Category: Population Health

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Greater Manchester lauded for approach to population health

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A new report from the King’s Fund had praised Greater Manchester’s progress on improving population health, emphasising the importance of addressing the wider determinants of health.

The King’s Fund has praised Greater Manchester for its work improving key measures of health and health inequalities. The influential national charity has called Greater Manchester “the poster child for devolution” in England and has recognised the time, effort and resources put in place helping people to live good lives, improve wellbeing and prevent illness.

The new report, published this week, shows how health is influenced by wider determinants such as high‑quality and secure housing, a good job and a healthy environment. It highlights the vital link between health, and the communities we live in as well as the value in aligning strategies to ensure improvement of both the economic and health status of the population.

Since 2015, Greater Manchester has had a wide-ranging devolution deal with Government on health which has led to improvements in life expectancy and other measures (see here for information). Greater Manchester’s model was integral to the creation of statutory integrated care systems in 2022 with improving outcomes in population health and health care a key aim.

The King’s Fund report reiterates the importance of population health being a core goal of integrated care systems and the value in different government departments below the national level working more closely together, including at mayoral level. It underpins Greater Manchester’s ‘live well model’ that aims to transform the relationship between work and health.

While this new publication recognises the financial challenges that the NHS and other public sector organisations face, it makes the case for continuing with a population health approach and the strong evidence that improvements in health can have for the economy at large.

Andy Burnham, Mayor of Greater Manchester and NHS Greater Manchester Integrated Care Partnership co-chair, said: “Greater Manchester’s health devolution journey has a simple but fundamental principle at its heart: that more local decision-making can deliver better outcomes for people.

“This report from the King’s Fund sets out clearly the wider social factors that impact people’s health and wellbeing, but also the power of devolution to draw the connections between those issues and tackle them systematically.

“That is the strength of our devolved approach, and the mission of the new Live Well service that we want to pioneer here in our city-region. There are still challenges and pressures that we face. But we’ve made progress already, including on healthy life expectancy, and by bringing together partners and joining up the support offer for residents – whether that’s health and social prescribing, housing advice, or employment support – we can deliver better, more efficient public services, and improve people’s life chances.”

Jane Pilkington, Director of Population Health for NHS Greater Manchester Integrated Care said: “The King’s Fund spotlighting Greater Manchester as leading the way in population health is pivotal to re-emphasise the important role the NHS plays in improving the health and wellbeing of residents, by focusing on preventing ill-health in the first instance rather than just treating sickness, as well as relentlessly working to reduce health inequalities.

In Greater Manchester we need to continue to work together with communities and the voluntary sector, local government, and the NHS to help create a place where everyone can live a good life, growing up, getting on and growing old in a greener, fairer more prosperous city-region – focusing on improving both the health and economic circumstances of our residents.”

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News, Population Health

Innovating beyond digital: A comprehensive ICS approach to musculoskeletal care

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Physiotherapy practitioner, Dr Carey McClellan, explores how supported self-management tools can help integrated care systems to support MSK patients across their entire care pathway.

Musculoskeletal (MSK) injuries and conditions impact approximately 20 million people in the UK, making them the leading cause of disability. They affect people’s daily lives, the NHS, the workplace and the economy.1

In fact, MSK problems cost the NHS £5 billion ever year, account for 14-18 per cent of all GP appointments in England, and result in 24 million lost working days annually.2,3  Despite this already substantial burden, the prevalence of MSK conditions is rising due to a combination of an ageing population and lifestyle factors.4

The case for self-management

The value in supporting people to self-manage MSK conditions as early as possible is well researched, and recommended within national guidelines and policy.5-13 However, it is not delivered consistently or at scale. A recent report by The Arthritis and Musculoskeletal Alliance (ARMA) highlighted the variation in strategy, leadership and prioritisation of MSK conditions across integrated care boards (ICBs) despite it being one of six priorities in NHSE’s major conditions strategy.

NHS England’s ‘Best MSK Health Collaborative’ and Getting It Right First Time’s (GIRFT) community MSK workstream have both highlighted the absolute need to adopt evidence-based digital technology to support people with MSK injuries and conditions.14 At the same time, there is a growing emphasis on the link between health and economic inactivity and a new government focused on improving both.15

Early intervention holds the key, but people are waiting too long

GIRFT has highlighted the need for early intervention in the MSK care pathway to reduce the primary impact and longer-term consequences. Additionally, not enough is being done to support people, or minimise the time they spend, on waiting lists. The BMA estimates that 8 million patients are currently waiting for consultant-led elective care.16 However, the number does not include the ‘hidden backlog’ – those who have not yet presented for care or are waiting for other services (e.g., physiotherapy or investigations).

There are up to six waiting stages before an orthopaedic procedure, each offering a chance to reduce deconditioning, encourage self-management, support a person’s return to work, and possibly avoid costly surgical intervention. Extended waiting times for MSK treatment at any point on this journey take a toll on patients’ physical and mental health, leading to deconditioning, increased pain, lesser quality of life, difficulty to work and, in some cases, irreversible deterioration.17

Enabling people to self-manage their recovery

Digitally supported self-management tools help integrated care systems (ICSs) to support MSK patients across their entire care pathway. They help people to trust their recovery, utilise less healthcare resource and return to work more quickly and safely.

For maximum impact, digital self-management pathways should be made available to people at the earliest possible opportunity wherever they connect with the health system or seek help – in the community (pharmacies, libraries, leisure centres), primary care (GP, first contact practitioner), urgent care or secondary care (elective care). Self-management support is suitable for 80 per cent of all new, recurrent, or long-term MSK conditions, including people on waiting lists.18

Tools like getUBetter enable people to self-manage their recovery by following a recovery and prevention pathway defined by their local healthcare system. And, because it’s digitally enabled, it supports people to manage their condition 24 hours a day, 365 days a year, taking them through their recovery day-by-day, and providing them with the knowledge, skills, and confidence to help themselves. Support is provided through triage, advice and guidance, exercises, outcome measures, dynamic safety netting and referral when necessary.

getUBetter also supports people by connecting them to treatment, local support and public health services (e.g., smoking cessation, weight reduction and return to work).

Behaviour change model

For a digital platform to have a positive impact on people and the NHS, it must be trusted, and help people change their behaviour. That’s why getUBetter was designed with an underpinning COM-B behaviour change model as its foundation.19 The COM-B model is a theoretical framework that incorporates key components (capability, opportunity, and motivation) considered to affect behaviour.

For example, all content has been created with behaviour change at its core and tailored depending on the individual’s stage of their recovery and how they are feeling. Content includes support to mitigate against negative behaviours and promote positive behaviour; it is personalised, targeted, and localised to clinical pathways, health services and community support. getUBetter includes support for safety netting as well as other factors such as psychological elements of MSK recovery, the relationship between work, home, and health and system obstacles to work. All can influence someone’s ability to recover, live and work well.

Digitising isn’t enough to drive clinical transformation and positive impact

The NHS is littered with examples of poorly designed patient-facing applications that have not been co-designed with their users. This leads to a frustrating experience and short-lived engagement.

An iterative design process ensures content is accessible, intuitive, inclusive, and easy to follow, while barriers to adoption such as digital exclusion are minimised.20 Working in partnership with ICB clinicians, champions and transformation stakeholders is essential. Their local expertise is crucial for ensuring that any digital tool integrates seamlessly into routine care. This ensures the best approach for deployment and adoption, and creates a blueprint for NHSE scale and adoption.21

The impact of digital self-management

Lord Ara Darzi’s Independent Investigation of the NHS in England confirms that it must move care into the community, enable patients to take active involvement in their own care, digitise, and help tackle economic inactivity. MSK digital self-management tools are ideally placed to play a central role in realising this.22

Earlier this year, NICE published an Early Value Assessment approving the use of five digital tools for use in the NHS for non-specific low back pain – the biggest cause of days taken off work.

An economic evaluation conducted by Health Innovation Network (HIN) South London highlighted the scale of the burden of back pain, and the possible return on investment that can be achieved by deploying digital self-management tools. The independent report demonstrated that a cost saving of more than £1.9 million for back pain alone could be achieved per area (place) of an ICS with a population of 330,000 through deploying digital self-management.23

Further research conducted by the HIN demonstrated that when using getUBetter, an ICS can expect a 13 per cent reduction in GP follow-up appointments, a 50 per cent reduction in MSK-related prescribed medication, a 20 per cent reduction in physiotherapy referrals, and 24-66 per cent fewer urgent care attendances. A Somerset NHS Foundation Trust evaluation revealed that 50 per cent of patients awaiting MSK physiotherapy appointments felt their needs were met after using getUBetter, prompting them to remove themselves from the waiting list. Those in NHS South East London ICS who utilised getUBetter before their physiotherapy appointments required 40 per cent fewer sessions compared to patients who did not use the app.24 NHS Frimley ICS reported 11 per cent fewer sick notes, helping people back to work.

The MSK problem in the UK is a complex one to solve and requires close collaboration with patients, clinicians, ICB leads, transformation experts, health systems, and the government to ensure the solution reflects local needs. While technology has a role as an enabler in digitising ICS-wide MSK pathways, it is not achievable without clearly defined methodologies of co-design, behaviour change and clinical transformation.

If you’d like to hear more about this approach and blueprint, please sign-up for the forthcoming webinar, Transforming MSK care across complex health systems with digital self-management support: Technology vs methodology on 26 September 2024.

List of references

1. Versus Arthritis. The State of Musculoskeletal Health 2023. 2023;1–65. Available from: https://www.versusarthritis.org/media/duybjusg/versus-arthritis-state-msk-musculoskeletal-health-2023pdf.pdf

2. Public Health England. Musculoskeletal Health: A 5-year strategic framework for prevention across the lifecourse [Internet]. PHE publications gateway. 2019. Available from: https://www.gov.uk/government/publications/musculoskeletal-health-5-year-prevention-strategic-framework

3. NHSE. Musculoskeletal health: What are musculoskeletal conditions? [Internet]. 2024. Available from: https://www.england.nhs.uk/elective-care-transformation/best-practice-solutions/musculoskeletal/#:~:text=In%20fact%2C

4. Community MSK – Getting It Right First Time – GIRFT [Internet]. Getting It Right First Time – GIRFT. 2024 [cited 2024 Sep 12]. Available from: https://gettingitrightfirsttime.co.uk/cross_cutting_theme/community-msk/

5. National Voices. Supporting self-management: Summarising evidence from systematic reviews. 2014. Available from: https://www.nationalvoices.org.uk/publication/supporting-self-management/

6. Ofcom. Online Nation: 2022 Report. 2022. Available from: https://www.ofcom.org.uk/siteassets/resources/documents/research-and-data/online-research/online-nation/2022/online-nation-2022-report.pdf?v=327992

7. Hunter R, Beattie M, O’Malley C, Gorely T. Mobile apps to self-manage chronic low back pain: A realist synthesis exploring what works, for whom and in what circumstances. PEC Innov [Internet]. 2023;3(September 2022):100175. Available from: https://doi.org/10.1016/j.pecinn.2023.100175

8. Hewitt S, Sephton R, Yeowell G. The effectiveness of digital health interventions in the management of musculoskeletal conditions:  Systematic literature review. J Med Internet Res. 2020;22(6). Available from:https://pubmed.ncbi.nlm.nih.gov/32501277/

9. Kloek CJJ, Van Dongen JM, De Bakker DH, Bossen D, Dekker J, Veenhof C. Cost-effectiveness of a blended physiotherapy intervention compared to usual physiotherapy in patients with hip and/or knee osteoarthritis: A cluster randomized controlled trial. BMC Public Health. 2018;18(1). Available from: https://pubmed.ncbi.nlm.nih.gov/30170586/

1o. Wanless B, Berry A, Noblet T. Self-management of musculoskeletal (MSK) conditions: What is most useful to patients? Protocol for a mixed methods systematic review. Musculoskeletal Care. 2022;20(2):271–8. Available from: https://pubmed.ncbi.nlm.nih.gov/34859560/

11. Kelly M, Fullen B, Martin D, McMahon S, McVeigh JG. EHealth interventions to support self-management in people with musculoskeletal disorders: A scoping review protocol. JBI Evid Synth. 2021;19(3):709–20. 10. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8994513/

12. Babatunde OO, Jordan JL, Van Der Windt DA, Hill JC, Foster NE, Protheroe J. Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PLoS One. 2017;12(6):1–30. Available from: https://pubmed.ncbi.nlm.nih.gov/28640822/

13. Razai MS, Oakeshott P, Kankam H, Galea S, Stokes-Lampard H. Mitigating the psychological effects of social isolation during the covid-19 pandemic. Available from: https://pubmed.ncbi.nlm.nih.gov/32439691/

14. Department for Health and Social Care. Major conditions strategy: case for change and our strategic framework. 2023. Available from: https://www.gov.uk/government/publications/major-conditions-strategy-case-for-change-and-our-strategic-framework/major-conditions-strategy-case-for-change-and-our-strategic-framework–2

15. Improving our nation’s health | NHS Confederation [Internet]. www.nhsconfed.org. Available from: https://www.nhsconfed.org/publications/improving-our-nations-health-whole-government-economic-inactivity 14

16. British Medical Association. NHS Backlog Data Analysis [Internet]. BMA. 2024. Available from: https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/nhs-backlog-data-analysis

17. Hoy et al (2016),The global burden of low back pain: estimates from the Global Burden of Disease 2010 study downloaded from http://ard.bmj.com/ on June 23, 2016 – Published by group.bmj.com

18. Savingy P, Kuntze S, Watson P, et al. (2009). Low back pain: early management of persistent non-speci c low back pain. London: National Institute of Clinical Evidence; 2009. http://www.nice.org.uk/CG88. Accessed Jun 4th, 2010.

19. Berry A, McClellan C, Wanless B, Walsh N. A Tailored App for the Self-management of Musculoskeletal Conditions: Evidencing a Logic Model of Behavior Change. JMIR Formative Research. 2022 Mar 8;6(3):e32669.

20. Wanless B, Hassan N, McClellan C, Sothinathan C, Agustín D, Herweijer T, et al. How Do We Better Serve Excluded Populations When Delivering Digital Health Technology? Inclusion Evaluation of a Digital Musculoskeletal Self‐Management Solution. Musculoskeletal Care [Internet]. 2024 Aug 23 [cited 2024 Sep 12];22(3). Available from: https://pubmed.ncbi.nlm.nih.gov/39180193/

21. Health Service Journal. HSJ Partnership Awards 2023: HealthTech Partnership of the Year [Internet]. Health Service Journal. Health Service Journal; 2023 [cited 2024 Sep 12]. Available from: https://www.hsj.co.uk/partnership-awards/hsj-partnership-awards-2023-healthtech-partnership-of-the-year/7034403.article

22. Independent investigation of the NHS in England [Internet]. GOV.UK. 2024. Available from: https://www.gov.uk/government/publications/independent-investigation-of-the-nhs-in-england

23. getUBetter evaluation report NHS SWL ICB/Health Innovation Network

24. Edward R, Hill A, Hooper S, Thurlow J. getUBetter Report: Somerset NHS Foundation Trust Pilot. MSK Physiotherapy.

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News, Population Health

How ICSs can benefit from a strategic, system-wide approach to social value

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By Becky Jones, Social Value and Sustainability Lead, NHS Arden & GEM CSU

Creating healthier, more resilient communities and reducing our environmental impact are essential elements in delivering a more sustainable NHS. These ambitions are reflected in the four core aims assigned to integrated care systems (ICSs), which are: to improve outcomes in population health and healthcare; tackle inequalities; enhance productivity and value for money; and, support broader social and economic development.

The NHS has set an ambitious target to become net zero by 2040, while public bodies have had a legal responsibility to commit to the social, environmental and economic sustainability of their communities for many years. As a result, social value and environmental commitments are increasingly embedded in procurement and other legislative requirements. But how we translate these often-fragmented commitments into quantifiable achievements is less clear. Social value could have a major role to play in tackling our most pressing health and social care challenges, but this will require ICSs to adopt a more cohesive and proactive approach.

Seizing opportunities

Social value advocates for looking much more broadly at the wider determinants of health and considering how system partners can work together to achieve more for their communities. This holistic approach encompasses social, economic and environmental areas such as education, housing, work, crime and community services, and how these connect and contribute to the overall wellbeing of an area and its population.

Using population health data to inform priorities, system-wide collaboration gives health, public and voluntary sector organisations an important opportunity to develop a coordinated, strategic approach to delivering social value. This requires bringing the right mix of skills and disciplines together to identify programmes that will have the greatest impact, and mapping out the connections that need to be made for this to work. We know, for example, that poor quality housing can affect health. The health service could invest resources in treating a patient’s pneumonia only to discharge them back to their draughty or damp home, which is likely to cause a return to ill health.

Similarly, if a voluntary organisation runs activities to help tackle social isolation but people cannot afford the transport to get there, the initiative won’t achieve its aims, despite appearing on paper to meet population needs. Sharing information and planning interventions across system partners creates opportunities to break these vicious cycles and move towards disease prevention and wellness.

Agreeing priorities

Organisations will typically have specific activity, savings or outcome targets to meet, or be used to working in certain ways. This is where data can help identify common challenges and demonstrate the value of becoming more aligned. What are your staff surveys telling you about workforce priorities? What recruitment and retention pressures does your system face? Where are the gaps in your health provision? Which patients are driving demand, and which communities are you not reaching? Engaging effectively across your ICS, and with your patients and communities, will help determine priorities at system, place and organisational levels.

Some initiatives may be unique to individual organisations or communities but aligning them to a broader set of strategic priorities will make it easier to evaluate overall impact and share learning. In Coventry and Warwickshire ICS, for example, the ICB is taking a system-wide approach to tackling health inequalities, drawing on partners’ roles as anchor institutions to deliver social value across the region. The system is establishing a charter that aims to act as a framework, enabling each partner organisation to do what it needs to do to meet its own requirements, albeit contributing to a wider strategy to deliver a more proactive and sustainable health and care service. The charter aligns to the system’s long-term planning process while giving a specific approach to delivering social value through an overarching framework.

In Cheshire and Merseyside, the ICS developed a Social Value Charter which defines what social value means to them, using a coproduction approach that enabled system partners, voluntary organisations, the private sector and citizens to contribute. The Charter sets out the principles and approach signatories sign up to, including how social value will be measured using a Social Value Outcomes Framework.

Making suppliers part of the solution

Setting social value priorities helps organisations seek meaningful contributions from suppliers. To fulfil procurement requirements, bidders are commonly required to come up with social value initiatives and carbon reduction plans which tend to be silo projects that are difficult to monitor and manage. By inviting them to show how they would contribute to your existing social value priorities, your system can start to harness a collective contribution towards priority programmes which can be measured and evaluated against agreed criteria.

This means working with procurement colleagues much earlier in the commissioning process and challenging established ways of working that prioritise savings and lower cost contracts. If your system has prioritised paying a real living wage, for example, contracts need to be assessed not just for efficiency but for the long-term, wider benefits that may come with using suppliers that pay their staff well.

Measuring impact

Social value is not about quick wins but long-term sustainability. It requires taking a step back from continuous day-to-day pressures to consider initiatives that it may take us years to fully benefit from. This makes measurement even more important – we need to be able to see steps towards achieving sustainability goals, which in turn will lead to better, broader outcomes. NHS Arden & GEM has been working with the Social Value Portal to adapt their social value themes, outcomes and measures system (TOM system) for healthcare which incorporates five key themes:

  • Jobs – opportunity for all
  • Growth – inclusive growth
  • Social – empowering communities
  • Environment – safeguarding and restoring our world
  • Innovation – new ideas to deliver social value.

The TOM system is endorsed by the Local Government Association and maps to both major external frameworks and the Government Social Value Model. Using robust data, proxy values are applied to each objective and outcome which helps organisations convert their progress into a quantifiable value. Using consistent standards across systems enables more reliable assessment and benchmarking, which in turn will strengthen best practice and accelerate learning across regions.

Where to start

ICSs and their individual partner organisations will be at different stages of maturity and will have varying support needs. In recognition of this, NHS Arden & GEM has established a Social Value Network to encourage information-sharing and innovation across England, and a Future NHS social value workspace where organisations can access free resources. More recently, we have partnered with the Social Value Quality Mark CIC and the Social Value Portal to create the Social Value in Health Excellence Programme, providing independent assessment, support and monitoring to help organisations move successfully through their social value journey. This is not about adding to the to-do list, but about developing best practice in social value to help ICSs deliver the four core aims they are already tasked with.

Understanding and adopting a system-wide approach to social value has the potential to deliver significant strides towards preventative care but it’s not an overnight solution. Although today’s pressures must be tackled, it is equally important to build the knowledge and confidence needed to make long-term investments in social value that will improve community health and resilience in the long-term.

Becky Jones, Social Value and Sustainability Lead, NHS Arden & GEM CSU
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From fragmentation to integration: Lessons for the NHS from New Zealand

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When David Meates became CEO of New Zealand’s Canterbury District Health Board in 2009, he took charge of a system that was “broken and fragmented”. 11 years later, the system’s fortunes were transformed. At a recent event, Meates shared his experiences and lessons from Canterbury’s transformation, offering vital insight for the NHS as it continues its own journey from fragmentation to integration.

On 14th August, Public Policy Projects (PPP) held a dinner for a group of carefully selected stakeholders to share lessons from international and devolved nations on the delivery of integrated care. Speaking to the assembled guests was David Meates, who, while current interim CEO of Rowing NZ, was CEO of New Zealand’s Canterbury District Health Board (DHB) from 2009-2020. During his tenure, Canterbury DHB undertook an ambitious series of reforms aimed at integrating the fragmented elements of the health service, which turned the ailing system into one of the most integrated health systems anywhere in the world.

Many of the issues Canterbury faced have parallels within the NHS, and as such, it provides valuable lessons for UK health and care transformation. Prior to Meates’ arrival, Christchurch Hospital (the district’s largest) was regularly ‘gridlocked’ due to a shortage of beds, while a fragmented system and growing demand for services were damaging staff morale and the system’s ability to deliver effective healthcare.

Meates took charge of Canterbury DHB in 2009, and noted that by 2007, leaders had already realised the system was unsustainable and needed change. He described it as “broken and fragmented”, siloed by profession, dominated by providers and lacking clear purpose. Exponential increases in funding over preceding years had led to little-to-no improvement in service delivery, productivity or patient outcomes.

Christchurch Hospital, Christchurch, New Zealand

Without reform, the system would have required another 600-bed hospital, a 23 per cent increase in GP practices, 2,000 more aged care beds, and 9,000 additional healthcare professionals (HCPs), simply to meet demand. Meates remarked that even with the necessary funds, the workforce to do this was simply not available. What was needed, Meates determined, was a new blueprint for delivering healthcare to Canterbury’s more than half a million residents, as well as a burning platform that would inspire substantial change.

First steps: identifying the vision

Much of Canterbury DHB’s early work – under the umbrella of Project 2020 – focused on understanding the shared challenges that affect large and complex systems in other sectors, and how these insights could be applied to a healthcare environment. One key initiative was Xceler8, an eight-week experiential leadership development programme that involved 1,500 doctors, nurses, and allied healthcare professionals from across the Canterbury system. Participants, convened in cross-disciplinary groups, spent time with leaders in other sectors to understand their challenges. At the end of the programme, these groups presented ideas for system improvements to a chief executive, with some being subsequently implemented. Beyond the positive changes this brought about, the programme also helped to embed principles of system thinking among the workforce and demonstrated that each part of the system has a role to play in broader system improvement.

Other programmes included Particip8 (a six-week night-school course focusing on change management techniques), and Collabor8 (a short course focusing on skills management).

These programmes also sought to familiarise staff members with Lean and Six Sigma methodologies – prioritising customer value and continuous improvement – as well as chaos theory – the idea that beneath the apparent randomness of complex systems, there are underlying patterns and constant feedback loops that can be quantified, measured and understood.

Through these initiatives, system leaders began identifying commonalities and principles that extended beyond traditional approaches to healthcare system transformation, such as the concept of ‘value.’ While ‘value’ in other sectors might refer to profit or market capitalisation, it was determined that in a healthcare context, creating ‘value’ could be understood as not wasting patients’, and by extension, the system’s, time. This realisation led to the establishment of three strategic goals, forming a framework for “a connected system, centred around people, that aimed not to waste their time”.

  1. People take greater responsibility for their own health
    Prioritising the development of services that support people and families to stay well and take increased responsibility for their own health and wellbeing.
  2. People stay well in their own homes and communities
    Prioritising the development of primary care and community services to support people and families in community-based settings, close to home, and to provide a point of ongoing contact and continuity – for most, this is in general practice.
  3. People receive timely and appropriate care
    Enabling the freeing-up of hospital-based specialist resources which can be responsive to episodic events and the provision of complex care and specialist advice to primary care.

These initiatives also led to a realisation that regardless of how fragmented a system may seem, all components form part of the same ecosystem. Shuffling patients around to meet ‘activity’ targets benefits the system little, whereas prioritising the patient’s best interests—minimising their time spent while achieving the best possible outcomes—benefits both the patients and the entire system. This insight gave rise to the principle of “One system: One budget”, which became the foundation for all subsequent reforms within Canterbury DHB.

One system: One budget

These guiding principles informed the first series of practical changes that Canterbury DHB implemented to better integrate the system and create better value both for patients and the wider system.

A crucial development was the creation of the community-based HealthPathways, aimed at improving the interface between secondary and primary care. This programme was initiated by clinicians who, after reviewing a backlog of referrals, identified that many common issues could have been prevented through better communication between hospitals and primary care providers. General practitioners and hospital specialists were then brought together to agree on optimal management and referral pathways for specific conditions. These pathways were subsequently presented to larger groups of hospital doctors, GPs, nurses, and HCPs for their input. Meates reflected on the traction that HealthPathways was gaining as an approach in the Northern hemisphere, with systems in England and Wales adopting the methodology as the operating system for their integrated systems.

A key lesson from Project 2020, as Meates has argued, is that “too often, we confuse activity with progress,” a criticism frequently directed at the NHS’s Payment by Results tariff system. To better align incentives across the Canterbury system, this approach was abandoned in favour of the newly established Canterbury Health System Outcomes Framework. This change supported the principle of “One System: One Budget,” ensuring that the various components of the system would now be rewarded for achieving the best outcomes for the system or the patient, rather than merely moving patients around and being compensated for this ‘activity.’

Another change was the establishment of the Canterbury Clinical Network – a collaborative of HCPs, health system users and cross-sector partners using a principles-based framework to decide how, when and where health services are provided. These principles included taking a whole systems approach to ensure the integration and sustainability of services, ensuring that people and communities were at the centre of any changes, enabling clinically led service development, and the system operating within its financial means. Crucially, while commissioners were involved, their role was to support the process and then work out how to realise the objectives, not to prescribe the objectives themselves.

An important step towards service integration was also made by the establishment of a connected data platform – HealthOne – an electronic shared care record combining GP, hospital and community pharmacy records, along with laboratory and imaging results. Since this was not replacing existing systems, but drawing on them, its implementation was relatively non-disruptive and enabled the scope of the records to be increased over time. Citizens could opt out of all or part of the system, with the process led by the system’s Consumer Council, while regular “dynamic” automated privacy audits ensured that patient privacy was always prioritised.

Reflections

In reflecting on Canterbury DHB’s transformation journey, Meates was wary of simplistic quick fixes to complex, systemic problems, and the importance of taking a holistic and long-term approach with any proposed solutions. “You need a whole system to work for the whole system to work – focusing on part of the system will not effect the change required,” he told the assembled guests. Considering this, during its transformation Canterbury DHB paid special attention to the language it used to refer to the system and its workforce, emphasising the use of “we” in official communications, and deliberately halting the use of language which went counter to the narrative of a single system.

The principles of integration and collaboration must also be reflected in the redesign of services and pathways by actively involving relevant stakeholders and ensuring their voices are heard. Meates emphasised that “change happens at the speed of trust,” which requires meaningful engagement with frontline teams, as well as input from the clinicians who will deliver the services and the communities who will use them.

Meates also cautioned that in any large-scale system transformation, facilitating cultural change among the people involved is as crucial as any change in process or structure. With the introduction of integrated care systems and their emphasis on collaboration over competition (a significant departure from the previous way of commissioning services), this is a point the NHS could do well to acknowledge. “You can’t expect the same people that have worked in a competitive environment and who have seen their success tied to the success of their organisation to suddenly collaborate,” said Meates. This is a case of both instilling that necessary cultural change, but also of facilitating systems to be collaborative, such as by realigning incentives towards system outcomes as opposed to individual organisational sustainability.

The cultural dimension is also highly relevant to funding issues, as “too often, these involve win/lose discussions” where different parts of a system manage their activity levels to safeguard their budgets and maintain status within the broader system. While outcomes-based remuneration is undoubtedly a key solution, it is equally important to embrace the idea that the best outcome for patients is also the best outcome for the system and its individual components.

On a practical level, Meates emphasised that although reforming contracts can be the most challenging area, it is perhaps the most critical. Contracts significantly limit what healthcare providers can do and how they operate, making them essential enablers of any strategic change. “While the goal is integration,” Meates argued, this is undermined if “existing contracts and reporting requirements continue to move in the opposite direction. Contracts give you all the reasons why you can’t change what you are doing.”

Conclusions for the NHS

The transformative journey of Canterbury DHB under David Meates offers critical insights for the NHS as it continues its transitions towards integrated care. The success of Canterbury’s reforms, driven by a commitment to collaboration, system-wide integration, and a focus on patient-centred outcomes, illustrates the importance of addressing systemic fragmentation holistically. According to Meates, people in Canterbury were “30 percent less likely to be admitted medically unwell compared with the rest of New Zealand” because of these reforms.

Canterbury DHB’s experience shows that applying process and quality improvement techniques like Lean and Six Sigma to complex systems such as healthcare is no simple task; it demands a long-term vision and strong commitment from leadership to act. For too long, the NHS has been consumed by day-to-day pressures, and the introduction of ICSs has not been accompanied by the necessary cultural changes that can only clear, top-down strategic direction can bring.

Additionally, while the NHS has sought to place greater emphasis on citizen-centred care, it still often fails to adequately engage marginalised communities and provide co-designed, holistic care services that meet their needs. The establishment of community diagnostic centres is certainly a positive step in this regard, more needs to be done to ensure that these services are accessible and tailored to the unique challenges faced by marginalised and underserved groups. This includes overcoming language barriers, addressing cultural sensitivities and ensuring that services are easily reachable for those most in need. Citizen-centred care required continuous engagement with these communities, fostering trust and enabling them to have an active role in shaping their own health outcomes.

Key lessons from Canterbury DHB include prioritising cultural change, realigning incentives to emphasise system-wide benefits, ongoing community and patient engagement and leveraging technology like shared care records to enhance communication across care settings. By adopting these principles, the NHS can achieve meaningful, sustainable reforms that deliver value for both patients and the wider healthcare system.

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Labour needs a preventative health strategy to transform public health

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Business for Health Founder and CEO, Tina Woods, discusses the crucial role that business can play in improving the nation’s health, and calls on the Labour government to adopt a shift towards evidence-based prevention.

As the new Labour Government enters its early stages in power, it is increasingly clear that the party has inherited a sick workforce, rising levels of economic inactivity and unsustainable pressure on the NHS.

Tackling our current broken health system requires a long-term, multifaceted approach that shifts the UK’s societal attitude from reliance on the NHS to a culture of prevention. Going forward, creating a comprehensive preventative health strategy should be Labour’s focus.

Laying the foundations for a ‘prevention first’ revolution

Labour’s Health Mission in their manifesto states the aim to “deliver a ‘prevention first’ revolution”, and with the right partners and a clear strategy, this vision can become a reality.

While the ambition to halve heart attacks and strokes, create a smoke-free generation, and reduce health inequality are commendable, translating these goals into tangible policy and action will be crucial.

A preventative health strategy must go beyond individual behaviour change and address the wider determinants of health. This includes creating healthy environments, reforming the food system, and ensuring good work and housing for all. Crucially, it requires coordinated action across government departments, and wider businesses.

Easing pressures on hospitals

The UK’s poor public health is placing immense pressure on the NHS, resulting in many hospitals having far too many patients, with far too long waiting lists.

Despite over 95 per cent of the NHS budget being spent on treatment, with little ring-fenced for prevention, preventable conditions like obesity, heart disease, and lung cancer account for a significant proportion of hospital admissions and healthcare costs.

The government should set a target to allocate a specific percentage of the total health budget to evidence-based prevention programmes within 5 years, rising by 2030. Moving more pathways of care into community health will alleviate pressure on hospitals and create a more sustainable healthcare system. To support in setting and managing these targets, Business for Health has partnered with the Office for National Statistics (ONS) to deliver an enhanced ONS Health Index which will be vital in tracking against the Government’s health and wellbeing plans.

Business is essential in prevention

Alongside the NHS, businesses also have a crucial role to play in this agenda, and the Labour government must work to cultivate meaningful partnerships with the private sector.

By creating incentives and frameworks for improving health, small and medium-sized enterprises can be encouraged to do more; exploring legislation, such as making workplace health reporting mandatory for larger companies, is another driver. To support businesses in creating these strategies, the next iteration of the ONS Health Index will include additional data and tools which businesses will be able to use to understand the health of their workforce and customers better.

Looking ahead, business leaders and employees alike will be eager to see legislation and clear targets from the Labour government, accompanied by investment to support a prevention economy. Businesses are essential partners in creating healthy workplaces, promoting active lifestyles, and tackling issues like obesity and mental ill-health.

A prescription for the future

Ultimately, Labour’s health agenda must move beyond short-term fixes and invest in long-term system change. This will require bold political leadership, a willingness to tackle vested interests, and a collaborative, cross-party approach bringing together government, business, communities and individuals. Only then can we build a healthier, more prosperous future for the nation.

Tina Woods, CEO and Founder, Business for Health
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ONS and Business for Health partner to enhance the ONS Health Index

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The Index will capture a wide range of health inputs, including wider societal and economic determinants, to fill the evidence gap on the interplay between health, business and work and encourage businesses to take responsibility for their impacts on health.

Business for Health and the Office for National Statistics (ONS) have announced a collaboration to develop the next iteration of the ONS Health Index – a tool to support businesses, local authorities, integrated care boards, and government on decisions to ‘invest for health and economic growth’ and inform the Treasury on the economic case for prevention.

The ONS Health Index, last published in summer 2023, measures health in its broadest terms and seeks to understand how it is changing over time. It tracks health in clinical terms (i.e. the prevalence of certain conditions), but also looks at the wider social, economic and environmental drivers of health, together with personal circumstances.

Building on these measures, the enhanced ONS Health Index will include additional data and tools relevant to businesses and their practices. These could range from capturing direct health impacts on employees and customers, to environmental impacts of a company’s products. This will increase the understanding of the interplay between health and business and work life and fill an important evidence gap. For example, it could be used at a local level to help measure corporate progress against key health and wellbeing aims.

More broadly, the additional business themed metrics will inform strategies around the link between health and wellbeing and workforce productivity, and the role of health within the Environmental Social and Governance discussion.

Business for Health, a business-led social venture, in collaboration with Lane Clark & Peacock (LCP), have identified demand from businesses and organisations for the continuation and enhancement of this tool to define their role in the economy and wider society.

They will engage with businesses to develop the next iteration of the Index that provides high-value data on the health and well-being of the nation, including the workforce. One of the key goals will be to encourage businesses to understand and take responsibility for their impacts on health. To this end, the next iteration of the ONS Health Index will seek to bring businesses into its core audiences and provide health-relevant data to the public that measures the impact of businesses on population health.

These additional data will aim to highlight key determinants influencing employee health, and in doing so, inform business decision-making and support organisational and corporate culture with health at its core.

With the UK’s general population currently facing significant health challenges, leading to long term economic inactivity and pressures on the health system, the enhancement of the ONS Health Index will enable focus on facilitating system change to improve health and wealth outcomes. This is vital for enhancing the health and economic resilience of the nation.

Tina Woods, CEO and Founder of Business for Health, said: “There is a clear need from businesses to receive better data on the role of health within wider workforce planning. The link between corporate culture and individuals’ physical and mental wellbeing is irrefutable and our role on the new ONS Health Index will act as a crucial tool in understanding how businesses can improve, report and measure their impact on health linked to economic growth.”

Lord Bethell, Former Health and Innovation Minister and Chair of Business for Health, said: “We are delighted to be working with the ONS and LCP to develop the next iteration of the ONS Health Index, which will differentiate itself by allowing companies to understand and define their social purpose alongside measuring their economic contribution.”

Jonathan Pearson Stuttard, Head of Health Analytics at LCP, said: “There is a need for employers, businesses and industry partners to work collaboratively with the government to ensure that long-term health challenges are tackled with the urgency that is required.”

Dr James Tucker, Deputy Director of Health, International and Partnerships, Office for National Statistics, said: “The importance of high-quality data to inform strategies and reporting on the health of our workforce is crucial. Working with businesses as core users of the next ONS Health Index will be key in accessing granular data from businesses to feed into the index and provide relevant health data.

 

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Harnessing innovation to deliver medicines optimisation at scale

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In this case study, Meera Parkash, Clinical Facilitator, Population Health Management at Optum UK, discusses how medicines optimisation can help free up pharmacy capacity and deliver key improvements to population health management.

At a time when the health system is urgently seeking new ways to cut costs, improve outcomes and reduce health inequalities, there are three areas where medicines optimisation can make an important contribution.

The first is non-adherence to medicines. It is estimated that half of all patients are non-adherent to their prescribed medication, costing the NHS £500m every year. The second concerns over-ordering and over-prescribing. About £300m worth of medicines go unused each year, and around half of this cost is believed to be recoverable. The third and final relates to adverse drug events (ADEs) in primary care, leading to hospital admissions. An estimated 72 per cent of ADEs are avoidable, costing the NHS £100m every year.

Traditionally, clinicians have had to manually search for patients who may need changes to their medication approach. This is extremely time-consuming and may not always be accurate if the data being used is out of date.

Population360® changes this. By integrating fully with clinical systems, it automatically finds and presents opportunities to improve medication safety, non-adherence and cost-effectiveness all in one place – transforming the speed, accuracy and scale of these processes.

Other prescribing decision support tools focus mainly on acute prescriptions and can only process them one patient at a time, whereas Population360 can proactively manage an entire patient population for an ICS at once. It does this by providing safety and adherence alerts for high-risk cases while surfacing lists of patients who may benefit from medication changes.

In light of resourcing pressures on pharmacy teams – which limit the number of structured medication reviews, programme switches, or high-risk drugs monitoring they can undertake using traditional methods – Population360 frees up capacity and helps them cover more ground. This demonstrates that it can be an important enabler for delivering medicines optimisation strategies at scale.

Evidence of success

Working with a GP practice covering 10,000 patients, Population360 flagged opportunities to save £82,376 through simple medication switches and recommended 1,171 patients for an adherence or safety intervention over a three-month period.

Based on these, a single pharmacy technician successfully reviewed 16 patients in less than 30 minutes, actively booking tests for 14 patients and initiating a patient consultation and de-prescribe for another.

Another pharmacist reviewed all female patients prescribed sodium valproate based on a targeted clinical rule. The pharmacist contacted patients, reminding them to follow up with their consultant to ensure Annual Risk Acknowledgement Forms were up to date (most of which were not) and contraception was in place.

Both examples demonstrate clinicians working proactively, supporting structured medication reviews, and closing important gaps in care.

The lead pharmacist at the GP surgery said: “It (Population360) gives us these patients very, very quickly and we can review them and take appropriate action – some of these patients are hard to reach people which is also an advantage.”

To see how Optum advances medicines optimisation (MO) and to learn more about proactive prescribing at scale, please click here.

Optum is a registered trademark of Optum, Inc. in the U.S. and other jurisdictions. All other trademarks are the property of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer.  
© 2024 Optum, Inc. All rights reserved.  

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Vic Townshend: ‘Whole person’ understanding is reliant on intelligence-informed decisions

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Vic Townshend, Programme Director for Population Health Management (PHM) at Lincolnshire ICS, speaks with Public Policy Projects’ Ameneh Saatchi.

Building capacity and capability for population health management (PHM) is perhaps one of the single most significant enablers of truly integrated care and ambitions for England’s 42 integrated care systems (ICSs). But while every ICS will place significant priority on establishing comprehensive PHM, immediate service pressures and restricted resources have led to mixed results across the country.

In Lincolnshire, the ICS has established the Lincolnshire ICS Population Health Management Programme, which uses a ground-breaking person-level linked dataset, recognised as one of the most extensive in the country. The Lincolnshire Joined Intelligence Dataset covers 100 per cent of the local GP registered population. It encompasses a range of data sources, including primary and secondary care, adult social care, elective waiting lists, deprivation indices, social vulnerability and isolation measures from the Office for National Statistics, Census data, and community asset registers.

This initiative originated with the NHS England sponsored Population Health Management development programme, which allowed for the system to test what PHM offered and supported the first linked dataset to be created for a proportion of the county’s population. Other systems do have linked datasets, but there are none currently known that have the same extent of sources and population coverage.

“I worked closely with the Director of Intelligence and Analytics [Katy Hardwick],” says Vic, explaining that the team entered a partnership with Optum UK, to build the first ever linked data set in 2019, which initially covered about 30 per cent of the population. “This gave us data joined at the personal level, allowing us to see a person’s journey through health and ill-health and how they interacted with services across Lincolnshire to support their needs.”

The data science tool employed by Lincolnshire ICS focuses primarily on measuring health and care utilisation across different contexts, emphasising unit of activity and associated indicative costs. Traditional metrics, such as length of stay are incorporated, offering a comprehensive view of resource utilisation. Moreover, the tool’s versatility allows for customised presentations of intelligence, enabling users to tailor insights to their specific needs. Insights into health inequalities are facilitated by comparing cohorts of individuals, shedding light on variation in outcomes and contributing to high quality decision-making.

In addition to traditional metrics and the sources listed above, the Lincolnshire dataset also encompasses prescribing and medicines utilisation data, facilitating a holistic, system-wide understanding of health and care activities, service utilisation and outcomes. The dataset captures activity from all community, acute and mental health services, drawing from data recorded in trusts’ National Minimum Data Sets. This ensures seamless integration of data, irrespective of where individuals receive treatment – even if that treatment is outside of Lincolnshire ICS.

In healthcare, intelligence-informed decision-making stands as a crucial factor in navigating complex systems effectively. Vic emphasises the importance of this approach, highlighting how linked data allows for a comprehensive understanding of the impact of interventions across healthcare settings.

“The linked data set allows us to identify where opportunities are for intervention and change [and] where we’re doing well,” Vic explains. “What it doesn’t tell us is what we should do with it, but it starts to prompt leaders to ask the right questions… there’s nobody in our system that just has diabetes, which brings into question why we are providing services for diabetics in silo when they have more than one long-term condition and are subject to many other wider determinants of health, such as deprivation.”

This enhanced visibility helps stakeholders to identify both direct and indirect benefits and drawbacks of interventions, leading to better-informed decisions.

“The linked data set allows intelligence-informed decision-making, [meaning] we can now see the impact of our actions across our organisational borders and identify indirect benefits and disbenefits. So, we can track how changes in general practice are improving outcomes across other services, or vice versa.”

The inclusion of indicative costing within the linked data set also provides insights into resource allocation and workforce interactions. This allows for a more subtle understanding of how resources are utilised within the healthcare system, facilitating efficient resource management and optimisation.

Evaluation plays a pivotal role in assessing the effectiveness of interventions and changes in healthcare delivery. Vic underscores the necessity of robust evaluation, encompassing both qualitative and quantitative measures. However, Vic also acknowledges the challenge of maintaining the usability of the linked dataset while incorporating qualitative elements, emphasising the need for flexibility in its development and usage.

“Intelligence-informed decision-making becomes your North Star; you’re all following the same intelligence that steers in the same direction, wherever you work within the system. It has allowed us to robustly evaluate qualitative and quantitative outcomes, so it’s not just about what we can measure in the dataset, but working with personalisation, understanding what outcomes are important to people.”

Overall, the linked data set serves as a valuable tool for identifying opportunities for intervention and making informed decisions that lead to improved outcomes for patient and wider health system.

Vic’s journey into PHM stems from a diverse background, transitioning from the RAF as a meteorology officer, to a decade in general management in healthcare, to change management in complex systems. A keen interest in data analysis has been the nexus between various positions throughout her career.

More recently, Vic has begun addressing performance improvement challenges in healthcare, focusing on the interconnectedness of prescribing practices and care pathways. As Director of the Population Health Management programme in Lincolnshire ICS, she emphasises the need for comprehensive, intelligence-informed decision-making in healthcare leadership, seeing it as pivotal for driving systemic change and improving outcomes. For Vic, PHM represents a transformative tool with the potential to fundamentally change healthcare systems and improve outcomes for all.

The inequality challenge

Intelligence Leads and Chief Analysts working within ICSs will have increasingly important roles in navigating the complexities of health inequalities. Such roles require skill sets that can play a crucial role in generating intelligence to inform various inquiries regarding clinical care outcomes, health and wellbeing, and wider determinants of health. By fostering relationships with them, healthcare professionals can gain access to previously untapped data sets or intelligence that can address longstanding questions or concerns.

While population health itself is not a new concept, the current level of focus being placed on PHM requires significant new infrastructure support, the need for which may not yet be universally recognised within individual health systems. Therefore, she advises initiating discussions with intelligence teams to explore existing available data and infrastructure.

Vic stresses the importance of incorporating intelligence specialists or analysts into discussions alongside clinicians and decision-makers. This tripartite arrangement ensures that data-driven insights inform decision-making processes effectively, leading to more informed and impactful strategy.

Wound care from the lens of population health management

Vic underscores several key priorities essential for improving Wound Care outcomes:

Consistent documentation on electronic systems

Vic emphasises the importance of developing consistent documentation of wound care activities on electronic systems across frontline services and at strategic level. This consistency ensures accurate data collection that is crucial, not only for clinical records, but also for evidence-based decision-making and outcome evaluation. This is something Lincolnshire ICS will be working to develop further, as Vic identifies a challenge in ensuring consistency across local teams to capture all necessary data for wound care. Addressing this challenge is fundamental for systems to improve efficiency and workforce challenges in the community but may require additional resources and strategies to improve documentation practices.

Personalised care approach

Vic discusses the need to personalise wound care, highlighting that different individuals may require different approaches based on their specific needs and preferences for self-care. This personalised approach ensures that care is tailored to everyone’s circumstances, improving overall outcomes.

Training and applying best practices

Ensuring that clinical teams involved in wound care across various organisations are trained in, and consistently utilise, best practices. This helps standardise care delivery with the aim of adhering to established standards and protocols and improves overall quality of care.

Evaluation and continuous improvement

Establishing mechanisms for evaluating the effectiveness of changes made in wound care practices and processes. This iterative approach to improvement allows for ongoing refinement and optimisation of care delivery. This involves identifying what works, what doesn’t, and adjusting accordingly to continuously improve care delivery.

Communication and engagement

Vic underscores the necessity of effective communication and engagement strategies to drive change and improve outcomes for individuals. Engaging the workforce and the population is essential for raising awareness about available treatments and promoting better understanding of wound care options.

Extending pharmacy services – the pros and cons

Vic acknowledges the potential of community pharmacists in wound care as they are in the heart of communities, close to the patients, and can have a further role in early intervention. But she raises concerns about the sustainability and consistency of extending their roles. Vic highlights challenges such as increased workload, inconsistent sign-up to extended services, and competing priorities within the pharmacy profession.

Vic also provides recommendations to apply population health management techniques to diabetes care for comprehensive support

Vic asserts the need to shift away from treating diabetes as a standalone condition and to instead adopt a holistic approach that addresses individuals’ overall health needs. She advocates for integrated care models that offer comprehensive support, ensuring that individuals receive assistance beyond diabetes management alone. This approach aims to improve overall health outcomes and reduce the likelihood of complications associated with diabetes, such as leg ulcers and amputations.

Empowering prevention strategies

Furthermore, Vic highlights the importance of prevention strategies in combating diabetes. She stresses the need for a cohesive and proactive focus on prevention, encompassing primary, secondary, and tertiary prevention efforts. By investing in preventive measures and proactive interventions, such as health and wellbeing initiatives and collaborations with voluntary sectors, individuals can be empowered to manage their diabetes effectively and avoid frequent visits to healthcare providers.

Personalised care: addressing individual needs

Lastly, Vic underscores the significance of a personalised approach to diabetes care. She advocates for a strengths-based conversation that empowers individuals to take charge of their health while ensuring that healthcare systems meet their personal needs. By tailoring care plans to individual circumstances and preferences, healthcare providers can address inequalities and deliver more effective and meaningful support. This collaborative approach involves engaging individuals in decision-making processes and considering factors such as housing, employment, and social support to create sustainable and equitable healthcare services. Figure 1 below demonstrates how population health analytics tools can improve outcomes and efficiency.

Figure 1: Population Health Management Tools, the bridge between the person and the system strategy (click to englarge)

Conclusion

Vic emphasises the critical need for consistent documentation of wound care activities across all levels of healthcare delivery. This ensures accurate data collection, essential for evidence-based decision-making and evaluating outcomes. Additionally, she underscores the importance of a personalised care approach, recognising that individual needs may vary significantly. Training in best practices, continuous evaluation, and effective communication and engagement strategies are identified as key priorities to drive improvements in wound care delivery.

However, a significant challenge arises from the inconsistent capture of data by community nurses. This gap in documentation poses a barrier to comprehensive data analysis and evidence-based decision-making. Addressing this challenge will require focused efforts to improve documentation practices and ensure that all relevant data are captured accurately. By prioritising efforts to enhance data collection consistency, healthcare providers can strengthen the foundation for effective wound care delivery and evaluation.

What’s next?

Diabetes and wound care are the second and third highest expense to the health system respectively, and impact millions of people in the United Kingdom. Public Policy Projects is launching the second part of its Diabetes Care programme in the autumn of 2024 called ‘Holistic approaches to diabetes care – treating the whole patient’. Vic Townshend will be presenting on 2nd December, in London at the PPP Wound Care conference.

Contact Ameneh Saatchi, Director of Market Access for Diabetes and Wound Care, should you wish to learn more about these programmes: ameneh.saatchi@publicpolicyprojects.com

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Prioritise nutrition and hydration to boost broader health outcomes, says new report

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New report from PPP finds that efforts to implement a multidisciplinary approach to nutrition and hydration are needed to help address the dysphagia burden across the NHS.

A new report from Public Policy Projects (PPP) finds that with the UK becoming a ‘super-aged’ society, declining nutritional and hydrational status among elderly and frail populations will place increasing strain on health and care services.

The report, Prioritising nutrition, hydration and dysphagia in an integrated care context, states that while considerable work and investment has been allocated to reduce the incidence of obesity and the diet-related diabetes, malnutrition and hydration are not given the same focus, despite their significant impact on health outcomes and its role in the management of other conditions.

The report is the culmination of two roundtables held by PPP in 2023, which convened stakeholders to discuss how ICSs embed nutritional and hydrational health into integrated care strategies. The discussions focused on specific elements of the debate, including improving the management of dysphagia and care provided for frail populations in different care settings. Attendees included NHS England clinical leadership, allied health professionals (AHPs), including speech and language therapists (SLTs), social care providers, primary care representation nurses and other key health and care stakeholders.

Graphic showing levels of elderly population at ICS level in 2021. Source: Census 2021

According to the report, recent reforms to the health and care sector (most notably, the introduction of ICSs) present new opportunities to develop comprehensive approaches to nutrition and hydration, in a way that improves holistic patient care and saves valuable resource for the NHS.

However, among its recommendations, the report calls on the Department of Health and Social Care to launch a national review into food and drink provided across the care sector, to help improve the nutritional and hydrational status of frail citizens in social care. This review should follow the structure and ethos of the NHS Hospital Food programme, the report argues.

It adds that addressing dysphagia should be central to broader NHS goals of enhancing the quality of life for the elderly population, and that by prioritising the management and screening of dysphagia, the NHS could prevent avoidable hospital admissions and promote more efficient use of resources across the health and care sector.

Download the report here

To address the complex and multifaceted challenge of dysphagia, with various medical, neurological, and anatomical elements potentially contributing, will require systems to adopt a multidisciplinary approach, says the report. This will necessitate close collaboration between diverse teams of healthcare professionals, each with specialised expertise.

It finds that a multidisciplinary approach that includes speech and language therapists, dietitians, and physicians, is essential for managing dysphagia and addressing the complex healthcare needs of the elderly in a holistic fashion. To help enable this multidisciplinary approach, the report argues that the model of speech and language therapy sitting in community settings should be scaled nationwide, and adopted across ICSs within integrated care strategies. These strategies should also closely involve the voluntary sector.

The report also recommends an expansion of the speech and language therapy workforce, with ring-fenced funding for broader allied health professionals – in line with ambitions set out in the NHS Workforce Plan.

“The nutritional and hydrational needs of our elderly and frail citizens has been neglected for far too long. As the UK moves towards a ‘super-aged’ society, NHS organisations, care providers and integrated care systems must increasingly focus efforts on improving nutritional and hydrational health,” said report author and Group Editor at PPP, David Duffy. “It is vital that resources are orientated to support allied health professionals, particularly speech and language therapists, who play a vital role in maintaining nutritional health for elderly and frail citizens.

“Nobody in the UK should suffer from malnutrition or dehydration in this day and age, especially not our frailest and most vulnerable citizens. We hope that this report will help shine a light, not just on the scale of the problem, but also on achieveable solutions that we believe will help address the terrible burden of dysphagia.”

Recommendations:

  1. NHS England must prioritise nutrition, hydration and dysphagia as part of its drive to improve system performance and broader health outcomes. Nutrition and hydration management are underdeveloped areas which can help enable success in key national strategies, such as the elective care backlog plan, workforce strategy, the urgent and emergency care plan and the delivery plan for recovering access to primary care.
  2. Integrated care systems should consider dysphagia and wider nutritional and hydrational health as key parts of preventative health policies that can help future proof local health systems.
  3. The Department of Health and Social Care (DHSC) should commission a national review into food and drink provided across the care sector. This review should follow the structure and ethos of the NHS Hospital Food programme. The review should be led by a range of stakeholders from within the NHS and social care, as well as representatives from industry and the private sector.
  4. As the population becomes a ‘super-aged’ society, an integrated strategy is required to manage the health of the elderly and frail population. This should draw upon global and international frameworks provided by the WHO’s ICOPE framework.
  5. ICSs should ensure that maximising the ‘intrinsic capacity’ of citizens is a key priority within integrated care strategies, to prevent deterioration of health and supplement preventative health policies.
  6. ICSs should work to prioritise evidence-based nutritional and hydrational approaches within the social care sector, harnessing tools such as nutritional supplements where necessary, to assist those who have difficulty eating, drinking and swallowing.
  7. The model of speech and language therapy sitting in community settings should be scaled nationwide, and adopted across ICSs within integrated care strategies. These strategies should also closely involve the voluntary sector.
  8. NHS England should undertake a national dysphagia screening drive to identify individuals as early as possible. Social care staff and AHPs should be trained to conduct dysphagia screenings for all elderly and frail patients in their care, and much like falls, dysphagia should be considered among the primary risks in any risk assessment of elderly and frail patients.
  9. The speech and language therapy workforce should be expanded with long-term ring-fenced funding for broader allied health professionals.

Download the report here.

 

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Will the disposable vape ban save the NHS from another health epidemic?

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As the government confirms its plans to ban the sale of disposable vapes, Sienne Amer examines the impact of vaping on the NHS so far, and to what extent the ban will help avert another health epidemic.

The UK government recently announced its plan to ban disposable vapes to protect children’s health and tackle the significant rise of vaping among young people. While we have not yet seen the full health impact of the younger generation using vapes, this ban may be a welcome first step in limiting the impact of what could have become the next health crisis.

The devices have appeared on the market recently and rapidly risen in popularity, which is why there is still little research available on the extent to which vaping harms our health. Introducing this ban has the potential to limit the impact vaping has on the NHS, which is already stretched responding to other health crises caused by tobacco smoking, alcohol abuse, obesity, and an ageing population.

There are 4.7 million people in Great Britain who use e-cigarettes, 31 per cent of whom are disposable vape users. Disposable vape brands are targeting children, using bright colours for packaging and a variety of interesting flavours, with the fruit flavours making them far more likely to appeal to children. A shocking 21 per cent of secondary school children have tried vaping and 57 per cent of disposable vape users are aged between 18 and 24. The most popular brand of disposable vapes, Elf Bars, were removed from supermarket shelves last year after the nicotine levels were found to be at least 50 per cent higher than the legal limit. The lack of regulation of these products is an issue, regardless of the effects of use.

Disposable vapes contain nicotine, and inflict similar impacts to any other nicotine product, including heart disease and other cardiovascular disorders, along with respiratory and gastrointestinal disorders. Children are especially susceptible to the toxicity of nicotine, which can impact brain development, leading to shorter attention spans, anxiety, depression and reduced cognitive function.

It has also been shown that when the coils in the e-cigarette are heated, toxic metals, including aluminium, chromium, iron, lead, manganese, nickel and tin leak into the e-liquid, which are then aerosolised, inhaled and absorbed by the lungs. E-liquids have been shown to contain ingredients that generate pulmonary irritants and carcinogenic carbonyl compounds, all of which can lead to respiratory, gastrointestinal, and constitutional symptoms, in addition to an increased risk of early onset strokes.

Although vaping is still recognised as a safer alternative to smoking by the NHS, there has not been sufficient investigation into the long-term impacts on health. Other countries, such as the United States, have recognised the impacts of vaping; in 2019, the US Center for Disease Control and Prevention announced an outbreak of e-cigarette/vaping product use-associated lung injury (EVALI) after it caused the deaths of several young people.

While there have not been any recorded e-cigarette related deaths reported in the UK, in 2023, the NHS recorded 420 vaping related hospital admissions, 15 of which were for children aged under 9, demonstrating the severe risk to health young children are exposed to.

When compared to just under half a million hospital admissions caused by cigarette smoking-related illnesses, the health impacts of disposable vapes appear to be minor. However, conventional cigarettes were only recognised as a significant health hazard in 1964, more than 40 years after the introduction of cigarette manufacture, showing the time it can take to fully understand the long-term effects a product can have on human health.

The NHS is already dealing with several other health epidemics, with smoking costing the NHS in England £2.6 billion per year, approximately 2 per cent of the NHS budget. Obesity costs around £6.5 billion a year and is the second biggest cause of preventable cancer. Alcohol abuse costs £3.2 billion a year in England. This is a total of £12.3 billion of the yearly NHS budget going towards preventable illnesses, and the cost of vaping would be an additional burden on NHS.

To what extent is vaping impacting the NHS?

At present, there is no record of the health-related costs associated with vaping. But modelling the cost to the NHS using smoking data could provide an estimation of the impacts vaping will have. The UK smoking population is equal to 6.4 million people, causing 474,000 hospital admissions a year at a cost of £2.6 billion. The model assumes that 7 per cent of the population requires hospital admissions, with each admission costing approximately £400.

The 420 admissions related to vape use last year would have cost the NHS approximately £168,000. However, vape-related hospital admissions only started to be recorded in 2019 and since then, there has been a 237 per cent increase in admissions. An annual growth of 10 per cent in the vaping population is also expected to cause an increase in admissions. This means that, if only 7 per cent of the vaping population is admitted, the cost to the NHS would be £132 million per year, excluding any impact of an uptake in the number of young people seeking mental health services as a result of the toxic effects of vaping.

The ban on disposable vapes is estimated to affect 2.6 million people in Great Britain – including 316,000 18-to-24-year-olds, who other than vaping, have never regularly used tobacco products – saving a large proportion of young people from the risks caused by nicotine dependence and vaping. As disposable vapes were initially introduced to the market as an alternative to cigarettes, there is a high risk that 75 per cent of people will revert to traditional tobacco products.

Since the focus of the ban is solely on disposable vapes, alternative e-cigarette products will continue to be available for people trying to quit smoking. It is crucial that information should continue to be collected and published, through platforms such as NHS Digital, to monitor and understand the health impacts of the current vaping generation, even post-ban. Hospitals should be advised to continue to use the ICD-10 code to improve data on vaping-related admissions, along with adjusting advisory information to support the disposable vape ban.

Sienne Amer is a Net Zero Graduate at Lexica.

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