Whole system working in Cheshire and Merseyside

Melanie Sirotkin –Centre Director, PHEFiona Johnstone –Director of Public Health, Policy & Performance, Wirral Counciland Chair of Champs

2

Nine local authorities covering a population

of 2.4 million people

3

Cheshire and Merseyside SystemCheshire & Merseyside

Public Health England Centre

9 Local Authorities – supported by

CHAMPs Network

• 2 x NHS England Area Teams

• 12 x CCGs

Voluntary & Independent

Sector

Health & Wellbeing

Board

4

What’s it like out there? – Wider determinants

• Deprivation – 5/9 authorities in the most deprived quintile. Child poverty and older people in deprivation is worse than the England average.

• Unemployment - higher than England average in 6/9 authorities (2011/12).

• Income - average weekly pay is lower than the England average in 8/9 authorities.

Index of Deprivation, 2010, %, Cheshire & Merseyside (comparing to England average)

5

What’s it like out there? (PHOF)*

*Compared to England average

• Life expectancy in both males and females is lower in most (8/9) local authorities.• Higher preventable mortality (liver disease, CVD, cancer)• Similar or better – health check offer but poorer health check take up.

• Rates of low birth weight better than or similar to. • Lower breast feeding rates.• Teenage conceptions lower or similar in 6/9 authorities.

• Excess weight in 10-11 year olds worse than or similar to (most authorities).• Similar levels of physical activity.

• Similar or less smoking in routine and manual groups.• Successful completion of drug treatment (opiate and non opiates –similar or better)

• Good coverage MMR, HPV and flu (at risk).

• Higher rates of injuries due to falls.• Emergency re-admissions within 30days of discharge from hospital is worse than

England average

6

Health and care indicators, 2011, %, Cheshire & Merseyside (comparing to England average)

Health & Care Indicators

7

What’s it like out there – North West mental health and wellbeing survey - key findings• All nine local authority areas within Cheshire and Merseyside (C&M)

participated in the 2012/13 North West survey.

• The WEMWBS scores varied in significance for the 9 local authorities with 2 showing an improvement between 2012/13 and 2009.

• Overall 15.3% of respondents had ‘low’ mental wellbeing, 64.1% had ‘moderate’ and 20.6% had ‘high’ mental wellbeing. This varied widely across the nine local areas.

• The mean life satisfaction score for Cheshire and Merseyside was significantly higher than the North West mean.

Source: North West Mental Health and Wellbeing Survey 2012/13

What’s it like out there?• Strong traditions of music, arts, culture

and sport rich heritage – castles, parks, historic building

• Vibrant voluntary sector – Change up consortium in Greater Merseyside working with 18 organisations and investing in voluntary, community and faith groups

9

Top 5 priorities from the Local Health and Wellbeing Board Strategies

• Mental Wellbeing• Children• Alcohol• Older people• Sustainable places

Champs public health collaborative serviceLed by the 9 Cheshire and Merseyside local authority Directors of Public Health, facilitated by a support team.

Owned and delivered by our local public health teams.

Generates efficiencies and improves service quality and outcomes.

It does this across four key areas:

• Improving commissioning

• Advising the NHS

• Protecting health

• Leading public health

Key successes• Mental health

• Asset based approaches • Mental health champions• Suicide prevention

• Behaviour change• PHE mental wellbeing pilot • Breastmilk It’s Amazing campaign• Pharmacies campaigns

• Sector led improvement• Health Checks review• National Child Measurement

Programme review• Sexual Health review

Healthy placesAn innovative large scale change programme.

A fresh approach to working with our commercial, public and 3rd sector partners.

Our aim is to support communities to create their own healthy places to live.

Ultimately, it’s about prevention and reducing reliance on services.

Shaping healthy placesCW&C – the journey so far

Caryn Cox – Director of Public HealthCheshire West and Chester Council

Wholesale changes to healthy system

Public health moved into the local authority

Planners unsure of how to engage with ‘health’

Raft of guidance and evidence already out there

Public health - no understanding of where health fitted into existing planning processes

The background

Established links with planners – strategic/spatial and development control

Public health hosted and facilitated a meetingCCGs x 2CSU – Cheshire and Merseyside Local authority plannersNHS England NHS PropCoPublic Health England

Commissioned health planners to audit existing processes and recent planning applications to understand baseline“Better Health Outcomes Through Spatial Planning”

Getting started and the baseline

The journey continuesLocal development framework consultation – significant PH submission and all key stakeholders also submitted

Agreement to develop a Supplementary Planning Document (SPD) as part of the Local Plan on Health and Wellbeing

Preparing evidence for the Community Infrastructure Levy (CIL)

All significant planning applications pass through Public Health

Active member of SPAHG (Spatial Planning and Health Group) and strong links with WHO at UWE

Housing links – local authority and RSLs

Healthy Places – new key area for ChaMPS

Cheshire & Merseyside PHE(North West KIT)

Key Assets for RecoveryTom Hennell

Friday 4th April 2014

19

Long-standing illness and wellbeingHealth Survey for England 2011; weighted for non-response

0% 20% 40% 60% 80% 100% 120%

lowest

fourth

third

second

highest

Qui

ntile

s of

Wel

lbei

ng (W

EMW

BS

scor

es)

percentages of quintile populationlimiting illness non-limiting illness no illness

20

Long-standing cardiovascular conditions and wellbeingHealth Survey for England 2011; weighted for non-response

0% 1% 2% 3% 4% 5% 6% 7%

lowest

fourth

third

second

highest

Qui

ntile

s of

Wel

lbei

ng (W

EMW

BS

scor

es)

percentages of quintile populationnon-limiting illness limiting illness

21

Observations on long-standing illnesses from population surveys

Long-standing conditions characteristically progress from being ‘limiting’ to being ‘non-limiting’.

The proportion of persons reporting a long-standing condition, and experiencing it as non-limiting/limiting, is an indicator or recovery/non-recovery.

Higher levels of positive wellbeing are associated with lower levels of limiting long-standing illness; through increased capability at ‘getting ill better’.

22

Odds of reporting long-standing illness as limitingHealth Survey for England 2011; adjusted for age, sex, and

employment status

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0

lowest

fourth

third

second

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Qui

ntile

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Wel

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Adjusted Odds Ratio

23

Odds of reporting long-standing illness as limitingHealth Survey for England 2011; adjusted for age, sex, employment status and EQ5D components (pain, anxiety, mobility, self-care, daily activities)

0.0 0.5 1.0 1.5 2.0 2.5 3.0

lowest

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second

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Adjusted Odds Ratio

24

Two agendas for Public Health‘Getting ill less’:

interventions aimed at reducing incidence of illness, through reducing exposure to avoidable health risks.

‘Getting ill better’:Interventions aimed at earlier recognition of illness, and reducing

inhibitions against becoming ill.Interventions aimed at reducing duration and recurrence of illness,

through improving access to recovery assets; and reducing inhibitions against recovery.

25

'Not good' general health, and household income per headadjusted odds ratios for persons aged 16+ in Health Survey for England 2011

0 1 2 3 4 5 6

highest income

second

third

fourth

lowest income

quin

tiles

of e

quiv

alis

ed h

ouse

hold

in

com

e

adjusted odds ratio; highest income quintile = 1.00

adjusted for age

adjusted for age, sex, education,ethnicity, drinking, smoking, dietand obesity

26 Presentation title - edit in Header and Footer

Proposed ‘characteristics of recovery’derived from reported experience of recovering persons; together with analyses of

self-reported limiting long-term illness in Health Survey for England and British Household Panel Survey.(see Bartley et al. JECH 2004; 58, 501-506)

Recovery is:Universal; everyone is potentially able to recover, given access to recovery

assets, and non-exposure to inhibitions,Non-clinical; recovery is to be distinguished from discharge from clinical

treatment or long-term condition management,Transformational; recovery is conditional on acquiring the capability to change

social context, such that the condition does not recur,Communicable; recovery is best achieved when co-produced within a

community of recovering persons, supporting practitioners and reciprocal social partners.

27

Jobs, Homes, FriendsEmployment and Job Security

Being able to retain employed status while recovering; together with flexibility and capability for adjusting employment conditions to support recovery and reduce risk of recurrence.

Housing and Financial Security Having access to secure and sufficient housing to support recovery; allied to

assurance of sufficient financial resource (especially including access to benefit income) for housing to be sustainable without creating or exacerbating problems of debt.

Wider Social Engagement and Shared RecreationSpecifically, having access to mutual support from other recovering persons –

as in ‘recovery communities’; but more widely in regular, non-work, engagement with friends and local neighbours outside of the immediate household, offering trust and being trusted.

Supporting local decision-making

- the i-hit tool -

Clare Perkins and Matt HennesseyKnowledge and Intelligence Team (North West)

i-hit• Originally developed by the former North West Public Health Observatory, with

Liverpool John Moores University, to support Salford PCT/LA and their partners in understanding where to invest to achieve maximum gain in life expectancy

• Salford wanted to develop a model that would predict the effect on life expectancy of improving key determinants of health, through investment in effective public health interventions. To better understand the ‘causes of causes’ and to identify priorities for multi-agency investment

• i-hit models statistical associations between indicators in the health profiles, using Bayesian mathematical methods and conditional independence algorithms, and quantifies the scale of change needed across all the health indicators to achieve ambitions for life expectancy

• The tool demonstrates that to achieve sustained health improvement, effort is needed across the spectrum of determinants of health

29 Engaging with Health and Wellbeing Boards and Wider Partners; the i-hit tool

30 Engaging with Health and Wellbeing Boards and Wider Partners; the i-hit tool

Click icon to add picture

32 Engaging with Health and Wellbeing Boards and Wider Partners; the i-hit tool

Scenario: What is the scale of change needed to improve life expectancy for men by 2 years?

33 Engaging with Health and Wellbeing Boards and Wider Partners; the i-hit tool

Scenario: What is the scale of change observed if we reduced adult smoking in Salford to the national average? Note the effect on child poverty and wider social determinants

34 Engaging with Health and Wellbeing Boards and Wider Partners; the i-hit tool

Scenario: What is the scale of change observed if GCSE attainment equalled the current national average? Note that life expectancy (males) would increase by over 4% and unemployment would be down by nearly 60%

Next steps for i-hit

Stage 1 (in progress)

• Refresh with recent data from Public Health Outcomes Framework and produce new map

• Increase map interactivity

• Scale up the tool for piloting across North West Local Authorities and Health and Wellbeing Boards

Stage 2

• Model impact for different geographies

• Develop functionality to be able to:

1) ‘fix’ indicators in the tool

2) model changes in multiple indicators ‘on the fly’

35 Engaging with Health and Wellbeing Boards and Wider Partners; the i-hit tool

Impact of i-hit in Salford• The tool was used in Salford to develop a

long list of priorities and to consider the scale of the challenge

• It increased the Board’s focus on social determinants of health which became one of the key priorities

• It strengthened wider stakeholder engagement in considering inter-relationships of factors e.g. smoking and child poverty, violent crime and life expectancy

• Shaped the scale of challenge – creating more realistic scaled challenges for the first three years of the strategy alongside aspiration for long term goals

36 Engaging with Health and Wellbeing Boards and Wider Partners; the i-hit tool

Local firstForthcoming National tools to support the local systems:

• National conversation on Health inequalities

• Health and Wellbeing Framework for England and menu of interventions

• Alcohol licencing support pack

Forthcoming NoE/Centre tools to support the local system:

• PHOF summary tool

• Health Equity North

• Horizon scanning for emerging issues

• Child health resource pack

• Working with NHS England to identify local data requirements

37

Wellbeing SeftonDr Janet Atherton

Director of Public Health

Sefton’s Award WinningArts on Prescription Programme for adults with mild to moderate depression, stress or anxiety

Creativity flourishes in Sefton

• Seed- ‘Arts & Health pilot’ in 2005• Roots- ‘Invest to Save’ three year

funding• Shoots- Weekly workshops in four

locations NHS Sefton/Council joint funding

• Fruits- Creative Alternatives as a jewel of The Atkinson Centre- ‘Sefton’s Centre for Wellbeing through Culture &Creativity’

Rooted & growing in Sefton

• Labyrinths• Mazes• Heritage walks• Exhibitions• Creativity with vulnerable

groups• Go with the Flow• Volunteering

The Impact?

The Data• I have struggled with anxiety since I was fourteen but

never found effective help. For me Creative Alternatives was a final attempt.

• At Creative Alternatives no one judged me, problems were shared and I have formed some special friendships.

• I have done many things through the programme which I never would have thought possible – they have encouraged me out of my comfort zone.

• Creative Alternatives has really increased my confidence in travelling to different places.

• Since leaving the programme I have been doing voluntary work. This was a big achievement for me as I had not worked for nine years as a result of anxiety. I loved seeing what a difference I could make to other people.

• I have halved my medication and now feel more in control of my anxiety, it doesn’t stop me from doing things as much as it used to, now I am living my life instead of just existing.

Case Study: Joanne’s StoryWellbeing• 78% improvement in mental wellbeing SWEMWEBS

measure 3.5 point shift from low to medium wellbeing

Lifestyle improvements• Physical activity 66%• Diet 36%• Increased social activity 68%• Smoking cessation 29%• Alcohol reduction 32%• Reduced medication 32%• GP visits reduced 34%

Social Return on Investment• £6.95 for every £1 invested

£6.95 for every £1 of expenditure

43

Sefton results:

5 point improvement on a 35 point scale from 20 to 25

Moving from low wellbeing to moderate wellbeing

Promote Prevent Recover

• SEAS- Sefton Emotional Achievement Service delivered in Sefton schools

• Wellbeing Sefton- a collaborative of social prescribing providers targeting adults with low wellbeing

• Recovery College- an approach by Mersey Care enhancing the talents, skills and resources of service users to support their own recovery

Community Wellbeing

• Building community resilienceCommunity asset development in 3 localities: ‘Fair Deal’ five ways to wellbeing kit utilised for community engagement

• Integrated Wellness Service- a holistic approach to individual and community wellbeing

• Green infrastructure for wellbeing• Healthy Streets

Champs Mental Wellbeing Programme

• Commissioning for mental wellbeing outcomes• Brief Intervention• Integrated Wellness Services• Social Prescribing• Leadership & Workforce Development• Public awareness- PHE marketing Five Ways• PH role in reducing burden of mental illness• Mitigating the impact of welfare reform

Steps to flourishing

• Vision & drive• Opportunities seized• Creativity• Partnerships• Evidence• Influence• ££ ?

Public Health Approach to addressing Domestic Abuse in Knowsley

Matthew AshtonDirector of Public Health

Knowsley MBC

Overview• Background

• Process

• Key findings

• Political scrutiny

• Scrutiny Recommendations

• Key messages

Background• Domestic abuse is a significant public health issue, having a

major impact upon those directly affected and their families.

• Locally, it had been raised as a issue at the Safeguarding Children’s Board and through the wider Knowsley Partnership.

• Previous needs assessments (and consequently services) developed from a Community Safety perspective.

• Need for new needs assessment from health perspective

In Knowsley1 in 3 females smoke

1 In 3 females suffer from domestic abuse

1 in 8 females have Cardiovascular Disease (CVD) – Heart disease and strokes

1 in 9 females drink alcohol at increasing & high risk levels

1 in 15 females have coronary heart disease (CHD)

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Population impact?Domestic abuse incidents (N =3409)

Domestic abuse crimes (N = 489)

Sanction detentions (N = 318)

Court cases (N = 288)

Successful convictions (N = 204)

Aims of Needs AssessmentThe aims of the needs assessment were; • To assess the levels of domestic abuse, and health and wellbeing

needs of those affected in Knowsley

• To identify the causes and drivers of domestic abuse

• To explore the links between domestic abuse and other risk taking behaviours

• To investigate the extent to which current service provision is

addressing the needs

Process

• Conduct Literature / evidence review

• Data intelligence collation and analysis (incl. service mapping and intelligence)

• Stakeholder engagement

• Scrutiny review

Overview of trendDomestic abuse Offences/crimesKnowsley Domestic Abuse Service ReferralsHousing issues / homelessness presentations

Incidents (police)A & E - Home AssaultsNational Survey prevalence

Financial Impact in Knowsley£56m human and emotional

£11m housing, civil, legal employment and other costs.

£3.8m physical and mental health care costs.

£2.4m criminal justice costs.

£452,000 social care costs.

• 76%Human and Emotional Costs

• 15%Housing, Civil and Legal Employment Costs

• 5%Physical and Mental Healthcare costs

• 3%Criminal Justice Costs

• 0.6%Social Care Costs

Calculated using estimates from (Järvinen et al, 2008) for domestic violence. Total annual cost to Knowsley economy estimated as £73 million.

Health and Wellbeing Needs – Victims and their children

VictimsShort term• Physical health (minor – severe)• Sexual health• Eating disorders / self harm• Fear and safety concerns (safety primary

concern)

Short and long term• Mental health and wellbeing (depression,

suicide, self harm, confidence, self esteem)

• Substance misuse (particularly alcohol)

• Housing• Employment & Poverty• Difficulties with relationships (intimacy,

trust)

• Isolation

Children and Young people• Mental health and wellbeing• Behavioural and emotional

problems• Links with substance misuse • Child Maltreatment and Child abuse

– identifying and dealing with it• Education / housing• Unsettled childhoods

• Long term impacts affecting life chances

• Links with crime, gangs and violence.

Political Scrutiny

• Scrutiny review by elected members on the draft needs assessment to;– Inform, sense check and develop

recommendations

• Three evidence sessions, involving expert witnesses, plus visits to MARAC and NICE stakeholder session

Identified needs / issues

Data / intelligence

issues

Strategic approach –

systems

Primary prevention

Support for victims

Support for affected children

Dealing with perpetrator

needs

Scrutiny recommendations• That the strategic approach to domestic abuse be reviewed

• That data and intelligence issues in relation to domestic abuse be resolved

• Seek all opportunities to break the cycle of domestic abuse through a greater focus on prevention

• That support for victim survivors is reviewed

• That support for affected children is reviewed

• That the way perpetrators are dealt with is reviewed

Key messages• Domestic Abuse is a significant public health issue in Knowsley

• Applying a public health approach to the needs assessment important

• Involving members through scrutiny of draft needs assessment was integral to raising profile, gaining ownership and development of recommendations.

• It raised issues for local authority and health commissioners, wider public sector and providers about referral processes and support services

• Addressing mental health problems, alcohol issues and healthy relationships potentially could significantly impact on domestic abuse levels.

• Current focus on dealing with consequences rather than prevention

Communication StrategyMethods

PostersPostcardsBeermatsBus / TaxisMedia ReleasesFacebookTwitterCommunity MessagingOne Stop ShopsGP Practices

Questions?

Matthew.ashton@knowsley.gov.uk

Recommendation 1

That the strategic approach to domestic abuse be reviewed by:

• Considering the strategic governance arrangements for domestic abuse;

• The council and its partners considering joint commissioning arrangements for domestic abuse specific services to enable a more flexible use of resources;

• Services focussing on addressing the behaviour of perpetrators as well as

resolving the needs of the victim survivor; and, • Standards/expectations being developed in the response times to resolve

domestic abuse incidents completely.

Recommendation 2 That data and intelligence issues in relation to domestic abuse be

resolved through: • Undertaking further work to improve the recording of domestic

abuse across partner agencies and exploring other sources of insight (particularly for teenage intimate partner violence and child on parent abuse); and,

• Exploring opportunities for the streamlining of referral forms from

various agencies to ensure a consistent approach and improving referral processes particularly from the Vulnerable Persons Unit (VPU).

Recommendation 3 Seek all opportunities to break the cycle of domestic abuse through a greater focus

on prevention by: • Developing a systematic approach to the primary prevention of domestic abuse; • Considering the inclusion of evidence based programmes on violence and

domestic abuse within the school curriculum and ensuring that their effectiveness is assessed;

• Investigating further the content of parenting programmes and exploring the introduction of a specific module on domestic abuse; and,

• Developing work with Her Majesty’s Prison Service that explores the use of more

domestic abuse programmes/modules on programmes for prisoners where domestic abuse isn’t necessarily their trigger offence.

Recommendation 4

That support for victim survivors is reviewed by: • Considering the threshold level and pathways

for low-medium risk victim survivors; and, • Delivering training on domestic abuse

awareness and how to support those affected to all front line responders including the police.

Recommendation 5 That support for affected children is reviewed by: • Evaluating the effectiveness of programmes to identify and support the needs of children

affected by domestic abuse and show they make a difference; • Reviewing the support for children affected by domestic abuse that fall below the threshold

for wellbeing support and identify whether their needs are being adequately addressed;

• Collecting insight from children and young people on the impact of domestic abuse and using this information to inform commissioning decisions; and

• Testing the feasibility of rolling out Operation Encompass across Merseyside, through police colleagues given that some of Knowsley’s school age children may attend schools across local authority boundaries.

Recommendation 6 That the way perpetrators are dealt with is reviewed by: • Assessing the long term effectiveness of existing perpetrator programmes; • Exploring the reasons why there are disproportionately higher levels of cracked and

ineffective domestic abuse trials in Knowsley;

• Exploring the greater use of sanctions for perpetrators who do not attend or complete community perpetrator programmes;

• Considering the use of civil action against perpetrators of domestic abuse where criminal convictions are not possible; and,

• Considering the broader use of Integrated Offender Management (IOM) for domestic abuse offenders to allow for a more intensive intervention to reduce the risk of reoffending and the risk of harm.

Asset based alcohol and drug recovery

Strategy

71 Asset based alcohol and drug recovery

“For too many people currently on a substitute prescription, what should be the first step on the journey to recovery risks ending there. This must change.”

“The voluntary and community groups,charities and social enterprises sector will be encouraged and supported to get involved.”

“We will encourage local areas to promote awhole family approach to the delivery of recovery services.”

Solutions

72 Asset based alcohol and drug recovery

Expert group chaired by Professor John Strang

‘For many people, treatment is an important

part of their recovery journey. It is a component of

a broader recovery-orientated system of health and

social care and support that harnesses the full range

of individual, social and community assets.’

Strategy changeDeficit Focused

CrimeOverdose

BBVIllicit heroin use

Asset Focused

Positive Social networksMutual AidWell-being

EmploymentHousing

Community Engagement

73 Asset based alcohol and drug recovery

‘Voluntarily sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society.’ UKDPC

Individual assets - Recovery capital

‘The breadth and depth of internal and external resources that can be drawn upon to initiate and sustain recovery’ Granfield and Cloud

74 Asset based alcohol and drug recovery

Be active Connect

Take Notice

Keep learning

Give

Measuring Assets

National Drug Treatment Monitoring Systemnow measures recovery activity including access to support with housing, ETE, family support, parenting, mutual aid

75 Asset based alcohol and drug recovery

Communities taking the lead

76 Asset based alcohol and drug recovery

Facilitating Access to Mutual Aid

77 Asset based alcohol and drug recovery

Public Services (Social Value) ActThe authority must consider—

(a)how what is proposed to be procured might improve the economic, social and environmental well-being of the relevant area, and(b)how, in conducting the process of procurement, it might act with a view to securing that improvement.

Potential lever to ensure that local recovery communities are at the heart of the commissioning of any future treatment/recovery systems and to ensure that the development of local recovery focused assets is a contracted outcome.

Social Value vs Best Value or Social Value as Best Value

78 Asset based alcohol and drug recovery

Paul Duffy – Health Improvement Manager (Alcohol and Drugs)

Paul.Duffy@phe.gov.uk

07771934310

79 Asset based alcohol and drug recovery