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

A Healthier Future
7th February 2017
STP Context
Tom 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

Context
Financial 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

A Healthier Future
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
PH.Intelligence@hertfordshire.gov.uk
For a copy of these slides please email
Jim.mcmanus@hertfordshire.gov.uk
© Copyright, 2017 Hertfordshire County Council Public Health

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
How the STP
population will
age
© Copyright, 2017 Hertfordshire County Council
Public Health

• 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
How the STP
population will
age
© Copyright, 2017 Hertfordshire County Council
Public Health

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

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? Examples
Levels of
Prevention
Crime and
Disorder
Mental Health Cancer
Prevent/Stop
harm 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/Mitigate
harm of need
Cheaper
alternatives? (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 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

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

 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

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 about
1. Get Linda volunteering/learning
2. Social Media, library facilities, technology
1. What vehicles of info do people trust/use?
2. Identifying and targeting
1. Soft intelligence
3. Housing sector potential
1. 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
publichealth@hertfordshire.gov.uk
#HWEPrevSummit

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