Kevin Fenton

Getting serious about
prevention
March 2016
Professor Kevin Fenton
National Director, Health and Wellbeing
Public Health England
Twitter: @ProfKevinFenton
Email: Kevin.Fenton@phe.gov.uk

Content
Opportunities to shift towards prevention
1. Understanding the context: The role of prevention in
addressing non-communicable diseases in England
today
2. The Five Year Forward View’s call for a radical upgrade
in prevention
3. Moving beyond the Five Year Forward View to
implementation and impact
2
Opportunities for prevention and improving outcomes @ProfKevinFenton

Understanding the NCD challenge
Why prevention matters

Understanding the NCD Challenge
Life expectancy at birth, 1990 and 2013 for England and EU 15+
Opportunities for prevention and improving outcomes
Between 1990-2013, life expectancy in England saw a 5.4 year increase
from 75.9 to 81.3 years (one of the biggest increases in EU15+
countries). This is mainly due to falls in the death rate from CVD, stroke,
COPD and some cancers.
@ProfKevinFenton

Leading causes of death in England
5 Getting serious about prevention
2013 figures
http://www.statista.com/chart/363/what-kills-english-people/
@ProfKevinFenton

Morbidity in England
• While life expectancy has increased, this hasn’t been
matched by improvements in levels of ill-health.
• So, as a population we’re living longer but spending
more years in ill-health. For several conditions, although
death rates have declined, the overall health burden is
increasing.
• For example, deaths rates from diabetes fell by 56%, but illness
and disability associated with diabetes went up 75%.
• Sickness and chronic disability are now causing a much greater
proportion of the burden of disease
• Low back and neck pain is now the leading cause of overall
disease burden.

GBD: Leading causes of DALYs 1990 & 2013

Health Inequalities
• While life expectancy has increased overall, there has been little, if
any, improvement in inequalities:
• By 2013, those living in the most deprived areas are only just
approaching the levels of life expectancy that less deprived groups
enjoyed in 1990.
• More deprived groups are affected proportionally more by
disease risk factors than less deprived groups. The types of
disease and risk factor are roughly the same across all deprivation
areas however.
• While the data highlights regional differences in life expectancy and
disease burden, inequalities are actually greater within regions
than between them - so largely related to deprivation not geography.

Social and structural determinants
• Economic prosperity and a good start to life
• While individuals’ behaviours do matter (Eg. studies show half of
health inequalities between rich and poor are the result of smoking),
the reality is that our health is impacted by a range of wider
determinants including:
• good employment
• higher educational attainment
• safe, supported, connected communities
• poor housing and homelessness
• living on a low income
• social isolation, exclusion and loneliness
• stigma and discrimination

Summary
• Addressing the health and wellbeing gap
• Healthy life expectancies gap
• Increasing burden of preventable disease
• Persistent health inequalities
• Addressing the care and quality gap
• Persistent variations in healthcare
• Addressing the financial gap
• Opportunity costs of not having a prevention focus
The need for a system wide approach of communities
supported by their NHS, local authorities and voluntary
sectors.
10 Getting serious about prevention @ProfKevinFenton

The Five Year Forward View (5YFV)
Calls for aradical upgrade in prevention
• A whole systems approach to tackling rising obesity rates
• Diabetes Prevention Programme – an intervention to improve
the health of patients at imminent risk of developing type 2
diabetes
• Population behavioural change through engaging and
activating patients to manage their own health
• Housing and health – ensuring the right home environment to
promote health and wellbeing across the life course
• Tackling health related worklessness – work as a clinical
outcome that benefits patients

Responding to the challenge
NHS cannot tackle obesity alone
We need a broad range of actions
across a wide range of players:
• Reformulation
• Fiscal measures to reduce unhealthy food
consumption
• Restrictions on advertising and promotions
• Enhanced planning powers
• Government Procurement Standards for
food in
public sector organisations
• Access to weight management services
• Public campaigns to support healthier
choices
• Promotion of activity (as part of healthier
lifestyle)
• Leadership to tackle the new social norms
• A wide coalition with industry and opinion
formers
Getting serious about prevention12 Getting serious about prevention @ProfKevinFenton

Diabetes Prevention Programme
• Commitment of the NHS Five Year Forward View
• Partnership between PHE, Diabetes UK and NHS England
• The NHS DPP aims to identify those at risk of type 2 diabetes early
and refer them into evidence-based lifestyle interventions,
underpinned by three core goals:
• Weight loss
• Achievement of dietary recommendations
• Achievement of physical activity recommendations
• Adults at risk of type 2 diabetes can be referred through:
• Existing GP practice registers
• NHS Health Checks
• Potential for opportunistic case finding

Population behaviour change
• Behavioural insights: provide opportunities for new approaches in
health; recognising role of both automatic and reflective systems in
decision-making.
• MECC: uses day-to-day interactions to support people to make positive
changes to their physical and mental health and wellbeing.
• Patient activation: a measure of a person’s knowledge, skills and
confidence to manage their own health and care.
• Could help 10% of those with long term conditions in England (1.5m people)
• Up to 40% of the population have low activation levels
• Low activation: >30% more likely to have unmet medical needs
• Activated people are more likely to attend screenings and check-ups and have
greater engagement in healthy behaviours e.g. regular exercise

Housing and health
• Health begins at home
• The right home environment is essential to
health and wellbeing, throughout life.
• Key features of a home in which to
start, live and age well:
• Warm and affordable to heat
• Free from hazards, safe from harm
• Enables movement around the home and
is accessible
• Promotes a sense of security and stability
• Support available if needed

Work and health
• Good work is good for health; being out of work is bad for health
• 28% of the working age population have a health condition or
disability and 40% (4.5m people) of those are not in employment
• The NHS directly employs around 1.2 million people in England.
• Staff health and wellbeing has a direct impact on patient outcomes
as well as sickness absence and agency costs.
• PHE is working with NHS England and 12 NHS providers, including
CCGs and the GP federation, to develop a response:
• Using the Workplace Wellbeing Charter as the road map for implementing NICE
guidance
• Rolling out NHS Health Checks for NHS Staff through NHS Occupational Health
• Tackling the food and physical activity environment across NHS settings

Moving beyond the 5YFV
1. Prevention interventions to save the NHS
money
2. Sustainability and transformation plans
3. System leadership for health

18
Hypertension
Sexual health
Improve management of hypertensives, reducing
likelihood of stroke, heart attack and kidney failure
PHE carried out an assessment to identify the most effective preventative interventions,
focusing on areas of high spend in the NHS. If delivered at the anticipated scale of
ambition, the potential savings could be up to £500m each year by 2020/21.
Interventions to improve health outcomes and save money
Falls and
fractures
Increase take up of more effective contraception (LARC)
through GPs and maternity and abortion services
Increase coverage of Fracture Liaison Service in
hospitals
CCGs
CCGs
and
LAs
CCGs
and
LAs
Commissioned by:
ReducingvariationPushingboundaries
Diabetes and
obesity
Improved management and care of diabetes; and
primary prevention of obesity
CCGs
and
LAs
Getting serious about prevention @ProfKevinFenton

19
Alcohol
identification
brief advice
Smokers in
secondary
care
Alcohol care
teams
Screen patients at next consultation spread over five
years, with GPs/nurses providing brief advice on alcohol
Expand 'identification and referral to improvement safety‘
programme in primary care to increase detection of
those suffering from domestic violence
Screen patients who smoke in secondary care, and refer
to stop smoking services
Introduce alcohol care teams (nurses) to manage
alcohol-related repeat admissions in all hospitals
PHE carried out an assessment to identify the most effective preventative interventions,
focusing on areas of high spend in the NHS. If delivered at the anticipated scale of
ambition, the potential savings could be up to £500m each year by 2020/21.
Domestic
violence
CCGs
CCGs
CCGs
and
LAs
CCGs
and
LAs
Commissioned by:
ReducingvariationPushingboundaries
Getting serious about prevention
Interventions to improve health outcomes and save money
@ProfKevinFenton

STPs should act as a vehicle for local health economies to develop and implement joined-up plans to
close the three ‘gaps’ in the 5YFV. They will be structured around these gaps and what footprints
propose to do to close them.
Local government is an essential partner in developing compelling STPs. They will provide valuable
public health advice to demonstrate how prevention can help to reduce demand for health and care
services across the whole local system.
Compelling plans, including a local, cross-partner prevention plan, will secure earliest funding
from the Transformation Fund (as early as April 2017)
Local Sustainability and Transformation Plan to close:
20
Health and
wellbeing gap
Care and quality
gap
Finance and
efficiency gap
Prevention Plan
Getting serious about prevention
Sustainability and transformation plans
@ProfKevinFenton

Identifying roles of different organisations is important:
• Health Education England
Specialist training recruitment, funding, training standards
• Faculty of Public Health
Curriculum and standards for trainees, consultant appointments,
continuing professional development standards
• PHE
“To review and make recommendations on the current operation of
the public health system in relation to the future capability, skills and
experience of the public health workforce to operate across all the
public health functions…to feed into the planned review of the public
health workforce strategy” Remit letter, Department of Health
21 Getting serious about prevention
Systems leadership for health: Training and capability
building
@ProfKevinFenton

Conclusions
• Prevention is vital to addressing the health and wellbeing gap
• Prevention also makes a key contribution to other two 5YFV
gaps – financial and care and quality
• Need for a system based approach
• NHS, local authorities and voluntary sector are key players
• Recent NHS guidance on sustainability and transformation
plans presents further opportunities for action through
prevention plans and identification of joint priorities for NHS
and local authorities.

Kevin Fenton

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