We’ve been working on articulating a public health approach to health and social care integration for a couple of months, and people have asked how we’re getting on.
Things have moved on quickly since we started before Easter
- We are awaiting our consultant in public health whose role will be to lead on public health approaches to health and social care full time joining us
- We have created a health psychologist post to work on embedding psychological approaches to patients and carers (resilience, self-management, coping) and staff (effective working with users and carers) based on what psychology has to offer
- We are putting psychology posts into drug and alcohol recovery services and into thriving families
- We are putting workforce redesign and psychology skills into home care and re-ablement work
- We have started a joint workstream across our CCGs, NHS and local authority on self-management
- With CCGs we have jointly assessed and re-negotiated our “core offer” of advice and support to them, and both ccgs are looking to employ additional public health project roles (clinicians who can be trained in public health practice) to deliver pathway work etc
- We are working with CCGs to establish clinical public health leads in every locality, whose role will be to support prevention and integration
- We have started to articulate what a whole system strategic approach to prevention looks like in support of integration, but this is early days
The self-management workstream
We held a workshop recently where we agreed that there were four main actions coming out of the self-management event:
1) Embedding behaviour change into existing pathways e.g. Map of Medicine
2) Getting a single comprehensive source for details of resources for clinicians, carers etc
3) Training for the wider workforce e.g. Motivational Interviewing
4) Handing this as a workstream to our forthcoming Behavioural Sciences Unit to deliver with a view to:
– Developing a network of Behaviour Change Champions across both sides of the county
– Training of practice staff in Behaviour Change principles and/or MI
– Ongoing support for Champions to ensure skills are put into practice
I’ve put the slides from this on slideshare so people can see where we are at.
We need strategies to keep people with existing disease at optimum levels of health and functioning. That needs a combination of good clinical management, supporting people to be resilient and self-manage, and ensure social support and coping are put to the top of our agenda. And it needs professionals to learn from people with long term conditions about what works for them. In some ways I have learned more about living with long term conditions from caring for my mother with diabetes, my father with heart disease and my own experience of overcoming cancer (a typically healthy Scots working class family there) than I did from any training.
Partners are understandably seeking high impact interventions to enable this to happen, ensure that health and social care integration is effective, ensure that resource is well spent, and achieve these challenging outcomes. We have set up a working group comprising a range of colleagues and partners from across NHS, local authorities and third sector.
The JSNA has identified that Health and Social Care Integration is a significant priority for Hertfordshire and this work is about identifying the Public Health role in supporting this.
Conceptualising the role of public health and the commissioning cycle
Public Health is often conceptualised as working across three domains of activity ; Health improvement, Health Protection and Service Quality. We’ve spent some time looking at these and we believe these three domains provide a significant opportunity for Public Health to play its part in Health and Social Care Integration. The opportunity is to ensure that work across the three domains considers how it can be done in a way that supports health and social care integration agendas. At a high level this looks like:
i) Health Improvement – commissioning public health services in such a way that they support integration (Example. ensuring joined up pathways for exercise referral include secondary prevention and rehabilitation in the community.) (Example: developing psychological approaches to self-management and rolling these out.)
ii) Health Protection – ensuring robust infection control in residential care, ensuring our population is effectively covered by screening, immunisation and vaccination to reduce the burden of avoidable disease on health and social care systems including staff seasonal ‘flu vaccination
iii) Service Quality – provide effective needs analyses for commissioners, provide advice on effective interventions and where evidence is silent provide advice on what interventions are likely to be effective, support development of outcome and evaluations.
3For Public Health we have conceptualised a cycle of public health delivery which is shown below. This has been developed by using the approach described since 2012 and it is suggested that this provides a useful conceptual tool for understanding the public health role both in its direct commissioning function (e.g. effective commissioning of drugs and alcohol services) and in it supporting function (supporting commissioners in effective mental health commissioning, for example.)
Key tasks for public health in health and social care integration
From this come some high impact tasks for Public Health in supporting health and social care integration:
- Providing analyses of data which combine epidemiology with analysis of system and patient data to produce an understanding of what the main issues are including intelligence on patient flows, pressure points, rates and issues. So for example we are working currently on mental health and on alcohol as just two examples.
- From the analyses identify the system and patient population issues causing most challenge to health and social care integration, in keeping people out of hospital
- Search and appraise evidence to identify possible candidates for commissioning to address these issues
- Where evidence is silent, support the development of interventions likely to work from existing theory and evidence
- Support development and implementation of integrated pathways across health and social care
- Commission public health services (e.g. weight management) in such a way that they contribute to the integration and out of hospital agenda
- Work to develop predictive models and tools to enable clinicians and commissioners to identify those most likely to experience avoidable hospital episodes
- Identifying the five most important things each CCG locality can do in its commissioning strategy (this is currently underway.)
Articulating a delivery model
Our working group has identified the following delivery model to work on health and social care integration
|Stage of PH Delivery Model||Examples of work underwayMore needs to be done and we have the opportunity to be more systematic|
|Understand what’s needed||
|Identify what works||
|Understand players, roles contributions||
|Right intervention, right delivery mechanisms||
What specific interventions are likely to work in integration
The working group set out to answer the following questions about specific interventions.
- What interventions will have the highest impact in integrating health and social care?
- What interventions will help keep and manage older people with multiple health problems in the community?
- What interventions will help keep adults with long term conditions in the community?
We are still working on this but have identified some quick high impact actions. We have chosen interventions which, from the available evidence, seem to be effective or show promise at integrating health and social care. The evidence for most of these interventions is of low quality because randomized designs are not common in social care. These interventions have been selected based on review of existing evidence and using the model of evidence appraisal suggested in the Kelly et al 2013 paper on a deductive model for public health
There is good evidence for lifestyle management and also for assertive management of risk factors such as
- effective prescribing of drugs to control blood pressure
- effective prescribing of drugs to reduce cholesterol
- supporting behaviour interventions (exercise on referral, diet, self-management, motivation)
- uptake of smoking cessation services
- increased anticoagulant therapy in atrial fibrillation
- improved blood sugar control in diabetes
The importance of these primary and secondary prevention initiatives should not be underestimated in ensuring people can remain stable in the community and less in need of complex services. There is also good evidence for cardiac rehabilitation, falls prevention and stroke pathways. We believe these are important foundations to make integration work.
An area which needs significant further investigation is competencies and skills in staff across NHS, social care, independent and third sector. There is some evidence to suggest that staff with these skill sets do better in keeping people in the community:
- Problem solving approaches
- Hybridisation of skills (e.g. social care staff who can do some basic clinical procedures)
- Supporting and motivating people effectively to cope, self-manage and develop skills and strategies for this
- These need to be supported by pathways wherever possible
The Interventions lists so far to support effective integration
Based on our discussions and early searches of evidence and experience from elsewhere, we are working on typologies of suggested high impact interventions to support health and social care. We are still working on these and will develop these further, but here is the very earliest cut of the Adults with Long Term Conditions and Older Adults tables so you can see our early thinking.
Adults with Long Term Conditions
|Topic||High Impact Action||Evidence|
|Early preventive work in newly diagnosed and those with established disease||Pathways in newly diagnosed and existing diagnosed for healthy lifestyles (physical activity, smoking cessation, weight management) combined with self management training and clinical management of diagnosed disease
|A further column providing the evidence citations or basis of judgement will be placed here|
|System pressure points / areas where practice could reduce avoidable admissions||Individual care plans for people with history of repeat admissions before they go into hospital|
|Predictive modelling of those whose risk factors indicates repeat admissions likely|
|Aggressive management of clinical risk factors and care plans of those whom predictive modelling has suggested are likely to be repeat admissions|
|Structured management guidelines and pathways in residential and nursing care to avoid emergency calls unless necessary|
|Better management of common UTIs and dehydration in residential and nursing care to avoid hospital admissions|
|Structured and early discharge planning|
|Care home review team to put in place plans to prevent re-admission|
|Better use of voluntary sector in home from hospital and out of hours|
|Stroke||Stroke pathway including early supported discharge|
|Self-Management and Resilience||Self management and resilience for all patients but especially those with asthma and COPD
Use of multiple platforms for this (e.g. face to face, film, group, online)
|Cardiac care||Cardiac rehabilitation pathway phases 1 – 4 including in community|
|Aggressive management of clinical risk factors in highest 10% of repeat admissions across all long term conditions|
|Topic||High Impact Action||Evidence|
|Preventing admissions||Falls prevention – multi factorial assessment and early intervention||A further column providing the evidence citations or basis of judgement will be placed here|
|Self management and health improvement (diet, basic exercise, social contact) in older people at risk of re-admission based on analysis of factors|
|Assistive technology – telecare and teleheath|
|Virtual wards and step up beds|
|Moving people from admission into their own home and reducing likelihood of re-admission||Virtual Wards|
|Community geriatrician and enhanced dementia support|
|Multi- Agency care|
|Structured discharge plans|
|Self-Management and resilience|
|Care home review team to put in place assertive management strategies in care homes to prevent admissions|
|Increased provision of step up beds|
This work is still in progress and our next step is to work further on these, and collaborate with public health England about where we want to go.
 A.J. Fischer, A. Threlfall, S. Meah, R. Cookson, H. Rutter, and M.P. Kelly. The appraisal of public health interventions: an overview J Public Health (2013) 35 (4): 488-494 first published online August 29, 2013