22 10

Public Health Wales

General document template

Consultation on the Draft Final Report of the

National Health Improvement Review

Author: Helen Howson, Strategic Programme Director, Public Health Wales

Date: 8 February 2013

Version: 1

Purpose and Summary of Document:

A draft of the final report of the National Health Improvement Review is included in the Board papers. The document reports on the findings of the Health Improvement Review and has been circulated to stakeholders for consultation. The Public Health Wales Board commented on the draft before it was circulated for consultation. The consultation period closes on 22 February 2013. Helen Howson will attend the Board meeting to discuss the emerging findings from the consultation exercise.

Once the consultation period has closed the Board will be given further opportunities to comment on the report before it is submitted to the Minister for Health and Social Services.

Sponsoring Executive Director: Dr Peter Bradley, Executive Director of Public Health Development

Who will present: Helen Howson, Strategic Programme Director, Public Health Wales

Documents attached: Transforming Health Improvement in Wales

The Draft Final Report of the National Health Improvement Review

Date of Board meeting: 21 February 2013

Committee/Groups that have received or considered this paper:

Health Improvement Advisory Group chaired by Professor Gareth Williams, Non Executive Director, Public Health Wales

Please state of the paper is for:

Discussion

X

Decision

Information

X

Transforming Health Improvement in Wales

The Draft Final Report of the

National Health Improvement Review

Author: Helen Howson, Strategic Programme Director, Public Health Wales

Date: 31 January 2013

Version: 1

Publication/ Distribution:

· Health Improvement Advisory Group

· Public Health Wales Board

· Public Health Wales website for the public domain

Purpose and Summary of Document:

This document provides a report on the findings of the Health Improvement Review. It outlines the approach taken and draws together evidence available from across key areas of work, as well as feedback from the public and professionals. More detailed information is available at www.publichealthwales.org/healthimprovementreview from each of the sub groups (Evidence Review, NHS, Health Economics and Communication and Engagement) which formed the basis of this report and its findings. Building upon our strengths to date, the Review provides a robust basis to move forward in our aims of improving health and wellbeing in Wales and reducing inequalities.

Work Plan reference: National Health Improvement Review

1 Foreword

By Professor Gareth Williams, Chair of the Health Improvement Advisory Group of the National Health Improvement Review.

It gives me great pleasure to introduce this report on Transforming Health Improvement in Wales.

Like all post-industrial societies Wales faces major challenges to the health of its population and, as a consequence, to its health policies – both for the delivery of health care and for the prevention of ill-health. Figures from the 2011 Census reveal that of the 10 local authority areas in England and Wales with the worst health, five are in Wales. Informing the work of this review, therefore, is the firm conviction that in order to improve the health of the population we in Wales must move from an ‘illness service’ to a ‘wellness service’, a service which places much more emphasis upon the prevention and promotion of better health. This is by no means a new idea - it has a long history in Wales31. Almost exactly 10 years ago the late Sir Derek Wanless warned that unless we find ways of attaining ‘full engagement’ of the public and the professions in disease prevention and health promotion we will see the build up of ‘unsustainable pressure’ on the health and social care sectors in Wales32. And that was during a period of increasing investment in the NHS.

Today we are in a very different situation: post-recessional, buffeted by a continuing economic downturn and subject to the UK Coalition Government’s austerity policies. Whatever one may think of those policies, they clearly concentrate the minds and the budgets of policy-makers working across all sectors in Welsh Government, not least in health.

While there have been significant examples of innovative health improvement initiatives, they have tended to lack integration across the health sector and between health and other sectors. This review has looked at the current status of health improvement activity in Wales, at what works well and what works less well, and points the way beyond the current landscape of stand-alone initiatives, duplication of effort and inadequate evidence to a more integrated approach based on a clear set of principles. While this review has focussed upon the health sector, it has done so with a clear understanding of the importance of building better partnerships with local government and the third sector.

Many people have been involved in this review, working to tight timescales and collecting and synthesising a variety of different points of view and forms of evidence. I am enormously impressed by the amount that has been achieved, and I firmly believe that this report can be used to put into action a more confident, forward-looking and sustainable approach to health improvement in Wales.

Contents

41Foreword

92Executive Summary

133Background

144Approach

155Introduction

155.1The challenges

155.2The future of health improvement

165.3Delivering the vision

176Health in Wales: The context

197Current Position: Mapping activity and establishing the baseline

228Sub-group findings

228.1Evidence review sub-group findings

238.2Health Economics and Programme Budgeting and Marginal Analysis (PBMA) sub-group findings

258.3Other services and initiatives

268.3.1Initiatives which represent core public health service activity but have previously been funded through a grant or other funding mechanisms

268.3.2Small Grant Schemes to support health improvement action

278.3.3Public health advocacy

278.3.4Public health action plans for specific groups

278.4Communication and engagement sub-group findings

288.4.1Local Public Health Teams

288.4.2Local Government

308.4.3Third sector and wider stakeholders

318.4.4Public views

338.5NHS sub-group findings

338.5.1Maximising the role of the NHS in supporting health improvement

358.6Health inequality

369Key Emerging Themes

369.1Communications

369.2Research and evidence

389.3Multifaceted and integrated approaches

399.4Impact and outcomes

399.5Efficiency and value for money

419.6Building on what we have

429.7Citizen centred approach and reducing inequality

439.8Health Improvement: Maximising its potential

4510Health Improvement: Fit for the future

4510.1Our vision

4510.2Our guiding principles

4810.3Our approach: Starting with people

5010.4Life course approach

5110.5Proportionate to need

51Delivering services proportionate to need:

5210.6Our wider community: Social and environmental impact

53Fitting all this together

5511Conclusions

5612Recommendations and actions

5612.1Delivering transformational change

5612.2Maximising health improvement potential

5712.3Transforming Health Improvement across Wales

5812.4Sustaining Health Improvement

5812.5Re -focus National Health Improvement Priorities

5912.6Building Evidence for Change

6113References

6514Acknowledgments

6514.1Health Improvement Advisory Group Members

6514.2Executive Delivery Team Members

6614.3Sub-groups

6614.3.1Evidence Review sub-group

6614.3.2NHS Health Improvement sub-group

6714.3.3Communication and Engagement sub-group

6714.3.4Economic sub-group

6714.3.5Inequalities sub-group

6714.3.6PBMA Expert Reference Panel

6814.4Health Improvement Review Programme Office

2 Executive Summary

Purpose and summary of report

This document provides a report on the findings of the Health Improvement Review to inform subsequent strategic direction and final recommendations. It provides an outline of the review process and sets out the case for transformational change. It articulates the:

i. current status of health improvement activity in Wales;

ii. challenges and opportunities that exist in a fast-moving and constantly changing operating environment; and

iii. case for, and the means by which, urgent transformational change should be expedited.

Health improvement in Wales

Health Improvement is crucial to the future sustainability of health and social care. Wales, as a nation, has to address a range of complex health challenges during what will continue to be a highly dynamic period of change. It is vital that through targeted investment in health improvement, prevention and early intervention across the NHS, local government and wider afield, we create a healthier Wales. We need to make sure we are getting the most from the resources we have, moving from an “illness dominated service” to a “wellness service” and to one where people and their needs are the focus1. With this in mind, the review has sought to understand and evaluate current health improvement activity across Wales and consider how we should reshape services, environments and the way we work to improve health and wellbeing.

Changing the way we work

There is a wide variety of work taking place across Wales to support health improvement, both nationally and locally. Despite many examples of best practice and excellence, our efforts to improve health and wellbeing remains static and needs to continually adapt to changing circumstances. The current fragmented model often based upon single approach solutions, silo teams, segregated budgets, inadequate evidence, outcomes and/or inappropriate targeting of need, is no longer viable. We need to change the way we work to more integrated and collaborative approaches engaging with local people, communities and professionals.

The Programme Budgeting and Marginal Analysis2 (PBMA) undertaken as part of the review provided a useful, systematic approach to draw together a wide range of evidence to inform the investment and disinvestment decision-making. The analysis created a context for discussion, dialogue and joint learning, through an independent panel to inform decisions on current programmes. It identified those which should be maintained and improved (Stop Smoking Wales, National Exercise Referral Scheme, Welsh Network of Healthy School Schemes), those that should continue to be monitored (Designed to Smile, Fresh Start, Champions for Health, HIV Prevention and Empower to Chose, ASSIST and Baby Friendly Initiative), those which needed further on-going consideration (Mental Health First Aid, No Smoking Day and aspects of the breastfeeding programme), and those which had the potential for disinvestment (The Cooking Bus, Smoke Bugs, and Smokers Helpline Wales). It also identified the need to strengthen outcomes, value for money, reach and sustainability in core public health activity, health improvement grant schemes, public health advocacy support and programmes for specific vulnerable groups.

The way forward

As funding pressures across the NHS intensify the need to target resources to achieve the best possible outcomes based upon evidence and value for money will increase. Equally pressing, is the need to explore and exploit opportunities for integration, collaboration, cross-sector working and greater use of digital technology.

The review concluded that the current model as it stands lacks critical mass, and is unsustainable. To ensure we achieve the best possible outcomes from the resources we have available we need to focus on a smaller number of High Impact Level Health Improvement areas with greater depth and integration. We also need to build upon existing best practice, pool resources, leverage our collective knowledge and skills and integrate and unite services.

Furthermore, the review concluded that Wales should adopt a more integrated approach based upon a guiding set of principles and addressing needs at different stages of life. The new approach should include a comprehensive portfolio of evidenced interventions, with complementary and reinforcing actions across a range of variables with clear outcomes.

The Health Improvement Review has identified key recommendations and actions to respond to the challenges transforming health improvement in Wales, summarised below:

· Transform health improvement in Wales through a people focused Life Course Framework and adopting a guiding set of principles.

· Adopt a combination of approaches for future activity including fiscal, legislative, social marketing and community engagement.

· Increase strategic collaboration and partnership working with key stakeholders, particularly local Government and the third sector, to support integrated local delivery.

· Reshape the portfolio of health improvement programmes making them more holistic and integrated.

· Re-direct resources into areas most likely to achieve greater reach and better outcomes.

· Explore innovative ways to work more closely and have more dialogue with local people and communities, building on their networks, support and assets.

· Tackle obesity as a priority through an integrated approach.

· Improve the monitoring, evaluation and reporting of health improvement programmes.

· Unify the public health workforce to create critical mass, share learning, and improve efficiency.

· Adopt a ‘proportionate to need’ approach to address inequality.

· Support local delivery through improved collaboration, innovation and integrated flexible services embedded into local systems.

· Ensure there is capacity and flexibility to explore new opportunities that arise from developments such as the proposed Public Health Bill.

· Actively pursue opportunities to strengthen health improvement across the NHS, particularly primary care.

· Improve efficiency and impact through the use of digital technology and social media.

· Ensure existing evidence to support health improvement interventions (particularly NICE guidance) is implemented consistently across Wales and adapted to local circumstances.

· Address evidence gaps through innovation and R&D in collaboration with academia.

Making it a reality

The review concluded that to achieve the strategic objective of moving from an illness service to a wellbeing service, a dedicated change programme of Health Improvement Transformation should be established as a matter of urgency. It should be supported by a steering group that should oversee the execution of the detailed recommendations set out in this report and also the requirements in the Programme for Government.

This transformation programme will ensure that the approach in Wales is re-focused, at pace, to:

· improve health outcomes

· reduce inequalities

· meet the changing and accumulating needs across the life course model

· work in partnership with key stakeholders

· maximise use of all resources.

3 Background

At the request of the former Minister for Health, Social Services and Children, Professor Sir Mansel Aylward CB completed a brief review of a number of key national health improvement programmes in 20113. From this, it was recognised that further consideration should be given to the future direction for health improvement and constituent programmes across the board. The current Minister has tasked Public Health Wales to undertake this, steered by a Health Improvement Advisory Group (HIAG) which will make recommendations.

The HIAG has been tasked with considering the future direction for health improvement and health improvement programmes in Wales. It must ensure sustainability, value for money and the delivery of priority outcomes consistent with national policy specifically ‘Programme For Government’, ‘Together for Health’, ‘Our Healthy Future’ and ‘Fairer Health Outcomes for All’. It will also need to take account of wider relevant policies which may be linked to health improvement. The work has also been guided by the following agreed objectives:

· The assessment of the most effective means of delivery in the future, taking account of wider evidence and innovative practice, cross cutting national policy, value for money and integration.

· A review of the future direction for health improvement and health improvement programmes in Wales with funding from Welsh Government’s Health and Social Care Directorate or Public Health Wales (taking account of other wider contributors and programmes).

· The identification of opportunities to strengthen the holistic delivery of health improvement including the realignment, restructuring, and transformation of current programmes that would help ensure sustainable and cost-effective outcomes are achieved.

· The consideration of the role Public Health Wales and other key contributors play in supporting health improvement, as an integral part of the wider context of health improvement in Wales.

4 Approach

The Health Improvement Advisory Group has steered the review process to establish the current position and baseline against which alternative models could be evaluated. Four separate sub-groups were established to undertake specific assessments on significant aspects of the review. They were:

· Evidence review

· Health economics

· Communication and engagement

· NHS

The outputs of these groups were used to inform the report. There has also been extensive consultation with professionals and wider stakeholders.

5 Introduction

5.1 The challenges

This review is taking place at a time of broad economic and social change, alongside specific transformation in health and social care services. Levels of smoking, obesity and alcohol consumption, along with technological and demographic change, are putting pressure on health and social care services, which are struggling to meet demand. The alarming increases in obesity, both in childhood and adults, suggest that by 2025, 40% of the population will be obese4. By, 2050 we are likely to be an ‘obese society’. In addition, the health of the poorest people in our communities is increasingly lagging behind the best5 for a complex combination of economic, social and cultural reasons.

Despite considerable effort across a range of interventions and programmes, inequalities in health have widened and progress with some health related behaviours have flat-lined at too high a level4,5. The need to make the best use of limited resources in the NHS has always been a priority, but the imperative is now greater than ever. Prioritising health improvement to reduce demand and lessen inequalities will be essential across all public services.

This overall situation, together with added concerns that some changes to the determinants of health (particularly cuts to welfare benefits) will further undermine the potential for progress, reinforces the need for this review.

The review provides us with a real opportunity to take stock and reflect on developments to date. It allows us to consider what we have achieved and think about where we need to go next. It will enable us to refresh our approach in the light of recent evidence and feedback, and to improve future health outcomes. It will also help us to see if there is scope for further investment and ensure that existing investment is being best used to improve health and wellbeing effectively, equitably and at pace.

Given the immense challenges ahead it is crucial we make Wales a world leader in health improvement. To do this we need to build on the good work achieved in many sectors, work collaboratively and systematically plan action to reduce the health inequality gap.

5.2 The future of health improvement

Health improvement aims to sustain and improve health and wellbeing, reduce inequalities and redress the unnecessary burden of illness and the associated costs. To achieve sustainable health improvement, we need to get this right and re-balance the context of care, based upon prevention, early intervention and health promotion across the board. The time has come to make a decisive shift away from managing sickness to creating a healthy Wales for everyone1,6. Ensuring health improvement becomes everybody’s business will be crucial to making this a reality.

5.3 Delivering the vision

To achieve sustainable health improvement is complex. Its determinants are rooted in a wide range of socio-economic, cultural and behavioural process requiring innovative and evidence-based services and policies inside and outside the health sector.

Fortunately, Wales has a strong policy framework provided through Together for Health and Our Healthy Future1,6 alongside a range of other related plans addressing more specific issues such as the Tobacco Control Action Plan and Fairer Health Outcomes for All. This framework is underpinned by a number of programmes which have promoted the health of Wales and shown progress through the dedication and hard work of many people. Some of these initiatives (Welsh Network of Healthy School Schemes, Corporate Health Standard and ASSIST) have achieved UK and international recognition.

The reality is that improving health is unlikely to be successful through a single intervention or programme. There examples where countries have managed to halt and reverse the decline in health damaging behaviours, for example, in Finland7,8 Australia9 and Canada10. So what makes the difference? Comprehensive and sustained approaches to population health appear to work best, and include a balance of action at the population level complemented by targeted approaches to high-risk groups. Preventive activities which focus on multiple risk factors are more likely than a single intervention to be effective.

Effective multi-faceted intervention programs often integrate the provision of information, education, structural and environmental changes, regulation, assessment, monitoring and treatment of high-risk individuals and are delivered through cross-sectoral co-ordination and co-operation11,12. Only through greater cross-sector working, multi-agency collaboration and partnership, and the deep integration of resources and effort, can the transition we desire in Wales take place. Dynamic engagement with stakeholders at community and individual levels will be essential. We will need to ensure we get the best from all the resources available across the system, including communities, individuals and other organisations.

6 Health in Wales: The context

The health and economic effects of illness related to our way of life are substantial, causing around 30% of premature deaths and substantial demands on resources. The four key risk behavioural factors most responsible for premature mortality are cancer, cardiovascular diseases, chronic obstructive pulmonary disease (COPD) and diabetes, as are the harmful use of alcohol and tobacco, unhealthy diets and physical inactivity. All of these show a social class gradient and need always to be understood in relation to economic and social circumstances, including the current context of rising prices and falling incomes. Tackling both behaviours and inequalities remains at the core of health policy in Wales, specifically Our Healthy Future1.

The following provides an overview of the health challenges we face in Wales:

Health Challenges for Wales13,14,

· Life expectancy at birth is increasing across all sectors of society in Wales; however it remains below the UK average.

· Healthy life expectancy at birth is increasing across all sectors of society in Wales; however, it remains below the UK average.

· People who live in more deprived communities in Wales not only live shorter lives, but live a shorter proportion of their lives in good health.

· The gap in life expectancy between the most and least deprived populations in Wales is wide, at nine years for males and seven years for females. This gap is widening.

· The gap in healthy life expectancy between the most and least deprived populations in Wales is particularly wide at 19 years for males and 18 years for females. This gap is widening.

· Cancer causes 40% of deaths in the under 75s in Wales and circulatory disease 25% of deaths.

· Deaths from major causes of disease, adjusted by age, have seen a steady decline over the last decade, particularly so in circulatory disease. However, deaths from external causes such as injury have failed to decline, whereas those attributed to alcohol have increased.

· Deaths rates due to liver disease among people under 65 in Wales have increased by about 80% in 14 years.

In summary, we need to ensure that children have a good start in life and we need to reduce health inequalities.

We have to reduce or halt the increase in obesity, reduce smoking and alcohol or drug abuse and ensure that we increase the amount of people who enjoy more independent years with a high standard of life. Understanding the challenges people face in achieving healthy lifestyles and supporting them to improve their own health and take greater responsibility for their wellbeing will be essential. However, taking responsibility under considerable conditions of disadvantage is something that none of us would find easy. We therefore need to see this through their eyes and help make this easier for people, improving access and creating conducive environments for positive health and wellbeing.

7 Current Position: Mapping activity and establishing the baseline

The initial stage of the work undertook a comprehensive mapping of programmes initiatives to identify the portfolio of health improvement work currently funded by the Minister for Health, Social Care and Children. This helped us to understand what activities were being funded, the topics and settings, and where there may be opportunities for consolidation and collaboration. Further details of this baseline can be found in the full report, but the main findings include:

· A range of over 37 elements of work, mainly single topic based, often fragmented, with little links between them or clear understanding of how they related or impacted upon each other, or the integrated needs of the people they were designed to support.

· The majority were interventions funded to support behaviour change as opposed to other approaches directed at fiscal, environmental or community development etc. To help understand this better these were grouped into topic areas, life course, tools, and support services. We also identified the new and emerging areas of work.

· The total costs across the initiatives were £17,573,875 with Public Health Wales accountable for managing 70% of the total. The majority (£4.6m) was spent on nutrition related work which included a total of £3.7m for Designed to Smile, followed by physical activity and smoking (£3.5 m, £3.4m). A breakdown of the total spend is outlined below:

Health Improvement Spend

· 25 of the 37 initiatives, accounting for 85% of spend, were included in the Programme Budgeting and Marginal Analysis (PBMA) process.

· Of this, the following represents an approximation of the breakdown across the life course:

Prenatal / maternal health /early years

School Child

Children and young adults

Working age adults

Older People

Elderly

£4,115,113

£2,905,313

£2,023,361

£2,787,997

£2,984,656

£175,946

· The remaining 12 initiatives (15% spend) did not form part of the PBMA process because they have no identifiable intervention or measurable outcome. They include networks, grant schemes, tools and support services, and were considered in the review through a separate process.

· A number of elements of work have also been identified for ‘wider consideration’, primarily as a result of a combination of funding where the majority has been supported through other departments or funding agencies. This includes work supporting workplace health from the Departments for Business Enterprise, Technology and Science, and other work supported from the UK Department of Work and Pensions.

· Substance misuse has not been looked at in detail and may require further analysis. This supports preventing crime, supporting substance misusers and their families, schools, education programmes and tackling availability and enforcement across Wales. The majority (£23m) is allocated as grants to local authorities.

· Feedback suggests that there is a need to map and ensure that other funding streams across wider policy areas such as Substance Misuse, Local Government and Communities (including Communities First, Mental Health, Education and skills and Leisure) are not duplicating work and that all opportunities for consolidation and collaboration are being maximised.

· Reviewing existing resources is an essential first stage. This has enabled us to identify gaps, duplication and opportunities for consolidation and collaboration that may exist, linked to the PBMA process.

· It is important to note that whilst this review has not directly taken account of the resources invested by Local Authorities impacting on health improvement through education, social services, leisure etc it recognises the significance of this and the need to work closely in improving health and wellbeing in our communities.

· It also helps us to consider wider comparative spend. The baseline spending estimate for Public Health England15 suggests that there is a considerable differential between allocations in England and Wales for health improvement.

8 Sub-group findings

Each of the sub-groups undertook detailed work to support their findings and this has been captured in supplementary reports available from www.publichealthwales.org/healthimprovementreview

A summary of the findings from each of these is captured below.

8.1 Evidence review sub-group findings

The work of this sub-group was to review readily available, high level evidence, relating to health improvement for each of the 10 public health strategic framework priority areas in Our Healthier Future. This included identifying approaches for which there was good quality research evidence of effectiveness or ineffectiveness, and those for which there was insufficient evidence of effectiveness on which to make a judgment. The extent to which effective, ineffective, or ‘evidence gap’ approaches were currently being implemented in Wales was assessed. Reports on these priority area evidence assessments can be found on the Health Improvement Review web pages. Thirty seven programmes were initially identified as being within the scope of the Health Improvement Review. Twenty five of these have an identifiable health improvement intervention which could be assessed against the evidence base. Separate evidence assessments were undertaken for these initiatives and these are also available from the website. This work was then made available to inform the health economic analysis (PBMA) component of the review. The remaining 12 initiatives have been considered separately.

A number of common themes were identified as part of this process which will need to be addressed in future planning:

· 4/25 initiatives had all of the elements in place you would expect i.e. clear mechanism of effect; clear outcomes; evidence of effect from outcome evaluation; evidence of effective implementation in a real world setting (all had room for improvement in terms of impact but the basic components were there).

· Approximately half lacked clearly defined outcomes.

· 3/25 did not clearly describe the mechanism by which they would impact on population health.

· 15/25 were not monitoring outcomes.

· 9/25 had no implementation evaluation/effectiveness.

· 6/25 had insufficient information to make a robust assessment.

A compilation of the full findings from the evidence reviews has been produced and is available for further information.

For population health, the benefits arise from widespread implementation and whilst each action or intervention may have a small effect, this becomes more significant with larger numbers. The evidence highlights the need to take account of the limited reach and impact of some of the interventions, such as MEND, as well as the potential for greater impact in others such as the National Exercise Referral Scheme (NERS) and the Welsh Network of Healthy Schools (WNHS).

Findings from the review suggest that the majority of Wales is partially implementing NICE guidance. There is no systematic implementation and monitoring of NICE or other evidence based recommendations in Wales. A summary of the health improvement interventions recommended by NICE which are being implemented in Wales and those that are not, is available in the full report. Where evidence exists to support health improvement interventions, we should ensure it is being implemented consistently across Wales as a priority.

For interventions with evidence of effectiveness currently being implemented in Wales, a number of programmes were identified where greater impact could be achieved through more systematic implementation, more robust monitoring and greater reach. Effective interventions not currently being implemented, with limited implementation or where no information was available, have also been identified. These relate to a range of issues including obesity, physical activity and smoking cessation and included telephone counselling, mass media interventions and programmes targeted at disadvantaged groups. These will need to be taken account of in future planning.

8.2 Health Economics and Programme Budgeting and Marginal Analysis (PBMA) sub-group findings

Ensuring we are getting the best returns for our investment is essential. To help us assess this we adopted a Programme Budgeting and Marginal Analysis (PBMA) approach2,16. PBMA provides a logical, transparent and auditable process for evidence based decision making and policy development and takes full account of the health economic issues alongside other important aspects such as the evidence, outcomes, stakeholder views and inequality, providing a systematic and holistic way of analysing a wide range of relevant information.

The approach taken for the Health Improvement Review was based upon the approach taken by Peter Brambleby and colleague2,16 and takes account of recent developments at the NHS Scotland Health Improvement Agency17. It helped to inform decisions on which programmes which may be suitable for further investment, disinvestment or continuation, as part of a process for refocusing and reviewing priorities.

A PBMA Expert Reference panel was established with representation from a range of stakeholders to assist with the assessment of the 25 initiatives for which individual summaries had been prepared. These contained evidence of effectiveness and cost effectiveness, budget, impact, equity implications, relevant partner organisations and stakeholder involvement.

Whilst this review looked specifically at the funds at the disposal of the Health Minister directly for health improvement, the need to undertake wider, higher level programme budgeting with related policy areas became evident. £17.1 million was identified, of which £15 million could be attributed directly to the 25 specific health improvement initiatives linked to ten Welsh Government priority areas and six life course stages.

There was some difficulty in disaggregating how this resource and its interventions married with other government programmes, such as Communities First and Flying Start and other mainstream services contributions such as education, social care etc. It highlighted the need to strengthen integrated planning across policy and programme areas to avoid duplication, gaps and ensure all resource is used to best effect. Evidence of effectiveness, cost-effectiveness and impact on inequalities were the most important criteria for judging current or future health improvement initiatives.

Current health improvement initiatives were primarily focused on individual level behaviour change interventions with limited evidence of effectiveness, or cost-effectiveness. In summary the PBMA concluded;

· There was recognition of the need to ensure a wider focus including other approaches such as environmental, social marketing, legislative and fiscal.

· The evidence basis for particular areas such as promoting breastfeeding, preventing smoking in pregnancy and limiting obesity in children was particularly disappointing. This suggested a need for pilot programmes.

· There was recognition of the potential effectiveness of brief interventions for lifestyle, particularly in mainstreaming these as part of health professional training and also in addressing multiple life style issues within a brief intervention model e.g. in primary care and community pharmacies.

· Need to make use of local assets and infrastructures such as schools, primary care, community pharmacies and leisure centres to get more out of initiatives such as the National Exercise Referral Scheme, reducing national and local administration costs and acknowledging that services facilities do not have to be free.

· Primary care as a vehicle for health improvement was important and further opportunities to strengthen this using existing levers and incentives within the system should be explored.

· There appear to be some initiatives that are not achieving their full potential. In the case of MEND, access and other issues were clearly identified as a problem and as a result the number attending was unlikely to make an impact at population level. Consideration should be given as to whether this initiative is more appropriately placed (and funded) as a treatment service rather than a health improvement initiative. Alternative options for population level impact such as building on the WNHS approach should be explored.

· The PBMA group recommend potential disinvestment in 7 out of 25 initiatives at a total cost of £1.5 million, (The Cooking Bus, Smoke Bugs, Skin Cancer Awareness, Health Challenge Wales Website, MEND, Mental Health First Aid and Smokers Helpline Wales). It was stressed that this was on the basis of a lack of evidence of effectiveness, cost-effectiveness or support from local public health teams, or any evidence of impact on inequality. It did not mean that the target stages of the life course e.g., primary school children, or the goal of limiting health harming behaviours or reducing obesity were less important than other goals. It suggests rather that such goals should be addressed in other, evidence based ways.

· The PBMA group also voted to recommend potential for partial disinvestment in further initiatives at a total cost of £7.3 million, including some big spend areas such as Designed to Smile and the National Exercise Referral Scheme. It is aware that initiatives such as Designed to Smile are ring fenced in the current government term, but recognised that oral health might be improved through other means with this budget of over £3 million representing a large proportion of the total health improvement budget under review.

· The PBMA group felt it important to treat pilot initiatives as pilots, ensuring that they incorporate rigorous evaluation. It also felt that there should be funds made available, through a wider research culture in Wales, to encourage research in public health.

· The PBMA process generated a list of interventions recommended by NICE that are not currently being delivered in Wales. The next step would be to generate evidence summaries for these, estimating what could be achieved.

8.3 Other services and initiatives

A series of services and initiatives were included within the Review scope, for which there were no clear single interventions which could be appraised through the PBMA process.

These initiatives were subject to a separate process, during which a panel collated and considered information regarding outcomes, reach, impact on health inequalities, value for money and sustainability. A series of recommendations have been made regarding future delivery of these services and initiatives. In many instances, it has been proposed that further work is undertaken as a result of wider factors which may impact directly on their future role. These include consultation on the proposed Public Health Bill18, the Public Health Development Directorate Transition Programme within Public Health Wales and other recommendations contained in this report e.g. future integrated approaches to communication and information for the public.

The services and initiatives can be broadly grouped under the following headings and a summary of the recommendations relating to each is included below.

8.3.1 Initiatives which represent core public health service activity but have previously been funded through a grant or other funding mechanisms

This group includes the Public Health Networks, Health Promotion Library, Early Years Pathfinder and Health Impact Assessment Unit. All of which are currently within Public Health Wales core funding and are similar to other public health service activities undertaken by Public Health Wales. It is proposed that the future of these functions are considered within the Public Health Wales Directorate of Public Health Development Transition Programme, which will also take account of the wider recommendations emerging from this review.

8.3.2 Small Grant Schemes to support health improvement action

This includes the Health Challenge Wales Voluntary Sector Grant and Well-being Activity Grant Schemes. Detailed reviews of each of the schemes funded within these initiatives were not possible due to the timescale of the review. Limited information was available on the activity or outcomes generated or the relationship between activity and strategic priorities.

It is understood that these are currently under review by the Welsh Government for the 2013/14 year. This review should consider closer linkage between what is funded and strategic priorities and action to support large scale change e.g. through innovative local approaches to the implementation of evidence based initiatives. It should also look at consider whether funding should be oriented towards activities that build capacity and assets for health rather than being used for ongoing service delivery. Close links to the proposed Public Health Outcomes Framework should also be made to ensure that funded activities contribute to achieving core outcomes.

8.3.3 Public health advocacy

This includes Alcohol Concern funding and may include elements of the Healthy Ageing Action Plan and the Mental Health, Vulnerable Groups and Offenders Programme although this was less clear. There is a case for providing core support to organisations which are able to provide independent advocacy for public health action in key areas. Welsh Government should review its current approach and commitments to these bodies, to ensure a consistency of approach and alignment to strategic priorities. A common framework for monitoring the outputs, outcomes and impact of these initiatives should also be developed.

8.3.4 Public health action plans for specific groups

This group include the Healthy Ageing Action Plan and the Mental Health, Vulnerable Groups and Offenders Programme. These initiatives include a range of actions, some of which may be appropriate for assessment using the process adopted for health improvement interventions within the review. However, this was not possible due to time constraints. It is important that these action plans sit within a broader strategic programme of work and are linked to the public health outcomes framework. Where interventions are included within the programme, these should be subject to an evidence review. There should be clarity regarding the overall programme co-ordination and where interventions and actions sit with the third sector, strong support and links should be made to specialist public health support from Public Health Wales.

8.4 Communication and engagement sub-group findings

A number of engagement and consultation events were held to ensure we collected the views of both the public and professionals. Workshops were held with Directors of Public Health and their teams, with local government representatives and Public Health Wales staff involved in health improvement. A series of eight engagement events for all stakeholders were also held in North and South Wales across the life course series. Beaufort Research was also commissioned to gather public views through a 1000 people survey and six representative focus groups covering a range of age and socio–economic groups and geography. The summary key points are set out below;

8.4.1 Local Public Health Teams

A structured discussion workshop was held with all Local Public Health Teams to help identify and collate their views and experiences of health improvement. All Local Public Health Teams reinforced the need to improve national and local working arrangements to support effective delivery of improved outcomes. Greater clarity was needed as to how Public Health Wales might best support this as part of a ‘whole team approach’. They also identified the need for ‘national’ initiatives to engage more effectively with local teams to ensure better delivery, avoid duplication and align and integrate complementary programmes to achieve better efficiency and effectiveness. There was a consensus on the need to maintain focus on health equity and inequality.

The Welsh Network of Healthy Schools programme was considered by all to be a good model to support the needs of schoolchildren at national and local levels. It was recognised however, that there were opportunities to build on local developments such as Schools Health Improvement Programme (SHIP) in Cardiff and the Vale and for linking more closely with the wider community and the schools health clinics developed in Betsi Cadwaladr University Health Board. Opportunities to develop and share good practice such as these were considered important.

The National Exercise Referral Scheme and Stop Smoking Wales were also thought to be valuable by four of the seven areas, whilst recognising there needed to be better links and flexibility in local areas. Initiatives felt to work ‘less well’ included the Cooking Bus and MEND.

Innovative developments mentioned included: Hywel Dda Health Board, Mind your Heart; Cardiff and Vale, Schools Health Improvement; Cwm Taf, Community Weight Management and Community Well Being Coaches; Aneurin Bevan, Community Health Champions; ABM, Obesity Management and Falls intervention; Powys, Schools Sexual Health Peer Support and BCU obesity management and School Nurse Health Clinics.

8.4.2 Local Government

Structured meetings were held with local government officers supporting local public health improvement across Wales and also through the National Environmental Health Officers meeting. Feedback indicated that the Welsh Network of Healthy Schools and National Exercise Referral Scheme were seen to be a good model and framework, but with further opportunities to improve and achieve more within current capacity. The Corporate Health Standard, Well Being Activity Grant and Healthy Options Award were amongst others mentioned. ASSIST appeared to have negative feedback from some schools, whilst MEND was considered to need better targeting, to be more easily accessible and flexible to include a school based model.

For local Government, Health Challenge Wales was thought to help provide a ‘national’ identity with the potential to adapt to each local authority area. The Health Challenge Wales grant scheme and awards were considered to help support local engagement and innovation. There remained confusion around the brands of Change for Life and Health Challenge Wales and a perception of lack of consistency of messages across professionals was identified.

Brief intervention training was felt to be good value for money in addressing key advice with NHS staff with potential for use across other sectors, particularly local government. Providing health champions in surgeries for example to help signpost, encourage and engage the public in healthy lifestyle activities was strongly supported.

There was a consensus on the need and urgency to strengthen links and maximise opportunities for health improvement across local government (see below) and between local authorities and health boards and public health, which appeared to have become weaker in recent years. There was a perception that some health boards were primarily interested in clinical issues and had less interest in wider health improvement.

There was a view that opportunities to engage with more disadvantaged groups through social services, education and housing were being missed. Issues of strategic ‘fit’, particularly around Communities First and local authority health improvement plans, were raised. There was concern around delivery support, with some health board teams acting in an advisory role only with insufficient capacity to deliver interventions.

The Single Community Plan19 offers an opportunity to align agendas and integrate priorities more closely to local needs. It was felt that this needed to be realised in practice.

The following outlines the range of services within local government that contribute to healthier lives and which offer further opportunities for greater collaboration and networking. These are usually the assets that more disadvantaged communities have and should be built on.

Services contributing to healthier lives and protecting the vulnerable

Improving health and wellbeing

· Healthy homes

· Housing renewal and improvement

· Air quality

· Education services

· Mobile library service

· Safe drinking water

· Provision of leisure and recreational facilities

· Access to the coast and countryside

· Regeneration programmes

Protecting and supporting vulnerable individuals

· Safeguarding and protection services

· Provision of residential care

· Supporting looked after children

· Fostering and adoption services

· Homelessness service

· Housing adaptations

· Behaviour support education

· Additional learning needs education

Empowering individuals and communities

· Promoting healthy lifestyles

· Community pride programme

· Youth offending services

· Family support services

· Provision of extra care housing

· Re-ablement services

· Meals at home

· Community care

· Entitlement and advice services

· Community First Programme

· Managing the night time economy

· Healthy schools programme

Protecting health and reducing inequalities

· Housing standards

· Consumer protection and advice

· Workplace safety

· Food safety

· Road safety

· Licensing services

· Disease control

· Abatement of statutory nuisances

· Cleansing and waste services

· Managing the built environment

· Beach safety

8.4.3 Third sector and wider stakeholders

There was recognition of the need to ensure full engagement and integration with the third sector and with people in local communities, building upon their skills, networks and knowledge. The eight workshops held across Wales focused upon three factors: health improvement needs, current services and support, and wider opportunities that existed across each of the life stages (early years, children and young people; working age adults, and older people).

Findings were specific to each life stage and detailed feedback is reported on the Health Improvement Review web pages. This will be used to inform future developments across each life course. In summary, the following common themes were identified;

· Needs – Access, including access to universal services, transport, leisure, education, training, communication and signposting, particularly on key messages, more integration in service delivery and the need to address social inclusion and inequity.

· Current Services – A wide range was available but not easy to navigate or access. The question of duplication was raised along with how services worked together to identify risk, engagement and integration opportunities. Services were still seen operating in silos with too little user engagement.

· Opportunities – Common themes emerged including better partnership working, sharing and adopting best practice, introducing schemes such as Making Every Contact count and using community assets more effectively. For example, utilising schools more as a community hubs, engaging with local communities and the use of social media and marketing.

8.4.4 Public views

Public views were also sought as part of the evidence gathering exercise. The methods included an online form (51 responses), a public survey (1000 respondents), six focus groups and six in-depth family interviews. During these sessions participants were also asked to design a smoking cessation service/healthy living service which would be right for them. A number of themes arose which apply across many of the initiatives and are detailed below.

On quitting smoking:

· Barriers identified included: the addictive nature of tobacco, lack of willpower, engrained behaviours, life incidents e.g. divorce.

· Varied motivations to quit included: deteriorating health, pressure/support from a family member, willpower, desire to quit.

· Awareness of support services included financial help towards buying nicotine replacement therapy and GP/pharmacy support.

Preferred approach to support when quitting smoking:

· Face-to-face, particularly with an ex-smoker.

· Local/community focus.

· Maintained support e.g. local support, through mobile apps, text messaging/reminders.

On helping children above a healthy weight:

· Awareness of good and bad food choices, but wariness of over-emphasising healthy eating in fear of upsetting children.

· Lack of exercise due to poor local facilities and costs of travel to sports clubs.

· Perceived cost of healthy food versus convenience food.

· After-school snacks, gaming consoles/internet use inertia an issue.

· Sometimes easier to give in to less healthy food.

· GPs perceived as unhelpful.

Preferred approach to supporting children above a healthy weight:

· Focus on younger children and better access to local facilities

· Schools to build advice into lessons and encourage pupils to bring ideas home

· Local support group with motivational ‘expert’ for individual support and group members for organising activities

· Focus on healthy lifestyle and fitness

A public survey of 1000 respondents, representative of the Welsh population, gave the following responses to questions about the awareness of the following programmes:

· 70% Stop Smoking Wales

· 65% Smokers’ Helpline Wales

· 42% Health Challenge Wales

· 31% National Exercise Referral Scheme

· 5% MEND

· 12% Cooking Bus

The overall conclusions from the public focused work are:

· Quantitatively, awareness of smoking initiatives high

· And significantly higher than for other, health related programmes tested

· Familiarity with smoking initiatives also relatively high

· Reasonably positive levels of reported action of some kind as a result

· Usage and impact falls away, the more involved the subsequent action (e.g. weekly groups)

· Quitting smoking: appears to be less prominent support with coping strategies, side effects

· Getting healthier: prospect of changing engrained behaviour vs current daily routines extremely challenging

· More acute with influences outside home

· Unlike smoking, no advertised products (NRT) to help change behaviour – and no obvious place to seek support

· Idea of existing support groups has some appeal – need to know more before deciding if could work for them

· Groups form basis for some suggestions for preferred initiative

· Community focus, ownership, responsibility may encourage some to take step and maintain behaviour change

· Professional involvement still required (advice, credibility) but personal experience may also be important

· Challenge remains how to involve some male partners, children in weight related initiatives - and avoid sense of stigma

· Inclusive, general wellbeing (‘getting fitter’) angle may be appropriate

· Education’s role may hold long-term key - with children’s behaviours around smoking, diet, and their influence at home

8.5 NHS sub-group findings

8.5.1 Maximising the role of the NHS in supporting health improvement

Together for Health6 sets out the challenge to ‘move away from managing sickness to creating a healthy Wales’. The NHS sub-group drew together a range of professionals and reviewed high level evidence to help identify how we can best maximise opportunities to improve health across the whole NHS, but focusing mainly on primary care as the first point of contact for most health issues. It recognised the need to create a world class NHS in Wales, fit for the future where prevention and early intervention should be its bedrock.

It suggested that health improvement should be more outcome-focused and holistic as silo projects addressing single issues such as alcohol and nutrition are likely to have a relatively low impact. A “topic” approach does not fit easily with the way that people engage with primary and community health care services and with the way they live their lives. There needs to be clear outcomes at higher levels, with devolved delivery at lower levels. Local teams should determine the mix of delivery methods best suited to their needs.

There is insufficient reorientation of resources within health services to enable the delivery of high impact, evidence-based health improvement. There is likely to be limited impact in programmes that focus on individual lifestyle behaviour change while there is a weak investment in other areas. There is a need to balance effective, specialist, evidence-based interventions with less specialist, effective interventions that may still have greater impact because of greater reach and accessibility.

Some interventions should be universal but there could be better targeting to address inequalities. Currently health visitors are the only health professionals that are trying to match workforce to need.

All staff have a role to play in supporting health improvement. Interventions such as Making Every Contact Count and brief interventions have been shown to be highly cost effective, as demonstrated by the Matrix Insight Report on Prioritising Investments into Preventive Health20. Brief interventions for smoking, alcohol and physical activity, delivered in GP practices, scored highly for reach, tackling inequalities and costs per Quality Adjusted Life Years (QALY). However, training in motivational interviewing and brief interventions has not reached the majority of GPs and frontline health workers in Wales. These interventions should be actively targeted to NHS staff with greatest population reach, supported by evaluation.

All four primary care contractor professions have considerable potential to impact on health behaviours and health literacy. The group have summarised the current delivery through GP, dental, pharmacy and optometry services and contracts, some of which remunerate health improvement activities, and reported on what could be done better and what barriers and opportunities exist.

This report provides evidence that mental health and lack of wellbeing is strongly linked with inequities in health and is often caused by a lack of money, the inability to participate meaningfully in society, and no sense of control. Interventions based in primary health care such as psychological therapies, debt counselling and return to work initiatives can improve health outcomes. Having a meaningful role (whether paid or not) is beneficial for health. GPs, in particular, have a central role, which many find uncomfortable, in certifying “fitness to work”.

Giving every child the best start in life will mean prioritising investment for interventions at the earliest life stage, including preconception. Primary health care professionals can increase the access to appropriate methods of contraception and support lifestyle changes such as smoking cessation, safe weight for pregnancy and safe use of alcohol. Closer integrated working, focused around families and between health visitors, GPs, midwives and other community workers is essential. Generic parenting support programmes for early years also improves lifestyle choices.

A single point of access for information and signposting to health improvement support could greatly increase reach and impact. This should be supported by a programme of education and awareness raising with monitoring and feedback. Various platforms could be used, such as websites, and phone apps to direct health professionals and the public to sources of local, up-to-date information. -

Much health improvement activity is not remunerated or incentivised but driven by self-motivated professional standards that could be better supported and more evidence-based. Financial incentives for health improvement interventions, such as those included in the Quality and Outcomes Framework, have a mixed evidence base and should not be the sole mechanism for encouraging health improvement through independent contractor contracts.

8.6 Health inequality

The Marmot Review21 recommends ‘proportional universalism’, providing services across society according to the needs of different population groups. This is exemplified in early years services in Wales, where every family receives health visiting services and the most vulnerable families receive an enhanced service under Flying Start.

An audit was carried out to help assess the equality focus of the health improvement initiatives included in the review and PBMA process. It found that some initiatives had a stated or implicit aim to reduce health inequalities/inequities (green), others without such a stated aim nonetheless had elements which could help to reduce the gap (amber), whilst some were universal initiatives where it was difficult to discern a potential positive impact on health inequalities (red). The categories reflect only what the initiative set out to do, rather than the degree of success in overall health improvement or in reducing health inequalities. The audit also did not consider the degree to which the initiative is functioning as described by the documentation and managerial contacts.

In summary, approximately one third of the initiatives were rated green, one third amber one third red. These ratings were included within the PBMA process and will need further consideration in future planning to reduce inequalities.

Further work will be needed to ensure that future investment/ reinvestment takes full account of equality impacts.

9 Key Emerging Themes

The work to date has identified a number of emerging key themes which underpin opportunities to improve the way we do things, ensure better health outcomes and value for money.

9.1 Communications

Communicating effectively with both professionals and the public is a core function underpinning health improvement. Ensuring that information is accessible, appropriate and easy to read is essential. The review has highlighted that this is not always the case and we do not maximise opportunities available to ensure this happens effectively and consistently.

Communicating information was the primary aim of a number of initiatives in the review (Health Challenge Wales website, Smokebugs, smoking resources, skin cancer awareness), while others (Stop Smoking Wales, the National Breastfeeding Programme) contain funding within them for public support materials. Stakeholders also recognised the need for easier access of information and greater consistency, particularly from health professionals.

The review concluded that initiatives such as Smokebugs do not appear to be effective in preventing smoking. The review findings suggest that information and messages focusing on key groups such as pregnant women should be developed and delivered to meet their needs. Opportunities to use resources to develop new ways of communication such as text messaging, apps or other IT interactive solutions, alongside a good website should be explored.

Public Health Wales provides a range of training and information support services for wider stakeholders, including health professionals and volunteers. Information and support is provided through services such as the library and five networks addressing sexual health, HIV, nutrition, physical activity and mental health. These should review how their work could be better aligned and integrated with core communication services, through consolidating websites, integrating service information and support to ensure efficient use of resources, and effective service delivery for wider stakeholders and the public.

‘Social marketing’ has an important role in communicating with the public and influencing health behaviours. It should be used alongside more traditional approaches as part of a co-ordinated package of interventions to affect change.

9.2 Research and evidence

The evidence review highlighted a number of generic issues relating to the availability, development and application of evidence. It clearly identifies a need for greater collaboration and partnership with academia to ensure we use expertise in research and evaluation to best effect and attract additional, external resources. There is also a need to ensure that national research policy supports this agenda as a priority. There is a clear need for research into health improvement interventions where the evidence gaps exist and developing solutions to Wales’ specific public health issues particularly using and building upon assets in communities. The review also demonstrated opportunities to improve how we collectively prioritise evidence needs, then share and apply the knowledge, at a local or national level, to best influence outcomes.

Available economic evidence has shown that the most public health interventions, considered by NICE, are a highly cost effective use of public funds. It also shows that changing peoples’ health related behaviour can have a major impact on some of the largest causes of mortality and morbidity.

NICE evidence is partially being applied in Wales which suggests there is potential for more systematic implementation and monitoring of NICE and other evidence based recommendations. A summary of the health improvement interventions recommended by NICE but not currently being implemented in Wales is available. Where evidence exists to support health improvement interventions we should ensure it is being implemented consistently across Wales as a priority.

The review group has highlighted a number of areas for further development to improve the way evidence is generated and used in practice across Wales. These include:

· More emphasis amongst the Welsh research community on developing solutions to Wales’ specific public health issues, not only on lifestyle interventions, but also interventions which focus on using and building upon assets in communities.

· Further work through the emerging Academic Collaboration to ensure that health improvement interventions are subject to rigorous outcome evaluation in addition to action research, implementation and process evaluations.

· The development and dissemination of standardised evaluation frameworks for health improvement interventions, where unavailable.

· An agreed process for the adoption and testing of innovative ideas and approaches, drawing on academic centres, that would enable good ideas to progress, gathering the necessary research evidence and ensuring there is a clear definition of ‘pilot’.

· Improved documentation and monitoring of interventions would enable future reviews and assessments of effectiveness to be conducted more readily.

· Discussion and agreement on what is understood by the term ‘evidence’ so that we can support health improvement development consistently.

9.3 Multifaceted and integrated approaches

A recent review22 (2012) by the Evidence Adoption Centre into the effectiveness of interventions targeting behaviour change, identifies the generic effectiveness of measures that are: from multiple sources; inter-agency; intense; aimed at multiple behaviours; individually tailored; followed up; supported by or otherwise involve family and social groups and characterised by feedback, advice and goal setting. This should be taken account of in future approaches used to support behaviour change.

To achieve large-scale changes to population health, a “bundle” of related, coordinated, preventative measures are needed, rather than one single intervention. These measures may include legislation, public information, policy, specific services, community action and embedding prevention in the work of other sectors. Implemented together they are likely to have a greater effect and future progress will be achieved by ensuring coordinated action is the norm.

Likewise, focusing on single health issues alone is less likely to address the holistic needs of individuals or maximise the opportunities for access and engagement. Addressing holistic needs within existing local services, alongside more specific targeted interventions, focusing on those in greatest need will be necessary.

This review identified a wide range of single interventions often acting independently and not necessarily linking with other initiatives or services in a planned or integrated way. In future we will need to ensure we plan interventions using different approaches, as well as develop more integrated models, to meet the changing needs of people as they grow older.

Focusing on people through a life course approach should help make this easier to plan and achieve. Opportunities exist to improve joint planning and links between policies, programmes, services and support, particularly across public services and the third sector. This also lends itself well to developing cross cutting policy approaches, and support at each life stage. This would help ensure that initiatives are developed within an appropriate strategic framework to ensure integration and, a coordinated programme of activity.

Public Health Wales provides a range of training and information support services for wider stakeholders. There is a need to review this for example, by consolidating the websites, integrating service information and support and developing core intervention training to cover more than one health behaviour etc.

9.4 Impact and outcomes

Some initiatives in the review did not clearly articulate how they were expected to deliver indirect or direct health outcomes, for example, through the use of logic models or a ‘Theory of Change’23. Often, evaluation focused on process and ‘perception of participants rather than on objective measures of impact or direct or indirect outcome indicators. In the case of the Cooking Bus, although children enjoyed the experience, the independent evaluation conducted pointed to a lack of outcome indicator monitoring and questions were raised by the PBMA expert reference panel regarding its reach, the value of targeting primary school children, as well as pursuing other opportunities within the school curriculum. There was consensus that this resource could be better targeted at more evidence based interventions to support healthy nutrition, weight management and physical activity as part of an integrated and targeted package.

Many of the initiatives reviewed did not have the appropriate reach necessary to change population level outcomes and were not sufficiently linked to other measures to maximise impact. While the Welsh Network of Healthy School Schemes reaches 99% of schools, services such as Stop Smoking Wales only reaches 3 – 4 % of smokers. Working with other sectors may help reach to be maximised.

Clarifying the expected outcomes at each life stage will help us monitor the impact of a variety of evidence based interventions acting together. An Outcomes Framework for health improvement activity will need to underpin this approach and will need to be agreed through discussion and dialogue aligned with action designed to achieve change at pace.

9.5 Efficiency and value for money

With the demands on health and social care systems increasing and with limited resources, there is an even greater need to ensure we are prioritising and targeting effectively. The case for embedding prevention and early intervention into the NHS and wider afield has never been stronger, if we are to achieve sustainable health and wellbeing and manage ever increasing spend.

It is estimated that obesity cost the NHS in Wales over £73 million in 2008/09. This increases to £86 million if overweight people are included. This equates to between £1.4 million and £1.65 million per week equivalent to £25 to £29 per person in Wales, representing between 1.3 and 1.5 per cent of total healthcare expenditure. Estimates for the annual costs to the NHS as a result of physical inactivity are between £1 billion and £1.8 billion. The costs of lost productivity to the wider economy have been estimated at around £5.5 billion from sickness absence and £1 billion from premature death of people of working age.

The NHS Confederation supports this in its publication ‘From Illness to Wellness’24 where it argues that investing in prevention is necessary for future sustainability. Butterfield et al25 recognised this, proposing that ‘the current 4% of NHS budget spend on prevention in England should at least be maintained to ensure that current levels of health in England do not worsen compared to other European countries’.

Wales spends a very small proportion of its NHS budget on health improvement. A recent document by Directors of Public Heath in England26 advocates an uplift of £1 billion (an additional £19 per head) in public health expenditure in England, equivalent to £57 million in Wales. The PBMA report also identified the case for further investment in health improvement.

Spreading funding too thinly across a range of areas is unlikely to be efficient or produce the desired impact. Doing less, but working better with others and achieving depth is likely to give the biggest returns on investment. The review has concluded that we should focus on a smaller number of ‘high impact level’ health improvement areas. Our Healthy Future suggests these should include smoking, obesity, nutrition, physical activity and alcohol. We also need to pioneer a new, more integrated approach, with a comprehensive portfolio of interventions and actions across a range of variables to achieve success. Tackling obesity in a comprehensive way is a priority because of its increasing trends and links with other lifestyle issues and should be addressed urgently.

The review identified how it can achieve better returns on its current investment in meeting these challenges. It has identified:

i) Initiatives primarily communicating information

Health Challenge Wales, Skin Cancer Awareness, smoking resources and others with a communication element should be consolidated, updated and considered within a wider Communications Action Plan

ii) Initiatives to be maintained and improved – Stop Smoking Wales, National Exercise Referral Scheme and the Welsh Network of Healthy School Schemes. It recognised their strengths and supports continued investment but also noted that larger-scale change could be achieved from these programmes, within their existing budgets, through embedded them in wider approaches to tackle population health.

iii) Initiatives to be monitored – There were a small number of programmes whose budgets were ring fenced (Designed to Smile), tied to a legislative process (Fresh Start), were newly introduced or pilots (Champions for Health, HIV Prevention and Empower to Chose) or were identified as having strengths (ASSIST and Baby Friendly Initiative - BFI). The time period for the delivery of each of these varied.

iv) ii) Initiatives for consideration– a range of initiatives presented mixed findings with both strengths and weaknesses and potential alternatives for delivery. These require further consideration within the wider context of proposals in this review. These included MEND, Mental Health First Aid, No Smoking Day and aspects of the breastfeeding programme.

v) ii) Initiatives for disinvestment – The review identified the Cooking Bus, Smokebugs and Smokers Helpline Wales as the strongest potential areas for disinvestment, although it was recognised that the Smokers Helpline telephone number would need to remain.

The PBMA approach provided a useful, systematic approach, drawing upon a wide range of evidence, to address investment and disinvestment decision making and should be built on in the future.

9.6 Building on what we have

There is a need for a guiding set of principles and unifying approach to underpin future work, building on existing policy frameworks and successful programmes. There appears to be a consensus around using a life-course approach, building on that taken in the Early Years Programme. This is important for three reasons: first, it brings into focus the accumulation of advantage and disadvantage over time; secondly, it enables a broader understanding of individuals and their changing needs at different stages of their lives; and third, it provides a framework for thinking about ‘critical periods’ during which different interventions can be targeted and access improved. This should build on a set of core principles such as sustainability, local assets and integration.

Using existing systems and services, and ensuring we are making the most of the resources we have at our disposal to improve health, is crucial. The NHS in Wales employs over 70,000 staff and each of them has the potential to improve their own health and act as health advocates, advising the people they come into contact with on key health improvement messages and signposting towards local services and support. To fully realise this potential we need to invest in training and support to staff across the NHS, as well as in other large organisations such as local government, building on the early developments delivered in Champions for Health, Every Contact Counts (Have a Word) and Brief Intervention training. This will need to be underpinned by robust evaluation. We should also further develop existing training programmes for alcohol and smoking to cover more than one health behaviour and roll this across Wales through the NHS, local government and third sector.

Further opportunities also exist to strengthen the public health impact within primary care, across all four contractor professions. Work is needed to progress this using the levers and incentives we have available to support this. Further opportunities to work with others and develop and test new models of primary care, such as the social enterprise models, will be important in ensuring we move away from ‘medical solutions’ to ones which fully integrate into the health and wellbeing of local communities.

9.7 Citizen centred approach and reducing inequality

Socio-economic position is directly linked to health, influencing people’s access to resources, power and control in relation to many aspects of their lives including behaviour21. The Welsh Government is committed to reducing inequalities across Wales as indicated in ‘Fairer Health Outcomes for All’5 and the ‘Welsh Poverty Strategy’27. However, recent evidence indicates that the inequality gap is increasing and greater effort is needed to redress this. Social and economic conditions can prevent people from changing their behaviour to improve their health and can also reinforce behaviours that damage it. We therefore need to focus on individuals, taking account of people’s varying needs and the circumstances within which they live.

To address health inequalities in Wales we need to find more effective ways to help people in lower socio-economic groups to reduce the number of unhealthy behaviours they have. The Kings Fund Report, Clustering of Unhealthy Behaviours28, identified that this is “only likely to work if a holistic approach is adopted that addresses lifestyles that encompass multiple unhealthy behaviours”. It identified the need for a more integrated approach to behaviour change, linking closely with inequality policy, and improving the health of the poorest as quickly as possible.

Currently the focus on inequality in health improvement varies, with uncertainty as to how this is best achieved across Wales. As this is a major priority, there is a need to see this embedded more consistently and systematically across all initiatives as part of the strategic approach to health improvement. We need to have a clear idea of what services and support should be provided for everyone. We also need to know where we should target resources specifically to meet the need of those at greatest need and specific circumstances, across each life stage.

Targeting proportionate to need is a key factor in addressing inequalities. Some services need to be targeted more specifically at those areas of greatest need or adapted to suit individual circumstances if we are to reduce inequalities and ensure effective and efficient use of resources. We also need to be mindful of other approaches and programmes outside of health aiming to achieve similar objectives and align work closely with them.

A citizen centred approach should take account of people’s varying needs and circumstances as an integral part of addressing the statutory dimensions of equality. Further work will be needed to ensure that future investment/ reinvestment takes full account of equality impacts.

9.8 Health Improvement: Maximising its potential

Health Improvement is key to the future sustainability of health and social care. We should reinforce effort and investment on health improvement, prevention and early intervention across the NHS, moving from an illness dominated service to a wellness service. Opportunities for further investment and increased capacity through working in partnership with others should be fully explored.

In this review we have investigated if we are making the most effective use of the resources currently available for health improvement and propose ways to address this in future. However, if we are serious about an approach to health improvement that takes social determinants into account, we cannot restrict our reviewing and analysis to the health sector alone. Many of the processes that limit health improvement are outside the scope of Public Health Wales and the NHS. We therefore also need to scope the wider potential of health improvement and preventative approaches in other sectors particularly Local Government and the third sector. These bodies provide services which are ideally placed to improve health, support people in self-care and in improving their own health and wellbeing.

We need to develop better models for cross-sector working to maximise this. For example, a joint focus on the needs of older people, in partnership with local government and the third sector.

In addition, there is a need to fully explore the economic case for further investment, including opportunities to work in partnership with others to support strong economic growth, promote a sustainable environment and attract additional resource to Wales.

10 Health Improvement: Fit for the future

High Risk Intervention

e.g. Teenage

pregnancyTargeted services and support e.g. looked after

children

Whole population –core servicesE.g. tailored, accessible ,information, and

lifestyle service

Surveillance & OutcomesIncreased need

This section of the report addresses how we should respond to the findings, emerging themes and challenges identified during the review. It sets out a new, exciting and progressive model for sustainable health improvement activity across Wales. The model is made up of the following core components:

· A strategic vision

· Guiding principles

· Core functions

· An overarching approach

10.1 Our vision

Having a clear vision of what we want to achieve in health improvement in Wales is important. The health challenges we face have been identified and the following provides us with a clear focus for this work:

To improve the health of all people in Wales and reduce health inequality ---- we need to ensure that children have a good start in life, reduce health inequalities, reduce or halt the increase in obesity, reduce smoking, alcohol or drug abuse so that more people can enjoy more active independent years with a high quality of life.

10.2 Our guiding principles

Throughout this review a number of common themes have emerged. These should be used as guiding principles to help guide future ways of working. These are consistent with current policy, reinforcing some elements, as well as identifying others which to date have not necessarily featured strongly.

It is suggested that the following key principles are adopted and applied across each selected intervention and age span in future work:

TRANSFORMING THE WAY WE WORK

From... To...

Professional led and top down

imposed services or support, not meeting needs, expensive and unsustainable

Assets based – using the skills and resources already available within communities and the individuals within them e.g. community volunteers trained to deliver community weight management programmes.

Universal services provided to all irrespective of need and often based upon demand with little or no differentiation

Proportionate to need – providing good core services for everyone with more focused and targeted support where most needed e.g. Flying Start, Communities First, targeting smoking in teen mothers.

Imposing solutions

and restricting choice often based upon the professionals’ needs or the systems in place, not the individual or community requirements

Helping people to make their own choices – supporting people to make their own health and wellbeing choices through community or individual-based interventions e.g. community engagement in planning and running services, youth mayor scheme/ community led stop smoking initiatives.

Short term and quick fix

unlikely to be effective or sustained and sometimes imposed on top of, or duplicating, some existing services or support opportunities

Long-lasting approaches – providing solutions for the long term by embedding support into exiting systems, services, organisations and amongst local people e.g. social enterprise / social capital models, National Exercise Referral Scheme.

Process focused - on ‘numbers t