Up scaling prevention and the STP, some questions for CCGs to ponder

Up scaling prevention and the STP, the role of CCGs

 

Some thoughts on a session for CCG Board on “up scaling prevention” – a la the 5YFV

The full version of this has some pretty graphics that haven’t transferred to the blog. Email me if you want them?

 

 

 

 

 

 

 

Intro points

Simon promised us a “Radical upgrade of prevention”.

I’m not feeling it yet.

 

NHS doing what it can and doing well but to really transform outcomes we need policies not pills

Long term investment to reduce NHS and social care service bill – many policies are free / cheap to implement, but we don’t implement them (for a range of rather difficult reasons)

Go also for the sustainability line – once you’ve got a disease your treatment will mean you use loads of carbon etc

Frame in the STP process

Lastly frame this as policies that will reduce the need for individuals to use state funded care

This short paper sets out some questions to consider from a CCG perspective

 

GF Feb 16


5 wicked questions to consider

 

1) does board agree that prevention is core role of CCG as NHS commissioner, and broader NHS as provider.

What is it that you are trying to “prevent” – death, disability, disease, complications

Is it “prevent” or “promote”

what services do you commission to prevent things

what are you trying to prevent

what are the limits of “prevention” when does it become something else?

 

2) How should the boundaries be set

  • LA vs NHS
  • policy level vs individual
  • how far back in the chain do you want to go – statins back to social policy.

 

3) Where do you want to focus your fire – I’m assuming adults & “unhealthy lifestyles”

Closest to disease endpoints.

 

4) What is the preferred approach or the balance between individual level vs Policy level

 

5) If you could do one thing what would it be

 

 

 

 

 

 

 

 

In more detail

 

 

1) does board agree that prevention is core role of CCG as Commissioner, and broader NHS as provider.

10% of health outcomes are attributable to health care.

40% of health outcomes are attributable to behavioural choices.

http://www.ncbi.nlm.nih.gov/pubmed/11900188

Stevens highlighted the need for the NHS to “scale up prevention” in a way not seen since the Wanless report on public health.

 

 

2) How should the boundaries be set

 

  • LA vs NHS
  • policy level vs individual
  • how far back in the chain do you want to go – statins back to social policy.
  • Pills versus policies
  • All are important – maybe depends on when you want to see return on investment

Social determinants – a la Dalghren and Whitehead

Versus health care focused prevention and health care improvement – eg under statinisation in high risk CVD, focused QI around CVD prevention


Policies v individual level approach Eg – Diabetes. Policies versus pills.

everyone is heading down “diabetes prevention” now PHE have developed the DPP roll out

absolutely focused on individual level interventions – this is what is deemed pragmatic and politically acceptable nationally?

BMJ editorial Greenhalgh -the difficult balance between personal level vs population level

medicalising a non medical problem at the ignorance of broader social & commercial context

Only the NHS is able to push back on broader healthy public policy approaches to this – local or national.

Can we actually afford to implement? Its cost effective (notwithstanding the efficacy / effectiveness in real life issue), is it affordable.

Massively high levels of population coverage will be needed to have a population impact.

Ultimately I think the NHS will need to push on this for government to act – local or national….there’s always political pragmatism….. but……

The PHE sugar report was highlighted for the “sugar tax” proposal – the evidence in the sugar report was clear that there are other powerful interventions that should be considered.

3) Where do you want to focus your fire – I’m assuming adults & “unhealthy lifestyles”

Closest to disease endpoints.

Most of the top risks contributing to the burden of disease are lifestyle related, many of the conditions causing this burden are lifestyle related.

See the pretty pictures in the UK Burden of Disease studies published in Lancet

But equally you might choose a life-course approach – maternity and childhood (by far) biggest opportunity.

4) What is the preferred approach or the balance between individual level vs Policy level

“Lifestyle services” – here weight management is what I pick on – (unfairlry?)

The population impact isn’t great. Many of those that are referred don’t attent, many that attend don’t engage, of those that engage many are not so successful (loosing weight is hard), of those that loose weight many regain (toxic food environment and other factors)

The Heneghan 1000 – 10 chart is beautiful. Of 1000 referred, 10 (9 women) attain and maintain their target weight.

Recent summary of NIHR systematic reviews[i]reinforced the view that individual weight loss and/or educational interventions are the least effective ways to reduce socio-inequalities in obesity, whereas community and environmental interventions were the most effective. For adults, the review found that primary care delivered weight loss programmes targeted at low-income groups can have positive short term effects (up to 9 months) but these are not sustained over the longer term

 

 

 

 

 

 

 

 

Something to stick on a vending machine to encourage our “free” choice. The “rethink your drink” picture – will probably make many people think about sugar quite hard.

 

 

Versus environment and policy interventions – advocate for others to address. Toxic food environment. Some local, some national issues here.

 

 


Issues to contend with

The rhetoric of nanny and interfering with free choice.

  • Yes I understand. But the state is shrinking.
  • Govt not willing to take on commercial interests.
  • Broadly accepted that local service to individuals offer will shrink, greater expectation that people help themselves. Does the same apply to policies that shape views and behaviours

This isn’t the role of CCG, this is the role of government.

Yes of course it is.

And its deeply political.

Sam Everington -“Don’t underestimate your influence with politicians for effective policy change Go as a group Trusted by community This is critical in terms of developing healthy public policy”

This should be an issue of personal responsibility.

Yes of course it should.

In an environment that isn’t full of subtle inducement to shape our views, attitudes and behaviours.

The broader context – not just health but the economy

The work in New York driven by the Mayor and commissioner for health was driven as much by economic concepts, as it was health ones. Lost productivity on account of days lost for non communicable disease.

Aggressive policies are old school health promotion, not politically viable and not within the ethos of contemporary society

  • “Helping free choice”. Even if “aggressive” policies are not viable – the debate during their formation shapes opinion
  • All parties agree re h pop the debate is how and at what cost – liberty & economic

“Nanny state is regressive”

  • no it’s not, it’s by far the most progressive and equitable. Individually focused education and service interventions will exacerbate inequity.
  • “If you think the sugar tax is regressive try diabetes”

 

 

Nudge, shove or budge

  • conceptual framework called libertarian paternalism – requires policies to protect individual liberty & to be focused specifically upon improving the welfare of those towards whom the intervention is targeted
  • In practice, however, many of the interventions that are being advocated as nudges do not meet all of these criteria.

 

Back to the five questions

1) does board agree that prevention is core role of CCG as Commisisoner, and broader NHS as provider.

What is it that you are trying to “prevent” – death, disability, disease, complications

Is it “prevent” or “promote”

what services do you commission to prevent things

what are you trying to prevent

what are the limits of “prevention” when does it become something else?

 

2) How should the boundaries be set

  • LA vs NHS
  • policy level vs individual
  • how far back in the chain do you want to go – statins back to social policy.

 

3) Where do you want to focus your fire – I’m assuming adults & “unhealthy lifestyles”

Closest to disease endpoints.

 

4) What is the preferred approach or the balance between individual level vs Policy level

 

5) If you could do one thing what would it be

 

 

[i] http://www.nihr.ac.uk/newsroom/blog/weigh-in-or-weigh-up-the-evidence.htm

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