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www.hertsdirect.org
Ten Minutes...on system leadership and public health
Workshop for elected members
Jim McManusDirector of Public [email protected]
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Some of what we do for Hertfordshire • 142 workstreams ranging from health protection to health
improvement• 40 staff on commissioning and technical/specialist side• £52m budget reducing to £46m• 35,000 hours of school nursing a year• 8000 hours of health visiting a week• 60,000 people using sexual health services • 15,000 children weight measured every year• 96% of children get hearing and eye screening• Immunising children and young people
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Protection
• Medical examiners for new death certification• Infectious Disease Outbreaks• Assurance on vaccs, imms, screening• Advice – contaminants and environment • Statutory consultee • Mentally disordered offenders• Child Death Overview Panel
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But• This is not the whole story• What would we do if someone else commissioned all this?• How do we make use of core PH services to impact on the
rest of the system?• How do we use core PH Skills to impact on the rest of the
system?– Equity, service redesign,
• What is the role of each bit of the system on Public Health?
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The 3 Domains of Public Health
Health Improvement
Health Protection
Service QualityThis area much underutilised by commissioner across the system
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We have built a culture where being healthy is not the default option for many
Only acting as a system will turn it round
And it will take phases of work across time, and work at different levels
If focusing on individuals really worked that well, why are we still in this mess?
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The History, and the Future..waves of Public Health
Adapted from Davies et al, 2014 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62341-7/abstract
Infectious Diseases
Lifestyle Diseases
CulturallyReinforced Diseases
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Big Ticket Issues
• Systematic approach to prevention• Systematic approach to health inequalities• Systematic approach to making systems better
at keeping people at optimum wellness• Cultural and social norms reinforcing that• Making health the default and easy option
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Can elected members think system in all they do on health? If not, we won’t reverse the wave of avoidable disability and disease
Smoking 10%
Diet/Exercise 10%
Alcohol use 5%Poor sexual health
5%
Health Behaviours 30%
Education 10%Employment
10%Income 10%
Family/Social Support 5%Community Safety 5%
Socioeconomic Factors 40%
Access to care 10%
Quality of care 10%
Clinical Care 20%
Environmental Quality 5%
Built Environment 5%
Built Environment 10%
Source: Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute. Used in US to rank counties by health status
While this is from a US context it does have significant resonance with UK Evidence, though I would want to increase the contribution of housing to health outcomes from a UK perspective.
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Ambitions• Protect and promote the health of the population• Look across the system and get the system to improve
health• Think Systems• Think 4 Es
– Economy– Effectiveness– Efficiency– EQUITY
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The System in EnglandNational LeadershipEvidence, Local centres ,health protectionImunisation and screeningDental PH
JSNA, Evidence, Advice esp CCGsCommissions pile of stuff (eg school nurses)Sits on HWBB
Vital to public health: communicable diseaseFood safety, range of EH Services
Counties andUnitaries
Unitaries and Districts
Counties andUnitaries
Trading Standards (esp tobacco control and public safety)
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A man called Wanless
• Worksheet in front of you we will be using later
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We cannot afford to be where we are anymore.
All the primary prevention in the world will not be the answer..need 2ndary and 3ary too. Especially system improvement
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System Leadership when the system is in crisis – need to speak in one voice not four
Authoritative(the law, policy)
Formal(what policy wonks and thought
leaders say)“Prevention core to future of NHS” “How will we get there, what’s
happening, big buzz word....”
Professed (what we say we do)
Operant (what we actually do)
“We believe in prevention and co-production”
“Here’s our plan. 97% of money stays where it is We’ll take comments by tomorrow.”
The Four Voices of Commissioning and Policy
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The voice we need
• The system despite valiant efforts from many needs to be re thought. We have short term, medium term and long term challenges.
• Let’s agree what they are and then agree how we get there
• Elected members need to push this discussion right across the system
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The avoidable spend areas in the 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 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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That evidence question again...when the desire for evidence is an attempt to ward off more work....
The question1. What evidence have you
got?2. What ROI have you got?3. Have you done a Health
Impact Assessment?4. What specific evidence
have you got?
What they mean1. What have you read that
I haven’t? (AoMRC report)
2. That’ll fox you...3. We never have, I’d love
to know what one looks like
4. Ok, you’ve done your homework but I’m still resistant...
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Building a public health mindset.
What population?
What issue/need?(Needs Assessment)
What outcomes do we want?
(Strategy)What interventions fit
best?(Prioritising,
Planning)How do we know it’s working?(Evaluation)
Where are we? Intelligence,
JSNA
Where do we want to be?
How do we get there?
Are we there yet?
