Better Health For All

Jacquie White, NHS England Director, explains why Public Health teams are needed at the top table of Integrated Care System discussions on Population Health

“The physicians surely are the natural advocates of the poor and the social problem largely falls within their scope.”

Reading this lovely quote from Rudolf Virchow on the front of the Faculty of Public Health’s Curriculum for Medical Schools made me think how many more opportunities we now have to tackle the fundamental issues impacting on our health and wellbeing by working together in Integrated Care Systems.

While local health and care teams are faced with the reality and consequences of ill-health daily, the partnerships in local systems are enabling and encouraging collective responsibility and action to start to solve some of the underlying determinants driving this.

And I believe we’re starting to see fresh shoots.

The NHS England and Improvement Population Health Management programme is trying to move our shared efforts in that direction and we really need your help.

The aim of the programme is to support local health and care systems and their emerging Primary Care Networks to work in partnership to improve care, and consequently to improve people’s lives, by designing local solutions to address the needs of local people.

I’m inspired daily by the enthusiasm and wealth of skills in public health teams who are driving a focus on proactive, preventative approaches to improve outcomes and reduce inequalities.

To help people struggling with health problems stemming from societal issues such as employment, environmental issues like air pollution, and behaviours like smoking, we need to learn from what’s already been achieved in public health.

With this in mind, the new Population Health Advisory Board, which includes your faculty’s President Maggie Rae and other public health expertise, will be key to guiding the programme and its ambitions over the coming months and years.

So much work has already been done, and the advent of Integrated Care Systems means we can now go further faster bringing together more skills in these partnerships and expanding our collective capacity.

With the NHS, councils, VCSE and other public services all around the table looking at new and very rich linked datasets and predictive analyses we’ve got a huge opportunity to tackle common problems together to maximise the impact and reduce duplication of already stretched resources. It allows systems to have a shared understanding of who their population are, and what is best for them in the long term.

For anyone not familiar with the NHS England and Improvement PHM programme, it’s the NHS’ commitment to working with local authorities and particularly public health colleagues to understand current, and predict future, health and care needs.  

It aims to help local systems and their providers design and deliver anticipatory and personalised care and support for individuals, more joined up and sustainable health and care services for local populations and make better use overall of public resources.

It’s the first time we’ve been able to bring together and analyse the right data to generate  local discussions in systems by the right groups of people about improving the health and well-being of communities. This includes health professionals, managers, commissioners, providers, data analysts, business intelligence, social care and of course public health colleagues.

So far, wave 1 of the programme has made some fantastic and very speedy achievements locally with more than 1,000 people being better supported, teams designing and starting to deliver new models of care for populations and inspiring the local workforce to feel re-energised about their jobs.

In Lancashire and South Cumbria for example, they focused on the wider determinants of people’s health using their links with the community and borough councils.

Primary Care Networks (PCNs) with their wider multi-disciplinary teams initially segmented their population and then asked analysts to bring in further insight – for example on assisted wheelie bin collections or where people are living in houses of multiple occupation – to help narrow down a specific at risk and impactable cohort of patients for initial action.

From the data – and following further predictive modelling on costed population segments –  they found people with needs not met by existing models of care, who are likely to experience a greater deterioration in health than others within similar population groups and who are likely to account for significant utilisation of health and care services in the next few years. They then worked together with local communities to design and agree a proactive tailored care model, including support for health, psychological and social needs.

The Public Health teams at LSC have been leading this work and were a fundamental part of its delivery.

Given that the potential for opportunity is greatest in influencing the wider determinants – and that we know only a small fraction of the factors that impact our health come down to our access to health services – we need more leaders from public health to help us in this mission. To succeed we must connect this work in systems with local teams and communities, and the leadership and expertise from Public Health is invaluable.

If your area is taking part in our programme or beginning to join up action on PHM then please get involved – we want this to be the kind of social movement Rudolf Virchow would be proud of.

Join the PHM Academy for lots more information and news on the development of PHM around the country.

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“Refugees are mothers, fathers, sisters, brothers, children, with the same hopes and ambitions as us – except a twist of fate has bound their lives to a global refugee crisis on an unprecedented scale.” Khaled Hosseini

According to data from UNHCR, displacement has risen to the highest level ever recorded, with an unprecedented 70.8 million people being forced from their homes and 25.9 million living as refugees.¹ A growing number of people are living long-term in settlements; raising families, seeking jobs and attending school. Furthermore, NCDs such as cancer, diabetes and heart disease are rising, contributing to 80% of deaths in LMICs.² This sheds light on the need to develop effective approaches to respond to, and treat the needs of, these populations. Recognising this need, an exploratory study was developed in collaboration with the International Rescue Committee (IRC) to investigate effective interventions for NCD prevention in LMICs, exploring opportunities for such interventions in a refugee setting. This May I spent time in a refugee settlement in northern Uganda conducting research for this study and I want to highlight three personal takeaways from my experience in the camp.

Getting off the small propeller plane in Arua with my colleague to await our vehicle, I wasn’t quite sure what to expect. While I had spent time in Africa before, this would be my first time in a refugee camp. Walking through the Ebola check point I stood still as the worker took my temperature. Next, our bags were loaded, and I hopped in the car as we set off on the hour journey to BidiBidi, one of the largest refugee camps in the world.

It was hard to tell where the town ended and where BidiBidi actually began. But as we neared the centre aid worker flags clearly defined the space. Every person we encountered, from the driver and NGO workers, to the refugees, were kind and welcoming. Eager to start our work, my colleague and I quickly started making plans. However, I was soon to learn the first of my three key lessons!

1. You will need to be adaptable

While having a plan is nice, you need to have a plan B, C and D and be prepared to think on your feet. Much of the nature of working in international development is dealing with setbacks and this was just as true with my research. In a refugee camp food rations are distributed on certain days, therefore if someone you are meant to interview is due to pick up food, that will be their priority. Additionally, locations will be moved due to other meetings taking place and time works a bit differently. When we wanted to hold our first focus group at 11:00am the health officer would happily tell the participants to meet at 9:00am. However, with a good attitude and entertaining colleagues, the underlying chaos ended up being my favourite part of the experience, as this was a true reflection of the reality.

2. Context is key

Much of my research was around addressing risk factors such as tobacco and alcohol use, unhealthy diets and lack of physical activity. Therefore, it was critical to understand the population; what are the drivers behind behaviours, what is the availability and accessibility and are there mechanisms in place for regulation? In BidiBidi the majority of the population are South Sudanese refugees who are Muslim; mostly women and children with little education. Shadowing a community health worker as he went into the villages gave me insight on the daily lives of the refugees and how to adapt research findings for this particular context.

3. Community is everything

Lastly, and most importantly, community is everything. Many of the people I spoke with escaped from war-torn South Sudan, witnessed violence and experienced discrimination. But the way the community remains cohesive, supports each other and stays positive, despite all circumstances, is inspiring. The doctors, health officers and community health workers are a united team working to break barriers and tackle challenges. Hopefully as new research and new technology emerges, it can be introduced in settings like BidiBidi. An advantage of working with the IRC is that they are an implementing organisation; research is put to practice and the people they are serving have a voice. While the current statistics are daunting, the people have the will and the capacity to introduce effective interventions which can prevent NCDs among the refugee community, creating better health for all.

Blog written by Lara Kontos, MSc Global Health

References

1. UNHCR (2019) Figures at a Glance. Available at: https://www.unhcr.org/uk/figures-at-a-glance.html (Accessed 14 August 2019).
2. World Health Organization (2018) Noncommunicable diseases. Available at: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases (Accessed: 18 July 2019).

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Hertfordshire has led the way in improving levels of physical activity in older adults via a social marketing campaign ‘Never Too Late’ which has seen almost 4000 people sign up – 4 times our target.

The 12-week campaign with a budget of £20,000 launched in April 2018 across social media, local Daily Mile schools (with children inviting older adults to join them for their Daily Mile), and through a wide range of partner organisations.

The campaign formed part of Hertfordshire’s Year of Physical Activity. It reached three quarters of a million people and generated nearly 30,000 hits to our webpage. The evaluation found that of those who reported doing no physical activity at the start of the campaign, 93% reported doing at least 30 minutes of physical activity per week at the end of the campaign. Overall, 79% of participants reported moving from doing less than 90 minutes of physical activity to doing more than 90 minutes per week by the end of the campaign. Just over half of those completing our post-campaign survey have reported meeting or exceeding their physical activity goals.

It targeted over-55s but messaging was tailored for specific behaviours, informed by insight from local focus groups and Sport England research. Key barriers (anxiety, lacking role models, thinking they do enough exercise already) and motivations (keeping up with grandchildren, healthy mind/body, social belonging, confidence, getting more from life) were central to messaging, which also promoted easy ways to fit ten minute activities into everyday life.

In Hertfordshire 42% of 65+ year olds are inactive and 58% do not meet national recommendations for physical activity. We used evidence-based behavioural science techniques (based on the COM-B Model) to encourage behaviour change:

• Action-planning/progressive tasks: an activity planner enabled people to move from intention to action
• Behavioural practice: personalised support from trained staff offered in a way that best suited participants’ needs
• Prompts: twice-weekly text/email messages, targeted by key motivation (health, social, mobility, enjoyment)
• Incentivisation: free activity pass and entry into prize draw for all participants
• Nudge theory: sign-up to resident e-newsletter provided ongoing contact beyond campaign

We used a range of tactics and channels to target residents:

• All traffic driven to webpage, which hosted case studies, information and registration survey. Through this we captured baseline and follow-up data to evaluate success.
• Creation and sharing of a suite of insight-led online content tailored to different groups, in particular tapping into the over-55s growing love for Facebook. We reviewed and updated regularly to keep fresh and promote best-performing content.
• Blitzing local and regional media, developing stories and media packages across the county.
• Developing unique and impactful relationships with partners to maximise reach and success.
• Identifying key periods of activity (our successful media launch and the 40+ school launch events) and supplementing these with ongoing activity across our own and partners’ communications channels. We cascaded messages, using key hooks and milestones to celebrate success and sharing pictures/videos from events.

Hertfordshire County Council’s director of Public Health, Prof. Jim McManus, said: “This campaign has demonstrated effective use of behaviour science techniques to help older people get closer to the guideline of 150 minutes of physical activity per week. This is an important element of our prevention agenda”.

“As a result of this success, we’ll be running the campaign again from 5th May 2020 in the lead up to the Tokyo Olympics”.

Case study

One person who found the campaign of benefit was Jim Furman who is 69 years old and retired. “I am much more positive than I was, both mentally and physically. I always feel better after any kind of physical activity, especially when it is enjoyable, which the activities I’ve discovered through this campaign are”. He heard about the campaign through the Council’s email newsletter and was very interested in the free day trial offer. “It has made a big difference to activity levels for both my wife and I. She has signed up to be a regular member of Stevenage leisure centre as a result of the free trial and we both now play badminton there together every week. I was very impressed with the gym. I was amazed at the whole set up, the equipment and facilities – I hadn’t realised how good they were. There was one particular activity I really enjoyed – a walking machine with a TV screen – and I’d love to go back to try that again, it was fun and made me feel really positive about exercising”.

Written by Nicola Ainsworth, Specialty Registrar (ST3), Hertfordshire County Council

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