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www.hertsdirect.org
Progressing Prevention Together
3rd November 2015
Presentation for PH/HV CCG Exec to Exec Meeting
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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 SOME prevention, but lots of variation, not systematic and lots of gapsWe could get more if we do it smarter
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Ultimate aims: scaling up prevention
• To ensure better communication over prevention plans & opportunities
– Realising potential of strategic shift to prevention– Drawing on pathways out of primary care– Embedded within Your Care, Your Future
• To develop closer working on prevention – leading to better prevention programmes– full contribution from all key parties
• To consider opportunities for co-commissioning– Including follow up of successful prototypes/pilots
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Where this fits: strategic shift to prevention
• The Health & Wellbeing Board has endorsed the need for a strategic shift to prevention
• Quick shared wins– Promotion of physical activity linked to
primary care (treatment & prevention)– Pathways out of NHS Health Checks– Self management for long term conditions– Prevention strategy for older people
But not enough to meet shared financial challenges
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Recap from Health and Wellbeing Board
1. Agreement to do prevention together AS A SYSTEM
2. A lead senior person from each partner3. A gap analysis on prevention from each
partner 4. From gap analyses produce a strategy5. A steer on governance of this from HWBB
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Problems we share
• Significant escalating and avoidable spend across system
– Primary Care Variation– Exacerbation of disease– avoidable disability– Multimorbidity– Risks for Circulatory Diseases and Cancers
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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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The Strategy HWBB wanted us to adopt1. 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 pharmacy
4. 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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Early big wins• Musculoskeletal health • Obesity • 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 • Avoidable disability• Variation in primary care with people with
established disease
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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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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 curveThe 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 curveThe Achievable
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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 3
Partner
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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Where this fits: Your Care, Your Future• The future model of care will support a shift
away from a medical model of care. – Empowering people to take care of their own
physical and mental wellbeing, through education and awareness, to stay well and prevent ill health.
– Ensuring we can live within our means. – If people need to access services, pathways
should be easy to understand and navigate. – Services should feel seamless and the focus of
health & care professionals should be to prevent escalation into more acute levels of care.
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Recap from Health and Wellbeing Board
1. Agreement to do prevention together AS A SYSTEM
2. A lead senior person from each partner3. A gap analysis on prevention from each
partner 4. From gap analyses produce a strategy5. A steer on governance of this from HWBB
www.hertsdirect.org
Principles • We all committed to driving progress on prevention; let’s gain collective benefits
– Promote our “products”/initiatives– Help us link the NHS to them effectively
• Ask, Assess, Advise, Assist/Signpost
– Identify key local gaps/opportunities– Amplify communications/campaigns– Enable appropriate clinical input– Proportionate input into key meetings/groups– Drive progress through our organisations– Co-commission proven programmes to
enable delivery at scale
