Psychology and the NHS Long Term Plan: Steming the Tide The centrality of public health

www.hertfordshire.gov.ukwww.hertfordshire.gov.uk
Stemming the Tide
The central importance of prevention and public
health
Prof Jim McManus, Cpsychol, FBPsS,CSci,FFPH
Director of Public Health, Hertfordshire County Council
Vice-President, Association of Directors of Public Health
17th June 2019
Psychology and the NHS Long Term Plan Event

www.hertfordshire.gov.uk
• What can Society achieve by genuinely effective
prevention of avoidable ill-health and
dysfunction,
• What can psychology do both for the system
and for people?
Opportunity

1. Good Start in Life
2. Good Education
3. Meaningful and fair employment
4. Healthy Place
5. Healthy Housing
6. Balance – Physical, Psychological, Spiritual, Interpersonal
7. Sustainable Environment
8. Healthy Living made easy and second nature
9. Connect, Be Active
10.Meaning, Purpose and Hope
The Building blocks of good health

Persistent Challenges
Variation in Life Expectancy (7.2 years men, 5.4 women)
Untoward Variation in Care
Economic Inactivity and Worklessness
Preventable Mental Ill Health
A system which can’t cope with complex problems
Preventable Disability
Not seeing Human Person as Unity across Life

Where do we focus our efforts?
6http://www.healthmetricsandevaluation.org

7http://www.healthmetricsandevaluation.org;
The Lancet, Early Online Publication, 5 March 2013doi:10.1016/S0140-6736(13)60355-4
Where do we focus our efforts?

Public Health is a Mindset
• Population focused
• Prospective
• Preventive
• Protective
• Systemic -
• Layered – from individual to societal levels
• Seen in this light so is community safety,
Policing, and much more

Waves of Public Health…where next?
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62341-
7/fulltext

• PH Has not always embraced psychology or
other behavioural sciences as thoroughly or as
well as it should
• This impoverishes our response
• If we need further waves of PH, we need a
wave which is psychologically informed
Challenges

Conceptualising the
contributions of behavioural
and social science disciplines
National policy
and delivery
Research
funders,
think tanks National
professional
societies and
networksRoyal
colleges and
academies
Stakeholders
Improving People’s Health 2018:
Behavioural and Social Science Strategy

Three Domains of Public Health
A traditional model but provides room for dialogue
Health
Improvement
Service Quality and
Outcomes
Health Protection

Three Domains of Public Health
Amended to a shared language….
Improvement and
Prevention
Quality and
Systems
Protection of the
Public

www.hertfordshire.gov.ukwww.hertfordshire.gov.uk
A Public Health Approach to Disease
Control
Monitoring of
incidence
Identify
risk factors
Intervene Evaluate
Identify
morbidity
mortality
cost
social
genetic
Environmental
Individual
group
prevalence
Prevention
primary – stop
Secondary - reduce

Use of Intervention Matrices
• The layers and levels matrix – 6 levels of Public Health
Action from the Hertfordshire Public Health Strategy –
eg Tobacco Control.
Structural Eg policy change
Legislative Legislation to support tobacco control
Environmental Public realm planning, no smoking in
buildings
Social Social marketing, social norms
Behavioural Behavioural and cognitive programmes
Biological Nicotine replacement, harm reduction

Some approaches
‘What is wrong with
‘Why are you
unhealthy ?’
‘What is stopping you
from being healthy ?’
 Smoking
 Poor diet
 Lack of fitness
 Drug and alcohol
misuse
 Poor coping skills
 Lack of lifeskills
• Powerlessness
• Isolation
• Pollution
• Stress
• Hazardous living
conditions
you ?’
 Heart Disease
 Cancer
 HIV / AIDS
 Diabetes
 Obesity
 Mental Health
 Hypertension
Individual Medical
Approach
Individual
Behavioural
Approach
Approaches
Behaviour in Context an
Socioenvironmental

Life course
perspective
17Regional Going Live Event: Health and Wellbeing directorate working together
Healthy Infants,
Children, and
Young Adults
Healthy Adults
and Older
Adults
Healthcare
Public Health
Healthy People
in Healthy
Places
Health in All
Policies
A focus on improving health and health
outcomes for mothers and infants, children,
teens and young adults.
All people, and especially those at greater risk
of health disparities, will achieve their optimal
lifespan with the best possible quality of health,
including mental health, in every stage of life.
Support sound decision-making and policy
change within the NHS to deliver, scale up,
evaluate and improve effective clinical
preventive services that drive population health.
Ensuring that the places where people live,
work, learn, and play will protect and
promote their health, especially those
people at greater risk of health disparities.
Inform and support partners in sound decision-
making and policy change at all levels to deliver
and evaluate programmes and address social
determinants of health.

https://www.local.gov.uk/so
cial-determinants-health-
and-role-local-government

LTP is an NHS Plan not a system plan
70% of causes of ill health are
social or environmental - 100% of
solutions in NHS Plan are clinical
• Will make a contribution but will not deliver what
we need
• Discourse that “local government is not
delivering”
• worst performance is in NHS England Section
7A performance

Big Ticket Priorities
• Prevention
• Clinical Priorities
• Shift to Primary and Community Care????
– Primary Care Networks
• System Redesign – ICS, CCGs
• Population Health Management

• NOT a clinical way of doing public health.
• Population Health Management is ONE subset
of a PH Approach
• Limited without Place and Wider Determinants
Population Health

Achieving Success
Making the
“Triple Aim”
Possible -
How
So what is Population Health Management, then?

Our agreed STP PHM ambitions: Reducing the need
and spend curve: Preventing avoidable spend in public
service Highest cost.
Reduce
and delay
Need here
Reduce or delay need here
Intervene here before need
escalates
Volume of
spend
Severity of need
Existing
curve
Potential
curve

The 5 Big Ticket Changes to Service
Models
• Boost ‘out-of-hospital’ care, and dissolve the primary and
community health services divide
• Redesign and reduce pressure on emergency hospital services
• People will get more control over their own health, and more
personalised care
• Digitally-enabled primary and outpatient care will go mainstream
across the NHS
• Local NHS organisations will increasingly focus on population
health and local partnerships with local authority-funded services,
through new Integrated Care Systems (ICSs) everywhere
• Great ambition. Issue is how and cant be done by NHS alone

Criticisms
• “That” Review of Public Health – Clumsy
• Workforce Issues
• Funding Insufficient?
• lack of demonstrating value for money
• the fact much of the money will stay inside the
NHS
• Individual Responsibilty Model
• NHS England Model of Roll Out could be done
better using mixed economy approach

“NHS Cannot do it by itself”
• Explicit statement
• NHS England expressed a desire to take over
PH services
• “That Review” – NHS Involvement in PH
services
• Cultural issues about NHS realising this

Best Start in Life
• reducing stillbirths/deaths during birth by 50%
• providing extra support for expectant mothers
at risk of premature birth
• perinatal and child mental health conditions
• taking further action on childhood obesity
• reduce autism assessment waiting times
• right care for children with a learning disability
• child cancer treatment

• Prevention Vision
• NHS Long Term Plan
• Green Paper on Prevention
• Social Care Green Paper (2 years and counting)
• Clean Air Strategy
• Serious Violence Strategy
• Spending Review – Errr….
– Wanting to get into Genomics, Technology
and Predictive Prevention (whatever that is)
The National Policy Agenda

DHSC Slides..what govt says the green paper will contain

DHSC Slides
DHSC Slides..what govt says the green paper will contain

But Problems with this,,,
• Nothing on wider determinants or systems
• Very “health” focused
• Trying to be cross-govt but not really
• Simplistic lifestyle narratives
• Very focused on narrative of personal responsibility
• Role of social sciences not articulated
• Lack of coherent lifecourse vision
• Very focused on clinical outcomes
• What about crime, work, sustainability, growth, air quality?

How might we work together?
• Common focus on Human Flourish
• Recognition of Value of Psychology across all aspects
of ambitions for this
• We need to
– Hold individual and social in dynamic tension
– Understand complexity and address it on multiple levels
– Understand and use systems approaches
– Think and act from wider determinants to clinical and back
again
– Think Lifecourse
– Think of the human person as Unity

• Population Health
– Wider Determinants
– Sustainability
• Population Health Management
• No Health Without Mental Health
• Complexifying
• Systems Approaches
• Better use of Data and Informatics
Opportunities to deliver this

Biomedical Psychosocial
Social
Structural and
Environmental
“Knowing” an issue
in its multiple
dimensions
Complexifying Challenges, Solutions
and Knowledge

Tertiary Prevention
Managing complex conditions, disease management
Secondary Prevention
Early Intervention and Remediation of Problems (eg behaviour at school, stress
in employment)
Primary Prevention
Healthy Society, Healthy Lifecourse, Healthy Settings, Healthy Organisations
Public Health and Psychology – Working
Together

thank you
Jim.mcmanus@hertfordshire.gov.uk

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Psychology and the NHS Long Term Plan: Steming the Tide The centrality of public health