Stepping Hill and Victoria CCG Neighbourhood Meeting

Find and Treat

2

Hazel Grove & Offerton and Victoria Neighbourhood

Headline Profile

Summary

• Slide 2 shows geographical site • Slide 3 complexity between resident and

registered• HG and O: 37,384 residents (HSCIC)

32,906 registered with GPs in area • Victoria: 57,121 residents (HSCIC)

46,672 registered with GPs in area (HSCIC)

Most deprived quintile

Second most deprived quintile

Mid deprived quintile

Second least deprived quintile

Least deprived quintile

Hazel Grove & Offerton 4.8% 9.0% 33.1% 17.7% 35.4%Victoria 23.1% 35.4% 24.9% 13.8% 2.7%Stockport 12.3% 18.1% 20.0% 21.7% 27.8%

Deprivation profile of residents:

Summary Offerton and Hazel Grove Victoria

Disease register – above Stockport average

CHD/ COPD/ Diabetes/ CKD/ Mental Health

Virtually all

Screening and Imm Cancer Under 2 Imm5 yearsFlu 65+

Close to Stockport AverageSlightly lower than S.A. Slightly higher than S.A. Slightly lower than S.A.

V.Close to Skport averageSlightly lower/close to SASlightly lower/close to SAV.Close to Skport average

6

• Average life expectancy of residents O andHG :

• Lifestyles of adult residents:Neighbourhood Stockport

Smokers 14.6% 16.9%

Unhealthy drinkers 25.1% 26.1%

Low mental wellbeing 11.3% 12.2%

Obesity(underestimate as self reported)

17.4% 16.2%

Not physically active enough

73.6% 73.6%

Eat 5 a day 14.4% 17.9%

Neighbourhood Stockport

At birth At 65 At birth At 65

Males 81.4 years 20.5 years 79.9 years 19.4 yearsFemales 85.2 years 22.5 years 83.0 years 21.1 years

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• Average life expectancy of residents: Vitorai

• Lifestyles of adult residents:Neighbourhood Stockport

Smokers 23.2% 16.9%

Unhealthy drinkers 24.3% 26.1%

Low mental wellbeing 16.2% 12.2%

Obesity(underestimate as self reported)

19.7% 16.2%

Not physically active enough

71.1% 73.6%

Eat 5 a day 16.3% 17.9%

Neighbourhood Stockport

At birth At 65 At birth At 65

Males 77.5 years 18.0 years 79.9 years 19.4 yearsFemales 80.4 years 19.0 years 83.0 years 21.1 years

How are Public Health proposing to re model our

services to fit practices/neighbourhood

needs

What did you say you wanted from Public Health previously

Services

• Increased funding for Health Checks• Supporting patients with lifestyle changes / Health education for patients, families• Modifying health behaviour/using appropriate services• Drug and alcohol services• Identify isolated vulnerable/complex patients• Support of the formal and informal care in community of the complex patient• Patient contracts/agreement of own responsibility of care

• Promotion of prevention services e.g. falls prevention etc.

Staffing • Direct visibility with practices

Information • Feedback outcome data

Advertising campaign

Prevention & Empowerment in the MCPEarly intervention &

prevention

Healthier

Lifestyles

Improved population health

& wellbeing

Health Protection

Behaviour Change Support

Hea

lthie

r liv

ing

Infection Control

Immunisation Workforce

development for prevention

L1: Self Help resources

L5: Intensive support

L3: Extended BI

L2: Brief advice

L4: Lifestyle coaching

Healthier Communities

Champions for

health

Healthy Workplac

es

Community

Development

Healthy Hospital

TPA & WIN

Soc Prescribing

& well-being

Healthy Living

Pharmacies

Specialist Dietary &

WM

Physical activity Services

New Healthy Stockport Service

Drug & Alcohol Services

Voluntary & Mutual

support

Sexual Health

Services

Public Health Care Assistants

Screening

Services

Social Marketing

Stop before the OpKnow your

Numbers

GP PHES

Find & treat

Prevention in Every pathway

Drug & Alcohol Early Intervention

Pharmacies

Proactive

Care

Planned Care

Red text indicates key P&E areas for development / review

Clinical needs

GP/

pro

fess

iona

l ref

erra

l by

sing

le

num

ber/

refe

rral

tem

plat

e gi

ving

ac

cess

to a

ll se

rvic

es

Soci

al n

eeds

Cond

ition

m

anag

emen

t

Self-care support

App/web info &

support

Expert Patient

Programme

• How are Public health and the Neighbourhood going to work together ?

• Workforce development of practice HCAs around screening and immunisation ? Or neighbourhood Public Health HCA’s, health

trainers, behavioural coaches etc

• Health intelligence, support around identification, templates and call / recall – grant access to your data

• New Healthy Stockport offer – where should it be delivered/ one access point

• Community identification of new hypertensives / diabetes awareness/ risk

What do we mean by Find and Treat

Models are emerging of Find and Treat

1. Focus health checks on potentially high risk as well as never screened.

Model this to identify your priority patients (eg. using qdiabetes, qrisk, deprivation postcodes, mental

illness, men of working age)

2. Actively following up people with CVD and known risk e.g. smokers/ obese patients?

3. Embedding prevention in all pathways - MDT, medication reviews etc

Which of these models do you like?

How can you see these working in your practice? reminder flags/ templates etc ?

What is the value of doing these at neighbourhood rather than practice levels

Are there any other models?

What is your Neighbourhood Clinical Priority?