Supporting Information

Context within which this strategy is produced

1.         National Context

 

‘The ambition is for health and wellbeing boards to go further than analysis of common problems and to develop deep and productive partnerships that develop solutions to those commissioning challenges, rather than just commenting on what those problems and challenges are. Building on enhanced JSNAs, the Bill places an additional duty on the local authority and CCGs to develop a joint health and wellbeing strategy for meeting the needs identified in the relevant local JSNA are to be met. This could potentially consider how commissioning of services related to wider health determinants such as housing, education or lifestyle behaviours can be more closely integrated with commissioning of health and social care services. Once again, this function is to be undertaken through the health and wellbeing board. In line with other local authority committees, the health and wellbeing board is able to request information for the purposes of enabling or assisting its performance of functions from the local authority and certain members and persons who are represented on the health and wellbeing board. In preparing JSNAs and joint health and wellbeing strategies, local authorities and CCGs must have regard to any guidance issued by the Secretary of State and to the Secretary of State’s mandate to the NHS Commissioning Board. The NHS Commissioning Board must appoint a representative to participate in preparation of JSNAs and joint health and wellbeing strategies. The joint health and wellbeing strategy may consider services beyond health and social care – how the commissioning of health and social care services, and wider health-related services, could be more closely integrated – enabling the board to look more broadly at factors affecting the health and wellbeing of their populations. Both JSNAs and joint health and wellbeing strategies must be published.’

 

A key element of the health reforms is the move towards commissioning for outcomes; rather than the current situation which is commissioning to achieve targets, that often relate to process, not outcomes.

 

The national ambition is to deliver outcomes that are amongst the best in the world, supported by three outcomes frameworks:

• The NHS Outcomes Framework,
• The Public Health Outcomes Framework and
• The Adult Social Care Outcomes framework

 

The three outcomes frameworks will drive future commissioning and thus are critical to the context of our health and Wellbeing strategy for Kent.

 

NHS Outcomes Framework

 

The NHS Outcomes Framework is structured around five domains, which set out the high-level national outcomes that the NHS should be aiming to improve. They focus on:

 

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; and
Domain 5	Treating and caring for people in a safe environment; and protecting them from avoidable harm.

 

 

Overall the NHS Outcomes aspiration is to:

• Reduce years of life lost from conditions amenable to health care intervention and improve under 75yrs of age life expectancy.
• Improve health related quality of life for people with long term conditions.
• Improve experience of people of the care they receive.
• Reduce emergency admissions (for acute conditions that should not usually require hospital admission) and readmissions within 30 days of discharge
• Reduce the number of patient safety incidents including those that result from sever harm or death.

 

 

Public Health Outcomes Framework

 

In January 2012 the Department of Health published ‘Improving Outcomes and Supporting Transparency. Part 1 A public health outcomes framework for England, 2012 to 2016’. The framework is geared to refocus around achieving positive health outcomes for the population and reducing health inequalities.

 

The framework is focused on two high-level outcomes which are:

1.                  increased healthy life expectancy

2.                  reduced differences in life expectancy and healthy life expectancy within and between communities

 

It is acknowledged that improvements in these outcomes make take years – sometimes even decades- to see marked change. Thus a set of supporting public health indicators have been developed to show how well we are doing year on year. These are as follows:

 

Domain 1	improving the wider determinants of health
Domain 2	health improvement
Domain 3	health protection
Domain 4	healthcare public health and preventing premature mortality.

 

 

Social Care Outcomes Framework (ASCOF)

 

 

The ASCOF is a set of outcome measures, which have been agreed to be of value both nationally and locally for demonstrating the achievements of adult social care. They are not a performance measurement tool but have been devised nationally to guide local commissioning and provision of service.. The framework will allow benchmarking and comparison with other areas which is critical to local accountability of councils and reporting to their citizens on a consistent basis

Again, the ASCOF is structured into four domains as follows:

 

Domain 1	Enhancing quality of life for people with care and support needs
Domain 2	Delaying and reducing the need for care and support
Domain 3	Ensuring that people have a positive experience of care and support
Domain 4	Safeguarding people whose circumstances make them vulnerable and protecting from avoidable harm

 

 

Delivery of these outcomes will require collective effort over all parts of the Kent system and Kent population and provides the opportunity for systematic coherence in order to protect and improve the health of the people of Kent.

 

2.         Local Context

Bold Steps for Kent

 

Bold Steps for Kent sets out how Kent County Council needs to change the way it works to reflect the changing shape of public services, as the Government has set out plans to fundamentally reform how key public services, such as education and health, will be provided in the future, underpinned by the clear message that residents should have more influence on how services are provided locally.

 

There are three clear aims that run throughout Bold Steps for Kent:

·        To help the Kent economy grow - We must support and facilitate the new growth in the Kent economy by delivering the priorities in our regeneration framework Unlocking Kent’s Potential, by delivering new housing and new infrastructure and by working with key business sectors.

·        To put the citizen in control – power and influence must be in the hands of local people so they are able to take responsibility for their own community and service needs.

·        To tackle disadvantage – We will make Kent a county of opportunity where aspiration rather than dependency is supported, particularly for those who are disadvantaged or who struggle to help themselves and their family.

More specifically the County set out the following in relation to Health:

 

Bold Steps for Health

The health reforms proposed by the Government will give greater power to GPs to choose the best services for their patients, with local government having strategic responsibility to ensure the County’s health needs are met. We must use this opportunity to improve the quality of the health service in Kent.

• We will help ensure that GP commissioning plans meet the health needs of all residents and communities in Kent. Working at County and District level we want Locality Boards to play a key role in this commissioning process, better connecting KCC and wider public services with health provision at the local level.
  
  
• We will work with GP consortia to encourage new healthcare providers to enter the market for health services in Kent. This will drive up standards, provide competition, increase choice and drive greater value for money for GPs and patients.
  
  
• We will work to join up and integrate health and social care service provision to reduce costs and demand that could be avoided - for example, by joining up our assessment processes.
  
  
• We will focus on a preventative approach to public health, supporting people to make better lifestyle choices and consider their own future health needs – so expensive health services aren’t required as frequently as now.

 

3          Summary

 

The context within which this Health and Wellbeing Strategy is produced reflects not only the national changes happening in a reorganising NHS and Local Authority environment, but also in a context of national and local aspiration to improve health outcomes, reduce health inequalities and integrate care in order to improve the health of the population of Kent.

 

 

 

Summary and priorities from the Joint Strategic Needs Assessment

 

What are the big issues in Kent and how can we get the biggest health gains for Kent?

 

National policy emphasises a life course approach towards improving health inequalities and health and wellbeing, where a combination of health, social and economic factors affect people’s health outcomes at different periods in their lives. In Kent, a number of priorities have been suggested orientated around five main areas:

 

1. Early Years

Improving the continuation (and recording) of breastfeeding rates beyond six weeks.

 

There is no doubt over the benefits of breastfeeding towards health and wellbeing of children. However breastfeeding is not being sustained into the early months of infancy for a large number of children. The rates of breastfeeding in Kent drop from around 70% at birth to 25% at six months of age.

 

Health and social care organisations need to fully implement key recommendations from the Healthy Child and Baby Friendly Initiative Programmes, in order to improve the uptake and continuation of breastfeeding.

 

Improving MMR uptake as well as general routine immunisation rates and reduce variation in general practice coverage to ensure herd immunity and prevent future epidemics.

 

The current MMR vaccination rates by Year 5 are 84% and 87% in east and west Kent respectively, well below the 95% coverage required for herd immunity (the level at which risk of spread of infection is reduced)

 

This will be achieved through closer working between the immunisation and vaccination coordination service and GP practices, utilizing a targeted approach to those practices and vulnerable population groups where uptake is lowest. Social marketing campaigns and improved monitoring systems.

 

Using Children Centres more effectively to deliver integrated services to

vulnerable high risk families

 

This includes services such as health visitors delivering messages around health promotion and behaviour change such as reduction of second hand smoke, alcohol and substance abuse, domestic violence and improving healthy weight and emotional wellbeing.

 

 

 

2. Young People and Lifestyle choices

The numbers of young people drinking responsibly has increased in Kent as it has nationally, and fewer children drink. However the small number of young people who do drink at increasing risk or higher risk levels and those who regularly binge drink are likely to be drinking more hazardously. 11% of 11- 16s in the Kent Children’s Smoking Drinking and Drugs survey (2008) indicated that they did drink alcohol most days or once or twice a week. They are also likely to be from a more vulnerable group of young people. In the same way, although most children will not misuse drugs, and most of those young people who do experiment will not continue to do so, these more vulnerable young people are more likely to continue in dangerous drug use. This small group of young people in Kent are likely to have multiple risk factors such as parental substance misuse, family breakdown, domestic violence, poverty, truancy or school exclusion. They show significant levels of poor physical and mental health as well as poor sexual health and substance misuse issues. They are often disengaged from school as a result of behavioural issues, and are more likely to be ‘Looked after Children’ or known to the Youth Offending Service. The more vulnerable the young person is, i.e. the more risk factors they have: the more likely it is that the child will misuse drugs, alcohol and tobacco.

 

Young people benefit from life skills approaches to early intervention. They need to be engaged in learning and in school: and positively engaged in activity to build resilience over time through developing friendships, life skills and positive social peer networks. Positive relationships with adults in specialist services who understand the needs of young people and adolescent behaviours like substance misuse and risking sexual health are also needed. Currently, there are specialist services commissioned to tackle young people’s substance misuse needs, and this includes understanding the dangers and consequences of a range of risk-taking behaviours. The DUST screening tool is promoted to identify those who need help, and further work is being developed in 2012 to support those families and young people in greatest need in Kent and help them to tackle their problems.

 

 

3. Prevention

 

Percentage of health years of life lost due to behavioural factors in wealthy nations.

Cabinet Office (2010) Applying behavioural insight to health

 

Significant variation in the prevalence of unhealthy lifestyles exists across the 12 districts, often linked with deprivation.

80% heart disease, stroke and type 2 diabetes, and 40% cancer could be avoided if common lifestyle risk factors were eliminated. Smoking, high blood pressure and alcohol contribute to the largest proportion of healthy years life lost [Figure 3]. Therefore, people, who are at future risk, need to be identified early enough and their lifestyle and behaviour should be modified accordingly through self management, supported by social marketing campaigns such as Change 4 Life and integrated frontline services such as Stop Smoking, IBA (Alcohol), and Healthy Weight. Therefore, the rollout of the national Health Checks programme across Kent needs to be accelerated across the county and a specific focus on keys areas such as Thanet and Swale.

 

 

4. The Shift to Out of Hospital Care

The population of Kent in the older age group (65+ and 85+) is predicted to increase significantly over the next 5 to 10 years. This is a demographic bubble leading to disproportionate numbers of older folk in our population. It is just emerging now and expected to persist for the next 25 years or so. This bubble along with the changing nature of longevity and health deterioration, has led us to consider major changes to the way the health and social care system work.

 

The system we operate comprises myriad silos of care, with inherently high levels of referral out of one and back to another. There is limited coordination and integration between them. The environment is such that, these transfers from one isolated part of the system to another, almost occur by default for reasons of infrastructure and culture. For example after hours care providers do not usually have access to information from the patient record, other providers who may need to make decisions in isolation e.g. community matrons, may be similarly disconnected from the central primary care information store. As a result, emergency admissions in the elderly for falls and dementia have increased by more than 50% and 85% respectively over the last 5 years.

 

Risk stratification of the Kent population is urgently required to pro-actively identify complex elderly patients in need of a multi disciplinary integrated approach (across primary care, community, and acute care and social services) towards crisis response and support, and exacerbation management ultimately resulting in hospital admission avoidance.

 

Risk stratification – key points

Predictive risk models are used for predicting events such as unplanned hospital admissions, which are undesirable, costly and potentially preventable.

 

Such models have been shown to be superior to other ‘case finding’ approaches, including threshold models and clinical opinion. Although the Department of Health has previously funded two predictive models for the NHS in England, the current policy is to promote an open market in terms of suppliers of risk tools.

Commissioners should consider a range of factors when choosing whether to ‘make or buy’ a predictive model, including the outcome to be predicted, the accuracy of the predictions made, the cost of the model and its software, and the availability of the data on which the model is run.

 

Predictive models should be seen as one component of a wider strategy for managing patients with chronic illness.

 

In NHS Blackpool, risk profiling was used to target resources more effectively to reduce unplanned care activity, using the combined predictive model. Approximate annual spend is around £26 million per year and makes up 65% of occupied bed days. The model used primary care and hospital data, (inpatient, outpatient and A&E data). The initial results showed that out of the 150,000 population in Blackpool approximately 765 patients were identified as very high risk generating more than 2,639 unplanned admissions in the previous year and the admissions avoided (323) if the necessary clinical intervention was delivered, generating £586,000 in gross savings. Apart from the benefits of identifying very high risk patients the tool enables access to real-time clinical patient data and prioritisation of community matron workload. Nuffiield Trust (2011)

 

5. Information sharing

The successful delivery and evaluation of programmes will depend on developing more robust arrangements for sharing information between health and social care organisations. For example use of an identifier such as NHS number will help to understand how patients access services across the continuum of care.

 

 

In summary the Kent JSNA in totality has pointed to a large number of priorities.

 

Specifically it highlights the following as priorities for Kent:

• Early Years
• Improving breast feeding rates
• Improving coverage of immunisations
• Improving the use of children and families centres
  
  
• Young people and lifestyle choices

 

• Prevention
• Reduction in risk from life style behaviours
• Roll out of Health Checks
  
  
• Shifting care to outside hospitals
• Risk profiling
• Provision of integrated care teams
• Move to self management
  
  
• Information sharing between organisations