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Prevention:What could we achieve?

Jim McManus, Director of Public Health, Hertfordshire County CouncilJim.mcmanus@hertfordshire.gov.uk

Hertfordshire Forward Strategy GroupJanuary 2017

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Context• We can no longer afford to treat after adverse

events • System never designed for this level of

need/demand• We need to prevent, reverse or mitigate need for

services • Significant avoidable and preventable burden of ill

health and inequality• The background to STPs

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A Prediction from 2000

• Derek Wanless– Too much rising demand for us to cope, from

avoidable need for service (preventable disability, long term ill health)

– Public services financially unsustainable– Could be reversed with a strategic shift to

preventing people need service– Needs determined strategy

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What is Prevention?• The avoidance, whether permanent or temporary,

of need for public service or an adverse event/hazard or exposure leading to need for public service

– SHORT TERM (eg up to 24 months)– MEDIUM TERM (eg 2-5years)– LONGER TERM (eg 5 years plus)

• Prevention is NOT rationing or restricting eligibility

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Levels of Prevention• three levels. Preventative activities may be delivered by any

agency.

• Primary Prevention – ‘prevent’ or stop harm or need for service arising in first place – physical activity, recycling

• Secondary Prevention – ‘reverse’ harm or need for service – rehabilitation

• Tertiary Prevention – ‘reduce’ or mitigate harm/need for service – an Anti Social Behaviour Order? A wheelchair for a diabetic foot amputation

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Immobility or lack of fitness?

• Much immobility due to ageing is preventable. Maintaining or losing strength to walk is an important predictor of other need for public service

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Reducing the need and spend curve: Preventing avoidable spend,

Volume of spend

Severity of need

Existing curve

The Achievable curve?

Reduce or delay need here

Highest cost. Reduce and delayNeed here

Intervene here before needescalates

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The Questions

• Where could we reduce need or demand for public service?

• What skills and strengths do we have that we could apply to this?

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So what could be done?

• A culture of self-reliance• A culture of nudging people to do right thing• Diversion

– Can we create a culture where people deal with minor issues themselves

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So what could be done? ExamplesLevels of Prevention

Crime and Disorder

Mental Health Cancer

Prevent/Stop harm or need

Reduce alcohol related injuries and violence

Reduce drug related crime

Prevent lost productivity by workplace ill-health

Routine physical activity for everyone to retain balance and mobility

Reverse harm or need

Physical activity for rehabilitation

Reduce/Mitigate harm of need

Cheaper alternatives? (social groups for lonelines)

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Quick wins in the system

• Drug testing on arrest and early referral in• Using “behavioural insights” on council tax notices and

letters and on recycling• Leisure centres and services• Early intervention to prevent slips, trips and falls• Using “behavioural insights” in recycling

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Quick wins in the system

• Night time economy work on alcohol with retailers• Routine, universal, physical activity• Physical activity and social contact for people isolated• Behavioural contracts with offenders• Mental Health First Aid • Getting people temporarily sick back into work

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Just suppose

• An army of signposters who as part of their day job signposted you to the lowest level of place which could meet your need

• We already have 1,300 mental health first aiders in employers – the UK’s largest number. What more can we do

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A good employer• Positive psychosocial workplace – the seven tips for

employers helps keep people at work

• Healthy workplace – simple things to keep people healthier longer

• Enable carers – help keep carers able to care

• Make it easier to get back to work

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5. Prioritising Prevention – the Decision Cycle

What population?

What issue/need?

What outcomes do we want?

Which interventions fit

best?

How do we know it’s working?(Evaluation)

1. Service cost and demand

2. Needs (JSNA)

Define the outcomes clearly so you can really assess

feasibility

1. Financial Assessment2. Evidence Assessment

3. Logic mode where evidence silent

1. Financial Assessment2. Outcome Assessment

Questions to ask Tools for HCC

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What can the science do

• Science of behaviour change– Behaviour insights “nudge” on council tax

payment and recycling behaviour– Behaviour change backed

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Desired Outcome

• An appropriate prevention plan which models savings achievable from prevention

• A plan underpinned by evidence and a logic model

• Clear articulation of who needs to deliver what to achieve it

• System wide expectations