Hertfordshire and West Essex Prevention Summit

Hertfordshire and West Essex

Sustainability and Transformation Plan

A Healthier Future Prevention Summit for the STP footprint

7th February 2017

#HWEPrevSummit




7th February 2017

STP ContextTom Cahill: STP Leader & Chief Executive, HPFT

STP National Aims

• Close the health and wellbeing gap• Drive transformation to close the care

and quality gap• Close the finance and efficiency gap



ContextFinancial pressures • Current system spend is

approximately £3.1bn • Forecast deficit of £94m for 2016/17

rising to £401m (£552m Inc. Social Care) by 2020/21 if we don’t take action

Increasing demand• Population expected to increase by

over 10% from 2011 to 2021.• Number of over 85s expected to

increase by approximately 45% from 2011 to 2021

Pressure on the health and care system• Primary care capacity• Acute care performance and quality

challenges• Social care funding

National drivers• NHS Five Year Forward View• NHS Constitution commitments• National service strategies, e.g.

mental health, cancer and maternity



Collaborative Commissioning Cameron Ward

Technology Katie Fisher

Estates and Infrastructure

Debbie Fielding

Communication and Engagement

Beverley Flowers

Workforce Jinjer Kandola

Health and Wellbeing Boards x 2

Stakeholders inc.Healthwatch x 2, Councils,

MPs, staff etc

Governance Structure Enabling Work

Streams

NHS Boards and Governing Bodies –via Chief Executives

NHS England

NHS Improvement

Back office consolidation Cameron Ward

Programme Board Chief Executive Leaders

Group

Prevention

Jim McManus

Mke Gogarty

Primary and Community Care

David Law Malcolm McCann

Acute Services Nick Carver Phil Morley

Finance and Activity Group

Alan Pond

Programme Management Office

(PMO)Clinical Reference

Group

Chairs Oversight Group

NHS Boards/GBs CC Members






7th February 2017

Prevention: Why, What, How?Prof Jim McManus, Director of Public Health, HCC

Data Analysis by Hertfordshire County Council Public Health Intelligence Team

[email protected]

For a copy of these slides please email

[email protected]

© Copyright, 2017 Hertfordshire County Council Public Health

mailto:[email protected]




Why?• Too many people getting complex preventable illness and

disability• Too many variations in primary care quality and outcomes• Not enough focus on preventing ill-health happening or

worsening• National sickness service not health service• Unsustainable, unaffordable, undeliverable

• Over the next 20 years, the shape of the population will change

• By 2022, people aged 65+ (highlighted in orange) will represent a greater proportion of the overall population…

1

How the STP population will

age

• By 2027, this change will be more noticeable (note the widening of the lines at the top)…

1


age


• By 2037, the change will be much more dramatic

• There will be c.23,000 more residents aged 90+ across the STP footprint by 2037 than in 2017

1


age




Multi-morbidity and service demand

• Local data analysis in Hertfordshire has shown older adults receiving what appears to be increasingly complex outpatient care

• Outpatients aged 80+ attended more appointments with more specialties in 2014/15 than in 2011/12 indicating the increased burden on local services is not driven by increasing resource user per patient, not only increasing patient numbers

• Findings suggested Hertfordshire a movement away from ‘generalist’ care of older adults towards involvement of multiple specialist teams and referrals occurring outside of primary care may be driving this trend




Falls injuries in older people




Variations in primary care: Atrial Fibrillation




Variations in primary care: Coronary Heart Disease




Variations in primary care: diabetes




Demand outpacing resource

• We can no longer afford to treat after adverse events

• System never designed for this level of need/demand

• We need to prevent, reverse or mitigate need for services

• Significant avoidable and preventable burden of ill health and inequality




What?• A population shift to prevention - mindset

• Primary• Secondary • Tertiary

• Everyone’s business • Mainstreaming



What is Prevention?

• The avoidance, whether permanent or temporary, of need for public service or an adverse event/hazard or exposure leading to need for public service– SHORT TERM (eg up to 24 months)

– MEDIUM TERM (eg 2-5years)

– LONGER TERM (eg 5 years plus)

• Prevention is NOT rationing or restricting eligibility




Levels of Prevention• three levels. Preventative activities may be delivered by

any agency.

• Primary Prevention – ‘prevent’ or stop harm or need for service arising in first place – physical activity, recycling

• Secondary Prevention – ‘reverse’ harm or need for service – rehabilitation

• Tertiary Prevention – ‘reduce’ or mitigate harm/need for service – an Anti Social Behaviour Order? A wheelchair for a diabetic foot amputation




Immobility or lack of fitness?

• Much immobility due to ageing is preventable. Maintaining or losing strength to walk is an important predictor of other need for public service


http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjkv-qtqLzRAhUkEpoKHcYGB-kQjRwIBw&url=http://www.allthingsgym.com/athlete-vs-couch-potato-quadriceps-mri-scan/&psig=AFQjCNGVODUjBRiVII8_jC6BleLpv1QmlA&ust=1484300485772191

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjkv-qtqLzRAhUkEpoKHcYGB-kQjRwIBw&url=http://www.allthingsgym.com/athlete-vs-couch-potato-quadriceps-mri-scan/&psig=AFQjCNGVODUjBRiVII8_jC6BleLpv1QmlA&ust=1484300485772191



Phasing and Layering• You don’t approach this like a blunderbuss

• Use scientific and business principles to identify what will have greatest impact in what timescale

• Phasing the interventions across time to produce results and yield

• Layering the interventions across populations to produce results and yield

• Still need to do primary prevention, but that’s long term




Reducing the need and spend curve: Preventing avoidable spend through phasing and layering

Volume of

spend

Severity of need

Existing curve

The Achievable

curve?

Reduce or delay need here

Highest cost.

Reduce and delay

Need here

Intervene here before need

escalates



The Questions

• Where could we reduce need or demand for public service?

• What skills and strengths do we have that we could apply to this?

• We will be using Scenarios




Mainstreaming Prevention

Consider impact of everything

you do on prevention

Consider what you can do

individually and together

Herts & West Essex Governance Structure v4

Healthier Population

needing fewer specialist resources



How?• Mindset• Establish clear priorities • Timescales – short, medium, longer term• Everyone’s business• Pathways• Redesign• Population Health Approach



So what could be done?

• A culture of self-reliance

• A culture of nudging people to do right thing

• Redesign services to change system behaviour and people behaviour

• Diversion

– Can we create a culture where people deal with minor issues themselves




So what could be done? ExamplesLevels of Prevention

Crime and Disorder

Mental Health Cancer

Prevent/Stopharm or need

Reduce alcohol related injuries and violence

Reduce drug related crime

Prevent lost productivity by workplace ill-health

Routine physical activity for everyone to retain balance and mobility

Reverse harm or need

Physical activity for rehabilitation

Reduce/Mitigateharm of need

Cheaperalternatives? (social groups for lonelines)



What can the science do

• Science of behaviour change

– Behaviour insights “nudge” on council tax payment and recycling behaviour

– Behaviour change backed

• Much better clinician push on prevention, self care and responsibility

Quick wins in the system - 1

• Drug testing on arrest and early referral in

• Using “behavioural insights” on council tax notices and letters and on recycling

• Leisure centres and services

• Early intervention to prevent slips, trips and falls

• Using “behavioural insights” in recycling



Quick wins in the system - 2• Night time economy work on alcohol with retailers

• Routine, universal, physical activity

• Physical activity and social contact for people isolated

• Behavioural contracts with offenders

• Mental Health First Aid

• Getting people temporarily sick back into work

• Getting people with one long term condition doing physical activity



Just suppose

• An army of signposters who as part of their day job signposted you to the lowest level of place which could meet your need

• We already have 1,300 mental health first aiders in employers – the UK’s largest number. What more can we do



A good employer• Positive psychosocial workplace – the seven tips

for employers helps keep people at work

• Healthy workplace – simple things to keep people healthier longer

• Enable carers – help keep carers able to care

• Make it easier to get back to work


Sustainability and Transformation PlanPrioritising Prevention – the Decision Cycle

What population?

What issue/need?

What outcomes do we want?

Which interventions fit best?

How do we know it’s working?

(Evaluation)

1. Service cost and demand2. Needs (JSNA)

Define the outcomes clearly so you can really assess feasibility

1. Financial Assessment2. Evidence Assessment

3. Logic mode where evidence silent

1. Financial Assessment2. Outcome Assessment

Questions to ask Tools for HCC



Desired Outcome

• An appropriate prevention plan which models savings achievable from prevention

• A plan underpinned by evidence and a logic model

• Clear articulation of who needs to deliver what to achieve it

• System wide expectations



Mainstreaming Prevention

Consider impact of everything

you do on prevention

Consider what you can do

individually and together

Herts & West Essex Governance Structure v4

Healthier Population

needing fewer specialist resources

An online meeting tool Acts like an electronic flip chart Allows anonymous and simultaneous input

Nominate a scribe for your table Capture your thoughts and ideas as you work

through the three scenarios

https://eu10.meetingsphere.com/87914295/stpprevention

https://eu10.meetingsphere.com/87914295/stpprevention

Feedback

• The next slides contain a summary of the most often raised themes or issues in your groups

• And one issue to unpick from each scenario

Key Themes from : Lifestyle (171 comments)

1. Workplace / Employer’s role

2. School etc roles

3. physical activity

4. Signposting to local opportunities

5. Doing stuff at low cost

Social prescribing definition

• A means of referring patients with a range of social and emotional needs to non clinical services often provided by community and voluntary sectors…

One to unpick from what you said…

• In lifestyle scenario

“what can our workplace do as employers ourselves – poor work environment, under lots of pressure, not access to healthy food and water….need to start with our own workforce first as a NHS.”

• Develop a programme which fits around our environment and workforce, to keep us healthy, perhaps run a yoga class before start of working day. Water, food….

• Each of the NHS organisations have a health and wellbeing programme for staff in place this year and next and people could link into this

• A much more inclusive and coherent programme around employers would be a big ticket issue for me speaking from an Essex perspective – bidding to SportEngland etc and getting some resource in for this work. Something compelling and coherent around public sector could really touch lives of many. Do something bold and coherent about that

Key Themes from: Community(109 comments)

1. More social prescribing and get it working and known about1. Get Linda volunteering/learning2. Social Media, library facilities, technology

1. What vehicles of info do people trust/use?

2. Identifying and targeting 1. Soft intelligence

3. Housing sector potential1. Across spectrum of need – state of house/energy

efficiency


• In community scenario

“How on earth do we know she’s there? Who’s radar is she on? Relying on old fashioned values of family and community here otherwise a helpless task. Need to be able to reach her children”

• We think there are lots of lindas out there in the community and from description our first question was how do we know she is there so someone can knock on door and start a dialogue? We thought she represented large proportion of communities

• Who is going to do this? Who is going to see it as their responsibility? Nobody knows there is a problem. Hard to see how this very vulnerable lady is going to be helped. Can GPs find a way of following up people who are vulnerable who haven’t been in touch

• Also very much about the mechanics that if you identified her, where do you go next? Who and how do you make a referral to? If shopkeeper had some information to put in her basket, for example? What can we do about a soft intervention which signposts them in right direction. Then the situation where youre concerned with someone’s wellbeing but too bloody British to do something about it.

• Trawling electricity or utility information to identify people• Database of voluntary agencies across the patch?• Social marketing and messaging for each scenario• Be careful we provide people with information rather than start creating services for them• Use local elected members more! • A project to identify people using existing information

Key Themes from : Multimorbid(135 comments)

1. Everyone who sees Pamela/Bob needs skills to help them manage

2. Preparing people in 40s for life in 70s-90s

3. More stuff out of hospital (eg pharmacy)

4. Assistive technology and social prescribing

5. Lifestyle – weight, smoking, etc


• In multimorbid scenario

“all three scenarios have attracted the comments that we’d have hoped that they’ve been “referred”….what does this mean then? We need to know what is going on, where and how to connect the dots and enable health and social care services to connect properly..”

• We would hope someone somewhere in system would refer people on. Do people even know who and where to refer to? Enabling people to make referrals whether it be social prescribing or offers from districts?

• We’re in danger of making this the public sector’s role not individuals…need to keep a focus on how we make it easier for people to help themselves. Referrals often mean cost

• Putting people in touch with opportunities already out there in community…..making sure people DO get in touch. Not just signposting

Discussion

• Intelligence, targeting, date

• Workplace

• Social Marketing

– Knowing what’s out there and then getting people into them

• Social Norms

If everyone did just one thing….

As we close…

• Report from MeetingSphere will be analysed and sent with slides

• If you want a workshop for your agency let us know – there will be link with mailing

• Work this into prevention plan for STP• Feed your views on engaging you into STP leaders• Welcome your ideas and suggestions• Clear theme on social marketing emerging from

today• Evaluation form coming electronically



Thank You!Remember if you want a prevention workshop for your

agency/group of agencies contact [email protected]

#HWEPrevSummit


Healthcare

Hertfordshire and West Essex Prevention Summit