1. Integration and Transformation: The public health contribution to the Social Care Agenda Jim McManus, CPsychol, CSci, AFBPsS, FFPH Joint Director of Public Health Birmingham City Council Jim.mcmanus@birmingham.gov.uk

2. What’s in a name? “the science and art of preventing disease, prolonging life and promoting, protecting and improving health through the organised efforts of society” Sir Donald Acheson, 1988 “Decency, Freedom from infection, Labour, Dignity” Sir Alfred Hill, Birmingham’s first MOH, 1866-1903

3. The Technology that is Public Health Outcomes Art Science How does the technology which is public health apply to social care in the context of the Christie Principles?

4. Or: What can the DPH do for social care? Transition of public health in England – Health and Wellbeing Board Welsh Partnerships Scots Partnerships

5. Marmot, Christie or Ottawa? Doesn’t matter Just Do It!!!!

6. Why should Public Health Care about Social Care? Burden of avoidable ill-health Demographic and growing demands Benefits to citizens Preventing service use Moves people into self-care We cannot afford the coming time bomb Justice and fairness are public health values

7. Birmingham’s costs of care

8. Birmingham Life Expectancy 4th out of 8 Male 5th out of 8 female MaleFemale England 78.382.3 Sheffield 77.881.5 Leeds 77.782.0 Bristol 77.281.9 Birmingham 76.481.3 Newcastle 76.281.0 Nottingham 75.280.3 Liverpool 74.579.2 Manchester 74.079.1

9. Life Expectancy by Ward

10. Birmingham

12. Per cent 5 year olds achieving ‘good development score’* Birmingham LA, West Midlands & England * in personal, social and emotional development and communication, language and literacy Source: Department for Education %

13. Hot Food Takeaways and Children Over 930 Hot Food Takeaways (HFTs) in Birmingham – not including KFC, Burger King, McDonalds, Subway etc (1200+ then) Majority are within 400 metres of a home or school Positive link between proximity and an increase in obesity There are numerous schools with as many as 18 HFTs within 400m Our response Influence and inform Planning/Local Centres SPD to cap HFTs in local centres All head teachers to become a consultee on HFT applications within 400m of a school Public Health becomes a consultee on planning applications/developments and policy development

14. Christie Commission Principles public services are built around people and communities, their needs, aspirations, capacities and skills, and work to build up their autonomy and resilience; public service organisations work together effectively to achieve outcomes; public service organisations prioritise prevention, reducing inequalities and promoting equality; all public services constantly seek to improve performance and reduce costs, and are open, transparent and accountable.

15. Our Burdens of Disease PrimarySecondary Tertiary NOT ENOUGH DONE HERE MEANS… EVERYBODY ENDS UP HERE

16. Health and Care: Our Burden of Disease is not the right way round Primary Prevention Secondary Prevention Tertiary Prevention The shift to prevention

17. Contributors to overall health outcomes need to be understood Smoking 10% Diet/Exercise 10% Alcohol use 5% Poor sexual health 5% Health Behaviours 30% Education 10% Employment 10% Income 10% Family/Social Support 5% Community Safety 5% Socioeconomic Factors 40% Access to care 10% Quality of care 10% Clinical Care 20% Environmental Quality 5% Built Environment 5% Built Environment 10% Source: Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute. Used in US to rank counties by health status While this is from a US context it does have significant resonance with UK Evidence, though I would want to increase the contribution of housing to health outcomes from a UK perspective.

18. How might Prevention look in Social Care? Prediction forecast / target services Secondary Prevention Primary Prevention Universal & Well-being LOW MODERATE SUBSTANTIALCRITICAL Reduce numbers of people coming into high-cost services and moving along FACS banding Intensive Home Support Residential Care Community Equipment Services Telecare Service Tertiary Prevention

19. A (very) Simplified Commissioning Cycle Monitor Plan Review Need for Service and Effectiveness of existing services Contract The Commissioning Cycle This is used just to introduce the concepts of what PH can help you with. Later we use the Commissioning Cycle as shown on page 10 of Health Reform in England: Update and Commissioning Framework. DH, 2006)

20. Public Health Input into the Commissioning Cycle Monitor/ Evaluate Plan Review Need for Service and Effectiveness of existing services Contract/Deliv er Public Health Input into the Commissioning Cycle. Can be throughout or can be on specific areas playing to the PH strengths Community Engagement Support in establishing meaningful indicators of delivery and outcome Model whether need will Be met by proposed volume Check whether plans equate To evidence and need and Test for equity / inequity Support and advise on Evaluation and conduct Bits of it if enough resource Needs Assessments Equity Auditing Evidence of Effectiveness Health Impact Assessment Triangle of critical influence – where public health should be most visible Public Health Input into the Commissioning Cycle

21. Where we are at… We’re in the middle of applying public health to social care. Social care is an equal factor in health care use, cost avoidance and risk stratification Public health methodology can bring strong benefits –Evidence based best practice, and the silence of evidence –Viable metrics /outcomes (qualitative, quantitative) –Population perspective –Equity 21

22. The Public Health Toolbox applied to Adult Social Care Assessing Population Need Identifying Equity Critical Appraisal of Evidence Assessing Impact on Health Modelling Population and effects of interventions Community Engagement Economic Modelling of Interventions Access to wider sources of expertise Being Internal Consultants 6 Candidate interventions – Telecare, Dementia, Depression in Older People, Stroke, Carers, Falls Impact of cost and volume on system Designed Strategic Shift to Prevention

23. The Components Impact on the whole, not on the ringfenced budget Telecare expanding to Telehealth Data warehouse Risk Stratification and Prediction (73% accuracy falls) Falls Dementia Depression Carers Stroke Third Sector Development

24. Prevention Programme Principles Financial Business Case System redesign Focus on easy opportunities where outcomes are poor – falls, dementia, post stroke, etc Growing evidence in social care Telecare as a part of this Other programmes Prediction and data programmes

25. The Tasks Now 1.Understand the context set by our population and the differences between it and the rest of the UK/Scotland/England 2.Understand the big ticket issues we need to work on 3.Use specialist public health to impact on the £4bn +, not commission the £77m – 4.Stronger role for behavioural sciences

26. The Big Ask: What success looks like...£37million Range of targeted/ Flexible Services Support to service user /Citizens Number of those receiving preventive services Prediction and Prevention Self management Supported to stay in their Home Customer Satisfaction Increased Improved flexibility Increased Increased through community resources Increased through joint interventions People supported to manage LTC

27. The Outcomes A public health approach in social care should bring the following benefits: –Less people in residential care –More people independent –Less costs to NHS and Social Care –Fewer costs to GPs for those with long term conditions and disabilities –A way of monitoring the new market and micro- commissioning 27

28. Components of a Public Health social care model Population approach to –projecting need –Identifying risks – risk stratify –Targeting interventions Intervention and outcome design Emphasise Prevention (science & art) Joining up (housing and social care, primary care and social care) 28

29. A new care model and public health Increasing Means Increasing Needs Citizen purchased care – state resources Citizen purchased care – own resources Enablement Prevention Universal offer

30. Risk Stratification A tool to support the model we have outlined above Help shift the balance of care from the acute to primary and community sectors and improve services locally. NHS commissioners should be as interested in this as social care 30

31. Risk Prediction & Prevention Assessing risks of adverse outcomes and assigning people to these Multiple mathematical algorithms Need to include BOTH health and social risks Identify interventions known to succeed in mitigating risks Implement 31

32. Falls Prevention In Birmingham, over 40,000 older people have falls every year. 35% of over 65s experience one or more falls. 45% of over 80 who live in the community fall each year. By reducing the common risk factors and by providing appropriate equipment, falls can be reduced by between 10 - 40%. A person’s home environment can also contribute to the risk of falling. Ageing demography means all this will increase 50% by 2020

33. 33 Prevent Falls – project approach By providing a pathway for people who may be at risk of falling to get the help they need checklist to identify people at risk at falls and link to services and information Multi-agency: Birmingham City Council, Health Services, Third Sector Training for participants Programme management –part of wider prevention Public health evidence based Referral to a selection of agencies

34. Prevention of Falls - Process Target Population Persons over 50 years living in Birmingham

35. 35 Results to date Over 500 people supported All received information on preventing falls Average number of services requested per checklist – 2.6 requests per person Number of people having a fall since – 14% (46% before checklist) Over 66% were very confident that the information and services they received would help them prevent falls in the future There was a reported 3.7% improvement in quality of life One woman £11k Service User evaluation commencing

36. Timeframes of impact/yield Years 0151015 Planning Education Vitamin Supplements Air Pollution Decent Homes Jobs Primary Care 20 CVD Events Self Care Vitamin D and TB Rickets CVD Events Acute Bronchitis Admissions Respiratory Mental Health overcrowding educational attainment Life Expectancy Healthier space useChanging culture of activity Life ExpectancyMental Health

37. Thankyou! Jim.mcmanus@birmingham.gov.uk until July 12 2012Jim.mcmanus@birmingham.gov.uk Jim.mcmanus@hertscc.gov.uk from then or jim.mcmanus1@nhs.netJim.mcmanus@hertscc.gov.uk jim.mcmanus1@nhs.net