Manchester’s Primary Care Led Prevention Programme Our Approach to a Radical Upgrade in Prevention and Population Health

“to ensure the greatest fastest possible improvement to the health and wellbeing of the 2.8 million citizens of Greater Manchester

Vision Person Partner Place Person Partner Place Keep residents healthy Narrow the gap between healthiest and least healthy Aims- Use and strengthen assets that promote health Tackle social, “root-causes” of ill-health Early identification of Long Term Conditions (LTCs) - “finding the missing 1000s” Proactive management and optimisation of care for LTCs Aims- Use and strengthen assets that promote health Tackle social, “root-causes” of ill-health Early identification of Long Term Conditions (LTCs) - “finding the missing 1000s” Proactive management and optimisation of care for LTCs

Who is this for? Conventional Medical Risk Model Acute risk Rising Risk Latent Risk

Who is this for? Prevention programme model based on Mosaic socio-demographic data

Life Course Objectives Health of the unborn child – maternal mental and physical health and wellbeing Oral health improvement Proactive management of asthma Health of the unborn child – maternal mental and physical health and wellbeing Oral health improvement Proactive management of asthma Support for people who are out of work to move towards employment Support for healthy lifestyle choices in relation to smoking, alcohol, nutrition, physical activity and emotional health Identification and proactive management for undiagnosed hypertension, diabetes, COPD, lung cancer Strengthening assets - work/housing/social connections - that help improve health and wellbeing for people with physical and mental long term conditions Support for people who are out of work to move towards employment Support for healthy lifestyle choices in relation to smoking, alcohol, nutrition, physical activity and emotional health Identification and proactive management for undiagnosed hypertension, diabetes, COPD, lung cancer Strengthening assets - work/housing/social connections - that help improve health and wellbeing for people with physical and mental long term conditions Physical activity and other programmes with focus on falls prevention from mid-life Improve social connections for lonely and socially isolated older residents Start Well Live well Age Well

How will we achieve this? Person Partner Place Local residents (registered with primary care) Local residents (registered with primary care) PRIMARY CARE - One Team - GP Dentistry Pharmacy Optometry PRIMARY CARE - One Team - GP Dentistry Pharmacy Optometry Other community health and mental health services Community assets Voluntary & Community Sector Groups and Organisations

A story….

Connecting people with community assets that promote health One to one support for enabling healthy lifestyles Neighbourhood health development Integrated approach to prevention in primary care Strengthening assets that promote health and tackling social causes of ill-health Supporting healthy lifestyle choices (physical activity, nutrition, alcohol, smoking cessation, emotional wellbeing) Early identification of long- term conditions “finding the missing 1000s” Proactive management and optimisation of care for physical and mental long-term conditions Enabling Self Care

What are we going to do? Develop and deliver an infrastructure that enables sustainable, coherent and effective community based approaches to prevention Offer one to one support for enabling healthy lifestyles Holistic health coaching and advice Pathways into employment Support for mild to moderate mental health disorder (level 2 IAPT) Connect people with community assets that promote health Social prescribing plus & community link workers Knowledge mobilisation approach for One Team Maintain and improve quality and effectiveness for Voluntary and Community Organisations Timebanking development

What are we going to do? (2) Neighbourhood health development Neighbourhood health coordination Neighbourhood health development grant/fund Training in “healthy conversations” for wider public sector workforce Enabling Self Care Implement organisational approach Training and embedding learning for staff Peer support programmes (accessed via neighbourhood development) Integrated approach to early identification and proactive management in primary care Integrated primary care clinical pathways Primary care transformation peripatetic team

Impacts Improved self care Achieve: self-reported health & wellbeing of residents increased Gap between healthiest and least healthy narrowed Achieve: self-reported health & wellbeing of residents increased Gap between healthiest and least healthy narrowed Improved: outcomes for people with mental health conditions mental health and emotional resilience life expectancy associated with CVD, respiratory disease & cancer Improved: outcomes for people with mental health conditions mental health and emotional resilience life expectancy associated with CVD, respiratory disease & cancer Reduction in: unplanned hospital admissions for people with LTCs people admitted to hospital due to falls children admitted to hospital for tooth extractions unplanned hospital attendances for children with asthma Reduction in: unplanned hospital admissions for people with LTCs people admitted to hospital due to falls children admitted to hospital for tooth extractions unplanned hospital attendances for children with asthma

Stakeholder involvement Manchester City Council Acute hospital trusts Housing associations General Practice, Pharmacy, Dentistry, Optometry Manchester CCGs Carer’s Forum BME Forum Citizen’s Advice Bureau MACC Mind Healthy me Healthy Communities LGBT Foundation, Big Life Group, Manchester Carers Forum VCSE organisations including: Patient and Public Involvement