Generative AI in Health Care a scoping review and a persoanl experience.
Revised slideshow afternoon session for e circulation june 13th
1. Primary Prevention –
cheaper than cure,
better outcomes for
children
Afternoon session June 13th 2012
Supported by
2. The Health perspective
Dr Ann Hoskins, Interim Regional
Director of Public Health/
Director of Children, Young People &
Maternity
Supported by
3. C4EO/ WAVE Trust conference
13th June 2012
Dr Ann Hoskins, Interim Regional Director of Public Health /
Director Children, Young People and Maternity Services
Healthier Horizons
4. Giving Every Child the Best Start in Life is Crucial to
Reducing Health Inequalities Across the Life Course
• Ensure high quality maternity services,
parenting programmes, childcare and
early years education to meet need
across the social gradient
• Ensuring that parents have access to
support during pregnancy is
particularly important
• An integrated policy framework is
needed for early child development to
include policies relating to the prenatal
period and infancy, leading to the
planning and commissioning of
maternity, infant and early years
family support services as part of a
wider multi-agency approach to
commissioning children and family
services
5. The Scientific Base
1. A child’s early experience has a long lasting impact on the
neurological architecture of their brain and their emotional and
cognitive development
2. Pregnancy and birth a key time for change – parents have an
instinctive drive to protect their young and want their child to be
healthy and happy and do well in life
3. Evidence that effective preventive interventions in early life can
produce significant cost savings and benefits in health, social care,
educational achievement, economic productivity and responsible
citizenship
4. There is scientific consensus that origins of adult disease are often
found in pregnancy and infancy
5
7. The Task of Commissioning for
Prevention
To prevent early adversities
becoming biologically embedded
723,165 new
opportunities available
each year in the UK
8. Factors That Can Hamper Positive
Development During Pregnancy
• Low birth weight in particular is associated with poorer long-term health and
educational outcomes
• Smoking can cause a range of serious health problems, including lower birth weight,
pre-term birth placental complications and perinatal mortality. In addition smoking
during pregnancy has been associated with poor child behaviour at age 5.
• Drug use in pregnancy can increase the risk of low birth weight, premature delivery,
perinatal mortality, cot death and impairment to the unborn child’s development.
• Drinking alcohol during pregnancy is associated with increased risk of miscarriage,
risk of Fetal Alcohol Syndrome whose features include: growth deficiency for height
and weight, a distinct pattern of facial features and physical characteristics and central
nervous system dysfunction.
• Maternal depression during pregnancy may affect brain development in the foetus,
reduce foetal growth and poses risks of premature labour. Antenatal depression has
also been linked to altered immune functioning in the baby after birth. Antenatal anxiety
at 32 weeks’ gestation has been linked to behavioural and emotional problems in the
child at age 4
11. Using maternal factors to consider likely outcomes at 5 years old
•Data already collected in
maternity units
•Predictive for outcomes at
population level
•Informs commissioners decision
making for early years resources/
services
Predictive Maps available for,
Behaviour, Learning and
Development , Health outcomes
www.chimat.org.uk
12. Find Out About the Early Years
Needs in Your Area
Child Health Learning, Development and
Behaviour
http://www.chimat.org.uk/prof http://www.education.gov.uk/
iles researchandstatistics/datasets/
a00198391/dfe-early-years-
foundation-stage-profile-
results-in-england-201011
Navigate to Figures at Local
Authority Level
13. Getting the Best Prevention from the
Resources you have for early years
• Plan strategically at a population level;
intervene proportionately at an individual
level. E.g. Family Nurse Partnership
• Health Visiting Service offers for families;
universal children’s service
• Promoting a ‘resilience developing’ asset
based style to underpin all interactions
14. Where Should Support for
Foundation Years Come From?
• Co-ordinated by health visitors: lead a system
for solutions, not services
• Children’s Centres – PbR pilots
• Building from & on citizens capacity
• Third sector and charities
15. What do parents What is HV contribution?
want? A community that
supports children
and families
Needs
Predicted
Services that
Assessed
give our baby/child
Expressed
healthy start.
Best advice on a
being a parent
To know our health
visitor and how to Health Visitor
contact them
To have the right A quick response if we
people to help over a have a problem and to
longer term when be given expert advice Response
things are really and support by the Provide
difficult right person Delegate
To know those people
Refer
and that they will work
together July 2012with us.
25 and 15
17. FNP Short Term Impact on Outcomes
Pregnancy & Birth ↓smoking in pregnancy
↓ pregnancy related complications
↑ uptake of antenatal care
↑breastfeeding initiation
↑birth weights in very young teens
↑improved diet & nutrition in pregnancy
Infancy ↓A&E visits –all reasons & for injuries and ingestions (indicator of abuse
(0-2 years ) and neglect)
↓ hospital admissions for injuries and ingestions
↓language delay
↓punitive parenting
↓subsequent pregnancies and births
↓welfare use
↑ more sensitive care giving
↑ father involvement in parenting
↑better home learning environment
↑employment
↑emotional development
18. FNP Medium /Long Term Impact On Outcomes
Medium term ↓ severe behaviour problems
(2-9 years) ↓ future pregnancies & births (greater duration between births)
↓ welfare use
↓involvement with criminal justice system (mother)
↑ employment and participation in education (mother)
↑ sustained relationship with child’s father/partner (mother)
↑ language development
↑ school readiness
↑ school achievement scores (reading and maths)
↑ home learning environments
↑ stimulating parenting
Longer term ↓ child abuse and neglect
(Age 15+) ↓ Less criminal and anti-social behaviour (child)
19. Can it Be Justified in Current
Economic Climate?
• US economic modelling- $1 spend prevents $5 spend.
Cost recovery by age 4.
• UK – because of licensing, get same outcomes as US;
economic analysis will be part of RCT scope
• Babies born to teenage parents at higher likelihood of
– £2,500/week to keep a child in residential care
– £400/week to support a child in need at home
– Up £300,000 /year for a child with additional support needs
– £1000 /unscheduled ante-natal admission for investigation with
overnight stay for under 18
– £15,000/year public service cumulative costs for a child with
’troubled behaviour’
20. The New Commissioning Landscape
Department
of Health
NHS
Public
Health
England
NHS Monitor CQC
Commissioning (economic (quality)
Board regulator) HealthWatch
(Local health Clinical Commissioning
improvement Providers
Groups
in LAs)
Local authorities (via health &
Local
wellbeing boards) HealthWatch
21. The universal prevention and early intervention pathway from pre-pregnancy to 5
Pre-pregnancy information
and services (e.g. stop
smoking clinics) to improve
women’s health
Woman discovers she is pregnant and
chooses which maternity service to book
with via the GP or directly with the midwife
Conception
GP Team
Midwife
Online resources, books, leaflets and websites
Promoting parents’ self-efficacy & helping them to care well for their child.
Linking to other community resources and services including SSCCs.
Facilitating community groups & community action
22. How Third Sector
organisations can help to
“make it happen”
Fiona Sheil, Public Service Delivery
Officer, NCVO
Supported by
23. How Third Sector organisations
can help to “make it happen”
13th June 2012
Fiona Sheil
@fionapsdn
fiona.sheil@ncvo-vol.org.uk
Public Services Team
National Council for Voluntary Organisations
37. Prevention and early
intervention – a
Croydon perspective
Jon Rouse, CEO, Croydon Council
Supported by
38. Prevention and early intervention – a
Croydon perspective
Jon Rouse
Chief Executive
39. Croydon
Borough
of contrasts
Low wage
economy with
increasing
unemployment
Diverse population
Major transport hub
40% minority ethnic
Good education system
Population growth –
baby boom
40. A philosophy – integrated teams around the
citizen to manage complex requirements
● Adult Learning Disabilities
● Adult Mental Health
● Family Justice Centre
● Turnaround Centre
● Youth Homelessness
● Integrated Offender Management
● Family Resilience Team
41. Croydon’s Journey from Total Place to
prevention and early intervention
• Customer-led transformation
• Evidence based approach
• A whole system approach to
early help
• Continued focus on early ‘early
intervention’
• Working out the metrics
42. The Escalating costs of intervention
Child looked after in secure
accommodation – £134,000
Child looked after in
per year placement costs
children’s home – £125,000
per year placement costs
Cost
Multi-dimensional Treatment
Foster Care – £68,000 per year
Costs increase as
for total package of support
children get older.
Increasing related
Child looked after in foster
costs such
care – £25,000 per year
yi mf / di hc r ept s o C
healthcare and the
placement costs
criminal justice
system make it
Family Intervention Projects – clear joined up
£8-20,000 per family per year working is a core
part of cost
effectiveness
l a l
Multi-Systemic Therapy –
£7-10,000 per year
Parenting programme
(e.g. Incredible Years –
£900-1,000 per family
Family Nurse Partnerships –
£3000 per family a year
Information services –
Around £34 via telephone helpline
Around £2 via digital services PEIP – £1,200 -
3,000 per parent
Children’s Centres - around £600 per user
Schools - £5,400 per pupil
Severity of assessed need
46. After Total Place - progress
Children’s Centres - based on collaborations – engaged
parents and communities in redesign
- hub of their community
- universal through to targeted support
- early help
Family Space - website in place and network of children’s
centres
Family Advocates & Peer to peer support - ‘Family
Navigators’ and commissioned services
47. After Total Place
Geographically based Family Engagement Partnerships
with early years practitioners equipped to spot early signs of
needs, know how to engage parents quickly in high quality
services including early identification and peer2peer
support
Struggling with Preparation for Parenthood
• children and parents experience system from
conception onwards which supports & develops
parenting capabilities
• pre-natal care holistic preparation for parenthood;
emotional needs of parents supported
48. Continuing to develop preventative and
early intervention service in Croydon
• Use a whole system approach and build our evidence
base
• Use the ‘wedge’ to help us plan interventions
• Reduce high cost families so that we can reinvest in
preventative services
• Continue to work with health colleagues
• Develop our metrics across the whole programme of
interventions
49. Mapping Change for Croydon EIFS: Driving better long-term outcomes for children and families
Target service level outcomes (Identified at
EYS objectives/drivers of change Broader immediate outcomes Long-term outcomes for children & families
practitioner workshop)
Greater family Sense of control and autonomy over decisions
Increased likelihood of parent
resilience and
Improved social networks & sense of community keeping / finding a job
autonomy
Stable housing and reduced homelessness Improved emotional Increased likelihood of financial
resilience security for the family
Stronger home learning environments
Reduction in number of children on
Child Protection Register/ looked
Higher learning achievement among parents after children
Improved child
Improved educational
behaviour at home and
achievement Improved learning outcomes among children Reduced likelihood of children
school
becoming NEET
Secure attachment between parent and child
Improved long-term and
Reduced risk of child intergenerational health including
Less abuse/ family violence protection issues reduced risk of mental ill-health
Improved parent-child
relationship
Improved parenting skills
Reduced likelihood of drug misuse
among parents, children/young
Optimise health of children and mothers adults
Improvements in child Reduced anti-social
and maternal health Having somewhere to play/ be active behaviour/ community
Reduced contact of parents with
violence
criminal justice system
Integration of family skills/experience into services
Reduced likelihood of children
More responsive and entering the criminal justice system
Staff awareness of child well-being
consistent services
Early identification of needs
Greater take-up of
universal services
Well coordinated, consistent services
50. Early Help & Staged Intervention
Support at Stage 1
Support at Stage 2
CRISS;
Family Space & Family
Practitioner Engagement
websites Support at Stage 3
Partnerships
Family
Peer2peer
Resilience
Family Navigator
Service
Parenting
Programmes
Troubled
Family
Find me Early
Navigators
UNIVERSAL LOW/VULNERABLE COMPLEX ACUTE
Children & Young People requiring Children & Young People with low Children, Young People & Children, Young People &
personalised universal level additional needs requiring Families with high level needs. Families with complex
services single agency support or an additional needs requiring
integrated response using a These children/young people specialist/statutory integrated
common assessment. include ‘Children in Need’ response; includes child
(Section 17) who require protection (Section 47) and
integrated, targeted support children whose needs / safety
cannot be managed in the
community
51. Croydon – working across the wedge, whole system approach
Cost
Severity of need
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52. Reducing High Cost Spend through Croydon’s
Family Resilience Service
Av.
savings Net saving
per year Caseload Caseload Net per family per
No. per family savings costs saving year
Phase
1 - 60 60 £48.5k £2.91m £840k £2.07m £34.5k
Whole
Pilot
231 231 £48.5k £11.2m £3.23m £7.9m £34.5k
53. Capturing net value – a complicated
business
• Costs to society include the
benefits foregone from not using
the resources for some other use
• Large differences in the
methodologies adopted by studies
(few UK studies) aiming to evaluate
the economic impact of early years
interventions
• Difficult to compare results across
interventions
• BUT emerging UK studies do
provide indications that early years
interventions generate benefits in
the long term that outweigh the
costs
54. Where we need to go next?
• Children and parents to experience system from conception
onwards which supports and develops parenting capabilities
• Pre-natal care holistic preparation for parenthood; emotional
needs of parents strongly supported
• Maternity services within hospitals transformed and
characterised by holistic preparation for parenthood
• Continue to build our early intervention approach - evidence
based and builds the resilience and autonomy of parents to
ensure young children thrive and develop
58. The benefits of primary
prevention
Andrea Leadsom, MP
Supported by
Notes de l'éditeur
In recent years research has shown that a child’s experience in the womb and in early life has a strong influence on their health, development and well being throughout life During the rapid development of the brain in the first years of life the neural pathways, synaptic connections and bio-chemical responses are significantly influenced by a child’s environment and experience. The quality of early care giving and the infant-parent relationship has a major influence on the child’s outcomes equal, if not greater, than socio-economic circumstances. Deficient early years parenting experiences have been linked to a range of adverse later life outcomes including anxiety and depression, poor learning and cognitive development, increased risk of abuse and neglect, poor behavioural outcomes, criminality and anti-social behaviour. Early parenting experiences are especially critical in the development of the child’s emotional regulatory system and a large proportion of adult mental health problems are thought to have their origins in early childhood The high level of malleability in the brain during this period means this is also the time when it is most open to influence and change so intervening early and ensuring positive experiences and preventing negative experiences provides the greatest opportunity for improving children’s outcomes and, in turn, adult outcomes.
Shirley - the title in green and the ‘to prevent early…..” should be on slide, then babies and 723,165 opportunities appear on next click – please can you tweak animation to make it work.
Factors at child’s age 9 months and child’s subsequent outcomes at age 5. What factors will you target to either prevent or mitigate for pregnant women and families with new babies?
Where is the local need in the most immediate timescale? How will you expect your commissioned health visiting services (likely to be the only truly universal service for children under 5 in the mid-term future) to be deployed to get better outcomes?
Aim is to keep families moving towards the Communities Offer and return families up stream after a ‘resilience dip’ has meant they needed support from Universal Plus and Universal Partnership Plus offers.
Cost to support with FNP = £3000 per year so £6000/child. Recovered by age 4. So each team of FNP can support at least 110 families. Even if only one antenatal stay, one children’s A&E admission, and 1 week without additional family support at home was avoided for every family supported with FNP at least £3000 spend is avoided. If attendance is more than this then potential for avoiding spend and making a saving. So initially where to spend the same money and what additional value. For example additional value through mothers more confident and use GPs less, mothers more likely to return to education, more likely to be employed etc etc.
An overview of how the new system works. (Still a bit simplified – e.g. doesn’t show NICE or Information Centre) Animated: DH allocates £ and sets objectives for NHS CB. No longer any NHS HQ in DH NHS CB allocates to GP consortia Who commission services from a range of providers Who are regulated on a consistent basis (no longer some of them managed by SHAs): by CQC as now for quality and by Monitor as economic regulator (3 functions: 1 promote competition, 2 regulate prices, 3 ensure continuity of essential services) Meanwhile LAs have new role shaping NHS commissioning LAs also feed into new public health service, with their role taken from PCTs of promoting local population health improvement. And Public Health England itself is now part of DH, with a separate, ring-fenced budget. More details published in Healthy Lives, Healthy People White Paper Then adult social care: no change to structure (the debate is about financing – Dilnot commission) Finally, HealthWatch, nationally and locally So DH does strategic coordination at national level; LAs at local level.
Provides a visual picture of the health pathway from preconception to 5 years.
Introduce NCVO Early Action Task Force Obviously there are a number of challenges: Making the economic case work Infrastrcuture in place to have it happen This is the story of involving the VCS through the process
Micro – 5% state funding; larger 1/3 Concentration because: Empathetic development of organisations (kids first) Early action / prevention is obvious Also: 22,677 culture and recreation 13,552 religious
Most obvious – as illustrated by last slide Value of services are: Local – responsive local governance User led Flexible / need driven Trusted Specialist R&D Fuelled by grants Form follows funding – what is good about it and research ON PAGE THAT FLOATS IN PbR examples: financial incentive as opposed to public incentive
Expected drop of 1.246 billion over spending review (cuts only – not loss through competition)
Although very little is state funded 13.9 billion 2009 from 8.6 billion 2001 Total sector income is 36.7 billion
Second areas of relevance – social and financial economy Very existence: proof of need and resource Further column of funding to support social services and interventions (eg social investment and state funding) Where we have been poor though is in measuring the value of these more fluid things: what does this mean for communities? Support and investment is required to prove the case
Skip straight into next slide…
Crucial voice in commissioning LVAC anecdote: stories to action. ‘story of place’: that’s what the VCS is. And this story of cause and effect is exactly what early intervention seeks to trace and address. How are organisations involved?
Originally published as Arnstein, Sherry R. "A Ladder of Citizen Participation," JAIP, Vol. 35, No. 4, July 1969, pp. 216-224
What you end up with: -multi layered and integrated partnership -parallel to govt and economic structures; formal and informal
3 points: Commissioning is about partnership: which requires communication and engagement throughout the process Needs assessment: causal and integrated Maximise social capital by integration, development and SV Bill; and through procurement that reflects and enable preventative services to work