prevention - why should you care?
TRANSCRIPT
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Prevention:Why should you care?
Jim McManus, Director of Public Health, Hertfordshire County [email protected]
Making partnerships a reality conferenceHertfordshire14th November 2016
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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
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This morning
• Introduce some structure and rationale• Develop a narrative
• For future we probably need some more in depth “can do” workshops
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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