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System wide action on prevention:Towards a strategy
Prevention Group
Health and Wellbeing Board Development Day 30 April
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Outcomes we’d like from today
1. Agreement to do prevention together AS A SYSTEM
2. A lead senior person from each partner3. A gap analysis on prevention from each
partner4. From gap analyses produce a strategy5. A steer on governance of this from HWBB
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The big win
“The NHS needs a radical upgrade in prevention if it is to be sustainable”
5 year Forward View 2014
Current Herts positionWe are doing prevention, but lots of variation, not
systematic and lots of gapsWe could get more if we do it smarter
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Problem you asked us to look at
• Significant escalating and avoidable spend across system
• Some efforts at preventing and reducing this• Growth of avoidable cost to system and
avoidable health problems• Growth of multimorbid health conditions• System wide problem, little system wide
preventive pathways
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What do we mean by prevention?Primary Prevention – ‘prevent’ harm •Example: promoting health and active lifestyles
Secondary Prevention – ‘reverse’ harm•Example: early detection and effective self management of diabetes
Tertiary Prevention – ‘reduce’ harm•Example: COPD + early stage heart failure + depression
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What Prevention are we doing• Primary – increasing and needs to be done but is a
very slow upstream burn• Secondary – we really need to do much more here to
prevent a 3-5 year cost curve increase• Tertiary – Could have high impact within twelve
months. We need to do more. Primary prevention alone, and tertiary prevention alone
not the answer. Target all three for maximum impact
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Case study – Martha 69• COPD• Diabetes• Early stage heart failure • Smokes
Tertiary PreventionWhich bit of the system could do what for her?
What do we need to do better?
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Case Study – Joe, 58
• Stroke• Poorly controlled blood pressure• Coping poor
How do we prevent escalation? (secondary prevention)
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Case Study – Joanne 39
• Very overweight• Inactive• Smokes• Single parent• Stressed• Manual work• Depressed• Always asking for prescriptions
How do we stop this becoming a major cost to the system?
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The Strategy1. Reduce cost to the system by implementing high impact actions
system wide to prevent worsening of health and management of cost
2. Improve quality of life by including clinical + lifestyle + behavioural components
3. Make more use of services in the community including pharmacy4. Develop preventive pathways 5. Work across primary, secondary and tertiary prevention to
deliver this in tandem6. Start with areas which will have highest impact
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Some early estimates
• Musculoskeletal health costs us• Obesity costs us • Poor management of long term conditions costs
us – including physical and mental health• Multimorbidity costs us – 16% of NHS spend on
2% most complex patients
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Multimorbidity – evidence • Definition - presence of two or more disorders• 42% patients 1+ morbidities and 23% were multimorbid• Prevalence increased with age and present in most 65
+ • BUT absolute number of people with multimorbidity
higher in those younger than 65 years • Onset of multimorbidity occurred 10–15 years earlier in
people living in the most deprived areas • Presence of a mental health disorder increased as the
number of physical morbidities increased and was much greater in more deprived people
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Multimorbidity – implications for practice?
• Is the single-disease framework fit for purpose?– individual long term condition (LTC) services can be
duplicative and inefficient, and burdensome for patients due to poor coordination and integration
• Is mental health a core component of LTC pathways?
• Need to support generalist clinicians to provide personalised continuity of care, especially in deprived areas
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Example from the Commissioning for Value CVD pathway• HVCCG
– Hypertension ratio (-7.1 % lower) opportunity for 5,828 people
– % anti-coagulation drug therapy for those with stroke risk >1 (using CHADS2 score) (-9.2 % lower) opportunity for 361 people
– E&NHCCG– % stroke patients blood pressure <150/90 (-2.6
% lower) opportunity for 200 people– % stroke patients record of cholesterol (-4.6 %
lower) opportunity for 347 people
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Pharmacy• We are not using pharmacy effectively• High impact actions (Year 1 and 2)
– More uptake of medicine use reviews & new medicine service
– More use of pharmacy based support for self management in long term conditions
– Minor ailments schemes– Healthy Living pharmacies in areas of highest need
• Develop further programmes in years 3 onwards
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The avoidable spend areas in the physical health system, with poor health/quality of life
Multi morbidRepeat admissionComplex care
Existing diseaseManaged sub-optimally
Sudden onset of acuteAvoidable events eg stroke
Volume of spend
Severity
Existing curve
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Key actions to reduce this PH spend curve Clinical + Lifestyle + Behavioural
Case managementSelf management
Optimal assertiveManagement of existing disease(lifestyle + pharmacological)
Optimal management of highRisk patients;
Volume of spend
Severity
Existing curve
The Achievable
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The avoidable spend areas in the mental health system, with poor health/quality of life
Crisis pathwaysAnd repeat Admissions, dualdiagnoses
People with long term mental ill healthWhose physical health deteriorates due toSub-optimal management
Prescribing practice whereIAPT or CBT could resolve issues
Volume of spend
Severity of condition
Existing curve
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Key actions to reduce this MH spend curve Clinical + Lifestyle + Behavioural
Recovery focusedcare
Channel shift: Greater use of online and community groups; less prescribing
Optimum physical health(eg quitting smoking reduces cost to MH services)
Volume of spend
Severity
Existing curve
The Achievable
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The Actions
• We’ve suggested the strategy• What follows are the actions
Main message:We need to reduce variation across the
healthcare system for these high impact actions
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High Impact Actions by Partner 1Who Primary Secondary Tertiary
Primary Care
NHS Health Checks
Making Every Contact Counts (MECC)
- Joint British Society recommendations for prevention of CVD (JBS3) - Blood pressure
- Weight - Alcohol
- Diabetes – eight care processes - Improved access to IAPT services - Early identification of atrial fibrillation and anticoagulation therapy
Self-Management
Optimise referrals to Pulmonary / Cardiac rehabilitation
Pharmacy Purple – contractualRed – requires fundingGreen – may need financial support
Healthy Living Pharmacies
Public Health (PH) Pathway into PH Services
Minor ailments with pharmacy
Medicine Use Reviews / New Medicines Service
Healthy Lifestyle AdviceHome MURs
(Bright Ideas Project)
LTC Pathways
Repeat dispensingExpansion of PH services – smoking, alcohol IBA, sexual health
Minor ailments
Healthy Living Pharmacies
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High Impact Actions by Partner 2Partner
Primary Secondary Tertiary
HCS Promote a healthy workforce
Making Every Contact Counts & brief interventions
Re-ablement
Public Health Continue to commission services
Use expertise to support prevention strategy
Enhance healthcare and social care public health offer
Use expertise to support prevention strategy
PH Pathway into PH Services
PH Pathway into PH Services
Community Wellbeing Services
Prevention Strategy for Older People
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High Impact Actions by Partner 3Partner
Primary Secondary Tertiary
HCT
Promote a healthy workforce
Implement NICE guidance -Smoking cessation in secondary care: acute, maternity and mental health services (PH48)
Brief Interventions /MECCAlignment of physical health and mental health / psychological support pathways
Acute Promote a healthy workforce
Implement NICE guidance -Smoking cessation in secondary care: acute, maternity and mental health services (PH48)
Brief Interventions /MECC
Referral pathways to community prevention services
Rehabilitation
Reduce variations in length of stay
Optimise Pulmonary / Cardiac Rehab Pathways
PH Pathway into PH Services
PH Pathway into PH Services
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High Impact Actions by Partner 4Partner
Primary Secondary Tertiary
Voluntary Sector Making Every Contact Count
Deliver resilience and psychosocial support
Programme delivery providers
Programme delivery providers
HPFT Promote a healthy workforce
Implement NICE guidance -Smoking cessation in secondary care: acute, maternity and mental health services (PH48)
MECC
Robust physical health pathways for patients with serious mental illness (SMI) and dementia
Recovery services
PH Pathway into PH Services
PH Pathway into PH Services
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High Impact Actions by Partner 5
Partner
Primary Secondary Tertiary
Childrens
Ensure universal public health offer aligns well with children's services
Schools mental health and wellbeing
School health
Ensure early intervention takes holistic approach
PH Pathway into PH Services
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Two things now...
How do we govern this?
• How do we make it happen system wide?
• Which fora do we use?• Who leads?• Resource – within existing
resources but some investment in programme capacity and look at prioritising?
Agreements we’d like today
1. Agreement to do prevention together AS A SYSTEM
2. A lead senior person from each partner
3. A gap analysis on prevention from each partner
4. From gap analyses produce a strategy for HWBB
