain on the full-time payroll of their own department
More complex arrangements include ones on a multi-jurisdictional basis, such as working jointly on community health assessments or joint epidemiology efforts covering all the participating jurisdictions. The most complex arrangements are where local health departments merge—in essence creating a new entity comprised of two or more former local health departments—or consolidate, where two or more departments are combined into an existing department.
NPH: What are good examples of shared relationships in place right now?
Patrick Libbey: There are lots of examples across the country. Several come to mind immediately. There are five relatively small health departments in the Colorado Rockies. They had environmental health services needs and only one of the five had the capacity to do it, so they worked out a way to share that capacity. They got needs met that they could not have met individually and as a result they are able to sustain the necessary expertise at the local level. From that, they then worked further to develop a joint community health assessment process, but will create individual improvement plans.
We tend to think smaller parties are the ones that need to share, but another example is a joint effort of the eight local health departments serving the greater Chicago metropolitan area including the Cook County and City of Chicago Health Departments. They do some of their planning and development work together, because in a sense, they share a population. People may live in one place but work in the other. So for public health emergencies, they have worked out arrangements for a single media communications process. It reduces confusion and gets out a clear message.
More recently, on a large scale, has been the merger of the Akron, Ohio, Health Department with the Summit County Health Department. This example gives you some idea of the complexities involved in a sharing effort at this scope. The merger came about as the result of a very thoughtful planning process beginning in mid-2009 including a thorough feasibility study, cost projections, political considerations and key partner and community involvement. Time was taken to ensure an orderly transition and to make sure necessary administrative and other operational details were carefully addressed before the merger was actually implemented. The newly merged Summit County Health Department began serving the population of Akron in 2011.
NPH: Have the relationships always been based on a need that emerged?
Patrick Libbey: What we saw for the most part was opportunistic—there was a funding opportunity or there was a need of service issue. We didn’t see as much proactive efforts, such as let’s get together up front, and agree to jointly fund a service or a capacity that could then be deployed as seen fit by the participating jurisdictions. What has been happening has been extremely pragmatic, though that may change over time or change as resources become more flexible. It has been reactive in a positive sense. But it works. That’s the litmus test.
You can demonstrate the benefits in ways that connect to the drivers—increased efficiency, increased cost-efficiency and improved service.
NPH: What factors contribute or detract from the success of these cross-jurisdictional relationships?
Patrick Libbey: There needs to be willingness on the part of both the health officials and the policy-makers. Not necessarily a champion, though that’s nice, but there needs to be openness to consider sharing services or capacities across jurisdictions . There also needs to be clarity up front about the intended purposes of such sharing. Improved public health performance and cost containment are both legitimate policy goals based often coming from different roles and perspectives. There’s some risk of conflict or perceived contradiction if the purposes of all the parties involved aren’t clear and attended to from the outset. There can be ways to get to a win-win opportunity but only when all the intended purposes are on the table.
Policy-makers need to know that their obligation to their constituency is met and potentially improved as a result of the service sharing and they need to have a say and an oversight in that. And health officials need to be in a position of assuring the public health needs of their respective jurisdictions are being met or improved. For the policy-makers, their obligation as an elected official is to their jurisdiction and their constituency. In that framework, they can’t willingly contribute to what may a greater good if it is seen as coming at a cost to the good of their jurisdiction. That’s not a turf issue, that’s a civic and an ethical issue.
Candidly, financial resources do make a difference. There’s a cost to putting shared arrangements together effectively. That cost sometimes is a direct expense in planning and implementing a shared arrangement and in other times it’s a lost opportunity expense, what else might have been done with the resources committed to developing the shared service relationship. It will cost something to take the time and energy to make this happen. Funding incentives have been helpful.
Long-term working relationships, history, the sense of local control and cultural factors—those are some of the other factors that are important to the success of a sharing arrangement.
NewPublicHealth: What will the Center’s goals be?
Patrick Libbey: The project will assist public health officials and policy-makers in how to consider the use of cross-jurisdictional sharing. One of the major features will be the recruitment of 18 sites across the country to serve as learning laboratories in a national learning community. These will include sites who are actively engaged in the development of cross-jurisdictional sharing arrangements, sites engaged in implementing such arrangements, and sites that have arrangements in place but are seeking to improve or expand them. The Center will provide technical assistance and support to these sites. The Center will also provide some technical assistance to other jurisdictions and organizations working on shared services. Beyond the benefit to the 18 sites and others directly receiving technical assistance, the Center will be capturing, synthesizing and sharing the learning from these efforts. This also includes gathering or developing if necessary useable tools for others to use. All the learning and resources will be shared with policy-makers, health departments and others with an interest in public health performance improvement. Put more simply, the overall intent really is to better understand, share and support ways in which cross-jurisdiction service sharing can be used to improve public health performance and efficiency.
>>Read more on sharing arrangements across public health department jurisdictions.
>>View for call for proposals to join the Shared Services Learning Community.