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People Centred Public HealthOpportunities for Community Agencies in a Strategic Shift to Prevention

Jim McManus

Director of Public Health

Sept 27th 2013

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What we want to get to

• Articulate what people centred public health means

• Explain the context• Explain what agencies can do• Suggest some models

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Healthier Herts: A Public Health Strategy for HertfordshireConsultation Draft

OUR PURPOSEto work together to improve the health and wellbeing of the people of

Hertfordshire, based on best practice and best evidence

OUR VISION:A Healthy, Happy Hertfordshire: everyone in Hertfordshire is born healthy, and lives full, healthy and happy lives. We compare well with England and every area in Hertfordshire compares well

against Hertfordshire

Priority 5: We understand what’s needed and we do what works

Priority 6: We make public health everybody’s business and work together

HOW WE WILL WORK TOGETHER(our strategic priorities: how we do it for

our County)

ThePublicHealthOutcomesFramework(the nationalPHOF willHelp us measureOur success)

WHAT WE WILL ACHIEVE WORKING FOR AND WITH OUT POPULATION

(our strategic priorities: what we achieve for our County)

Priority 1: Our Population lives Longer, Healthier Lives

Priority 2: Our Population Starts Life Healthy and Stays Healthy

Priority 3: We narrow the gap in life expectancy and health between most and least healthy

Priority 4: We protect our communities from harm (chemical, biological, radiological and environmental)

BuildingBlocks For the Public Health Family

Strong Leadership

Capable, Skilled People

Co-production with citizens

Effective Partnerships

Evidence and Knowledge Driven

Plan and Deliver for Localism

Whole System Approaches

Making better use of behavioural sciences at individual, interpersonal, community and service levels

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1. OUR CHALLENGES

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Hertfordshire

• 1.1m People in 37 Settlements• 10 Districts• 1 County Council• 2 NHS CCGs• 8 NHS Trusts• 1400+ vol orgs• Urban/Rural mix

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Major Disease Shifts

• 1st – Poverty, Living Conditions

– Improvement in incomes, reduction in deaths

• 2nd –Communicable Diseases

– Now on average 6-11% of deaths in UK. Was 85% of deaths before 1900

• 3rd – Non-Communicable Diseases

– Over 60% of deaths due to lifestyle and behaviour

– Poorest fare worst (smoking, diabetes, heart disease)

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Learning the lessons from theNational Audit Office 2010not on course!

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Interface of PH, health inequalities & social care• NHS gone from infectious disease focus in 1948 to LTCs, cancer and

mental health in 21st century • 1 in every 7 GP appointments for LTCs*• 50% of adults with a mental health problem had a MH, behavioural or

emotional problem before the age of 14 yrs• MH biggest spend of NHS than any other health condition• Social determinants AND quality and accessibility of health & social care• Old model of health and social care – deliver to, not with…co-production,

co-creating health, shared decision-making …• Personal budgets… for social care (and health ??)• Shift from one size fits all

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The Big Strategic Challenges for Hertfordshire

Health Improvement

Health Protection

Service Quality

Imms

Vaccs

TB

HCAI

Environment

• Non Communicable Disease

• Public Mental Health

• Development

• Ageing

Health Care QualityPublic Service Outcomes

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2. THE CONTEXT

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Conceptualising wider determinants

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.

Contributors to overall health outcomes

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40 years of science/policyon wider determinants

• From Rose to Black to Marmot....

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Systems thinking on wider determinantsGetting everyone on the same systems page

The wider determinants of Health and Local Government functions (Must adopt a Lifecourse approach!)

The Lives people lead and whether LA functions help or hinder healthy lifestyles (policy, service quality, access, behavioural economics, behavioural sciences)

The services people access such as primary care (high quality, easy access, good follow up, behavioural and lifestyle pathways wrap around)

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3. WHERE WE WANT TO GET TO

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People Centred Public Health

• Every service understands and owns a public health role

• We skill and motivate people to self-manage their health and wellbeing

• We focus on the person and co-ordinate around them

• Physical, Social, Psychological and Spiritual are all part of the dynamics of health

• Mindset of staff,volunteers, carers and users

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Healthier Herts: A Public Health Strategy for Hertfordshire

OUR PURPOSEto work together to improve the health and wellbeing of the people of

Hertfordshire, based on best practice and best evidence

OUR VISION:A Healthy, Happy Hertfordshire: everyone in Hertfordshire is born healthy, and lives full, healthy and happy lives. We compare well with England and every area in Hertfordshire compares well

against Hertfordshire

Priority 5: We understand what’s needed and we do what works

Priority 6: We make public health everybody’s business and work together

HOW WE WILL WORK TOGETHER(our strategic priorities: how we do it for

our County)

ThePublicHealthOutcomesFramework(the nationalPHOF willHelp us measureOur success)

WHAT WE WILL ACHIEVE WORKING FOR AND WITH OUT POPULATION

(our strategic priorities: what we achieve for our County)

Priority 1: Our Population lives Longer, Healthier Lives

Priority 2: Our Population Starts Life Healthy and Stays Healthy

Priority 3: We narrow the gap in life expectancy and health between most and least healthy

Priority 4: We protect our communities from harm (chemical, biological, radiological and environmental)

BuildingBlocks For the Public Health Family

Strong Leadership

Capable, Skilled People

Co-production with citizens

Effective Partnerships

Evidence and Knowledge Driven

Plan and Deliver for Localism

Whole System Approaches

Making better use of behavioural sciences at individual, interpersonal, community and service levels

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The Opportunity for Herts

• The conditions for everyone to be healthy• The conditions for the poorest and worst off to

be healthier• Public services which put this at the core of their

business• People thriving and prosperous• Healthy workforce, prosperous County

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The Strategy Pyramid1

HWBS

Herts PHS

Local Strategies

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The Strategy Pyramid2

Mission Vision: Where we want

to get to

Strategy: How we want to get to the vision

Implementation Plans : What we need to do in each area of the business and for each topic

Individual Plans: My personal objectives and must dos

Mission:

Why ? Where/What do we want to be?

Why do we Exist ?

How we want to get there?

What we need to do!

What I need to do!

Values, what’s important to us ? {

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A Lifecourse approach

• Conception to death• Protective and vulnerability factors (e.g. obesogenic or

energy balanced environment)• Healthy outcome in one age is cumulative impact of

earlier ages• Poor outcome in one age may be risk factor for another

(low birth weight and CVD)• Early investment, early prevention (lifetime mental ill

health and under 13s)• Data, Evidence, Implementation key

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Mission

• Our mission is to work together to improve the health and wellbeing of the people of Hertfordshire, based on best practice and best evidence*

•  • *Best evidence means not just effectiveness

but cost-effectiveness

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Vision

• Healthy, Happy Hertfordshire: Our vision is that everyone in Hertfordshire is born healthy, and lives full, healthy and happy lives.

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Timeframes of impact/yield

Years

0 1 5 10 15

Planning

Education

Vitamin Supplements

Air Pollution

Decent Homes

Jobs

Primary Care

20

CVD Events

Self Care

Vitamin D and TBRickets

CVD Events

Acute Bronchitis Admissions

RespiratoryMental Health overcrowding educational attainment

Life Expectancy

Healthier space use Changing culture of activity

Life ExpectancyMental Health

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4. WHAT WE NEED TO DO

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What it means for public health

• Design pathways around people• Whole life approach• Whole school approach to health• Whole place approach to health• Commission preventive services which join up

with clinical services• Build protective factors

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What it means for NHS Services, for example

• Preventive services in every patient pathway• Preventive services in clinical services link up to

community services (referral for leisure and behavioural interventions)

• Making Every Contact Count• Commissioning for self-management in chronic

disease

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What it means for community agencies

• Identify need and be part of needs assessment process

• Co-design public health services with public health commissioners

• Embed public health skills across your services• Build resilience in users and communities• Motivate people to self-manage• Become health promoting in all you do

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Health Improvement

Health Protection

Commissioning priorities, Evidence, acting when evidence is silent, making it work, supporting implementation

Ensuring we have the right frameworks in place

Long term, medium term, short term impacts

Let’s assume you run a day centre.....

FALLS PREVENTION?

Service Quality andImprovement

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What Outcomes can I contribute to?

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Values - Ottawa Charter, 1986• Underpins strategic role of local government

• "The goal of a healthy public policy is health promotion, i.e., to enable people to increase control over and improve their health.

• It is also essential to

– create supportive environments,

– strengthen community action,

– develop personal skills and

– reorient health services.

All of these are areas for elected member leadership

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The public health mindset means working across different dimensions of time and responsibility

•Think through what we can do short term

•Start work on the medium term

•Set the policy framework for the long term

•Build this understanding among partners

•Get started and realise

•County, District, Parish, NHS, Business and Community Sector working together

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HERTFORDSHIRE LOCAL PUBLIC HEALTH MODEL (For Place or for People Settings)Development of a local plan for each area and agency between partners with use of existing

community networks

2. WORK ON THE COMMON RISK FACTORS FOR BIG KILLERS

Neighbourhood interventions forDiet, Physical Activity, Smoking,

Alcohol,

3a. IMPROVE LOCAL NEIGHBOURHOOD QUALITY

Physical Environment, Green Space, Crime/ASB. INCREASE SOCIAL CONTACT BETWEEN NEIGHBOURS

4. INCREASE UPTAKE OF PREVENTIVE HEALTH PROGRAMMESImmunisation, Screening, This may differ from area to area depending on

issues

1. Complete a Basic health profile – identification of health issues salient for the neighbourhood or service user group by checking the basic basic profile from JSNA or other source

5. Skilling people for their own health– develop and deliver basic personal health skills training. (Physical and mental health)

So…towards a modelexplicitly designed to be as easy as possible for non-health specialists can implement it

3b. IMPROVE SALIENT HEALTH OUTCOMESAddress issues specific to your population e.g. Coping and resilience for carers

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So

• Does this make sense?• Is it doable?• What do you think can make it better?• How do we improve?• Where do we go from here?• What can you do?• What do we need to do to helpyou?