Towards a whole system strategy on prevention
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This presentation aids a Health and Wellbeing Board session on developing prevention across the health and social care system, in answer to financial challenges and the NHS FIve Year Forward View
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Towards a whole system strategy on prevention
- 1. www.hertsdirect.org System wide action on prevention: Towards a strategy Prevention Group Health and Wellbeing Board Development Day 30 April
- 2. www.hertsdirect.org Outcomes we’d like from today 1. Agreement to do prevention together AS A SYSTEM 2. A lead senior person from each partner 3. A gap analysis on prevention from each partner 4. From gap analyses produce a strategy 5. A steer on governance of this from HWBB
- 3. www.hertsdirect.org The big win “The NHS needs a radical upgrade in prevention if it is to be sustainable” 5 year Forward View 2014 Current Herts position We are doing prevention, but lots of variation, not systematic and lots of gaps We could get more if we do it smarter
- 4. www.hertsdirect.org Problem you asked us to look at • Significant escalating and avoidable spend across system • Some efforts at preventing and reducing this • Growth of avoidable cost to system and avoidable health problems • Growth of multimorbid health conditions • System wide problem, little system wide preventive pathways
- 5. www.hertsdirect.org What do we mean by prevention? Primary Prevention – ‘prevent’ harm •Example: promoting health and active lifestyles Secondary Prevention – ‘reverse’ harm •Example: early detection and effective self management of diabetes Tertiary Prevention – ‘reduce’ harm •Example: COPD + early stage heart failure + depression
- 6. www.hertsdirect.org What Prevention are we doing • Primary – increasing and needs to be done but is a very slow upstream burn • Secondary – we really need to do much more here to prevent a 3-5 year cost curve increase • Tertiary – Could have high impact within twelve months. We need to do more. Primary prevention alone, and tertiary prevention alone not the answer. Target all three for maximum impact
- 7. www.hertsdirect.org Case study – Martha 69 • COPD • Diabetes • Early stage heart failure • Smokes Tertiary Prevention Which bit of the system could do what for her? What do we need to do better?
- 8. www.hertsdirect.org Case Study – Joe, 58 • Stroke • Poorly controlled blood pressure • Coping poor How do we prevent escalation? (secondary prevention)
- 9. www.hertsdirect.org Case Study – Joanne 39 • Very overweight • Inactive • Smokes • Single parent • Stressed • Manual work • Depressed • Always asking for prescriptions How do we stop this becoming a major cost to the system?
- 10. www.hertsdirect.org The Strategy 1. Reduce cost to the system by implementing high impact actions system wide to prevent worsening of health and management of cost 2. Improve quality of life by including clinical + lifestyle + behavioural components 3. Make more use of services in the community including pharmacy 4. Develop preventive pathways 5. Work across primary, secondary and tertiary prevention to deliver this in tandem 6. Start with areas which will have highest impact
- 11. www.hertsdirect.org Some early estimates • Musculoskeletal health costs us • Obesity costs us • Poor management of long term conditions costs us – including physical and mental health • Multimorbidity costs us – 16% of NHS spend on 2% most complex patients
- 12. www.hertsdirect.org Multimorbidity – evidence • Definition - presence of two or more disorders • 42% patients 1+ morbidities and 23% were multimorbid • Prevalence increased with age and present in most 65 + • BUT absolute number of people with multimorbidity higher in those younger than 65 years • Onset of multimorbidity occurred 10–15 years earlier in people living in the most deprived areas • Presence of a mental health disorder increased as the number of physical morbidities increased and was much greater in more deprived people
- 13. www.hertsdirect.org Multimorbidity – implications for practice? • Is the single-disease framework fit for purpose? – individual long term condition (LTC) services can be duplicative and inefficient, and burdensome for patients due to poor coordination and integration • Is mental health a core component of LTC pathways? • Need to support generalist clinicians to provide personalised continuity of care, especially in deprived areas
- 14. www.hertsdirect.org Example from the Commissioning for Value CVD pathway • HVCCG – Hypertension ratio (-7.1 % lower) opportunity for 5,828 people – % anti-coagulation drug therapy for those with stroke risk >1 (using CHADS2 score) (-9.2 % lower) opportunity for 361 people – E&NHCCG – % stroke patients blood pressure <150/90 (-2.6 % lower) opportunity for 200 people – % stroke patients record of cholesterol (-4.6 % lower) opportunity for 347 people
- 15. www.hertsdirect.org Pharmacy • We are not using pharmacy effectively • High impact actions (Year 1 and 2) – More uptake of medicine use reviews & new medicine service – More use of pharmacy based support for self management in long term conditions – Minor ailments schemes – Healthy Living pharmacies in areas of highest need • Develop further programmes in years 3 onwards
- 16. www.hertsdirect.org The avoidable spend areas in the physical health system, with poor health/quality of life Multi morbid Repeat admission Complex care Existing disease Managed sub-optimally Sudden onset of acute Avoidable events eg stroke Volume of spend Severity Existing curve
- 17. www.hertsdirect.org Key actions to reduce this PH spend curve Clinical + Lifestyle + Behavioural Case management Self management Optimal assertive Management of existing disease (lifestyle + pharmacological) Optimal management of high Risk patients; Volume of spend Severity Existing curve The Achievable
- 18. www.hertsdirect.org The avoidable spend areas in the mental health system, with poor health/quality of life Crisis pathways And repeat Admissions, dual diagnoses People with long term mental ill health Whose physical health deteriorates due to Sub-optimal management Prescribing practice where IAPT or CBT could resolve issues Volume of spend Severity of condition Existing curve
- 19. www.hertsdirect.org Key actions to reduce this MH spend curve Clinical + Lifestyle + Behavioural Recovery focused care Channel shift: Greater use of online and community groups; less prescribing Optimum physical health (eg quitting smoking reduces cost to MH services) Volume of spend Severity Existing curve The Achievable
- 20. www.hertsdirect.org The Actions • We’ve suggested the strategy • What follows are the actions Main message: We need to reduce variation across the healthcare system for these high impact actions
- 21. www.hertsdirect.org High Impact Actions by Partner 1 Who Primary Secondary Tertiary Primary Care NHS Health Checks Making Every Contact Counts (MECC) - Joint British Society recommendations for prevention of CVD (JBS3) - Blood pressure - Weight - Alcohol - Diabetes – eight care processes - Improved access to IAPT services - Early identification of atrial fibrillation and anticoagulation therapy Self-Management Optimise referrals to Pulmonary / Cardiac rehabilitation Pharmacy Purple – contractual Red – requires funding Green – may need financial support Healthy Living Pharmacies Public Health (PH) Pathway into PH Services Minor ailments with pharmacy Medicine Use Reviews / New Medicines Service Healthy Lifestyle Advice Home MURs (Bright Ideas Project) LTC Pathways Repeat dispensingExpansion of PH services – smoking, alcohol IBA, sexual health Minor ailments Healthy Living Pharmacies
- 22. www.hertsdirect.org High Impact Actions by Partner 2 Partner Primary Secondary Tertiary HCS Promote a healthy workforce Making Every Contact Counts & brief interventions Re-ablement Public Health Continue to commission services Use expertise to support prevention strategy Enhance healthcare and social care public health offer Use expertise to support prevention strategy PH Pathway into PH Services PH Pathway into PH Services Community Wellbeing Services Prevention Strategy for Older People
- 23. www.hertsdirect.org High Impact Actions by Partner 3 Partner Primary Secondary Tertiary HCT Promote a healthy workforce Implement NICE guidance -Smoking cessation in secondary care: acute, maternity and mental health services (PH48) Brief Interventions /MECC Alignment of physical health and mental health / psychological support pathways Acute Promote a healthy workforce Implement NICE guidance -Smoking cessation in secondary care: acute, maternity and mental health services (PH48) Brief Interventions /MECC Referral pathways to community prevention services Rehabilitation Reduce variations in length of stay Optimise Pulmonary / Cardiac Rehab Pathways PH Pathway into PH Services PH Pathway into PH Services
- 24. www.hertsdirect.org High Impact Actions by Partner 4 Partner Primary Secondary Tertiary Voluntary Sector Making Every Contact Count Deliver resilience and psychosocial support Programme delivery providers Programme delivery providers HPFT Promote a healthy workforce Implement NICE guidance -Smoking cessation in secondary care: acute, maternity and mental health services (PH48) MECC Robust physical health pathways for patients with serious mental illness (SMI) and dementia Recovery services PH Pathway into PH Services PH Pathway into PH Services
- 25. www.hertsdirect.org High Impact Actions by Partner 5 Partner Primary Secondary Tertiary Childrens Ensure universal public health offer aligns well with children's services Schools mental health and wellbeing School health Ensure early intervention takes holistic approach PH Pathway into PH Services
- 26. www.hertsdirect.org Two things now... How do we govern this? • How do we make it happen system wide? • Which fora do we use? • Who leads? • Resource – within existing resources but some investment in programme capacity and look at prioritising? Agreements we’d like today 1. Agreement to do prevention together AS A SYSTEM 2. A lead senior person from each partner 3. A gap analysis on prevention from each partner 4. From gap analyses produce a strategy for HWBB
Editor's Notes
- England faces an epidemic of largely preventable non-communicable diseases, such as heart disease, cancer, Type 2 diabetes and liver disease. The WHO Global Burden of Disease Study shows us that the leading causes of premature mortality are tobacco, raised blood pressure, obesity, physical inactivity and poor diet. The radical upgrade in prevention needs population-level approaches. But it also needs ongoing behaviour change support and medical treatment for individuals during their repeated contacts with primary care.
- Secondary prevention - interventions happen after an illness or serious risk factors have already been diagnosed. The goal is to halt or slow the progress of disease (if possible) in its earliest stages; in the case of injury, goals include limiting long-term disability and preventing re-injury. Tertiary prevention - focuses on helping people manage complicated, long-term health problems such as diabetes, heart disease, cancer and chronic musculoskeletal pain. The goals include preventing further physical deterioration and maximizing quality of life.
- Referral from GP to CP could result in Education and counselling by CP can result in improvements to cardiovascular risk profile of patients with diabetes. (Manor Pharmacy/UoH pilot article attached) MURs in pharmacy or patient’s home (Bright Ideas project – IM sponsoring) may prevent hospital admission, by ensuring prescribed medication compliance/concordance
- Stroke/Coping poor Referral to support services – detail needed on what they are? Community navigator role? Why are bloods poorly controlled? Provide community based anti-coag service? Could be in CP or other suitable venue? Could be nurse/CP lead?
- Needs multi-disciplinary solution – HPs, social care, voluntary sector etc CP could signpost, also offer SS service, Rx support – are meds being prescribed appropriately
- Not addressing relationship between LTCs and mental health and its impact on self management NHS England LTC Dashboard 1 LTC (31% EN; 31.7% HV) 2 LTCs (12.4% EN; 12.5% HV) 3 LTCs (9% EN; 8.1% HV) Commissioning for Value (CfV) - 2% most complex patients of which 60% aged 65 years+ E&NH – 16% spend, 1497 patients, av. 2.8 conditions and 6.2 admissions per year – circulation, cancer and GI top 3 areas of spend HV – 15.9% spend, 1530 patients, av. 2.91 conditions and 6.7 admissions per year– circulation, cancer and MSK top 3 areas of spend Obesity associated with the four most prevalent disabling conditions in the UK: arthritis, back pain, mental health disorders and learning disabilities 1/3 obese adults have a limiting long term illness or disability compared to a quarter of adults in the general population Multimorbidity is associated with high mortality, reduced functional status, and increased use of both inpatient and ambulatory health care The Global Burden of Disease study (2010) - growing burden of disability, particularly from mental disorders, substance use, musculoskeletal disorders, and falls deserves an integrated and strategic response
- 314 GP practices in Scotland (2007) Prevalence of both physical and mental health disorder 11%, in most deprived area vs 6% in least deprived Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012;380(9836):37–43. CrossRefPubMed cross-sectional study data on 40 morbidities from a database of 1 751 841 people registered with 314 medical practices in Scotland as of March, 2007. analysed the data according to the number of morbidities, disorder type (physical or mental), sex, age, and socioeconomic status. D Defined multimorbidity as the presence of two or more disorders.
- challenge the single-disease framework by which most health care, medical research, and medical education is configured
- The CHADS2 score is a clinical prediction rule for estimating the risk of stroke in patients with non-rheumatic atrial fibrillation (AF), a common and serious heart arrhythmia associated with thromboembolic stroke. It is used to determine whether or not treatment is required with anticoagulation therapy or antiplatelet therapy,
- & new medicine service (50% drugs stopped before end of first month without this and often GPs unaware)
- The NHS Health Check is a systematic approach to identifying local people at high risk of CVD, offering behaviour change support and early detection of hypertension, CKD, diabetes and pre-diabetes. Modelling suggests that 75% uptake will lead to substantial reductions in premature mortality. What proportion of our local eligible population is receiving the NHS Health Check and how effective is their follow up risk factor management in primary care? 12.8% offered an NHS Health Check (18.4% in England). 65.3% of people received an NHS Health Check of those offered (49% in England). http://www.guidelines.co.uk/cardiovascular_bmj_jbs3_jul14 Diabetes Diabetes observed prevalence compared to expected prevalence ENH 82% & HV 73% 8 care processes – CfV data on pathways - Cardiovascular disease profile - Diabetes (March 2015) ENH- People with diabetes who have had the eight recommended care processes = 42.4% HV- People with diabetes who have had the eight recommended care processes = 63.2% CVD pathway CfV - What questions should we ask in our CCG? 1.For each indicator how wide is the variation in achievement and exception reporting? 2.How many people would benefit if all practices performed as well as the best? 3.How can we support practices who are average or below average to perform as well as the best in: •Identifying people who are obese, inactive or smokers •Identifying and managing high CVD risk •Identifying and managing high blood pressure •Identifying and managing pre-diabetes 4.What is the quality of brief interventions we offer our patients? 5.How available are preventive services such as weight management and smoking cessation? Stroke Atrial fibrillation increases the risk of stroke by about 6 fold, and strokes caused by AF are often more severe with higher mortality and greater disability. Anticoagulation substantially reduces the risk of stroke in people with AF. Around 25-30% of people with AF are unaware they have the condition and less than a half of patients are adequately treated – many do not receive anticoagulants and of those who do, many are undertreated. Only 30% of people with known AF admitted with stroke are on anticoagulant treatment at the time of their stroke. Secondary prevention of stroke For people who have had a stroke anti-platelet treatment and good control of blood pressure are key to reducing the risk of a further stroke Pharmacy – Lisa Healthy Lifestyle advice contractual and includes healthy eating, physical activity, smoking, alcohol etc. Advice given generally as well as during MURs and as part of contractual Health Promotion campaigns. Medicines Use Review (MUR)/New Medicines Service (NMS) – contractually funded but need multidisciplinary buy in. Prioritise by specific target groups eg respiratory disease, recently discharged from hospital. Could also have local target groups eg: musculoskeletal conditions. Direct funding not required but knowledge of local pathways/training etc Expansion of PH services – need to look at where GP/Pharmacy services are lacking and encourage contractors to become accredited. Referral process where GP or CP is not providing to ensure patient needs are met. LTC Pathways – CP rarely included until issues arise or targets unmet eg: Under 65yrs target groups for flu vaccine. When are pathways reviewed? How can CP be involved? Repeat dispensing – contractual service that CPs must promote but only GP can issue – need both to work together. Patient benefits as CP must assure that requested medication is required. Opportunity to discuss with patient on monthly basis. Potential to improve compliance/concordance and recognise problems at early stage. Home (domicilary) MURs – project doc attached Healthy Living pharmacy – expansion of current ohort (18) across Herts. Promotes PH interventions and proactive working with clients in pharmacy and as part of outreach
- HCS Levels and competencies from brief intervention onwards Preventive services as part of commissioned services Link up to community services (referral for leisure and behavioural interventions) Culture change Embedding good practice Evidence on what is effective
- Pulmonary / Cardiac Rehab Pathways - uptake/access and follow up