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Public Health

Being more re preventive vol 2 – Things we have learned along the way

This is the second in a set of 4 blogs on what becoming a preventive organisation looks less like. This one focuses on some of the discussions and learning along the way.

1 Frame of “prevention” – in the language of capital and assets not business cases and money
Services for people or places where people live, life context. Or both. Both matter.

• We get into concepts of capital – Human – long term investments / Environmental  / Fixed / Social. how can different forms of capital be built to help us meet a goal

• The offer around capital is different in different parts of our areas. Equal is not ok, needs to be unequal if we are to address unequal need or outcomes. Consider the barriers to capital, and be seeking to develop a place, and people that can be Independent, well, capable, educated.

2 Language matters and has different meanings to different people

• Language matters – Everyone struggles with the term prevention. It’s negative, means different things to different people in a range of contexts. It’s difficult to get a unifying theme.

• We’re moving towards Promotion of good stuff, sometimes at expense of Prevention. Promoting good things is at least as good a proposition as preventing bad stuff

• Resilience is important – but also has different meanings to people.

• Ditto empowerment – I can be “empowered” but still live in a place with illegal air that is bad for my health.

• Would be helpful to come back to the why are we here discussion, and develop a set of renewed reference points for what we are trying to achieve.

• Fundamentally about strengths based approaches.

• The answer to what are we preventing may come from different stakeholders arranged on on service efficiency for service users vs optimising outcomes in populations (what outcomes, what timeframes)

• “Demand management is not prevention”. Well yes it is, but just with a different spin

3 Be clear about what are we preventing.

• Prevention of demand – antisocial behaviour, grass growing and our inability to afford to cut it, social care, litter. The answer will look different in different parts of the organisation.

• Promoting good outcomes is a better proposition that an org can align around. But equally definition of “good outcomes” may look different. See points about single concept to align around.

• The answer to the question can either be high level and or service / problem specific. If the latter then the answer needs to be bespoke to that area. If the former then it’s hard to come up with an all encompassing concept, other than “demand”, or more usefully flipping it on it’s head promoting good outcome.

• Picking up on Steve Laitner’s questions. When we say “prevention” is really important we need to also say:

1. Of what?

2. In whom?

3. Addressing which risk factors?

4. How?

5. With what expected outcome?

6. When?

7. There isn’t a “prevention department”,

8. there isn’t a service you can refer to for all your prevention needs.

9. It’s your job and it’s something you need to start being a wee bit better at.

10. Now

Build actionable propositions. we all want more prevention. Can you describe this in terms of Narrative and propositions

• Evidence for effectiveness of different models of intervention. AND status quo, or doing nothing

• The same for data on demand or need and how it shifts if you do something (or do nothing)

• Actionable propositions – policy, environment, services in specific cohorts or geographies

• Don’t wait for it all to be perfect before you do something though.

4 Upstream matters. A lot. In EVERY context and circumstance

I’ve written enough on this, and won’t repeat.

In any policy or service delivery area you might mention addressing the upstream determinants of demand is both important AND necessary.

Upstream matters A LOT more than downstream. Must move upstream and towards structural stuff. Think in the context of your service and a system

This requires different things, different approaches to intervention. More of the same will not do the job.

It does require some brave decisions, and does require us to change the way we both fund and operate services.

All paths are obviously leading to the notion that we cant solve these tricky problems by only focusing on downstream stuff – ie we cant build bigger hospitals as a solution to poor health, we can arrest our way out of knife crime – etc……

Its needed – obviously you cant not arrest folk who’ve done bad stuff, you cant. So need upstream.

Upstream almost always makes bigger impact, by miles, than downstream. If you can think of examples where this isn’t the case, let me know.

5 What is success. What is the acid test

• acid test is that all staff and at all levels see prevention as THEIR job, not referring onto someone else, some other “preventive” service.

• Expectation that chunks of your organisational machinery work on specific propositions, build investment cases where needed.

6 There will be some tricky stuff about overlaps between spaces, it may be difficult to get to a single coherent ting that binds it all together

For example “person centred approaches” vs “preventive”. All quite tricky.

• What is the pre eminent organising principle

• All stakeholders will see the world through a specific set of lenses, guided by the world view people have, the drivers in their sector, historical issues and other factors.

• Wherever you work you have a different perspective on the “thing” you are trying to solve or improve

• We all bring our own biases and history to the thing etc

• Obviously we all tend to emphasise short term and clearly measurable (basically a New Public Management oriented approach).

• Occasionally this puts us at odds with a complex system approach.

• Of course one might say “community” or “asset based” or “well being” (or a combination of the three) should be the organising theme / the thing that we all align around / the thing that binds us all together

• But – I fear we will never get there, and spend ages trying to get all stakeholders to “the thing” aligned round a common organising theme and not get there

• Those with an NHS starting point will tend to focus their attention in that space first, then look broader. Those from a housing sector starting point similar.

• There isn’t a single thing that naturally binds all these perspectives that have coherence and cogency at both operational and strategic levels.

• Stakeholders from different backgrounds may need different hooks to bring them into the party. This is OK.

• Some aspects of prevention are not person centred. For example sugar tax, bans on smoking in public places, regulatory approaches to improve air quality are not person centred, they take away freedoms, but they are preventive

7 be clear what our ask is on staff

• Build “prevention” into skill set we expect, induction, ongoing training

• a general message re don’t wait for someone else to do something. Pretention is your job and it’s urgent

• What is our approach to clients – person-centred, don’t set up or systematise dependency. Be led by their priorities. “What matters to you” v “what’s matter with you and how can we help”,

• Develop and use technical skills – evidence base, appraisal, why, critical questioning, value for money

• The plan requires thoughts relevant to individual service areas. Services obviously shoinldy wait for permission to “become more preventive”. Nor should anyone wait for the grand master plan.

• Not something “someone else does”, got to be a core part of everyone’s business.

8. Everyone says its someone else’s job

• “Preventing stuff” seems almost always someone else’s problem in the face of pressing immediate demand.

• This isn’t necessarily a NHS and social care issue, but it is fair to say the NHS and social care sector can always

• The “leaders” – We have developed a generation of tactical leaders who are excellent at delivering technically efficient services. Sometimes this is at the expense, or maybe even the detriment of, a broader strategic picture.

• Middle manager often cited as the blocker. The middle manager response is ahhh no, we are driven by the expectations of our senior execs and board, the performance and financial framework is the thing at fault, or the board expectations.

• So we get a scenario where each “bit” of a complex adaptive system is pinning the fault

• Place and built environment etc matters too, but that’s a different story. We don’t (yet) have the link in narrative, business process, heart and minds or anything else straight between social care demand and the place we build. A planning officer I recently heard saying – ‘ “health” is nothing to do with me, the health service should sort that out, I ensure towns are well build are compliant with the regulations’. That was in the concept of obesity…. The line of argument was “what’s planning got to do with obesity”. Cropped up in this study also.

We all know if it’s always someone else’s problem, it will never get addressed….. not addressing it simply set up downstream demand for social care.

9 the focus on the high risk and high unit cost vs shifting the population dial

The prevention paradox. High risk focus vs shifting the curve across a whole population.

• The Geoffrey Rose & prevention paradox –  (most cases don’t come from the ‘high risk’ group, population approach needed). The prevention paradox applies to almost everything.

• In NHS, see the conclusions of Barnettt on multi morbidity, more emphasis should be put on whole population approach. see also the Uber classic from Roland and Abel reducing emergency admissions, are we on the right track (good stats lesson on high risk vs whole pop. Both of the above are in the health care policy domain, the lessons are generalizable to other policy areas.) Accumulated evidence over a few decades says a sole focus on top x% is pointless as its quite tough to make change in the top x% and even massive change in the top x% is relatively trivial in net terms.

• emphasis on distribution of the thing in population, not just totals or averages.

• Focus on low volume high (unit) cost / impact vs high volume low (unit) cost / impact. The former is alluring, very visible and difficult to ignore.

• Time after time, policy area after area we keep needing to relearn that it’s shifting the latter that is also very necessary

• The focus on top x% sort of analysis also tends to draw the mind to the top 5% that are heavy service users, the small minority who commit most crimes, those with complex needs or problems, and draw conclusions of if only we could sort that we would more financially viable. Evidence suggests otherwise, they are quite poorly (advanced care management is pretty marginal in its impact), they are hardened criminals (changing behaviors on that cohort is hard.

• the top x% analytic approach tends to make assumption that the population is static, it is not – there is fluidity.

• The aim should be to shift demand across a whole population thus a whole population approach is needed – aim is to prevent and delay – reduce and manage risk across the whole pop – primary, sec and tertiary prevention

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