Progressing prevention together mcmanus
•
0 j'aime•413 vues
A presentation to NHS Clinical Commissioning Group Executive on how we work together on prevention
Recommandé
Recommandé
Contenu connexe
Tendances
Tendances (20)
En vedette
En vedette (7)
Similaire à Progressing prevention together mcmanus
Similaire à Progressing prevention together mcmanus (20)
Plus de Professor Jim McManus AFBPsS,FFPH,CSci, FRSB, CPsychol
Plus de Professor Jim McManus AFBPsS,FFPH,CSci, FRSB, CPsychol (20)
Dernier
Dernier (20)
Progressing prevention together mcmanus
- 1. www.hertsdirect.org Progressing Prevention Together 3rd November 2015 Presentation for PH/HV CCG Exec to Exec Meeting
- 2. www.hertsdirect.org The big win “The NHS needs a radical upgrade in prevention if it is to be sustainable” 5 year Forward View 2014 Current Herts position We are doing SOME prevention, but lots of variation, not systematic and lots of gaps We could get more if we do it smarter
- 3. www.hertsdirect.org Ultimate aims: scaling up prevention • To ensure better communication over prevention plans & opportunities – Realising potential of strategic shift to prevention – Drawing on pathways out of primary care – Embedded within Your Care, Your Future • To develop closer working on prevention – leading to better prevention programmes – full contribution from all key parties • To consider opportunities for co-commissioning – Including follow up of successful prototypes/pilots
- 4. www.hertsdirect.org Where this fits: strategic shift to prevention • The Health & Wellbeing Board has endorsed the need for a strategic shift to prevention • Quick shared wins – Promotion of physical activity linked to primary care (treatment & prevention) – Pathways out of NHS Health Checks – Self management for long term conditions – Prevention strategy for older people But not enough to meet shared financial challenges
- 5. www.hertsdirect.org Recap from Health and Wellbeing Board 1. Agreement to do prevention together AS A SYSTEM 2. A lead senior person from each partner 3. A gap analysis on prevention from each partner 4. From gap analyses produce a strategy 5. A steer on governance of this from HWBB
- 6. www.hertsdirect.org Problems we share • Significant escalating and avoidable spend across system – Primary Care Variation – Exacerbation of disease – avoidable disability – Multimorbidity – Risks for Circulatory Diseases and Cancers
- 7. www.hertsdirect.org What do we mean by prevention? Primary Prevention – ‘prevent’ harm • Example: promoting health and active lifestyles Secondary Prevention – ‘reverse’ harm • Example: early detection and effective self management of diabetes Tertiary Prevention – ‘reduce’ harm • Example: COPD + early stage heart failure + depression
- 8. www.hertsdirect.org What Prevention are we doing • Primary – increasing and needs to be done but is a very slow upstream burn • Secondary – we really need to do much more here to prevent a 3-5 year cost curve increase • Tertiary – Could have high impact within twelve months. We need to do more. Primary prevention alone, and tertiary prevention alone not the answer. Target all three for maximum impact
- 9. www.hertsdirect.org The Strategy HWBB wanted us to adopt 1. Reduce cost to the system by implementing high impact actions system wide to prevent worsening of health and management of cost 2. Improve quality of life by including clinical + lifestyle + behavioural components 3. Make more use of services in the community including pharmacy 4. Develop preventive pathways 5. Work across primary, secondary and tertiary prevention to deliver this in tandem 6. Start with areas which will have highest impact
- 10. www.hertsdirect.org Early big wins • Musculoskeletal health • Obesity • Poor management of long term conditions costs us – including physical and mental health • Multimorbidity costs us – 16% of NHS spend on 2% most complex patients • Avoidable disability • Variation in primary care with people with established disease
- 11. www.hertsdirect.org Multimorbidity – evidence • Definition - presence of two or more disorders • 42% patients 1+ morbidities and 23% were multimorbid • Prevalence increased with age and present in most 65 + • BUT absolute number of people with multimorbidity higher in those younger than 65 years • Onset of multimorbidity occurred 10–15 years earlier in people living in the most deprived areas • Presence of a mental health disorder increased as the number of physical morbidities increased and was much greater in more deprived people
- 12. www.hertsdirect.org Multimorbidity – implications for practice? • Is the single-disease framework fit for purpose? – individual long term condition (LTC) services can be duplicative and inefficient, and burdensome for patients due to poor coordination and integration • Is mental health a core component of LTC pathways? • Need to support generalist clinicians to provide personalised continuity of care, especially in deprived areas
- 13. www.hertsdirect.org Example from the Commissioning for Value CVD pathway • HVCCG – Hypertension ratio (-7.1 % lower) opportunity for 5,828 people – % anti-coagulation drug therapy for those with stroke risk >1 (using CHADS2 score) (-9.2 % lower) opportunity for 361 people –E&NHCCG – % stroke patients blood pressure <150/90 (-2.6 % lower) opportunity for 200 people – % stroke patients record of cholesterol (-4.6 % lower) opportunity for 347 people
- 14. www.hertsdirect.org The avoidable spend areas in the physical health system, with poor health/quality of life Multi morbid Repeat admission Complex care Existing disease Managed sub-optimally Sudden onset of acute Avoidable events eg stroke Volume of spend Severity Existing curve
- 15. www.hertsdirect.org Key actions to reduce this PH spend curve Clinical + Lifestyle + Behavioural Case management Self management Optimal assertive Management of existing disease (lifestyle + pharmacological) Optimal management of high Risk patients; Volume of spend Severity Existing curveThe Achievable
- 16. www.hertsdirect.org The avoidable spend areas in the mental health system, with poor health/quality of life Crisis pathways And repeat Admissions, dual diagnoses People with long term mental ill health Whose physical health deteriorates due to Sub-optimal management Prescribing practice where IAPT or CBT could resolve issues Volume of spend Severity of condition Existing curve
- 17. www.hertsdirect.org Key actions to reduce this MH spend curve Clinical + Lifestyle + Behavioural Recovery focused care Channel shift: Greater use of online and community groups; less prescribing Optimum physical health (eg quitting smoking reduces cost to MH services) Volume of spend Severity Existing curveThe Achievable
- 18. www.hertsdirect.org High Impact Actions by Partner 1 Who Primary Secondary Tertiary Primary Care NHS Health Checks Making Every Contact Counts (MECC) - Joint British Society recommendations for prevention of CVD (JBS3) - Blood pressure - Weight - Alcohol - Diabetes – eight care processes - Improved access to IAPT services - Early identification of atrial fibrillation and anticoagulation therapy Self-Management Optimise referrals to Pulmonary / Cardiac rehabilitation Pharmacy Purple – contractual Red – requires funding Green – may need financial support Healthy Living Pharmacies Public Health (PH) Pathway into PH Services Minor ailments with pharmacy Medicine Use Reviews / New Medicines Service Healthy Lifestyle Advice Home MURs (Bright Ideas Project) LTC Pathways Repeat dispensingExpansion of PH services – smoking, alcohol IBA, sexual health Minor ailments Healthy Living Pharmacies
- 19. www.hertsdirect.org High Impact Actions by Partner 2 Partner Primary Secondary Tertiary HCS Promote a healthy workforce Making Every Contact Counts & brief interventions Re-ablement Public Health Continue to commission services Use expertise to support prevention strategy Enhance healthcare and social care public health offer Use expertise to support prevention strategy PH Pathway into PH Services PH Pathway into PH Services Community Wellbeing Services Prevention Strategy for Older People
- 20. www.hertsdirect.org High Impact Actions by Partner 3 Partner Primary Secondary Tertiary HCT Promote a healthy workforce Implement NICE guidance - Smoking cessation in secondary care: acute, maternity and mental health services (PH48) Brief Interventions /MECC Alignment of physical health and mental health / psychological support pathways Acute Promote a healthy workforce Implement NICE guidance - Smoking cessation in secondary care: acute, maternity and mental health services (PH48) Brief Interventions /MECC Referral pathways to community prevention services Rehabilitation Reduce variations in length of stay Optimise Pulmonary / Cardiac Rehab Pathways PH Pathway into PH Services PH Pathway into PH Services
- 21. www.hertsdirect.org High Impact Actions by Partner 4 Partner Primary Secondary Tertiary Voluntary Sector Making Every Contact Count Deliver resilience and psychosocial support Programme delivery providers Programme delivery providers HPFT Promote a healthy workforce Implement NICE guidance - Smoking cessation in secondary care: acute, maternity and mental health services (PH48) MECC Robust physical health pathways for patients with serious mental illness (SMI) and dementia Recovery services PH Pathway into PH Services PH Pathway into PH Services
- 22. www.hertsdirect.org High Impact Actions by Partner 5 Partner Primary Secondary Tertiary Childrens Ensure universal public health offer aligns well with children's services Schools mental health and wellbeing School health Ensure early intervention takes holistic approach PH Pathway into PH Services
- 23. www.hertsdirect.org Where this fits: Your Care, Your Future • The future model of care will support a shift away from a medical model of care. – Empowering people to take care of their own physical and mental wellbeing, through education and awareness, to stay well and prevent ill health. – Ensuring we can live within our means. – If people need to access services, pathways should be easy to understand and navigate. – Services should feel seamless and the focus of health & care professionals should be to prevent escalation into more acute levels of care.
- 24. www.hertsdirect.org Recap from Health and Wellbeing Board 1. Agreement to do prevention together AS A SYSTEM 2. A lead senior person from each partner 3. A gap analysis on prevention from each partner 4. From gap analyses produce a strategy 5. A steer on governance of this from HWBB
- 25. www.hertsdirect.org Principles • We all committed to driving progress on prevention; let’s gain collective benefits – Promote our “products”/initiatives – Help us link the NHS to them effectively • Ask, Assess, Advise, Assist/Signpost – Identify key local gaps/opportunities – Amplify communications/campaigns – Enable appropriate clinical input – Proportionate input into key meetings/groups – Drive progress through our organisations – Co-commission proven programmes to enable delivery at scale
Notes de l'éditeur
- England faces an epidemic of largely preventable non-communicable diseases, such as heart disease, cancer, Type 2 diabetes and liver disease. The WHO Global Burden of Disease Study shows us that the leading causes of premature mortality are tobacco, raised blood pressure, obesity, physical inactivity and poor diet. The radical upgrade in prevention needs population-level approaches. But it also needs ongoing behaviour change support and medical treatment for individuals during their repeated contacts with primary care.
- Link to previous presentation
- Link to previous presentation
- Secondary prevention - interventions happen after an illness or serious risk factors have already been diagnosed. The goal is to halt or slow the progress of disease (if possible) in its earliest stages; in the case of injury, goals include limiting long-term disability and preventing re-injury. Tertiary prevention - focuses on helping people manage complicated, long-term health problems such as diabetes, heart disease, cancer and chronic musculoskeletal pain. The goals include preventing further physical deterioration and maximizing quality of life.
- Not addressing relationship between LTCs and mental health and its impact on self management NHS England LTC Dashboard 1 LTC (31% EN; 31.7% HV) 2 LTCs (12.4% EN; 12.5% HV) 3 LTCs (9% EN; 8.1% HV) Commissioning for Value (CfV) - 2% most complex patients of which 60% aged 65 years+ E&NH – 16% spend, 1497 patients, av. 2.8 conditions and 6.2 admissions per year – circulation, cancer and GI top 3 areas of spend HV – 15.9% spend, 1530 patients, av. 2.91 conditions and 6.7 admissions per year– circulation, cancer and MSK top 3 areas of spend Obesity associated with the four most prevalent disabling conditions in the UK: arthritis, back pain, mental health disorders and learning disabilities 1/3 obese adults have a limiting long term illness or disability compared to a quarter of adults in the general population Multimorbidity is associated with high mortality, reduced functional status, and increased use of both inpatient and ambulatory health care The Global Burden of Disease study (2010) - growing burden of disability, particularly from mental disorders, substance use, musculoskeletal disorders, and falls deserves an integrated and strategic response
- 314 GP practices in Scotland (2007) Prevalence of both physical and mental health disorder 11%, in most deprived area vs 6% in least deprived Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012;380(9836):37–43. CrossRefPubMed cross-sectional study data on 40 morbidities from a database of 1 751 841 people registered with 314 medical practices in Scotland as of March, 2007. analysed the data according to the number of morbidities, disorder type (physical or mental), sex, age, and socioeconomic status. D Defined multimorbidity as the presence of two or more disorders.
- challenge the single-disease framework by which most health care, medical research, and medical education is configured
- The CHADS2 score is a clinical prediction rule for estimating the risk of stroke in patients with non-rheumatic atrial fibrillation (AF), a common and serious heart arrhythmia associated with thromboembolic stroke. It is used to determine whether or not treatment is required with anticoagulation therapy or antiplatelet therapy,
- The NHS Health Check is a systematic approach to identifying local people at high risk of CVD, offering behaviour change support and early detection of hypertension, CKD, diabetes and pre-diabetes. Modelling suggests that 75% uptake will lead to substantial reductions in premature mortality. What proportion of our local eligible population is receiving the NHS Health Check and how effective is their follow up risk factor management in primary care? 12.8% offered an NHS Health Check (18.4% in England). 65.3% of people received an NHS Health Check of those offered (49% in England). http://www.guidelines.co.uk/cardiovascular_bmj_jbs3_jul14 Diabetes Diabetes observed prevalence compared to expected prevalence ENH 82% & HV 73% 8 care processes – CfV data on pathways - Cardiovascular disease profile - Diabetes (March 2015) ENH- People with diabetes who have had the eight recommended care processes = 42.4% HV- People with diabetes who have had the eight recommended care processes = 63.2% CVD pathway CfV - What questions should we ask in our CCG? 1.For each indicator how wide is the variation in achievement and exception reporting? 2.How many people would benefit if all practices performed as well as the best? 3.How can we support practices who are average or below average to perform as well as the best in: •Identifying people who are obese, inactive or smokers •Identifying and managing high CVD risk •Identifying and managing high blood pressure •Identifying and managing pre-diabetes 4.What is the quality of brief interventions we offer our patients? 5.How available are preventive services such as weight management and smoking cessation? Stroke Atrial fibrillation increases the risk of stroke by about 6 fold, and strokes caused by AF are often more severe with higher mortality and greater disability. Anticoagulation substantially reduces the risk of stroke in people with AF. Around 25-30% of people with AF are unaware they have the condition and less than a half of patients are adequately treated – many do not receive anticoagulants and of those who do, many are undertreated. Only 30% of people with known AF admitted with stroke are on anticoagulant treatment at the time of their stroke. Secondary prevention of stroke For people who have had a stroke anti-platelet treatment and good control of blood pressure are key to reducing the risk of a further stroke Pharmacy – Lisa Healthy Lifestyle advice contractual and includes healthy eating, physical activity, smoking, alcohol etc. Advice given generally as well as during MURs and as part of contractual Health Promotion campaigns. Medicines Use Review (MUR)/New Medicines Service (NMS) – contractually funded but need multidisciplinary buy in. Prioritise by specific target groups eg respiratory disease, recently discharged from hospital. Could also have local target groups eg: musculoskeletal conditions. Direct funding not required but knowledge of local pathways/training etc Expansion of PH services – need to look at where GP/Pharmacy services are lacking and encourage contractors to become accredited. Referral process where GP or CP is not providing to ensure patient needs are met. LTC Pathways – CP rarely included until issues arise or targets unmet eg: Under 65yrs target groups for flu vaccine. When are pathways reviewed? How can CP be involved? Repeat dispensing – contractual service that CPs must promote but only GP can issue – need both to work together. Patient benefits as CP must assure that requested medication is required. Opportunity to discuss with patient on monthly basis. Potential to improve compliance/concordance and recognise problems at early stage. Home (domicilary) MURs – project doc attached Healthy Living pharmacy – expansion of current ohort (18) across Herts. Promotes PH interventions and proactive working with clients in pharmacy and as part of outreach
- HCS Levels and competencies from brief intervention onwards Preventive services as part of commissioned services Link up to community services (referral for leisure and behavioural interventions) Culture change Embedding good practice Evidence on what is effective
- Pulmonary / Cardiac Rehab Pathways - uptake/access and follow up
- Link to previous presentation