Prevention - why should you care?

www.hertsdirect.org
Prevention:
Why should you care?
Jim McManus, Director of Public Health, Hertfordshire County Council
Jim.mcmanus@hertfordshire.gov.uk
Making partnerships a reality conference
Hertfordshire
14th
November 2016

www.hertfordshire.gov.uk
Context
• We can no longer afford to treat after adverse
events
• System is creaking
• We need to prevent, reverse or mitigate need
for services and poor health
• Significant avoidable and preventable burden of
ill health and inequality

This morning
• Introduce some structure and rationale
• Develop a narrative
• For future we probably need some more in
depth “can do” workshops

1. 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

2. 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
• Secondary Prevention – ‘reverse’ harm or need
for service
• Tertiary Prevention – ‘reduce’ or mitigate
harm/need for service

2. Which level takes which length of
time?
Levels of
Prevention
Short Timescale
0-24 mths
Medium
Timescale
2-5 years
Longer
Timescale
Over 5 years
Prevent/Stop
harm or need
Reverse harm or
need
Reduce/Mitigate
harm of need

3. Reducing the need and spend curve:
Preventing avoidable spend, morbidity and
mortality
Volume of
spend
Severity
Existing curve
The Achievable
curve?
Reduce or delay need here
Highest cost.
Reduce and delay
Need here
Intervene here before need
escalates

4. Phasing prevention
• Identify those areas which will generate best
returns (demand management or activity
reduction) first and work on them
• Assess what you want to do and how you will
deliver it
• Assess feasibility including savings and benefits
• Implement
• Invest more in areas further down benefit curve
as benefits are generated

5. Prioritising 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
demand
2. Needs (JSNA)
Define the outcomes clearly
so you can really assess
feasibility
1. Financial Assessment
2. Evidence Assessment
3. Logic mode where
evidence silent
1. Financial Assessment
2. Outcome Assessment
Questions to ask Tools for HCC

5. Cost Benefits
What
intervention
Cost-Benefit Time frame
for
investment
Time frame
for return
Return to
HCC and
others

6. Feasibility
2 Steps – business case
•Likelihood of working – likely to need a minimum
rating of 4 to be worthwhile proceeding. If score
less than 4 need very clear model detailing risk of
achieving outcomes
•Feasibility – minimum score of 40 to be worth
proceeding

6. Feasibility: Step 1 – Likelihood of Working
Select
one
score
Criterion (the more of these
criteria a project meets, the
stronger the case for acting)
Level of
Promise/Priority
(i.e. the level of promise
it could work or level of
priority we do for it)
Example What happens if this is
missing?
1 Needs or issues which have
significant cost to the system
Meeting this criterion is
essential but not
sufficient requirement for
prevention programme
Older people falling
repeatedly
Cant continue
2 Issues which affect a definable
population
essential but not
Older people who
have had a fall more
than once
Cant continue
3 A conceptual framework of the
“system” is possible so
intervention could be designed
to alter the system or situation
essential but not
We can map and
understand the
circumstances of
when and why and
where people fall
Map the system
4 There is financial modelling of
cost and alternative situations
If it meets the above
criteria and this, it
becomes a Promising
candidate for prevention
There is data
suggesting
preventing falls can
save money
Undertake some
modelling based on
system mapping
The more of these you meet, the greater the likelihood of working

6. Feasibility: Step 1 – Likelihood of Working
Criterion (the more of these
criteria a project meets, the
stronger the case for
acting)
Level of
Promise/Priority
(i.e. the level of
promise it could work
or level of priority we
do for it)
Example What happens if
this is missing?
5 There is consensus of which
elements of the system could
have an intervention to
prevent an occurrence and
financial model of
effectiveness
becomes a Promising
candidate for prevention
Professionals agree that
dizziness and gait
instability are high risk
factors
Undertake some
consensus work
6 There is a model of practice
from elsewhere with financial
assessment
becomes a very
Promising candidate for
prevention
Other areas have
pathways and models
which show good
outcomes saving cost to
the system
Literature search
7 There is evidence of
effectiveness from elsewhere
that prevention works
criteria and this,it should
be prioritised for delivery
because it is evidence-
based and effective
The “Blue Book” for falls
has evidence of proven
interventions for falls
Literature search, if
no evidence,
proceed to
hypothesise and
test through pilot
8 There is evidence of cost-
effectiveness from elsewhere
that prevention works
Candidates which meet
all above criteria and this
give the highest
probability of delivering
return and highest
priority for prevention
There are studies which
show cost return of
preventing falls
Literature search, if
no evidence but
pilots, proceed to
model and then
undertake cost
effectiveness
analysis
The more of these you meet, the greater the likelihood of working

6. Feasibility Criteria Step 2: Deliverability
Very
Promising
Promising Unlikely to be
cost effective
Effectiveness High (10) Medium (5) No impact (-5)
Flexibility Very Positive (10) Positive (5) Neutral (0)
Sustainability Positive (10) Positive (5) Negative (-5)
Political Feasibility High (10) Medium (5) Low (-5)
Administrative
Feasibility
High (10) Medium (5) Low (-5)
Time Short (10) Medium (5) Long (-5)
Cost High (0) Medium (5) Low (10)
Return on investment High (10) Medium (5) Neutral (0)
Negative (-5)
The more of these you meet, the better the likelihood of outcome

Examples: what good could look like
Category Primary Prevention
Work
“stopping it
happening”
Secondary
Prevention Work
“stopping it getting
worse”
Tertiary Prevention
Work
“damage
limitation”
Social Care –
Adults
Preventing adults with
learning disabilities
from needing social
care interventions
Keeping adults who
need services at
highest level of
functioning to have
little need for services
Rehabilitating high
need adults to
moderate or low
need
Social Care –
Children
Every child gets
supported to be
resilient physically
and psychologically
If problems are
found, early
intervention to return
them to full
developmental
potential
Intensive support
to gain best level
of development
possible

Work
“stopping it
happening”
Secondary
Prevention Work
worse”
Tertiary Prevention
Work
“damage
limitation”
Environment Sustainable planning
and transport, safe
roads and highways,
sustainable waste
Behaviour change
work with speeding
drivers
Effective intervention
to reduce risk at
identified road
accident hotspots
Economic
Development
Ensuring everyone
who wants to can be
economically active
according to ability
Ensuring people who
are vulnerable and are
out of work or
workless are helped
back into work
Supporting people
with very complex
needs into work
Fire Preventing fires,
preventing anti-social
behaviour, major role
in preventing falls.
Significant further
potential
Addressing hot spots
and returning them to
normality
Identifying vulnerable
people at risk and
signposting/ referring

Work
“stopping it
happening”
Secondary
Prevention Work
worse”
Tertiary Prevention
Work
“damage
limitation”
Environment Sustainable planning and
transport, safe roads and
highways, sustainable waste
Behaviour change work with
speeding drivers
Effective intervention to
reduce risk at identified road
accident hotspots
Economic Development Ensuring everyone who wants
to can be economically active
according to ability
Ensuring people who are
vulnerable and are out of work
or workless are helped back
into work
Supporting people with
very complex needs into
work
Fire Preventing fires, preventing
anti-social behaviour, major
role in preventing falls.
Significant further potential
Addressing hot spots and
returning them to normality
Identifying vulnerable
people at risk and
signposting/ referring them
to relevant services

Category Primary Prevention Work
“stopping it happening”
Secondary Prevention Work
“stopping it getting worse”
Tertiary Prevention Work
“damage limitation”
Trading Standards Preventing harm to residents Where harm occurs, reducing
it as much as possible
Community Safety Preventing harm from crime
and disorder which impacts
on need for public services
Addressing areas which are
worsening in order to reduce
levels (eg drug interventions)
Addressing areas of
worst cost to reduce
them (EG Complex
Adults)
Public Health
(Examples)
Keeping people from
developing avoidable
diseases and cancers
(smoking cessation, weight
management)
Commissiong services for
diseases which can worsen
(eg sexual health services) or
building self-management for
long term conditions (with
NHS)
Re-enablement and
rehabilitation for very
seriously addicted and
advising others on how
to do this
Providing public health
skills and consultancy
( evidence review, needs
assessment, evaluation
etc), support and
information which other
functions use to design and
deliver preventive initiatives
Providing advice, support
and information which other
functions use to design and
deliver preventive initiatives
Providing advice, support
and information which
other functions use to
design and deliver
preventive initiatives

Critical Success Factors
Critical Success Factor Achievable

Not
Achievable x
1. Leadership & accountability for a programme
approach
2. practice that supports people to fully realise
prevention/self management potential
3. Prevention to be systematically written into
contracts, service level agreements, and business
plans
4. Reshaping what we do in a planned and ordered
way

Approach – scoping and saving
• Identify those areas which will generate best
returns (demand management or activity
reduction) first and work on them
• Continue primary prevention appropriately
targetted as
• Invest more in primary prevention as benefits
from secondary and tertiary are generated

Modelling results (1)
Ranking
of
Priority
Prevention Target Ranking from
Modelling
Comments
A Achieving a 10% reduction in the
number of ‘increasing risk’
drinkers.
Keep on Table Could achieve
savings but would
require investment
D Achieving a reduction in the
incidence of avoidable AF-related
strokes in all AF patients.
Park It Already being worked
on
A Achieving a reduction in the risk of
diabetes by 25% in 10% of non-
diabetic adults in the general
population.
Deliver Use NDPP funded
programme
B Achieving a 10% reduction in the
risk of diabetes-related
complications in 10% of diabetic
adults
Further
discussion
needed
B Achieving a reduction in blood
pressure from above 140/90
mmHg to below this figure in 10%
of hypertensive patients
Keep on the table

Modelling Results (2)
Ranking
of
Priority
Modelling
Comments
D Provision of school-based social
and emotional learning
programmes for all 10 year olds to
prevent childhood conduct
problems.
Park There is a general
lack of confidence in
the validity of the
assumptions in the
original source on
which this model was
based and a lack of
clarity around
delivery.
C Improving access to physiotherapy
for MSK patients in general
practice by allowing self-referral.
Discuss further
B Enrolling 10% of obese adults in
evidence based weight
management services
Keep on the table
B Achieving a 10% reduction in the
number of current smokers.
Keep on the table

2ndary/3ary Areas not yet modelled
Area of Focus Suggested Initial
Outcomes
Current Spend
COPD Reduce repeat admissions
Smoking in people with
long term conditions
Reduce repeat
consultations, prescribing
and admissions
Falls Reduce admissions and
prevent long term care need
CVD Monitoring through
telehealth
Management of condition
and reduce admissions
Minor Ailments in
pharmacy
Reduce GP activity
Social Prescribing for
Mental Health
Reduce MH caseload length
Recovery College MH Reduce intensive care
Social Prescribing for
LTCs
Reduce GP repeat care and
psychological

2ndary/3ary Areas not yet modelled
Area of Focus Suggested Initial
Outcomes
Current Spend
Physical activity in long
term conditions
improve self management
and outcomes
Pre Diabetes Prevention Prevent people developing
diabetes and needing
specialist care
Early MH intervention
and social prescribing
Prevent people needing
specialist care
Alcohol A and E Reduce episodes and cost
Management of long
term conditions in
pharmacy
Reduce hospital and GP
activity

Areas for consideration not yet
modelled
Rankin
g of
Priority
Modelling
Comments
People with long term conditions
developing further morbidities
Needs to be scoped
Falls
People with severe mental ill
health
Adults with learning disabilities
developing preventable ill-health
Mental ill-health prevention in
working age adults
Prevention of frailty and poor
coping in older adults

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

Key dependencies
• Modelling
• Roles of other bits of the system – cant do
prevention without changing clinical behaviour
and pathways
• Understanding the impact of this work (i.e. does
it really prevent future need)
• The articulation of a logic model for prevention
• Understanding what action is needed
• System being able to deliver it

Next Steps
• Discuss and agree approach
• Discuss and agree priorities
• Establish workstreams
• Really need a Prevention Summit

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Editor's Notes