Hertfordshire and West Essex
Sustainability and Transformation Plan
A Healthier Future Prevention Summit for the STP footprint
7th February 2017
#HWEPrevSummit
Hertfordshire and West Essex
Sustainability and Transformation Plan
A Healthier Future Prevention Summit for the STP footprint
7th February 2017
STP ContextTom Cahill: STP Leader & Chief Executive, HPFT
STP National Aims
• Close the health and wellbeing gap• Drive transformation to close the care
and quality gap• Close the finance and efficiency gap
Hertfordshire and West Essex
Sustainability and Transformation Plan
ContextFinancial pressures • Current system spend is
approximately £3.1bn • Forecast deficit of £94m for 2016/17
rising to £401m (£552m Inc. Social Care) by 2020/21 if we don’t take action
Increasing demand• Population expected to increase by
over 10% from 2011 to 2021.• Number of over 85s expected to
increase by approximately 45% from 2011 to 2021
Pressure on the health and care system• Primary care capacity• Acute care performance and quality
challenges• Social care funding
National drivers• NHS Five Year Forward View• NHS Constitution commitments• National service strategies, e.g.
mental health, cancer and maternity
Hertfordshire and West Essex
Sustainability and Transformation Plan
Collaborative Commissioning Cameron Ward
Technology Katie Fisher
Estates and Infrastructure
Debbie Fielding
Communication and Engagement
Beverley Flowers
Workforce Jinjer Kandola
Health and Wellbeing Boards x 2
Stakeholders inc.Healthwatch x 2, Councils,
MPs, staff etc
Governance Structure Enabling Work
Streams
NHS Boards and Governing Bodies –via Chief Executives
NHS England
NHS Improvement
Back office consolidation Cameron Ward
Programme Board Chief Executive Leaders
Group
Prevention
Jim McManus
Mke Gogarty
Primary and Community Care
David Law Malcolm McCann
Acute Services Nick Carver Phil Morley
Finance and Activity Group
Alan Pond
Programme Management Office
(PMO)Clinical Reference
Group
Chairs Oversight Group
NHS Boards/GBs CC Members
Hertfordshire and West Essex
Sustainability and Transformation Plan
Hertfordshire and West Essex
Sustainability and Transformation Plan
A Healthier Future Prevention Summit for the STP footprint
7th February 2017
Prevention: Why, What, How?Prof Jim McManus, Director of Public Health, HCC
Data Analysis by Hertfordshire County Council Public Health Intelligence Team
For a copy of these slides please email
© Copyright, 2017 Hertfordshire County Council Public Health
Hertfordshire and West Essex
Sustainability and Transformation Plan
Why?• Too many people getting complex preventable illness and
disability• Too many variations in primary care quality and outcomes• Not enough focus on preventing ill-health happening or
worsening• National sickness service not health service• Unsustainable, unaffordable, undeliverable
• Over the next 20 years, the shape of the population will change
• By 2022, people aged 65+ (highlighted in orange) will represent a greater proportion of the overall population…
1
How the STP population will
age
• By 2027, this change will be more noticeable (note the widening of the lines at the top)…
1
How the STP population will
age
© Copyright, 2017 Hertfordshire County Council Public Health
• By 2037, the change will be much more dramatic
• There will be c.23,000 more residents aged 90+ across the STP footprint by 2037 than in 2017
1
How the STP population will
age
© Copyright, 2017 Hertfordshire County Council Public Health
Hertfordshire and West Essex
Sustainability and Transformation Plan
Multi-morbidity and service demand
• Local data analysis in Hertfordshire has shown older adults receiving what appears to be increasingly complex outpatient care
• Outpatients aged 80+ attended more appointments with more specialties in 2014/15 than in 2011/12 indicating the increased burden on local services is not driven by increasing resource user per patient, not only increasing patient numbers
• Findings suggested Hertfordshire a movement away from ‘generalist’ care of older adults towards involvement of multiple specialist teams and referrals occurring outside of primary care may be driving this trend
© Copyright, 2017 Hertfordshire County Council Public Health
Hertfordshire and West Essex
Sustainability and Transformation Plan
Falls injuries in older people
© Copyright, 2017 Hertfordshire County Council Public Health
Hertfordshire and West Essex
Sustainability and Transformation Plan
Variations in primary care: Atrial Fibrillation
© Copyright, 2017 Hertfordshire County Council Public Health
Hertfordshire and West Essex
Sustainability and Transformation Plan
Variations in primary care: Coronary Heart Disease
© Copyright, 2017 Hertfordshire County Council Public Health
Hertfordshire and West Essex
Sustainability and Transformation Plan
Variations in primary care: diabetes
© Copyright, 2017 Hertfordshire County Council Public Health
Hertfordshire and West Essex
Sustainability and Transformation Plan
Demand outpacing resource
• We can no longer afford to treat after adverse events
• System never designed for this level of need/demand
• We need to prevent, reverse or mitigate need for services
• Significant avoidable and preventable burden of ill health and inequality
© Copyright, 2017 Hertfordshire County Council Public Health
Hertfordshire and West Essex
Sustainability and Transformation Plan
What?• A population shift to prevention - mindset
• Primary• Secondary • Tertiary
• Everyone’s business • Mainstreaming
Hertfordshire and West Essex
Sustainability and Transformation Plan
What is Prevention?
• The avoidance, whether permanent or temporary, of need for public service or an adverse event/hazard or exposure leading to need for public service– SHORT TERM (eg up to 24 months)
– MEDIUM TERM (eg 2-5years)
– LONGER TERM (eg 5 years plus)
• Prevention is NOT rationing or restricting eligibility
© Copyright, 2017 Hertfordshire County Council Public Health
Hertfordshire and West Essex
Sustainability and Transformation Plan
Levels of Prevention• three levels. Preventative activities may be delivered by
any agency.
• Primary Prevention – ‘prevent’ or stop harm or need for service arising in first place – physical activity, recycling
• Secondary Prevention – ‘reverse’ harm or need for service – rehabilitation
• Tertiary Prevention – ‘reduce’ or mitigate harm/need for service – an Anti Social Behaviour Order? A wheelchair for a diabetic foot amputation
© Copyright, 2017 Hertfordshire County Council Public Health
Hertfordshire and West Essex
Sustainability and Transformation Plan
Immobility or lack of fitness?
• Much immobility due to ageing is preventable. Maintaining or losing strength to walk is an important predictor of other need for public service
© Copyright, 2017 Hertfordshire County Council Public Health
Hertfordshire and West Essex
Sustainability and Transformation Plan
Phasing and Layering• You don’t approach this like a blunderbuss
• Use scientific and business principles to identify what will have greatest impact in what timescale
• Phasing the interventions across time to produce results and yield
• Layering the interventions across populations to produce results and yield
• Still need to do primary prevention, but that’s long term
© Copyright, 2017 Hertfordshire County Council Public Health
Hertfordshire and West Essex
Sustainability and Transformation Plan
Reducing the need and spend curve: Preventing avoidable spend through phasing and layering
Volume of
spend
Severity of need
Existing curve
The Achievable
curve?
Reduce or delay need here
Highest cost.
Reduce and delay
Need here
Intervene here before need
escalates
Hertfordshire and West Essex
Sustainability and Transformation Plan
The Questions
• Where could we reduce need or demand for public service?
• What skills and strengths do we have that we could apply to this?
• We will be using Scenarios
© Copyright, 2017 Hertfordshire County Council Public Health
Hertfordshire and West Essex
Sustainability and Transformation Plan
Mainstreaming Prevention
Consider impact of everything
you do on prevention
Consider what you can do
individually and together
Herts & West Essex Governance Structure v4
Healthier Population
needing fewer specialist resources
Hertfordshire and West Essex
Sustainability and Transformation Plan
How?• Mindset• Establish clear priorities • Timescales – short, medium, longer term• Everyone’s business• Pathways• Redesign• Population Health Approach
Hertfordshire and West Essex
Sustainability and Transformation Plan
So what could be done?
• A culture of self-reliance
• A culture of nudging people to do right thing
• Redesign services to change system behaviour and people behaviour
• Diversion
– Can we create a culture where people deal with minor issues themselves
© Copyright, 2017 Hertfordshire County Council Public Health
Hertfordshire and West Essex
Sustainability and Transformation Plan
So what could be done? ExamplesLevels of Prevention
Crime and Disorder
Mental Health Cancer
Prevent/Stopharm or need
Reduce alcohol related injuries and violence
Reduce drug related crime
Prevent lost productivity by workplace ill-health
Routine physical activity for everyone to retain balance and mobility
Reverse harm or need
Physical activity for rehabilitation
Reduce/Mitigateharm of need
Cheaperalternatives? (social groups for lonelines)
Hertfordshire and West Essex
Sustainability and Transformation Plan
What can the science do
• Science of behaviour change
– Behaviour insights “nudge” on council tax payment and recycling behaviour
– Behaviour change backed
• Much better clinician push on prevention, self care and responsibility
Quick wins in the system - 1
• Drug testing on arrest and early referral in
• Using “behavioural insights” on council tax notices and letters and on recycling
• Leisure centres and services
• Early intervention to prevent slips, trips and falls
• Using “behavioural insights” in recycling
Hertfordshire and West Essex
Sustainability and Transformation Plan
Quick wins in the system - 2• Night time economy work on alcohol with retailers
• Routine, universal, physical activity
• Physical activity and social contact for people isolated
• Behavioural contracts with offenders
• Mental Health First Aid
• Getting people temporarily sick back into work
• Getting people with one long term condition doing physical activity
Hertfordshire and West Essex
Sustainability and Transformation Plan
Just suppose
• An army of signposters who as part of their day job signposted you to the lowest level of place which could meet your need
• We already have 1,300 mental health first aiders in employers – the UK’s largest number. What more can we do
Hertfordshire and West Essex
Sustainability and Transformation Plan
A good employer• Positive psychosocial workplace – the seven tips
for employers helps keep people at work
• Healthy workplace – simple things to keep people healthier longer
• Enable carers – help keep carers able to care
• Make it easier to get back to work
Hertfordshire and West Essex
Sustainability and Transformation PlanPrioritising Prevention – the Decision Cycle
What population?
What issue/need?
What outcomes do we want?
Which interventions fit best?
How do we know it’s working?
(Evaluation)
1. Service cost and demand2. Needs (JSNA)
Define the outcomes clearly so you can really assess feasibility
1. Financial Assessment2. Evidence Assessment
3. Logic mode where evidence silent
1. Financial Assessment2. Outcome Assessment
Questions to ask Tools for HCC
Hertfordshire and West Essex
Sustainability and Transformation Plan
Desired Outcome
• An appropriate prevention plan which models savings achievable from prevention
• A plan underpinned by evidence and a logic model
• Clear articulation of who needs to deliver what to achieve it
• System wide expectations
Hertfordshire and West Essex
Sustainability and Transformation Plan
Mainstreaming Prevention
Consider impact of everything
you do on prevention
Consider what you can do
individually and together
Herts & West Essex Governance Structure v4
Healthier Population
needing fewer specialist resources
An online meeting tool Acts like an electronic flip chart Allows anonymous and simultaneous input
Nominate a scribe for your table Capture your thoughts and ideas as you work
through the three scenarios
https://eu10.meetingsphere.com/87914295/stpprevention
Feedback
• The next slides contain a summary of the most often raised themes or issues in your groups
• And one issue to unpick from each scenario
Key Themes from : Lifestyle (171 comments)
1. Workplace / Employer’s role
2. School etc roles
3. physical activity
4. Signposting to local opportunities
5. Doing stuff at low cost
Social prescribing definition
• A means of referring patients with a range of social and emotional needs to non clinical services often provided by community and voluntary sectors…
One to unpick from what you said…
• In lifestyle scenario
“what can our workplace do as employers ourselves – poor work environment, under lots of pressure, not access to healthy food and water….need to start with our own workforce first as a NHS.”
• Develop a programme which fits around our environment and workforce, to keep us healthy, perhaps run a yoga class before start of working day. Water, food….
• Each of the NHS organisations have a health and wellbeing programme for staff in place this year and next and people could link into this
• A much more inclusive and coherent programme around employers would be a big ticket issue for me speaking from an Essex perspective – bidding to SportEngland etc and getting some resource in for this work. Something compelling and coherent around public sector could really touch lives of many. Do something bold and coherent about that
Key Themes from: Community(109 comments)
1. More social prescribing and get it working and known about1. Get Linda volunteering/learning2. Social Media, library facilities, technology
1. What vehicles of info do people trust/use?
2. Identifying and targeting 1. Soft intelligence
3. Housing sector potential1. Across spectrum of need – state of house/energy
efficiency
One to unpick from what you said…
• In community scenario
“How on earth do we know she’s there? Who’s radar is she on? Relying on old fashioned values of family and community here otherwise a helpless task. Need to be able to reach her children”
• We think there are lots of lindas out there in the community and from description our first question was how do we know she is there so someone can knock on door and start a dialogue? We thought she represented large proportion of communities
• Who is going to do this? Who is going to see it as their responsibility? Nobody knows there is a problem. Hard to see how this very vulnerable lady is going to be helped. Can GPs find a way of following up people who are vulnerable who haven’t been in touch
• Also very much about the mechanics that if you identified her, where do you go next? Who and how do you make a referral to? If shopkeeper had some information to put in her basket, for example? What can we do about a soft intervention which signposts them in right direction. Then the situation where youre concerned with someone’s wellbeing but too bloody British to do something about it.
• Trawling electricity or utility information to identify people• Database of voluntary agencies across the patch?• Social marketing and messaging for each scenario• Be careful we provide people with information rather than start creating services for them• Use local elected members more! • A project to identify people using existing information
Key Themes from : Multimorbid(135 comments)
1. Everyone who sees Pamela/Bob needs skills to help them manage
2. Preparing people in 40s for life in 70s-90s
3. More stuff out of hospital (eg pharmacy)
4. Assistive technology and social prescribing
5. Lifestyle – weight, smoking, etc
One to unpick from what you said…
• In multimorbid scenario
“all three scenarios have attracted the comments that we’d have hoped that they’ve been “referred”….what does this mean then? We need to know what is going on, where and how to connect the dots and enable health and social care services to connect properly..”
• We would hope someone somewhere in system would refer people on. Do people even know who and where to refer to? Enabling people to make referrals whether it be social prescribing or offers from districts?
• We’re in danger of making this the public sector’s role not individuals…need to keep a focus on how we make it easier for people to help themselves. Referrals often mean cost
• Putting people in touch with opportunities already out there in community…..making sure people DO get in touch. Not just signposting
Discussion
• Intelligence, targeting, date
• Workplace
• Social Marketing
– Knowing what’s out there and then getting people into them
• Social Norms
If everyone did just one thing….
As we close…
• Report from MeetingSphere will be analysed and sent with slides
• If you want a workshop for your agency let us know – there will be link with mailing
• Work this into prevention plan for STP• Feed your views on engaging you into STP leaders• Welcome your ideas and suggestions• Clear theme on social marketing emerging from
today• Evaluation form coming electronically
Hertfordshire and West Essex
Sustainability and Transformation Plan
Thank You!Remember if you want a prevention workshop for your
agency/group of agencies contact [email protected]
#HWEPrevSummit