What IS the “Public Health” contribution to the NHS Sustainability and Transformation Plan

Up and down the country the NHS is busy working out how it’s going to transform and stuff

This is enshrined into (yet another) NHS planning process known as the STP
Public Health types are being asked to contribute. Quite rightly – we’ve got a chunk of stuff to usefully add
I don’t know the answer, unfortunately. But I did have a careful think about what PH folk can usefully do….
1)

Maybe first reflect on the key challenges for the NHS, as expressed in the 5 Year View
The tests of ambition.
Test of ambition for NHS 1

Stephens told NHS – radical upgrade to prevention

Will STP see this commitment delivered in terms of £ invested?

Test of ambition for NHS 2

Stephens told NHS to radically transform delivery model

Will the STP deliver REAL change in this, or just business as usual

Test of ambition for NHS 3

Stephens told NHS to sort out efficiency

Will STP REALLY stop worthless stuff, and invest in demand mngt

2)

Then a considered response to what the PH types can add.

 So I had a bit of a chance to think about it now…….

 
 

The challenge set to PH types is

 

a) A “health needs assessment”

b) Support to the NHS to nail what “a radical upgrade in prevention” feels like

 

 

 

 
 

 

 

 

 

On a)……………health needs assessment

I’d personally try to keep it very very simple

 

Remembering its simply just another NHS planning exercise to access some “transformation” cash, that will basically be used to keep the system afloat – sustain – not really transform

 

 

 

 

So we need to articulate the “health and well being gap”.

What about something along the lines of looking at the Marmot Profiles or / and the PHE profiles (I’d do both as it shows we are all rounded and social model and medical model) ….

Where do we stand on some of the relevant indicators comparing to a suitable comparator.

A small bit of commentary and what is the size of the prize in terms of numbers of people, events, things (rather than rates, ratios and whatnot)

That way we get to focus on stuff that is readily grappleable with and focus on stuff we CAN do

Maybe come back to the BIG population risk issues – lipids, BP, cigs, lack of sweat and too much booze

Focus on GBD risk factors (I assume you’ve seen the lancet papers on that) and big p population medicine focused management of risk factors – some pretty pictures from in the attached

 

 

Health needs assessment per se

We’ve done one – Its called the JSNA

So if we MUST do something ……………………. I’d be minded to go v macro and v v strategic 

· section on Pop (PHE State of Region done it?) / ditto provider footprints?
· High level summaries from our individual JSNAs (though I haven’t read them – Id bet a months pay they all say largely the same thing!)
· section on main h needs with emphasis on preventable morbidity etc and also multi morbidity – from our JSNAs?
· I’d also big up mental h, section on outcomes attributable to good health care at population scale (back to respiratory and CVD???)
· Given that it’s a high level HNA to inform a “transformation plan” …………a section on macro service models – I’d use the “HNA” as an opportunity to further push towards real transformation and thinking big about transformation models etc – this will go some way towards the care and quality gap issue. I know everybody is telling me “we are not ready for Accountable Care”….. but whats plan B…. I’m def of the opinion that ACO and the like is NOT a pancea, and will probably not deliver short term cashable savings….but remembering where Simon Stevens spent a lot of his working life… this is where he is going, and I suspect this is what NHSE will want to hear…..
· If we need to I might also add in some nuclear stuff….and set out some unpalatable things…..? what do we know about GP distribution per capita (and inequity within our patches), bed base per capita (the KH03 will help there – re hospital overnight beds, intermediate care beds (step up / down split – NAIC may help here), nursing home capacity….variability in Mental Health spend???

· I agree with the later email re segmenting…. One approach preferred. I don’t care which as the differences between different approaches to segmentation will be pretty marginal. But would try to seek an approach to segmentaion that works with NHS and local govt?? in the spirit of caring and sharing and whatnot…

 

John S tells me that there’s an expectation of a major focus on workforce etc…. I’d avoid in the HNA bit – as there largely isn’t any data and v little collected intelligence…. So not a lot we can say!

 

10 pages max

This way we’ve done our job, not written war and peace, not spent months rehashing existing stuff and moved it on a bit.

 

Given that the NHS has agreed a South Yorkshire footprint I think we should NOT do this at each CCG level (and we will need to resist pressure there)…… 

 

  

  

On b)……………………..radical upgrade and whatnot….

The challenge is basically not rehashing all of our health and well being strategies and whatnot

That would be futile, pointless and a waste of everyone’s time

There’s the added challenge of umpteen different stakeholders each of whom have a different understanding of “prevention”, a different place on the medical model / social model spectrum and a different lens (the mental health types couldn’t give a stuff about statins etc)

Complicated by people using “prevention” and “demand management” as synonymous things….

 
So quite what “radical upgrade” actually means I don’t think I could nail.

 

So given that it’s an NHS plan….. And that the NHS as been told to upgrade ……in terms of radical upgrade – I think I’d like to see….:-
· Far greater investment in primary care – specifically combination of general practice and pharmacy

· Far greater emphasis on development of place based GP – interface between GP, VCS and non NHS providers in localities. Really nailing the social prescribing thing, with an emphasis on mental well being etc

· Concerted effort to focus on the under implementation of cardiovascular risk management using quality improvement methodology in general practice (and no Im not talking about health checks….. but addressing statin and HTN management)

· Investment in stop smoking, move more and weight management (im not wholly convinced re the latter….but…..)

· ramping up coverage of lifestyle interventions both in prmary prevention, but also clinical treatment pathays – at scale. – ie loosing 5% of weight and sweating more will achieve as much good as an additional HTN med etc etc etc…..and its cheaper, and theres a whole load of positive spin offs and no negative side effects – this is a massive framing issue.

· Far greater emphasis given to a policy approach to health promotion around major lifestyle issues (as opposed to approach based on services to change behaviour person by person) – collectrive approach across the STP area, led by HWBBs (ie my email of last week? – fast food, more tobacco control, booze policy stuff etc)

· Seeing as we must – some token effort towards Diabetes prevention (sigh)

 

If we nail those, I think that would be upgrade enough for now???

 

Others may have views / things to add??

 

 That’s my view 

 

 

3)

 My learned colleague generally agrees……

Agree on describing the gap, would use already published PHE profiles and Marmot. I used the Marmot ones in my DPH report but there is a gap when it comes to health/NHS (interestingly) so PHE complements them

A sensible comparator (?NUTS level) and size of the prize (costs avoided etc)

Would want something on tobacco, activity, nutrition and alcohol and the CVD risk, couched within the Robert Wood Johnson contributors to health diagram (slide 1)

 

 

HNA agree as macro and as strategic as possible, profiles, the state of the region and if we must the Attain report (only due to length).

Our summary of the JSNA is the PHE profile

And agree with the other suggestions, our JSNA may not have what’s needed for morbidity/multi-morbidity

Also would go for a single STP approach (just like an old strategic clinical network approach)

 

On the radical upgrade I think the demand management /prevention discussion is the crux of it

 

I’m happy with the NHS focus place based primary care, CVD risk management, and MH

Focus on smoking, physical activity, nutrition and alcohol in every pathway with NHS investment (as I haven’t got any), but with the policy approaches bolted in, as this could become the DEVO health plan

Might want to go for a 40-60year ‘turn off the taps’ approach, but also improve reablement (i.e. exercise as a protector for cancer recurrence etc)

Would also want to see better use of digital, technology (wearables) and patient activation

 

 
 4)

 We don’t know if we are right……..
But ….This is the response I’d give in on off the cuff answer to the question of what should PH types be up to STP wise.

It’s drafted in the typical breakneck speed of NHS planning processes……and, frankly, this is all a bit transactional…….
The transformational aspect of ‘the contribution of PH types to sustaining and transforming of the health and care system’ is rather more difficult to describe
It will follow………

What do you think???

 

 
 
 

 

 

 

 

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