prevention - why should you care?

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www.hertsdirect .org Prevention: Why should you care? Jim McManus, Director of Public Health, Hertfordshire County Council [email protected] Making partnerships a reality conference Hertfordshire 14 th November 2016

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www.hertsdirect.org

Prevention:Why should you care?

Jim McManus, Director of Public Health, Hertfordshire County [email protected]

Making partnerships a reality conferenceHertfordshire14th November 2016

www.hertfordshire.gov.uk

Context

• We can no longer afford to treat after adverse events

• System is creaking• We need to prevent, reverse or mitigate need

for services and poor health• Significant avoidable and preventable burden of

ill health and inequality

www.hertfordshire.gov.uk

This morning

• Introduce some structure and rationale• Develop a narrative

• For future we probably need some more in depth “can do” workshops

www.hertfordshire.gov.uk

1. 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

www.hertfordshire.gov.uk

2. 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

• Secondary Prevention – ‘reverse’ harm or need for service

• Tertiary Prevention – ‘reduce’ or mitigate harm/need for service

www.hertfordshire.gov.uk

2. Which level takes which length of time?Levels of Prevention

Short Timescale0-24 mths

Medium Timescale2-5 years

Longer Timescale

Over 5 years

Prevent/Stop harm or need

Reverse harm or need

Reduce/Mitigate harm of need

www.hertfordshire.gov.uk

3. Reducing the need and spend curve: Preventing avoidable spend, morbidity and mortality

Volume of spend

Severity

Existing curve

The Achievable curve?

Reduce or delay need here

Highest cost. Reduce and delayNeed here

Intervene here before needescalates

www.hertfordshire.gov.uk

4. Phasing prevention

• Identify those areas which will generate best returns (demand management or activity reduction) first and work on them

• Assess what you want to do and how you will deliver it• Assess feasibility including savings and benefits• Implement• Invest more in areas further down benefit curve as

benefits are generated

www.hertfordshire.gov.uk

5. Prioritising 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 demand

2. 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

www.hertfordshire.gov.uk

5. Cost BenefitsWhat

interventionCost-Benefit Time frame

for investment

Time frame for return

Return to HCC and

others

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6. Feasibility2 Steps – business case

•Likelihood of working – likely to need a minimum rating of 4 to be worthwhile proceeding. If score less than 4 need very clear model detailing risk of achieving outcomes

•Feasibility – minimum score of 40 to be worth proceeding

www.hertfordshire.gov.uk

6. Feasibility: Step 1 – Likelihood of Working

Select one score

Criterion (the more of these criteria a project meets, the stronger the case for acting)

Level of Promise/Priority

(i.e. the level of promise it could work or level of

priority we do for it)

Example What happens if this is missing?

1 Needs or issues which have significant cost to the system

Meeting this criterion is essential but not sufficient requirement for prevention programme 

Older people falling repeatedly

Cant continue

2 Issues which affect a definable population

Meeting this criterion is essential but not sufficient requirement for prevention programme

Older people who have had a fall more than once

Cant continue

3 A conceptual framework of the “system” is possible so intervention could be designed to alter the system or situation

Meeting this criterion is essential but not sufficient requirement for prevention programme

We can map and understand the circumstances of when and why and where people fall

Map the system

4 There is financial modelling of cost and alternative situations

If it meets the above criteria and this, it becomes a Promising candidate for prevention

There is data suggesting preventing falls can save money

Undertake some modelling based on system mapping

The more of these you meet, the greater the likelihood of working

www.hertfordshire.gov.uk

6. Feasibility: Step 1 – Likelihood of WorkingCriterion (the more of these criteria a project meets, the stronger the case for acting)

Level of Promise/Priority(i.e. the level of

promise it could work or level of priority we

do for it)

Example What happens if this is missing?

5 There is consensus of which elements of the system could have an intervention to prevent an occurrence and financial model of effectiveness

If it meets the above criteria and this, it becomes a Promising candidate for prevention

Professionals agree that dizziness and gait instability are high risk factors

Undertake some consensus work

6 There is a model of practice from elsewhere with financial assessment

If it meets the above criteria and this, it becomes a very Promising candidate for prevention

Other areas have pathways and models which show good outcomes saving cost to the system

Literature search

7 There is evidence of effectiveness from elsewhere that prevention works

If it meets the above criteria and this,it should be prioritised for delivery because it is evidence-based and effective

The “Blue Book” for falls has evidence of proven interventions for falls

Literature search, if no evidence, proceed to hypothesise and test through pilot

8 There is evidence of cost-effectiveness from elsewhere that prevention works

Candidates which meet all above criteria and this give the highest probability of delivering return and highest priority for prevention

There are studies which show cost return of preventing falls

Literature search, if no evidence but pilots, proceed to model and then undertake cost effectiveness analysis

The more of these you meet, the greater the likelihood of working

www.hertfordshire.gov.uk

6. Feasibility Criteria Step 2: Deliverability

VeryPromising

Promising Unlikely to becost effective

Effectiveness High (10) Medium (5) No impact (-5)

Flexibility Very Positive (10) Positive (5) Neutral (0)

Sustainability Positive (10) Positive (5) Negative (-5)

Political Feasibility High (10) Medium (5) Low (-5)

Administrative Feasibility

High (10) Medium (5) Low (-5)

Time Short (10) Medium (5) Long (-5)

Cost High (0) Medium (5) Low (10)

Return on investment High (10) Medium (5) Neutral (0)Negative (-5)

The more of these you meet, the better the likelihood of outcome

www.hertfordshire.gov.uk

Examples: what good could look likeCategory Primary Prevention

Work“stopping it happening”

Secondary Prevention Work

“stopping it getting worse”

Tertiary Prevention Work

“damage limitation”

 Social Care – Adults

Preventing adults with learning disabilities from needing social care interventions

Keeping adults who need services at highest level of functioning to have little need for services

Rehabilitating high need adults to moderate or low need

Social Care – Children

Every child gets supported to be resilient physically and psychologically

If problems are found, early intervention to return them to full developmental potential

Intensive support to gain best level of development possible

www.hertfordshire.gov.uk

Examples: what good could look likeCategory Primary Prevention

Work“stopping it happening”

Secondary Prevention Work

“stopping it getting worse”

Tertiary Prevention Work

“damage limitation”

 Environment Sustainable planning

and transport, safe roads and highways, sustainable waste

Behaviour change work with speeding driversEffective intervention to reduce risk at identified road accident hotspots

 

Economic Development

Ensuring everyone who wants to can be economically active according to ability

Ensuring people who are vulnerable and are out of work or workless are helped back into work

Supporting people with very complex needs into work

Fire Preventing fires, preventing anti-social behaviour, major role in preventing falls. Significant further potential

Addressing hot spots and returning them to normalityIdentifying vulnerable people at risk and signposting/ referring them to relevant services

 

Trading Standards Preventing harm to residents

Where harm occurs, reducing it as much as possible

 

Community Safety Preventing harm from crime and disorder which impacts on need for public services

Addressing areas which are worsening in order to reduce levels (eg drug interventions)

Addressing areas of worst cost to reduce them (EG Complex Adults)

Public Health(Examples)

Keeping people from developing avoidable diseases and cancers (smoking cessation, weight management)

Commissiong services for diseases which can worsen (eg sexual health services) or building self-management for long term conditions (with NHS)  

Re-enablement and rehabilitation for very seriously addicted and advising others on how to do this 

Providing public health skills and consultancy ( evidence review, needs assessment, evaluation etc), support and information which other functions use to design and deliver preventive initiatives

Providing advice, support and information which other functions use to design and deliver preventive initiatives

Providing advice, support and information which other functions use to design and deliver preventive initiatives

NHS Little real primary prevention going on beyond flu vaccine and some smoking and lose weight work and health checks (all commissioned by Public Health) 

High quality primary care ensuring prompt and effective treatment of people on long term conditions, avoids sending people to social care

Intensive support for people with high levels of need to restore them to best possible function (eg mental health recovery)

Skills and capabilities

There is a skills and methodological deficit for some people expected to deliver preventive working. Language, evidence base, methodology and evaluation frameworks are not common or sometimes missing. Confidence on raising and dealing effectively with preventative issues may be lacking for some staff. But there are pockets of real and substantial skill and commitment (e.g. social care for adults; some GP practices etc)

www.hertfordshire.gov.uk

Examples: what good could look likeCategory Primary Prevention

Work“stopping it happening”

Secondary Prevention Work

“stopping it getting worse”

Tertiary Prevention Work

“damage limitation”

 Environment Sustainable planning and

transport, safe roads and highways, sustainable waste

Behaviour change work with speeding driversEffective intervention to reduce risk at identified road accident hotspots

 

Economic Development Ensuring everyone who wants to can be economically active according to ability

Ensuring people who are vulnerable and are out of work or workless are helped back into work

Supporting people with very complex needs into work

Fire Preventing fires, preventing anti-social behaviour, major role in preventing falls. Significant further potential

Addressing hot spots and returning them to normalityIdentifying vulnerable people at risk and signposting/ referring them to relevant services

 

www.hertfordshire.gov.uk

Examples: what good could look likeCategory Primary Prevention Work

“stopping it happening”Secondary Prevention Work“stopping it getting worse”

Tertiary Prevention Work“damage limitation”

 Trading Standards Preventing harm to residents Where harm occurs, reducing

it as much as possible  

Community Safety Preventing harm from crime and disorder which impacts on need for public services

Addressing areas which are worsening in order to reduce levels (eg drug interventions)

Addressing areas of worst cost to reduce them (EG Complex Adults)

Public Health(Examples)

Keeping people from developing avoidable diseases and cancers (smoking cessation, weight management)

Commissiong services for diseases which can worsen (eg sexual health services) or building self-management for long term conditions (with NHS)  

Re-enablement and rehabilitation for very seriously addicted and advising others on how to do this 

Providing public health skills and consultancy ( evidence review, needs assessment, evaluation etc), support and information which other functions use to design and deliver preventive initiatives

Providing advice, support and information which other functions use to design and deliver preventive initiatives

Providing advice, support and information which other functions use to design and deliver preventive initiatives

www.hertfordshire.gov.uk

Critical Success Factors  Critical Success Factor

 Achievable

Not

Achievable x

1. Leadership & accountability for a programme approach  

   

2. practice that supports people to fully realise prevention/self management potential 

   

3. Prevention to be systematically written into contracts, service level agreements, and business plans 

   

4. Reshaping what we do in a planned and ordered way 

   

www.hertfordshire.gov.uk

Approach – scoping and saving

• Identify those areas which will generate best returns (demand management or activity reduction) first and work on them

• Continue primary prevention appropriately targetted as

• Invest more in primary prevention as benefits from secondary and tertiary are generated

www.hertfordshire.gov.uk

Modelling results (1)Ranking of Priority

Prevention Target Ranking from Modelling

Comments

A Achieving a 10% reduction in the number of ‘increasing risk’ drinkers.

Keep on Table Could achieve savings but would require investment

D Achieving a reduction in the incidence of avoidable AF-related strokes in all AF patients.

Park It Already being worked on

A Achieving a reduction in the risk of diabetes by 25% in 10% of non-diabetic adults in the general population.

Deliver Use NDPP funded programme

B Achieving a 10% reduction in the risk of diabetes-related complications in 10% of diabetic adults

Further discussion needed

 

B Achieving a reduction in blood pressure from above 140/90 mmHg to below this figure in 10% of hypertensive patients

Keep on the table  

       

www.hertfordshire.gov.uk

Modelling Results (2)Ranking of Priority

Prevention Target Ranking from Modelling

Comments

D Provision of school-based social and emotional learning programmes for all 10 year olds to prevent childhood conduct problems.

Park There is a general lack of confidence in the validity of the assumptions in the original source on which this model was based and a lack of clarity around delivery.  

C Improving access to physiotherapy for MSK patients in general practice by allowing self-referral.

Discuss further  

B Enrolling 10% of obese adults in evidence based weight management services

Keep on the table  

B Achieving a 10% reduction in the number of current smokers.

Keep on the table  

       

www.hertfordshire.gov.uk

2ndary/3ary Areas not yet modelledArea of Focus Suggested Initial

OutcomesCurrent Spend

COPD Reduce repeat admissions

Smoking in people with long term conditions

Reduce repeat consultations, prescribing and admissions

Falls Reduce admissions and prevent long term care need

CVD Monitoring through telehealth

Management of condition and reduce admissions

Minor Ailments in pharmacy

Reduce GP activity

Social Prescribing for Mental Health

Reduce MH caseload length

Recovery College MH Reduce intensive care

Social Prescribing for LTCs

Reduce GP repeat care and psychological

www.hertfordshire.gov.uk

2ndary/3ary Areas not yet modelledArea of Focus Suggested Initial

OutcomesCurrent Spend

Physical activity in long term conditions

improve self management and outcomes

Pre Diabetes Prevention Prevent people developing diabetes and needing specialist care

Early MH intervention and social prescribing

Prevent people needing specialist care

Alcohol A and E Reduce episodes and cost

Management of long term conditions in pharmacy

Reduce hospital and GP activity

www.hertfordshire.gov.uk

Areas for consideration not yet modelled

Ranking of Priority

Prevention Target Ranking from Modelling

Comments

  People with long term conditions developing further morbidities

  Needs to be scoped

  Falls      People with severe mental ill

health   

  Adults with learning disabilities developing preventable ill-health

   

  Mental ill-health prevention in working age adults

   

  Prevention of frailty and poor coping in older adults

   

www.hertfordshire.gov.uk

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

www.hertfordshire.gov.uk

Key dependencies• Modelling• Roles of other bits of the system – cant do prevention

without changing clinical behaviour and pathways• Understanding the impact of this work (i.e. does it

really prevent future need)• The articulation of a logic model for prevention• Understanding what action is needed• System being able to deliver it

www.hertfordshire.gov.uk

Next Steps

• Discuss and agree approach• Discuss and agree priorities• Establish workstreams• Really need a Prevention Summit