East Surrey Clinical Commissioning Group Commissioning Strategy 1. Prevention, Screening and Immunisation October 2017 Page 1 of 13
Summary The NHS and the wider health and social care system are facing a world of increasing complexity in terms of both the services it provides and the way we currently access care. There is a need for a whole system rethink with a shift in focus to keeping people healthy and a reduction in handoffs between providers. This links with NHS England s Sustainable Transformation Plans, which encourage a collaborative approach so local leaders can plan around the needs of whole areas, not just those of individual organisations. This strategy supports delivery of the care interventions detailed in the Sussex and East Surrey STP and more locally the North CSESA plans, and includes improving quality and developing new models of care; improving health and wellbeing; and improving efficiency of services. All this is occurring at a time of rising financial difficulties for many NHS organisations but with pressure to meet these challenges and deliver financial balance for the NHS. The future of commissioning services for East Surrey CCG lays in the creation of a simple system in which patients and professionals know which option to choose. It will be enabled through the functional integration of services in terms of access, assessment, advice and treatment with providers working together, both for urgent and emergency care and planned care activity. The vision is a system that is easy to access and works together to direct patients to the level of care that they need. It will span the breadth of the population responding to the differing physical and mental health needs of Children and Young People, Working Age Adults, older people and Frail Elderly. We will place much more emphasis on keeping people healthy and well, and providers will work together differently to ensure that people can access the care that they need, as well as to build stronger and more resilient communities. The strategy is predicated on the commissioning of a whole system model based on a detailed understanding of how our patients currently flow across the health and social care system and the future opportunities for our strategic landscape. The commissioning model is based on four Strategic Change Programmes. The details of each strategic programme can be found in four supplementary documents which, should be read in conjunction with the overarching strategy. 1. Prevention, Screening and Immunisation 2. Access to services 3. Emergency and Acute Care System 4. Out of Hospital Care Multispecialty Community Partnership October 2017 Page 2 of 13
1. Prevention, Screening and Immunisation National and Local Guidance and Research The NHS Five Year Forward View sets the context for how the health service needs to change. It proposes a series of measures to bring about the triple integration of primary and specialist hospital care, of physical and mental health services, and of health and social care. In doing this it also argues for a more engaged relationship with patients, carers and citizens so that we can promote wellbeing and prevent ill-health. It provides the focus for ensuring interventions are offered earlier in care pathways, reducing the demand in the acute sector and improving placebased services. The future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health. Public Health England s new strategy sets out priorities for tackling obesity, smoking and harmful drinking; ensuring that children get the best start in life; and that we reduce the risk of dementia through tackling lifestyle risks, amongst other national health goals. The NHS Five Year Forward View set out a central ambition for the NHS to become better at helping people to manage their own health: staying healthy, making informed choices of treatment, managing conditions and avoiding complications. One of the key requirements of the Sustainability and Transformation Plan (STP) is to develop a cross-partner prevention plan, with particular action on obesity and diabetes and locally identified priorities to reduce demand and improve the health of local people. October 2017 Page 3 of 13
The NHS as a whole is undergoing unprecedented challenges in terms of long term sustainability which is driven by demographic changes, complex illnesses and higher levels of expectations, all of which are operating in the context of a funding gap. The specific issues around the health and wellbeing, quality and finance and efficiency gaps are well highlighted in the Five Year Forward View. The NHS spends more than 15.5 billion per annum treating illness which directly results from alcohol and tobacco consumption, obesity, hypertension, falls, and unhealthy levels of physical activity. Most of this treatment is avoidable. The Five Year Forward View sets out that a radical upgrade in prevention is needed to improve people s lives and achieve financial sustainability of the health and care system. Sustainability and Transformation Plans (STPs) provide the NHS with an opportunity to work closely with local government and other local partners to build on existing local efforts and strengthen and implement preventative interventions that will close the local health and wellbeing gap, such as: Providing targeted brief intervention and advice to tackle excessive alcohol consumption and smoking Creating healthy environments in health and care settings to promote healthy eating and physical activity to support action to reverse trends in childhood and adult obesity Intervening earlier and managing long term conditions better to keep people healthier for longer and reduce their care needs. Prevention is also covered in the standalone guides on mental health and cancer Public Health Outcomes Framework The Public Health Outcomes Framework Healthy lives, healthy people: Improving outcomes and supporting transparency sets out a vision for public health, desired outcomes and the indicators that will help us understand how well public health is being improved and protected. The framework includes two overarching outcomes to be achieved across the public health system. These are: Increased healthy life expectancy; Reduced differences in life expectancy and healthy life expectancy between communities. These outcomes reflect the focus not only on how long we live our life expectancy, but on how well we live our healthy life expectancy, at all stages of the life-course. As well as on reducing health inequalities between people in our society. NHS Outcomes Framework Indicators in the NHS Outcomes Framework are grouped in five domains, which set out the high-level national outcomes that the NHS should be aiming to improve. For each domain, there are a small number of overarching indicators followed by a number of improvement areas and focus on improving health and reducing health inequalities. Domain 1: Preventing people from dying prematurely; Domain 2: Enhancing quality of life for people with long-term conditions; Domain 3: Helping people to recover from episodes of ill health or following injury; Domain 4: Ensuring that people have a positive experience of care; October 2017 Page 4 of 13
Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm. Mental Health Five Year Forward View Poor mental health carries an economic and social cost of 105 billion a year in England. The ambition is to deliver rapid improvements in outcomes by 2020/21 through ensuring that 1 million more people with mental health problems are accessing high quality care. The Five Year Forward View supports the need to establish integrated care services that are sustainable and focus on longterm outcomes. The Mental Health Five Year Forward View sets out a vision where local communities will be supported to develop effective mental health prevention plans, and use the best data available to commission the right mix of services to meet local needs. By 2020/21, NHS commissioning will be underpinned by a robust understanding of the mental health needs of the local population, bringing together local partners across health, social care, housing, education, criminal justice and other agencies, with a clear recognition of the mental health needs of people treated for physical ailments and vice versa, and with greater integration across agencies to build stronger, more resilient communities. The Case for Change The total resident population of East Surrey CCG population is 184,800 1 and the population is expected to grow by 11% in the next 10 years (Surrey average 8%). The age cohort of 65 and over is projected to grow by 24%. Older people aged over 75 years are the most intensive users of healthcare services and the treatment costs associated with this group are higher than for other groups, mainly due to chronic disease such as diabetes, cardiovascular disease, and chronic obstructive pulmonary disease (COPD). Life expectancy (LE) is a measure of how healthy a population is and can show the extent of health inequalities between groups of people. Residents of East Surrey can expect lower life expectancy compared to their counterparts in Surrey. LE is 80.6 years for men and 83.9 for women in East Surrey compared to 81.2 and 84.5 respectively for Surrey. At age 65, men in East Surrey can expect to live an additional 19.2 years and women an additional 21.3 years. This is considerably higher than the England average for men (18.6) but is similar for women (21.1) and significantly lower for women when compared to the Surrey average (22.0, confidence interval 21.9-22.1). There is a considerable gap in both male and female life expectancy at ward level. LE at birth for men ranges from 85.7 years in Felbridge ward to 76.3 years in Merstham, a difference of almost 9.4 years. When thinking about prevention, much of the burden of ill health, poor quality of life and health inequalities in East Surrey is preventable. A focus on prevention and early intervention is crucial to improving health and wellbeing outcomes for our whole population, reducing health inequalities, and to helping manage demand for health and care services in both short and longer term. Health commissioners will need to work together with public health, social care services and community health providers to ensure that this population has the support they need to live a healthy and independent life for as long as possible. When considering prevention, it can be helpful to look at it as a series of different levels including - primary, secondary, and tertiary. (See Figure 1). 1 Housing Constrained population based on 2016 Office of National Statistics Mid-Year Estimates projected to 2017 October 2017 Page 5 of 13
The long term outcomes of prevention are through wider determinants (such as housing, employment, education and the built to environment) and primary prevention which requires a whole system approach. The short term outcomes of prevention are through secondary and tertiary prevention to prevent further the deterioration of disease and subsequent complications. Usually, interventions in secondary and tertiary prevention will deliver net cashable savings by reducing hospital admissions and overall improve health and wellbeing. However, this requires early diagnosis of disease and for those patients who have a confirmed diagnosis of the disease would require support in selfmanagement and self-care by a health professional. The prevention spectrum LEVELS OF PREVENTION Whole population through public health policy Whole population selected groups & healthy individuals Selected individuals with high risk patients Patients Primordial prevention Establish or maintain conditions to minimise hazards to health Primary prevention Prevent disease well before it develops Reduce risk factors Long term interventions Secondary prevention Early detection of disease (e.g. Screening & intervention for pre-diabetes) Tertiary prevention Short term interventions Treat established disease to prevent deterioration SUSTAINABLE SYSTEM Figure 1. Factors Affecting Health & Wellbeing Surrey as a whole is the fifth least deprived county in England ranking 144th out of 149, with 60.9% of the population falling into the least deprived quintile. However, there are pockets of significant deprivation and variation across the county. The four most deprived Lower Super Output Areas (LSOAs) within East Surrey CCG are in the wards of: Merstham Horley West Redhill West Horley Central These areas will have significant health needs. Health inequalities should be addressed through targeted prevention and ensuring that those residents are aware of and able to access healthcare services. October 2017 Page 6 of 13
Health Behaviours The East Surrey CCG population have a prevalence of increasing risk drinking similar to the England average. Excess alcohol consumption increases the risk of hypertensive disease, some cancers, cirrhosis of the liver, cardiac arrhythmias, depression, weight gain, unintentional and intentional injuries and sexual problems. Reducing levels of excess alcohol consumption and its associated healthcare costs will require prevention, early identification and management of alcohol misuse through supported behaviour change programmes and appropriate follow-up. This will require a partnership approach with collaboration between organizations including NHS, local government and the criminal justice system. Estimated smoking prevalence in East Surrey is 16% but has significant ward level variation, with ward smoking prevalence ranging from 8.6% in Chaldon to 20% in Redhill East, Horley Central & Whyteleafe wards. Reducing the number of people who smoke and its associated healthcare costs will require action to prevent young people starting smoking and help for smokers to give up through supported behaviour change programmes such as the NHS Stop Smoking Service and Smokefree initiatives. In East Surrey CCG, just under two thirds of all adults are overweight or obese. Approximately 1 in 5 children in reception year and over 1 in 4 children in year 6 are overweight or obese. Being overweight or obese raises the risk of people developing major diseases such as diabetes, heart disease and cancer. This will put further strain on NHS services in the decades ahead, therefore every effort should be made to prevent obesity and to help patients maintain a healthy weight. Physical activity is important for both physical and mental health and wellbeing. Around 1 in 4 adults in East Surrey are physically inactive, meaning they undertook less than 30 minutes of activity per week. This puts them at greater risk of disease and in combination with obesity this will place increased demands on the NHS in the next decades. Disease Prevalence East Surrey CCG has a lower prevalence of many common diseases than England, however it is likely that the true prevalence of these conditions is higher. For example the; Prevalence of hypertension is 12.3%, compared to 13.7% in England Prevalence of diabetes mellitus is 5.0% well below the England average 6.2% Prevalence of coronary heart disease is 2.9%, below the England average 3.3% Prevalence of stroke and transient ischaemic attack is 1.6%, compared to 1.7% in England Increasing identification of these common diseases through measures such as case finding and NHS Health Checks can support early diagnosis and treatment, which can reduce premature mortality. Promoting weight loss, regular exercise, healthy eating, smoking cessation, and raising awareness of the harmful effects of alcohol can help to reduce the risk of people developing these common conditions. Prevention Conclusions There are specific health and wellbeing gaps which need to be addressed as part of the future strategy for keeping people well. Delivering prevention across the whole system not just bits of it requires large scale cultural change and up-skilling of our workforce. October 2017 Page 7 of 13
Making best of our community assets by working more collaboratively with and investing in the voluntary and community sector to help support residents, families and communities to make healthier choices. We recognise the negative impact of wider social factors on health and well- being. We will design services/interventions with our partners that concentrate on those individuals, families and communities most adversely affected. October 2017 Page 8 of 13
1. Prevention, Screening and Immunisation 1.1 Vision and Ambition Our vision is to increase the number of years people live in good health, by encouraging individuals to make healthy lifestyle changes to prevent disease from developing, as well as preventing complications of existing disease. We will build stronger and more resilient communities which support people to maintain independence and manage their own health and wellbeing across the course of their lives. The aims are: To increase healthy life expectancy (at birth for men and women) To reduce health inequalities. Our ambition is to embed a preventative approach across local health, public health and local authority services in East Surrey in order to reduce premature mortality and health inequalities. Taking a system-wide approach, we will work closely with multi-agency partners across physical, mental health and social care to deliver interventions that support primary, secondary and tertiary prevention and promote independence through initiatives such as self-care. As part of the prevention strategy, East Surrey CCG is committed to ensuring that immunisation programmes are incorporated within the cycle of business particularly amongst the vulnerable and hard to reach groups as stipulated within the NHSE health promotion strategy. In collaboration with NHS England and Public Health England, the CCG will promote the uptake of childhood immunisations, seasonal flu jabs and other recommended vaccinations within Primary Care. 1.2 Components The five key components will be to: 1) Support a good start in life, including delivering a whole systems approach to healthy weight and promoting emotional wellbeing and good mental health in children 2) Improve the health and wellbeing of working people through the development of workplace health and wellbeing programmes 3) Prevent the development of long term conditions (LTCs) through primary prevention programmes focused on the major causes of ill health, including smoking, poor diet, lack of physical activity, alcohol, mental health and loneliness 4) Improve health outcomes for people with LTCs, including cancer through a staged approach of early detection, support for self-care and robust clinical management of LTCs by addressing the physical health of those with mental illness to reduce the life expectancy gap 5) Empower citizens to remain independent in their own homes, taking an asset based approach to support carers, strengthen social networks and communities. 1.3 What will be different Prevention will be included as part of the clinical care pathway redesign, recognising primary, secondary and tertiary prevention. The CCG will work closely with multi-agency partners including Surrey County Council (Public Health, Adult Social Care) the district and borough councils, primary October 2017 Page 9 of 13
care and community providers to deliver the prevention agenda. The work will be aligned to the delivery of the national drivers contained in the Five Year Forward View: Radical upgrade in prevention and public health, including action on obesity, smoking, alcohol and workplace wellbeing initiatives NHS and other local employers improving the health of their workforce 2020 Goals - Government Mandate to the NHS Measurable reduction in child obesity as part of the Governments obesity strategy 100,000 people supported to reduce their risk of diabetes through the National Diabetes Prevention Programme To close the health gap between people with mental health problems, learning disabilities and autism and the population as a whole. 1.4 How will we get there Partners across the system in East Surrey have developed prevention plans, which are all aligned to the Surrey Health and Wellbeing Board priorities, and are interdependent. We will build on this work by identifying opportunities for joint working to strengthen and embed prevention across the whole system. 1.4.1 Support a good start in life, including delivering a whole systems approach to healthy weight and promoting emotional wellbeing and good mental health in children: Explore commissioning perinatal mental health services to improve mental health and wellbeing outcomes for mothers and their babies Support maternity providers to ensure early antenatal booking, smoking cessation, breastfeeding promotion (in line with UNICEF guidelines) and implementation of the outcomes of the Maternity Services Review Work with Surrey County Council (SCC) to develop an emotional resilience pathway that includes a preventative approach Support the Active Surrey Strategy to support 20,000 more children and young people to have an active start in life Support Surrey County Council Public Health to develop and roll out a multi-agency child and family healthy weight strategy Explore co-commissioning a healthy weight pathway for children requiring treatment, supporting referral into the Tier 2 service 1.4.2 Improve the health and wellbeing of working people through the development of workplace health and wellbeing programmes: Sign up to the Workplace Wellbeing Charter and support all Sustainability and Transformation Plan (STP) partner organisations to sign up to the Workplace Wellbeing Charter at achievement level or better, including implementation of the Wheel of Wellbeing within organisations to increase levels of personal emotional wellbeing in the local health and social care workforce Encourage NHS providers to implement the Eat Out Eat Well Standards to support the relevant national CQUIN October 2017 Page 10 of 13
Promote the national/local One You campaign and maximise opportunities to signpost residents to the One You website and resources Explore opportunities to embed Making Every Contact Count (MECC) locally, across health and social care staff and wider community Increasing awareness of dementia and how people can reduce their risk of developing it (e.g. life style factors). 1.4.3 Prevent the development of LTCs through primary prevention programmes focused on the major causes of ill health, including smoking, poor diet, lack of physical activity, alcohol, mental health and loneliness: Work with Surrey County Council Public Health to develop integrated health and wellbeing services that include behavioural change methodologies ranging from brief advice to more advanced and intensive interventions Embed early identification of alcohol misuse and brief interventions across primary and secondary care services and Alcohol Liaison services in secondary care Strengthen smoking cessation pathways across primary and secondary care and support providers to implement smoke free sites. Work with Surrey County Council to support schools in their approach to health and wellbeing by providing support in the Personal, Social, Health and Economic (PSHE) curriculum. 1.4.4 Improve health outcomes for people with LTCs, including cancer: through a staged approach of early detection, support for self-care and robust clinical management of LCTs; by addressing the physical health of those with mental illness to reduce the life expectancy gap; and through programmes on patient education and support for self-care: Continue to work with partners such as NHS England, SCC Public Health, Cancer Research UK and the newly formed Cancer Alliance to improve local uptake for national screening programmes, including cervical, breast screening and bowel screening Improve prevention and early detection of LTC s, through a combination of prioritised NHS Health Checks, the National Diabetes Prevention programme and case finding in primary care Continue to support GP Practices to refer patients at high risk of type 2 diabetes into the National Diabetes Prevention Programme, a ten month intervention programme designed to reduce their risk of developing the disease Develop approaches in self-care, including patient education and support programmes for LTC s, such as through the new diabetes community model planned for East Surrey Support primary care to actively promote robust management of LTCs including selfmanagement and shared care planning Embed referrals to Mental Health and Wellbeing Services, including exercise referral and IAPT (Increasing Access to Psychological Therapies) in primary care pathways for chronic disease Embed physical health checks in mental health pathways and ensure brief advice on physical activity is included in care pathways for mental health October 2017 Page 11 of 13
1.4.5 Empower citizens to remain independent in their own homes, taking an asset based approach to support carers, strengthen social networks and communities: Build on local work to implement a system-wide asset based community development approach to connect people through social prescribing i.e. Wellbeing Prescription Service and Care Navigators in addition to other approaches to non-medical and community support Support carers and community connections including identifying carers in GP Practices and extending the utilisation of digital technologies Work with statutory and voluntary sector partners to develop innovative approaches to promote and support self-care so that people are helped to stay healthy, manage their conditions effectively and understand how to access healthcare appropriately Explore commissioning and community integrated falls prevention treatment and management pathway including self-management. October 2017 Page 12 of 13
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