Basildon and Brentwood Prevention Strategy
2015-2020
1 Basildon and Brentwood Prevention Strategy
Contents 1. Introduction ...... 7 2. Background ...... 8 The Purpose of Prevention ...... 9 3. Strategic Context ...... 10 3.1 National Strategic Context ...... 10 The Care Act (2014) ...... 10 3.2 Essex County Council Strategic Context ...... 12 Commissioning Strategies (All Outcomes) ...... 12 Housing Strategy (in development) ...... 12 Assistive Technology (in development) ...... 12 Reablement ...... 12 Physical Impairment Strategy (in development) ...... 12 Older People’s Strategy ...... 12 Carers’ Strategy ...... 12 Information, Advice & Guidance Strategy ...... 12 Who Will Care? ...... 12 Essex 5 year health and care plan ...... 14 Market Position Statement ...... 14 3.3 NHS Strategic Drivers ...... 14 3.4 District and Borough Council Strategic Drivers ...... 15 4. Strategic Vision ...... 16 5. Local Current and Future Projected Need ...... 17 5.1 Introduction ...... 17 5.2 Older People (OP)...... 17 5.2.1 Adult Social Care Use by Older People ...... 19 6. Primary Prevention ...... 22 6.1 Antenatal and Newborn Screening Programmes ...... 22 6.1.1 Introduction ...... 22 6.1.2 Future commissioning intentions ...... 22 6.2 The 0-19 Healthy Child Programme ...... 22 6.2.1 Introduction ...... 22 6.2.2 What works? ...... 22 6.2.3 Future Commissioning Intentions ...... 24 6.3 Child Poverty ...... 25 6.4 Education and Lifelong Learning ...... 26 6.4.1 School Readiness ...... 26 6.4.2 School Improvement ...... 26 6.4.3 Children and Young People with Special Educational Needs and Disabilities (SEND)...... 27 6.5 Reducing Risk Behaviours in Children ...... 28
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6.5.1 Introduction ...... 28 6.5.2 What works? Evidence Base...... 28 6.5.3 The situation in Essex ...... 28 6.5.4 Future commissioning intentions ...... 29 6.6 Promoting Health Weight in Children and Adults ...... 29 6.6.1 Introduction ...... 29 6.6.2 What works? The evidence base on weight management...... 29 6.6.3 The current situation in Basildon and Brentwood ...... 31 6.6.4 Future Commissioning Intentions ...... 32 6.7 Promoting Physical Activity ...... 33 6.7.1 Introduction ...... 33 6.7.2 What works? The evidence base on promoting physical activity...... 33 6.7.3 The situation in Basildon and Brentwood ...... 33 6.7.4 Future Commissioning Intentions ...... 34 6.8 Immunisation ...... 35 6.8.1 Introduction ...... 35 6.8.2 What works? Evidence base on immunisation ...... 35 6.8.3 The situation in Basildon and Brentwood ...... 36 6.8.4 Future Commissioning Intentions ...... 37 6.9 Reducing the Prevalence of Smoking ...... 38 6.9.1 Introduction ...... 38 6.9.2 What works? The evidence base on reducing smoking prevalence...... 38 6.9.3 The current situation in Basildon and Brentwood ...... 38 6.9.4 Future Commissioning Intentions ...... 39 6.10 Alcohol harm minimisation and treatment ...... 39 6.10.1 Introduction ...... 39 6.10.2 Evidence Base ...... 40 6.10.3 The situation in Essex ...... 40 6.10.4 Future commissioning intentions...... 40 6.11 Strengthening Community Resilience ...... 41 6.12 Promoting Self-Care: Information, Advice and Guidance ...... 45 6.12.1 Introduction ...... 45 6.12.2 What works? Evidence base on IAG and Self Care ...... 45 6.12.3 The current situation in Essex ...... 46 6.12.4 Commissioning Intentions ...... 46 7. Secondary Prevention...... 48 7.1 Health Checks ...... 48 7.1.1 Introduction ...... 48 7.1.2 What works? Evidence base on Health Checks ...... 48 7.1.3 The situation in Basildon and Brentwood ...... 48 7.1.4 Commissioning Intentions ...... 48 3 Basildon and Brentwood Prevention Strategy
7.2 Senior Health Checks ...... 49 7.2.1 Introduction ...... 49 7.2.2 What works? Evidence base on Senior Health Checks ...... 49 7.2.3 The current situation in Basildon and Brentwood ...... 49 7.2.4 Commissioning Intentions ...... 49 7.3 Prevention of strokes through case finding and treating undiagnosed hypertension and improving the clinical management of circulatory disease...... 49 7.3.1 Introduction ...... 49 7.3.2 What works? Evidence Base on Stroke Prevention ...... 50 7.3.3 The situation in Basildon and Brentwood ...... 50 7.3.4 Future Commissioning Intentions ...... 51 7.4 Prevention of Strokes in Patients with Atrial Fibrillation through effective anti-coagulation treatment...... 51 7.4.1 Introduction ...... 51 7.4.2 Evidence Base ...... 51 7.4.3 The situation in Basildon and Brentwood ...... 51 7.4.4 Commissioning intentions ...... 52 7.5 Improving Mental Health through early intervention ...... 52 7.5.1 Introduction ...... 52 7.5.2 What works? Evidence base...... 53 7.5.3 The situation in south Essex ...... 53 7.5.4 Future Commissioning Intentions ...... 53 7.6 Improving Housing and Homelessness Support ...... 54 7.6.1 Introduction ...... 54 7.7 Assistive Technology ...... 58 7.7.1 Introduction ...... 58 7.7.2 Evidence base ...... 58 7.7.3 The current situation in Essex ...... 59 7.7.4 Future Commissioning Intentions ...... 59 7.8 Support to Carers ...... 59 7.8.1 Introduction ...... 59 7.8.2 Evidence ...... 60 7.9 Improving Offender Health ...... 61 7.9.1 Introduction ...... 61 8.1.1 Introduction ...... 64 8.1.2 What works? The evidence base on falls ...... 64 8.1.3 The situation in Basildon and Brentwood ...... 64 8.1.4 Commissioning Intentions ...... 66 8.2.1 Introduction ...... 67 8.2.2 What works? Evidence base on continence ...... 67 8.2.3 The situation in Essex ...... 67 8.2.4 Commissioning Intentions ...... 68
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8.3 Improve the Management of Stroke/TIA in Primary Care ...... 68 8.3.2 What works? Evidence Base on Stroke Management ...... 68 8.3.3 The situation in Basildon and Brentwood ...... 68 8.3.4 Commissioning Intentions ...... 70 8.4 Increase the provision of Stroke Early Supported Discharge (ESD) ...... 70 8.4.1 Introduction ...... 70 8.4.2 Evidence Base ...... 71 8.4.3 The situation in Essex ...... 71 8.4.4 Commissioning Intentions ...... 71 8.5 Improve the Diagnosis and Management of COPD in Primary Care ...... 71 8.5.1 Introduction ...... 71 8.5.2 What works? Evidence base on Diagnosis and Management on COPD ...... 71 8.5.3 The situation in Basildon and Brentwood ...... 72 8.5.4 Commissioning Intentions ...... 75 8.6 Commission integrated, preventative health and social care services aimed at frail elderly people ...... 76 8.6.1 Introduction ...... 76 8.6.2 Evidence Base: Integrating health and social care ...... 76 8.6.3 The situation in Basildon and Brentwood ...... 76 8.6.4 Commissioning Intentions ...... 79 8.7 Reablement ...... 79 8.7.1 Introduction ...... 79 8.7.2 Evidence Base ...... 80 8.7.3 The situation locally ...... 80 8.7.4 Commissioning Intentions ...... 81 8.8 Sensory Loss...... 81 8.8.2 Evidence ...... 81 8.8.3 The current situation...... 81 8.7.4 Future Commissioning Intentions ...... 81 8.9 Improving support to people with physical disabilities ...... 84 8.9.1 Background ...... 84 8.9.2 The situation in Essex ...... 84 8.9.3 Future Commissioning Intentions ...... 85 8.10 Improving support to people with learning disabilities ...... 85 8.10.1 Background ...... 85 8.10.2 Evidence base ...... 86 8.11 Improve support and treatment of patients with more serious mental health problems to promote independence and prevent relapse...... 87 8.11.1 Introduction ...... 87 8.11.2 The current situation in south Essex ...... 87 8.12 Improving support to people with dementia ...... 91 8.12.1 Introduction ...... 91
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8.12.2 What works? The evidence base on dementia ...... 91 8.12.3 The situation in Basildon and Brentwood ...... 91 8.12.4 Future Commissioning Intentions ...... 94 9. Strategy Implementation and Monitoring ...... 95 9.1 Workforce Planning ...... 95 10 References ...... 96
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1. Introduction
The Health and Social Care system both nationally and locally is under increasing pressure. The NHS has faced an unprecedented and sustained slowdown in spending growth in recent years, and local government significant spending cuts. Against this there is increasing demand for services both from an ageing chronically ill population, and through the increasing expectations of individuals. In order to prevent the system from becoming unsustainable, both health and social care will need to work in radically different ways than they did in the past.
One key solution is for health and local government, in partnership with the communities they serve to embrace and deliver the prevention agenda. This requires a fundamental shift from reactive services that address ill health and care needs once they have arisen, to proactive services that seek opportunities to intervene at the earliest possible stage and throughout the life course of our population in order to empower individuals and communities to stay healthier for longer. It requires a shift in thinking from ‘doing to’ to ‘doing with’ and it involves holistic integration of what are often currently fragmented services around the individual.
There is a need to ensure that the support we provide for children, young people and their families across the County represents the right support, for the right families at the right time and that we work with partners and communities to develop the most effective model of intervention to make measurable improvements in outcomes for children in the early years of their life which will then form a strong foundation for improved outcomes across the life course
The Care Act (2014) sets out a range of additional statutory duties for local authorities related to the prevention agenda. It is critical to the vision in the Care Act that the care and support system works proactively to promote wellbeing and independence, rather than simply waiting until people reach crisis point. As such it requires top tier local authorities to work with key strategic partners to develop and agree a strategic approach to deliver the prevention agenda.
This strategy has been produced by Essex County Council in partnership with Basildon and Brentwood CCG, Basildon Borough Council and Brentwood Borough Council. It sets out our thinking in terms of how to deliver The Prevention Agenda across the services that we commission and provide. Where available, a critique of the published evidence and local need is also discussed together with our commissioning intentions for the future.
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2. Background
‘Prevention’ can refer to a range of measures, services, facilities or other resources. There is no one definition for what constitutes preventative activity; it can range from wide-scale whole population measures aimed at improving health, to more targeted, individual interventions designed to improve the skills or functioning of one person or a particular group of people. It can also include measures to lessen the impact of caring on a carer’s health and wellbeing.
“Prevention” is often broken down into three general approaches: primary, secondary and tertiary prevention which are described below.
Primary Prevention: Measures to prevent ill health and promote wellbeing.
Primary prevention is defined as interventions, services, or resources aimed at individuals or populations who have no current particular health or social care support needs. The aim of primary prevention is to help people avoid developing needs for care and support by maintaining independence, good health and increased wellbeing.
Primary prevention measures are usually universal (i.e. available to all) which may include but are not limited to: Provision of universal access to good quality information Support for safer neighbourhoods Health improvement interventions to promote healthy lifestyles and help people avoid or change health damaging behaviour such as smoking or poor diet. Schemes to reduce social isolation
Secondary Prevention: Measures to identify those at increased risk of poor health or wellbeing and intervene early.
Secondary prevention refers to interventions or services aimed at individuals who have an increased risk of developing needs, with the aim of helping to slow down further deterioration or preventing more serious ill health from developing. In order to identify those individuals most likely to benefit from such targeted services, screening or case finding is generally employed.
Examples of secondary prevention measures include: Public health screening and case finding programmes that aim to identify disease early and intervene, for example hypertension screening, health checks/senior health checks Provision of housing, benefits and debt advice to those with existing mental health conditions to try and prevent their mental health and social circumstances worsening.
Tertiary Prevention: Measures that delay or minimise the impact of existing health conditions
Tertiary prevention refers to interventions aimed at minimising the effect of disability or deterioration in people with existing health conditions, complex care and support needs or caring responsibilities including supporting people to regain skills and reduce need where possible. Local authorities must provide or arrange services, resources or facilities that maximise independence for those who already have such needs. Tertiary prevention can also include helping carers to continue to care by enabling them to have breaks from their caring responsibilities or developing mechanisms to cope with the stress associated with caring.
Examples of tertiary prevention measures include: Falls prevention programmes that provide interventions to older people who have already had a fall Reablement programmes which focus on helping people to regain skills and capabilities after serious health events such as stroke. Personalised budgets that allow clients to purchase a range of services that maximise their independence 8 Basildon and Brentwood Prevention Strategy
The Purpose of Prevention
The course of someone’s journey through prevention services is not necessarily a straight line with a person moving through the levels of preventative services in a successive way. For example, a person may still benefit from good quality information (primary prevention) whilst they are in or being discharged from Intermediate Care (tertiary prevention).
Although broader in scope, the interventions identified in this strategy are in line with the approach underlying the recent King’s Fund review of what works in avoiding hospital admissions: This includes bringing together different parts of the health and social-care system, doing things we know are effective, stopping doing things we know are not effective, and evaluating the outcomes of things we do not know about.1 The 2013 Essex Council Annual Public Health Report2 builds on this by undertaking a comprehensive critique of published evidence relating to interventions that are effective and ineffective in delivering system savings through reducing demand on unplanned health care and social care services.
Figure 1 depicts a system-level overview of transitions between stages of dependence. These stages (general population, low to moderate needs, substantial needs, complex needs) are depicted in boxes, with the flows into and out of them depicted as the arrows joining them. The factors potentially affecting these flows are located at the top part of the diagram (for factors potentially preventing flow towards reduced independence) and the bottom part of the diagram (for factors potentially promoting regaining of independence).
Figure 1 System level overview of flows between different stages of dependency.
Source Lang, 2010a.
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3. Strategic Context
3.1 National Strategic Context
The Care Act (2014)
The Care Act (2014) sets out a range of additional statutory duties for local authorities including a number related to the prevention agenda. It is critical to the vision in the Care Act that the care and support system works proactively to promote wellbeing and independence, rather than simply waiting until people reach crisis point.
The Care Act places a duty on local authorities to provide or arrange for the provision of services, facilities or resources, or take other steps, which it considers will— (a) contribute towards preventing or delaying the development by adults in its area of needs for care and support; (b) contribute towards preventing or delaying the development by carers in its area of needs for support; (c) reduce the needs for care and support of adults in its area; (d) reduce the needs for support of carers in its area.
In particular, local authorities must consider how to identify “unmet need” – i.e. those people with needs which are not currently being met, whether by the local authority or anyone else. Understanding unmet need will be crucial to developing a longer-term approach to prevention that reflects the true needs of the local population.
In order to meet this challenge, the health and social care system will need to fundamentally change such that it intervenes early to support individuals, and helps people to retain or regain their skills and confidence and prevents or delays further deterioration wherever possible.
The Care Act specifies that a local authority’s responsibilities for prevention apply to all adults including: Adults who do not have any current needs for care and support Adults with needs for care and support, whether their needs are eligible and / or met by the local authority or not Carers, including those who may be about to undertake a caring role, or who do not currently have any needs for support.
The Care Act mandates local authorities to undertake a number of prevention activities:
We MUST : • Identify and understand current and future demand for preventative services (JSNA and ASC demand management forecasts) • Understand the supply of services, facilities and other resources already available that could support prevention and be part of an overall local approach (Healthwatch Assets catalogue, Market position statements and asset based elements of JSNA) • Consider how to identify “unmet” need • Promote diversity and quality in provision so that people have a choice of provider • Ensure the integration of prevention with health and health-related services including housing • Establish a service providing information and advice - including preventative services.
We SHOULD: • Engage all providers to encourage innovation in supporting a preventative approach • Consider how to align/integrate prevention approaches with local partners • Consider the different opportunities for coming into contact with people including where the 1st contact is not the local authority.
The Care Act Guidance also outlines situations or trigger points for the local authority to consider whether the provision of a preventative service or some other step is appropriate. These include:
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initial contact through a customer services centre, whether by the person concerned or someone acting on their behalf; contact with a GP, community nurses, housing officers or other professionals which leads to a referral to the local authority; an assessment of needs or a carer’s assessment which identifies that the person would benefit from a preventative service or other type of support available locally.
In addition approaches to identifying those people who may benefit from preventative support should consider how to locate people in such circumstances, for example:
bereavement; hospital admission and/or discharge; people who have been recently admitted to or released from prison; application for benefits such as Attendance Allowance, or Carer’s Allowance; contact with/use of local support groups; contact with/use of private care and support; changes in housing.
Table 3.1 references chapters, sections and sub-sections within this strategy that meet the ‘must do’s’ and ‘should do’s’ in the Care Act (2014).
TABLE 3.1
We MUST : Where this can be seen in this strategy • Identify and understand current and future demand for • Chapter 4 preventative services • Understand the supply of services, facilities and other • ‘The current situation in Basildon and resources already available that could support prevention Brentwood/Essex’ sub sections of and be part of an overall local approach (Healthwatch Chapters 6,7 and 8. Assets catalogue, Market position statements and asset based elements of JSNA) • Consider how to identify “unmet” need • Sections 6.1.4, 6.2.4, 6.3.4, 6.5.4, 6.6.4, 6.7.4, 7.1.4, 7.2.4, 7.3.3/4, 7.4.4, 7.5.4, 7.7.4, 7.8.4, 8.1.4, 8.2.4, 8.3.4, 8.5.4, 8.6.4, 8.8.4, 8.11.4, 8.12.4 • Promote diversity and quality in provision so that people • Sections 6.2.4, 6.3.2, 6.6.3/4, 6.7.3/4, have a choice of provider 7.6.4, 7.8.4, 8.6.4, 8.11.3/4 • Ensure the integration of prevention with health and • Chapter 6, Primary Prevention health-related services including housing • Sections 7.1, 7.2, 7.3, 7.4, 7.5, 7.6, 7.7, 8.1, 8.3, 8.6, 8.8, 8.11, 8.12
• Establish a service providing information and advice - • 6.7 Promoting Self Care; Information, including preventative services. Advice and Guidance We SHOULD: • Engage all providers to encourage innovation in • Chapter 6, Primary Prevention supporting a preventative approach • Chapter 7, Secondary Prevention • Chapter 8 8, Tertiary Prevention • Consider how to align/integrate prevention approaches • Chapter 6, Primary Prevention with local partners • Chapter 7, Secondary Prevention • Chapter 8, Tertiary Prevention • Consider the different opportunities for coming into • Sections 6.1, 6.3, 6.4, 6.5, 6.7, 7.1, 7.2, contact with people including where the 1st contact is not 7.3, 7.4, 7.5, 8.1, 8.2, 8.3, 8.4, 8.5, 8.6, the local authority. 8.7, 8.8, 8.11, 8.12
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3.2 Essex County Council Strategic Context
Prevention is at the core of a large part of Essex County Council’s work. All our agreed Strategic Outcomes impact on the prevention agenda with two of our corporate outcomes having particularly strong links to prevention:
People in Essex enjoy good health and wellbeing
People in Essex can live independently and exercise control over their lives
However, prevention is not just a public health or social care issue and links can be made to a number of other services and ECC strategies including:
Commissioning Strategies (All Outcomes) ECC is operating an outcomes based commissioning model. This has led to the development of commissioning strategies based on each of the seven corporate outcomes.
Housing Strategy (in development) Good quality housing can play a key role in a person’s wellbeing. The Care Act makes this link between wellbeing and housing clearer by making housing a health related activity.
Assistive Technology (in development) Assistive technology and equipment can enable people to remain in their own homes for longer offering a means for them to undertake day to day tasks that they may otherwise be unable to do. It is therefore a vital preventative service.
Reablement Reablement is referenced in the Care Act guidance as a preventative service. At Essex County Council we strongly believe in the benefits of reablement and have increased the focus on this service in recent years, with it now forming a key part of our adult social care offer.
Physical Impairment Strategy (in development) Whilst our main commissioning approach has been based around outcomes, additional strategies have been developed to emphasis the needs of particular groups. This targeting of services fits the definition of secondary and tertiary prevention where services are focussed on risk groups.
Older People’s Strategy As above this strategy has been developed to highlight the particular needs of this group. As older people are the largest client group for adult social care in Essex, it will be vital that this prevention strategy reflects the needs of this group.
Carers’ Strategy Carers play a vital role in helping people remain in their own homes and keep a level of independence. Essex County Council has acknowledged the role they play and outlines our commitment to supporting them in a Carers’ Strategy.
Information, Advice & Guidance Strategy Information advice and guidance can provide an effective means of helping people access support away from formal social care. By helping people find information on local services, support groups and other community initiatives near them they can remain independent for longer without local authority intervention.
Prevention will also link to key partnership projects, building on existing work and shaping our actions in the future.
Who Will Care? In January 2013, Essex partners tasked f five independent commissioners to answer the question: how will we care for ourselves and our communities right now and in the future? 12 Basildon and Brentwood Prevention Strategy
The commissioners, under the chairmanship of Sir Thomas Hughes-Hallett, developed five high impact solutions in their September 2013 report ‘Who Will Care?’:
1. Agree a new understanding between the public sector and the people - the public sector needs to be up- front and honest with us, clarifying the extent of the ‘care offer’ available to us 2. Prevent unnecessary crises in care - a new approach to change the focus of care from treating disease and chronic conditions to supporting individuals earlier 3. Mobilise community resources 4. Use data and technology to the advantage of the people of Essex 5. Ensure clear leadership, vision and accountability
Children and Young People Essex County Council is committed to improving outcomes for children, young people and their families. Commissioning Strategies have been developed to enable these outcomes to be achieved and ECC is committed to working with partners to ensure that there is a whole systems approach to support this.
Outcome One – Children in Essex get the best possible start in life
The Percentage of children ready for school
The Percentage of children achieving a good level of development by the age of five
Outcome Two – People in Essex enjoy good health and wellbeing
People in Essex have a healthy life expectancy
Prevalence of healthy lifestyles
Percentage of children achieving at school
Prevalence of mental health disorders among adults and children
Prevalence of teenage pregnancy
Outcome Three - People have aspirations and achieve their ambitions through education, training and lifelong learning
Percentage of children attending a good school
Percentage of children achieving at school
Early Years Review
In Autumn 2013 ECC led a whole system review of support for families in the early years - from pregnancy through to children aged 5. This major piece of work afforded a unique opportunity to consider some key points that have significant bearing on the way services for families with young children are commissioned including
How well are parents’/carers’ needs understood?
Are their needs met in ways that are accessible and empowering?
Overall does the system do well enough in growing confident, effective parenting, enabling parents /carers to give children the best start in life?
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As a result ECC have been able to gather intelligence that identifies opportunities for:
Innovation across the system, especially co-production with families
Removal of duplication of resources and roles
Determining what a common understanding and model of child development should look like
Skilling up the workforce to deliver new approaches
Developing a consistent offer at all the system ‘touch points’
Work is continuing to explore and test out how best a more integrated approach to increasing resilience amongst families and improving the service offer made to them can be progressed.
Essex 5 year health and care plan This plan focuses upon pan-Essex improvement interventions and pan-Essex enablers, and also provides an overview of the financial impact of the plans of contributing organisations.
Whilst the primary unit of planning for 2014 – 2019 Five Year Plans is the CCG systems, it was agreed by Essex system partners that there were also benefits from developing an over-arching Essex wide plan to enable us to deliver our shared vision.
The Shared vision is:
‘By 2018 residents and local communities will have greater choice, control and responsibility for health and wellbeing services. Life expectancy overall will have increased and the inequalities within and between our communities will have reduced‘.
Market Position Statement
The Market Position Statement (MPS) has been produced to provide a better understanding for organisations about the supply and demand of integrated care services in Essex in the medium and long term. It provides the market with key messages about the Council’s approach, and emphasises the focus on prevention, personalisation and partnerships.
The Council wishes to see service offers from all parts of the market that are targeted at prevention and avoiding harm to vulnerable people wherever possible. Market collaboration involving the Third Sector in solutions will be a priority for our service offer moving forward.
3.3 NHS Strategic Drivers NHS Basildon and Brentwood CCG’s Five Year plan contains a number of strategic actions supporting the prevention agenda. These include:
• Integration of Health and Social care services around the patient through the Better Care Fund with an aim that by 2019, only those patients with an appropriate medical need will be admitted to hospital. • Providing a care coordination model to the frail elderly including a named accountable professional that will coordinate care around the professional with a view to providing early intervention to reduce the risk of unplanned care admissions. • Delivering ‘Making Every Contact Count’ at practice level and commissioning providers to do the same. • Developing a ‘Lifestyles Balanced Scorecard” for each GP practice with detailed recommendations for improving the health of the practice’s population and tackling health inequalities
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• Delivering a consistent high performance on health improvement programmes commissioned by ECC and Public Health England including smoking cessation, health checks, immunisation and screening and sexual health. • Focusing coordinated commissioned programmes on populations facing high levels of deprivation including Vange, Pitsea, St. Martins, Fryerns and Laindon Park
The South Essex CCGs in conjunction with ECC have developed an agreed a South Essex Joint Mental Health Strategy. The strategy contains a number of key elements relating to the prevention agenda including improving primary care and preventative mental health services, improving crisis response so that fewer people need in patient care, promoting self-management and commissioning a recovery college.
3.4 District and Borough Council Strategic Drivers *** TO FOLLOW
From these documents several themes emerge
Encouraging Healthy Lifestyles Improving Education Promoting independence and community resilience Accommodation and suitable housing Evidence based preventative clinical interventions Targeting activities towards vulnerable groups Empowering individuals Improving employment Reducing hospital admissions Safeguarding The Care Market, choice and sustainability
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4. Strategic Vision
Health, local government and community and voluntary sector services will work in partnership with the people of Essex to allow every individual to enjoy the best possible health and well-being that they can, to stay independent for as long as possible and to create strong resilient communities.
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5. Local Current and Future Projected Need
5.1 Introduction
This section examines the current and future projected population within the key population age cohorts of older people and working age adults across the two localities of Basildon and Brentwood and for the population of the CCG area as a whole. The cohorts of working aged adults and older people have been examined as these best best map across to the relevant audience of prevention interventions discussed later in this strategy. They have been defined as follows:
Older People population forecasts – by district (aggregated to CCG area), gender, and age bands (65-74, 75-84, 85+) Working Age population forecasts – by district/CCG, gender and age bands (18-24, 25-34, 35-44, 45-54, 55-64)
The current population profile of Essex and its components are observed, and forecasts provided for the next 20 years based on Sub National Population Projections 2012.
5.2 Older People (OP).
FIGURE 5.1: BASILDON & BRENTWOOD CCG POPULATION GROWTH
There is currently a population of 253,413 people of all ages across Basildon & Brentwood. The over 65 population is 46,196 (2014). The total population is expected to increase by 3.45% by 2019 and 14.29% by 2034. The proportion of older people is expected to experience a greater increase (8.12% by 2019 and 46.45% by 2034).
FIGURE 5.2: BASILDON & BRENTWOOD CCG POPULATION GROWTH BY DISTRICT
The over 65 population is expected to grow in both Basildon and Brentwood. 17 Basildon and Brentwood Prevention Strategy
FIGURE 5.3: FIVE YEAR GROWTH BASILDON & BRENTWOOD CCG
Growth is expected across both districts, however the over 65 growth (by 2019) is substantially higher than whole population growth rates.
FIGURE 5.4: TWENTY YEAR GROWTH BASILDON & BRENTWOOD CCG
After twenty years Basildon can expect to see an additional 14,659 people aged over 65, and Brentwood an extra 6,797 older people.
FIGURE 5.5: BASILDON & BRENTWOOD CCG POPULATION GROWTH
Figure 5.5 illustrates the disproportionate growth in the over 65 cohort compared to the total population growth within the CCG area. 18 Basildon and Brentwood Prevention Strategy
FIGURE 5.6: BASILDON & BRENTWOOD CCG AGE/GENDER POPULATION FORECASTS
There will be an additional 7,910 older people by 2034 in Basildon and Brentwood. Given that specific age/gender cohorts have a greater propensity for using services, it is important to know the demographics of the anticipated additional over 65 population. By 2034 there are significant increases in all age bands over 65. The greatest rate of increase is those aged 85+ for both males and females reflecting greater longevity of future generations. Whilst this is to be welcomed, it is imperative that we also ensure that our population remains healthier and more independent for longer, if we are to avoid unsustainable demand on future health and social care services.
5.2.1 Adult Social Care Use by Older People
FIGURE 5.7: BASILDON & BRENTWOOD ADULT SOCIAL CARE SERVICE USE (2014)
Figure 5.7 shows a snapshot of adult social care service use as of the end of 2014. This includes residential care, home care (and cash payments) and day care. A large proportion of current service use in the CCG area is dominated by females (71.39%) and over 85s (53.23%) . After five years the total volume of service users is expected to increase by 178 (based upon growth rate of 2.4% calculated in modelling exercise).
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5.3 Working Age Population
FIGURE 5.9: BASILDON & BRENTWOOD POPULATION GROWTH (VOLUME)
The working age population of Basildon and Brentwood is currently 151,129. This is expected to demonstrate a small increase. By 2019 there will be an additional 2,769 people aged 18-64, and by 2034 an additional 8,170.
FIGURE 5.10 BASILDON & BRENTWOOD CCG POPULATION GROWTH BY DISTRICT (VOLUME)
Both districts are expected to see growth in working age adults. Brentwood percentage growth is higher than the Basildon growth rate, but the absolute volume of additional working age adults will be greater in Basildon Borough.
FIGURE 5.11: FIVE YEAR GROWTH BASILDON & BRENTWOOD CCG
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After five years Basildon will gain an additional 1,871 working age adults (a growth of 3.26% on its 2014 working age population). Brentwood 18-64 cohort will increase by 3.89% (1, 284 people).
FIGURE 5.12: TWENTY YEAR GROWTH BASILDON & BRENTWOOD CCG
After twenty years Basildon can expect an additional 4,782 working age adults, and Brentwood an additional 3,388.
FIGURE 5..13: BASILDON & BRENTWOOD CCG POPULATION GROWTH (%)
The chart above (figure 5.13) illustrates the comparatively low growth for working age adults within the CCG area when compared to the growth of the whole population.
.
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6. Primary Prevention
6.1 Antenatal and Newborn Screening Programmes
6.1.1 Introduction Screening tests are used to find people at higher risk of a health problem. This means they can get earlier, potentially more effective, treatment or make informed decisions about their health. Women are offered a range of screening tests at various points throughout their pregnancy and further screening tests are offered to parents for their new-born babies in the immediate postnatal period. The following programmes are offered universally Infectious Diseases in Pregnancy Screening Programme Down’s Syndrome Screening (Trisomy 21) Programme Fetal Anomaly Screening Programme Sickle Cell and Thalassemia Screening Programme Newborn Blood Spot Screening Programme Newborn Hearing Screening Programme Newborn and Infant Physical Examination Screening Programme
6.1.2 Future commissioning intentions The commissioning responsibility for antenatal and newborn screening sits with NHS England. It is important that all professionals who work with parents during the antenatal and postnatal period promote these programmes and that awareness raising is part of the service offer made to the target population.
6.2 The 0-19 Healthy Child Programme
6.2.1 Introduction Giving every child the best start in life is crucial to reducing health inequalities across the life course and affects the health, educational and economic outcomes of individuals throughout their life course. Universal and specialist public health services for children are important in promoting the health and wellbeing of all children and reducing inequalities through targeted intervention for vulnerable and disadvantaged children and families. Successive reviews have demonstrated the economic and social value of prevention and early intervention programmes in pregnancy and the early years.
Commissioning responsibility for the 5-19 Healthy Child Programme has been vested in Local Authorities since April 2013 as part of the transition of public health commissioning from the NHS under the terms of the 2012 Health and Social Care Act.
On 1st October 2015 the commissioning responsibility for the 0-5 Healthy Child Programme transfers to Essex County Council from NHS England and work is in place to ensure that this is smooth, robust and has no impact on service delivery.
6.2.2 What works? The Healthy Child Programme (HCP) is the universal clinical and public health programme for children and families from pregnancy to 19 years of age. The HCP offers every child a schedule of health and development reviews, screening tests, immunisations, health promotion guidance and support for parents tailored to their needs, with additional support when needed and at key times. The aims of service delivery are to Achieve the best health outcomes and wellbeing outcomes for all children and young people of school age to enable them to make the most of their education and wider social opportunities; Provide a high quality service that is accessible to children, young people and families Tackle health inequalities, by targeting those children and young people most in need; Work in partnership with other agencies, thereby enabling all young people to reach their full potential in life;
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Maximise the contribution to safeguarding through provision of early help, referral when appropriate to specialist services and multi-disciplinary working, and by participating in child protection and child in need processes; Provide a proactive, reactive and responsive service
0 – 5 HCP Service The overarching aim of public health services for children under 5 (https://www.gov.uk/government/publications/healthy-child-programme-pregnancy-and-the-first-5-years-of-life ) is to protect and promote the health and well-being of children in the early years with key objectives as set out below Improve the health and well-being of children and reduce inequalities in outcomes as part of an integrated approach to supporting children and families; Ensure a strong focus on prevention, health promotion, early identification of needs and clear packages of support; Ensure delivery of a universal core programme to all children and families; Identify and support those who need additional support and targeted interventions, for example, parents who need support with their emotional or mental health and women suffering from postnatal depression; Improve services for children, families and local communities through expanding and strengthening health visiting services; Building on the mandation of services outlined above, and subject to parliamentary approval, the Government now intends to mandate certain universal elements of the 0-5 HCP namely:- Antenatal health promoting visits; New baby review; 6-8 week assessment. 1 year assessment 2-2½ year review. Mandation will ensure that the increase in health visiting services’ capacity achieved following the implementation of A Call to Action,( https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213110/Health-visitor- implementation-plan.pdf ) continues as the basis for national provision of evidence-based universal services - supporting the best start for all our children and enabling impact to be measured. Thus Local Authorities will be required to ensure that these service elements remain in scope and clearly defined in any subsequent redesign following the transfer of the commissioning responsibility but will have flexibility to ensure that these universal services support local community development, early intervention and complex care packages.
5 – 19 HCP Service The 5- 19 Healthy Child Programme (http://dera.ioe.ac.uk/11041/1/dh_108866.pdf ) which is a progressive universal programme tailored to individual child and family needs and anticipated outcomes, focussing on public health priorities and is delivered by a specialist workforce of healthcare professionals working with children, young people and their families in school based and community settings on both a group and individual basis. It includes a universal minimum core for all children with enhanced and additional preventative services and programmes. To make the best use of resources and improve access for children and young people the HCP requires integrated working with all relevant stakeholder organisations to achieve the best possible outcomes for the client group. The objectives of the programme can be idenitifed as follows To move from school focus to population health needs focus to reflect the wider health needs of the child; To ensure the role, function and access of the 5-19 HCP service is promoted within the school age population, local community and among other agencies working with this cohort of children and young people and their families; To work in partnership to identify local needs and priorities, enabling the 5-19 HCP team resources to be targeted in-line with the health needs of this population and to provide a more responsive service; To build capacity in communities which include the school age population to enable them to prevent poor health and improve health and wellbeing amongst children and young people; To support the development of the school as a health promoting environment; To ensure the family/child are supported to maximise the child’s school attendance and ability to participate in school life; To support children, young people and their families in developing healthy behaviours and reducing risk behaviours; To support parents/carers to be confident, positive and resilient in their parenting/caring; To maintain high level coverage for the NCMP reception and year 6 (excluding special schools and independent schools private schools ); 23 Basildon and Brentwood Prevention Strategy
To contribute to meeting the needs of children and young people who have life-long conditions, disabilities and/or additional health needs (including mental health problems) in school and community environments; To ensure children, young people, their families and carers, have the information and knowledge necessary to make the best use of all available services and to effectively manage their own health and wellbeing needs where clinically appropriate; To facilitate transition arrangements for children to adult services (if required) to ensure that the services provided continue to be appropriate to the age and needs of the young person involved; To target those most in need, tackling inequalities and transforming the life chances of the most disadvantaged and vulnerable children by targeting services and support to meet their needs.
Healthy Schools Programme The Healthy Schools programme provides a framework for partnership work within schools which supports the ‘Your Community’ stage of the 0-19 pathway (Getting it Right for Children, Young People and Families, DoH2012). Schools engaged in the Healthy Schools programme can help to identify and address the collective health needs of children and young people. They reinforce positive health behaviours, make most effective use of health partners to deliver interventions supporting wellbeing and establish an overall culture and ethos which is supportive of families and promotes improved attendance and attainment. Through engagement with the programme, schools are supported to have a coordinated approach to health and wellbeing, ensuring that key messages across health interventions and curriculum provision (PSHE education and SRE) are delivered consistently and effectively. Taking part in Healthy Schools, and working successfully for the tiered awards will enable schools to directly support the health and wellbeing of their pupils and staff. The aim of the Healthy schools programme is to deliver real benefits for children and young people, specifically: To support children and young people in developing healthy behaviours To help raise the achievement of children and young people To help reduce health inequalities To help promote social inclusion
6.2.3 Future Commissioning Intentions The future commissioning of an integrated 0-19 HCP service proposes to:- Improve matching of clinical and economic resources to the overall prevention agenda while maintaining required safeguarding approach and links to other service provision for children and young people e.g. Early Years provision, Children’s Centres, Family Solutions, Education Welfare, CAMHS and other key services Improve outcomes and reduce inequalities in the health and wellbeing of children linking to Public Health Outcomes Framework, the Essex Joint Health and Wellbeing Strategy, the Essex Children and Young Peoples Plan and ECC’s Commissioning Strategy with respect to both “Children in Essex get the possible start in life” and “People in Essex enjoy good health and wellbeing Achieve efficiencies focussing on both improved quality and value for money ensuring that resources are focussed on evidenced need rather than historical spend Embed evidence based prevention in service provision in order to reduce future spend on health and social care by ensuring children and families are supported to make informed decisions that will improve health and wellbeing on a sustainable basis Deliver accessible services for customers which are more responsive to client need as identified in the Early Years Review. People will find it easier both geographically and in terms of how “user friendly” the service is to access services and will be more likely to attend if in need. Although data held by ECC is anonymised, technical questions will be added to the evaluation process at procurement stage to ensure that data processed by provider on behalf of ECC will be treated appropriate and securely. Improve the integrated universal offer to children, young people and their families through more effective delivery of the Healthy Child Programme and increasing good outcomes for clients as a result. There are potential benefits through early intervention and the subsequent reduction of the burden of costly crisis type interventions. Improved partnership working to ensure that clients move seamlessly between services when specialist approaches are required will enable professionals to ensure that interventions are tailored to meet specific identified needs and result in sustainable outcomes.
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By aligning this with the opportunities afforded by the redesign of the early years/children’s centres offer it will be possible to test out some innovative approaches to holistic provision that will be responsive to the needs of families are articulated through the Early Years Review process.
6.3 Child Poverty
Poverty costs emotionally, physically and financially. Children from low income families are up to nine months behind their peers in developmental terms and the estimated cost of Child Poverty to the UK economy is in excess of £29 billion per year The Government has set a target to reduce relative poverty to 10% by 2020 but the best indications of experts are that poverty will increase by 2015 because of the complex nature of the issue and the many causes and consequences
The Essex economy is buoyant with increasing investment, more jobs being created and reducing levels of unemployment, yet almost 1 in 5 children in Essex live in poverty (16.1%) equating to in excess of 49,000 children. with highest levels found in Harlow (21.1%), Basildon (21.9%) and Tendring figures (24.4%). In some wards, over 50% of children are in poverty.
Although this is lower than the 20.1% national average, it is higher than some of our neighbouring counties 13.2% in Hertfordshire and 12.6% in Cambridgeshire.
Essex is a county where prosperity and disadvantage exist in close proximity. Indeed, in some wards, more than half of children are living in poverty (Rush Green Ward and Golf Green Ward [Tendring], poverty levels are as high as 51.4% and 49.1% respectively.)
Areas of greatest disadvantage in Essex echo the areas where health, early years and educational outcomes are also low, shown as red on this map (Basildon, Harlow and Tendring). Based on the latest data (2008-2011), the picture of poverty in Essex remains unchanged as the number of children in poverty has reduced, but then so too has the National Median income.
Table 1 illustrates the distribution of the prevalence of childhood poverty across the County
Table 1
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The Essex Child Poverty Strategy aims to consider the drivers of poverty, describe the extent of the problem in Essex, and provide a set of principles around which we can move forward together through local decision making and intervention based on local issues and knowledge. Any actions will be determined locally rather than imposed through a central mandate but all action will be required to deliver tangible improvements where need is greatest and stand up to robust evaluation over the duration of the strategy. The model set out in this strategy identifies three clear phases:- Identifying vulnerable families wherever they are in Essex through intelligent use of data and effective, collaborative partnership working. The focus is on giving children the best quality of life possible and supporting them to reach their full potential.
Building on the excellent examples of family support to nurture lasting success. Building trust as an essential first step towards longer term success. Jointly tackling some of the day to day challenges faced by families and supporting families to build positive relationships between individuals, peers and communities that will create stability and resilience.
Improving access to training, skills and meaningful, regular and well paid employment. Working with parents to think about what support they might need in order to improve the longer term future of the family. Working with businesses to match employment opportunities with local skills.
6.4 Education and Lifelong Learning Essex County Council is responsible for ensuring that Essex residents are enabled to achieve their ambitions through the opportunities that are provided to them from birth and throughout the rest of their lives. This encompasses early years development, the provision of quality education in schools, access to training focused on improving employability and skills and the identification and provision of other learning and development opportunities focused on enriching life generally. This outcome is also about ensuring that our residents always have high ambitions for what they wish to achieve and are enabled to identify what they need to do to bring these about.
6.4.1 School Readiness We want all children to achieve the best start in life that they can during their early years so that when they start school they enjoy learning and have a strong foundation for continued learning throughout the rest of their lives. Increased educational attainment is an important driver of economic growth and people who have higher levels of attainment are also more likely to have longer, safer and healthier lives. We want to drive out inequality across Essex to lead the UK in attainment and to foster a culture of lifelong learning so that people of all ages have a thirst for learning. School readiness is an indicator of achievement in later life and it is therefore essential that we strive to maximise the proportion of children who achieve a good level of development (GLD) on school entry at the age of 4-5 In 2014, 61% of 4-5 year olds achieved a good level of development (GLD) in Essex, which is the same as the national average. However, there is a wide variation in achievement due to differences in children’s family circumstances, with a 21% gap (43% vs 64%) in GLD attainment between children receiving free school meals compared to those who don’t. Schools in more deprived areas and with unsatisfactory Ofsted rating also have significantly lower proportions of children achieving a good level of achievement. Schools with unsatisfactory ratings had 52% of children with GLD compared to 67% in outstanding schools. Children in Essex do not have equal access to an environment that is required to maximise their capabilities and development. Targeting these childhood inequalities will improve their current and future health and well-being.
6.4.2 School Improvement Developing aspirations and ambitions at an early age is vital and attendance at a good school is considered crucial to this. Consideration has therefore been given to both the percentages of good and outstanding schools and the percentages of children attending these schools. The Ofsted Report (Dec 12) indicated significant regional variation in quality of education in the UK with the East of England being the area of most significant concern; this is a particular issue for primary education.
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Overall in Essex there has been a positive trend in respect of the numbers of schools being graded good and outstanding from 2009 with the percentage of schools increasing from 66-71% and the percentage of pupils in these schools increasing from 67-71%. Further improvement is however required and there are some localised and specific areas of concern to be tackled. Across all provider types (Nursery, Primary, Secondary, PRU and Special) there is clear evidence of a smaller percentage of children attending good or outstanding schools in the most deprived areas. The Standards and Excellence service have clear processes and protocols to RAG rate all underperforming schools, enabling a clear prioritisation of intervention and support to be established and appropriate commissioning for support undertaken. Support is prioritised for schools requiring improvement and in a category; however these are supplemented by visits to good and outstanding schools to enable more collaborative working and sharing of good practice Commissioned support, including that provided by Essex Education services, is being targeted at leadership and management, as that is shown to have the greatest impact on school performance. At the heart of school improvement are two key indicators The percentage of children attending a good school The percentage of children achieving at school
Underpinning both these indicators is a number of strategic actions
The percentage of children attending a good school Establish and promote a demanding vision and expectations Robustly tackle underperformance Facilitate and promote the development of school to school support Develop leadership in schools at all levels to improve quality of teaching and learning Ensure the availability of appropriate and targeted support for vulnerable groups Commission and decommission school places to meet need and as a driver for improvement in the quality of provision Transform internal systems and operating models
The percentage of children achieving at school Establish and promote a demanding vision of expectations Ensure that children are ready to start school and that an accurate baseline is available for all Ensure quality first teaching is available for all reflective of the needs of individual children Ensure the availability of appropriate and targeted support for vulnerable groups Ensure all children and well supported to learn at home
6.4.3 Children and Young People with Special Educational Needs and Disabilities (SEND)
Essex County Council places a high priority on improving the outcomes and raising aspirations of our children and young people aged 0-25 years with Special Educational Needs and Disability (SEND). To achieve this and meet the changing legislative requirements a five year strategy has been developed.
There are some 35,455 children and young people identified as having SEND in Essex, representing 17.0% of the schools population. Despite being below the national average of 18.7% it outlines the importance of having a clear strategy for what is a significant vulnerable group within the county, of these:
a greater proportion, than identified nationally, have Moderate Learning Difficulties (MLD) identified as their primary need. In primary schools, 33.0% (20.3%), in secondary schools 33.5% (21.6%) and in special schools 29.7% (17.8%). Numbers of pupils with Autism Spectrum Disorder (ASD) in Essex primary schools have risen by 44% since 2008 but remain comparable with England in terms of this being identified as their primary need (7.9% compared to 7.8% across England). For secondary schools the rise is 78%, yet this is still below the England rate. For Special schools Essex has seen a fall in numbers despite a 46% increase nationally. Numbers of those with Behaviour, Emotional & Social Difficulties (BESD) have increased consistently across all age groups in Essex since 2008.
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Essex has seen a 48.8% increase in Severe Learning Difficulties (SLD) pupils in special schools since 2008 compared to 13.5% nationally. SLD pupils account for 33.6% of all pupils in Essex special schools, greater than the national average of 24.7%. In spite of rising Speech, Language and Communication Needs (SLCN) pupil numbers in both primary and secondary schools since 2008, Essex remains below the national rate for SLCN pupils
The vision of the Strategy is to ensure that all Children and Young People with SEND have a full range of support and opportunities available to them and are provided with opportunities to maximise their life chances, goals and aspirations. It focuses not only on education but recognises the other services that play a part in delivering this ambition. The following four priorities will help to achieve this vision for all Children and Young People with SEND Ensure every child with SEND can go to a good or outstanding school or education setting Commission/deliver a range of high quality provision for all children and young people with SEND Ensure a smooth progression to adulthood for all young people with SEND Improve the assessment and identification of SEND across agencies
The delivery of this vision and priorities will be underpinned by the following principles:
Easily accessible and available information is shared effectively between organisations and services. Services are delivered through partnership working and joint commissioning where appropriate (including between education, health and social care providers). A strong and coordinated approach to early intervention and support exists. Most SEND needs are met in mainstream settings - with access to specialist support. Parents, families and carers are viewed as experts regarding their child’s needs and are involved with young people themselves in decision making. Inclusion and participation in family, school and community life. Equality of access to a range of services with increased choice and control. Quality provision is based on robust evidence. New, existing and evolving statutory responsibilities are and continue to be met.
6.5 Reducing Risk Behaviours in Children
6.5.1 Introduction Adolescence is a time of great change, when young people take on new roles and responsibilities, renegotiate relationships with adults, peers, and the community, and experiment with things symbolic of adult life. These developmental tasks are often accompanied by the adoption of risk-taking behaviours that can compromise health and wellbeing. Healthy risk-taking is a positive tool in an adolescent's life for discovering, developing, and consolidating his or her identity. It is the extent to which an adolescent engages in risky behaviours, and the overall impact of these behaviours on personal development, that are of increasing concern. The research suggests that young people who participate in multiple risk-taking behaviours increase the likelihood of experiencing a range of problems, some of which could become entrenched and long-term.
6.5.2 What works? Evidence Base There is a growing body of evidence (largely based on studies in the USA) that many risk behaviours in youth tend to cluster together, particularly in young people from the most deprived backgrounds. There is also evidence that early initiation of a particular behaviour, such as smoking or alcohol use for example, is associated with other risk-taking behaviours in later adolescence and early adulthood, such as sexual risk taking, binge drinking, teenage pregnancy and delinquency. Historically, interventions aimed at preventing risk behaviours have targeted single risk behaviours. The apparent clustering of risk behaviours, and the identification of common underlying risk and protective factors have led to the proposal that new interventions should perhaps focus on addressing generic (or multiple), as opposed to single risk behaviours.
6.5.3 The situation in Essex In 2013 Essex County Council and The Training Effect entered into a joint venture to design and deliver an innovative school based intervention. The programme focuses on the early identification and subsequent intervention for young people engaging in risk-taking behaviour or at risk of behaviours which harm health and social functioning. The Risk-
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Avert programme has grown from an 8 school pilot project, to a current level of delivery focused on 25 schools across Essex including the screening of over 6ooo young people The approach aims to: Explore why young people participate in multiple risk taking behaviour Identify early those young people ‘at risk’ of multiple risk taking behaviour later in life Look beyond the behaviour and understand the access points to risk taking Provide an evidence based programme to reduce multiple risk taking behaviour in identified young people and groups
6.5.4 Future commissioning intentions The future commissioning intentions for Risk Avert are: to roll out the programme to all secondary schools in Essex to address risk behaviours in multiple year groups in multiple settings To develop additional strands eg Healthy Relationships, Emotional Health and Wellbeing and Gangs. To expand the offer to other local authorities
6.6 Promoting Health Weight in Children and Adults
6.6.1 Introduction Being overweight or obese presents a major challenge to the current and future health of the adult local population. Higher Body Mass Index is associated with an increased risk of morbidity and mortality from a range of conditions including hypertension, heart disease, stroke, type 2 diabetes and several cancers. It also contributes to increased social care costs.
Obesity is strongly related to socioeconomic status in children and this result remains, almost entirely consistent, across a range of different socioeconomic status indicators. There is an almost linear relationship between obesity prevalence in children and the Index of Multiple Deprivation 2010 (IMD) decile for the area where they live. Child obesity prevalence in the most deprived tenth of local areas is almost double that in the least deprived tenth. The Income Deprivation Affecting Children Index (IDACI) shows a similar increase in child obesity as income deprivation increases. Child obesity prevalence in areas with the highest level of income deprivation is almost double that of areas with the lowest level Children with at least one obese parent are more likely to become obese themselves. Up to 79% of young people who are obese in their early teens are likely to remain obese as adults
In 2011, just over one-quarter of adults in England (24% of men and 26% of women aged 16 or older) were classified as obese (BMI 30 kg/m2 or more). A further 41% of men and 33% of women were overweight (BMI 25 to 30 kg/m2) (The NHS Information Centre 2013).
Maternal obesity increases childhood obesity and infant mortality as well as impacting on the mother’s immediate (complications during pregnancy) and future health. Women who are obese when they become pregnant face an increased risk of gestational diabetes, miscarriage, pre-eclampsia, thromboembolism and maternal death. An obese woman is more likely to have an induced or longer labour and after birth wound healing can be slower. Babies born to obese women also face severe health risks including a higher risk of foetal death, stillbirth and congenital abnormality (NICE PH27, 2010).
ECC is committed to reducing the prevalence of obesity in children, young people and adults in Essex and it forms part of ECC’s corporate outcomes framework under outcome two of ‘People in Essex enjoy good health and wellbeing’. The commitment also dovetails with the Essex Health and Wellbeing Board’s Joint Health and Wellbeing Strategy.
6.6.2 What works? The evidence base on weight management. Interventions for childhood overweight and obesity should address lifestyle within the family and in social settings and offer regular, non-discriminatory long-term follow-up by a trained professional., who coordinates the care of children and young people around their individual and family needs. Services should aim to create a supportive environment that helps overweight or obese children and their families make lifestyle changes and ensure that interventions are tailored to the needs and preferences of the child and the family. It is vital that parents (or carers) are encourage to take the main responsibility for lifestyle changes for overweight or obese children, especially if they are younger than 12 years.
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Programmes should be tailored according to individual need and be multi component including:- Diet and healthy eating habits Physical activity Reducing the amount of time spent being sedentary Strategies for changing the behaviour of the child or young person and all close family members. Behaviour change techniques Positive parenting strategies
In terms of Adult obesity, in March 2014, NHS England published the ‘Report of the working group into: Joined up clinical pathways for obesity’. The report concluded that the preferred options for commissioning responsibility are: Tier 1 (Commissioned by Local Authority): Services that focus on preventing obesity – universal services such as health promotion, and social marketing Tier 2 (Commissioned by Local Authority): Multicomponent lifestyle weight management services for overweight and obese children and adults – Lifestyle and behaviour change interventions delivered often within group settings Tier 3 (Commissioned by CCGs): Specialist weight management services – Clinically led multidisciplinary services for the very obese (those at risk of surgical intervention) Tier 4 (Commissioned by NHS England): Surgical treatments for obesity, such as bariatric surgery
Tier 1 services relate to the obesity prevention agenda, such as health promotion and social marketing including DH funded national campaigns such as Change 4 Life and the Responsibility Deal. ECC is already commissioning a range of programmes • Community breast feeding support • Community well- being programmes • Health Trainers • NHS Health Checks • Health Champions • Youth Health Champions • Healthy Schools • School Meals • Marketing and promotion of health improvement programmes through small media and effective use of social media • Brief and opportunistic training for health and social care professionals •
Tier 2 services These services are supported by recently published NICE guidance. They have much lower unit costs than Tier 3, and are delivered to larger numbers of the population. They are typically provided for those who are overweight (BMI 25-30) as well as those who are obese (BMI >30). NICE have undertaken analysis which showed that lifestyle weight management interventions are cost effective although this is very sensitive to how well people maintain their weight loss and people often do regain lost weight.
ECC commissioned services include:- • non-activity based group programmes, • 121 motivational interviewing and combined activity/ class room sessions
Tier 3 services are a key element within the pre-bariatric surgery care pathway. They are clinically led, have a high unit cost (typically around £1000) and are provided for a comparatively small element of the population. A Tier 3 obesity service is for obese individuals (usually with a body mass index ≥35 with co-morbidities or 40+ with or without co- morbidities) who have not responded to previous tier interventions. A Tier 3 service is comprised of a multi-disciplinary team of specialists, led by a clinician and typically including: a physician (consultant or GP with a special interest); specialist nurse; specialist dietician; psychologist or psychiatrist; and physiotherapist/physical activity specialist/physiology.
These services are commissioned by the CCG.
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6.6.3 The current situation in Basildon and Brentwood The proportion of children in Essex who have excess weight is lower for both reception year and year 6 pupils than the national average. Whilst there has been a slight increase from 20.5% to 21.2% in the percentage of 4-5 year olds (reception year) who are overweight (including obese) in Essex this is not significant change. For year 6 pupils (aged 10- 11 years) the percentage of overweight/obese Essex children has remained around 30%.
Source: www.phoutcomes.info
Source: www.phoutcomes.info
Figure 6.6 shows the percentage of member practice’s population aged 18+ that have had their BMI recorded in the last two years.
FIGURE 6.6
Regular population wide BMI recording is generally poor in general practice. Overall, the 28.9% of patients aged 18-74 have had their BMI recorded in the last 24 months. Performance across practices ranges from 15% to 59.9%.
Figure 6.7 shows the percentage of patients aged 18+ that have a record of BMI in the last two years, that are overweight, obese or morbidly obese. Being overweight, obese or morbidly obese has been defined as having a BMI >25, >=30 and >=40 respectively. 31 Basildon and Brentwood Prevention Strategy
FIGURE 6.7
Figure 6.7 may over-estimate the levels of obesity in GP practice populations in the sense that practice staff are more likely to record BMI in patients that are obviously overweight compared to those that look like they are of healthy weight. Figure 6.8 shows the percentage of patients aged 18+ that are overweight, obese and morbidly obese. Figure 6.8 is likely to under-estimate true levels of obesity in GP practice populations because of the relatively low level of overall BMI recording (figure 6.6).
FIGURE 6.8
Both figure 6.7 and figure 6.8 show a high prevalence of patients that are overweight or obese in many practice populations. The conservative figure in 6.8 suggests levels of obesity ranging from 4.5% to 18% in patients aged 18+. Amongst the cohort that have had a record of BMI recorded in the last two years, obesity prevalence ranges from 22.4% to 44.4%.
6.6.4 Future Commissioning Intentions ECC has recently completed the process to commission a service provider to design and deliver an evidence based and outcomes focused Tier 2 Weight Management Service for Adults, Children and Young People. The service will support children and young people to reach and maintain a healthy BMI, for adults to lose weight and learn to maintain a healthy weight and for pregnant women to be provided with advice in line with NICE guidance and will focus on delivering programmes that :- • Are multi-component in design and are built upon the strongest evidence base available • Coordinate and deliver flexible interventions suited to different groups and needs ensuring continuity of support on entry, during and on leaving • Ensure a minimum of 20% of people engaged on the programme are from the 20% most deprived ONS Middle Super Output Areas (MSOA) in the identified areas of Essex • Ensure a minimum of 5% of people engaged on the programme are from a BME group • Collaborate with other professionals to establish pathways and protocols to ensure referrals between services as appropriate 32 Basildon and Brentwood Prevention Strategy
• Establish clear referral pathways with midwifery services (via both primary and secondary care) to ensure pregnant women are referred to the sessions on healthy eating and how to be physically active during pregnancy. • Establish a clear referral pathway with the health visiting service to ensure that six week post natal women are referred to the adult element of the WMS
The purpose of the service is to support: Children and young people aged between 6 and 18 years of age who have a Body Mass Index (BMI) equal to or greater than the 91st centile to reach and maintain a healthier BMI. Adults aged 16 years and over with a BMI equal to or greater than 25 (or 23 for those from black African, African-Caribbean or Asian (South Asian and Chinese) populations) to lose weight and learn to maintain a healthier weight. (The age overlap between children and adults provides the flexibility to decide which services to refer young people to). For all pregnant women by providing a series of single sessions of advice and support on healthy eating and how to be physically active during pregnancy. For women who have a BMI equal or greater than 30 at 1st antenatal booking, to be referred six week post natal to lose weight after pregnancy and prior to subsequent pregnancies via support from the adults service. This service will contribute towards reducing obesity prevalence in the identified geographical areas of Essex. It is envisaged that the new service will be in place by 1st April 2015.
Brentwood Borough Council will influence the diet of residents away from those substances (salt, fat and sugar) which are known to contribute towards obesity. Building on the ECC Leader’s Innovation Fund, Brentwood Borough Council will encourage local takeaways in providing healthier food choices. The project will be promoted via the Council’s Healthier Brentwood website and via their Communications team.
6.7 Promoting Physical Activity
6.7.1 Introduction Regular physical activity can play an important role both in the prevention and treatment of cardiovascular disease (CVD), hypertension, non-insulin dependent diabetes, diabetes mellitus, obesity, stroke, some cancers, and osteoporosis, as well as improve the lipid profile (DOH 2004; Folsom 1997; FNB 2002; US Dept. Health 1996; WHO 2004). Research demonstrates that the most physically active have a 30% lower risk of cardio-vascular disease compared to the least physically active. (Williams 2001
The English Chief Medical Officer (CMO) advises that adults should undertake at least 30 minutes of 'moderate intensity' (5.0-7.5 kcal/min) physical activity on at least 5 days of the week to benefit their health (DOH 2004).
In addition over 70% of people in Essex are not sufficiently physically active i.e. 30 minutes moderate intensity activity 5 days a week to meet the Chief Medical Officer’s guidelines, this situation is worsening.
6.7.2 What works? The evidence base on promoting physical activity. A Cochrane review of evidence on promoting physical activity identified a wide range of studies detailing interventions successful in increasing physical activity in different cohorts. They concluded that there is some evidence to suggest that interventions designed to increase physical activity can lead to moderate short and mid-term increases in physical activity, at least in middle age. Interventions which provide people with professional guidance about starting an exercise programme and then provide on-going support may be more effective in encouraging the uptake of physical activity.3
6.7.3 The situation in Basildon and Brentwood Primary Care practitioners are in an excellent position to encourage physical activity within their practice populations and high quality primary care should include holistic lifestyle assessment and prevention activity. In order to undertake this effectively it is important that the physical activity levels of patients are recorded, such that those who have low levels of physical activity can be encouraged to address their lifestyles.
The GPPAQ tool allows primary care clinicians to assess physical activity levels in their patients. It is designed to be used for anyone between the ages of 16 and 74.
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Figure 6.9 shows the percentage of patients in member practice populations aged 16-74 who have had their physical activity status recorded. Like smoking status, there is generally inadequate recording of physical activity status on patient records.
FIGURE 6.9
Figure 6.10 shows the percentage of patients aged 16-74 whose physical activity status is recorded as moderately active or active (as a proportion of those with any record of physical activity status on their patient record). Like smoking there is significant variation in levels of physical activity in GP practice populations and considerable scope for population health gain in this area.
FIGURE 6.10
6.7.4 Future Commissioning Intentions Active Essex are the commissioners for physical activity, school sport and community sport, working across and with all twelve local authority areas in Essexand the two neighbouring Unitaries, with the primary aim of increasing physical activity and sport. Working with a range of partners, in particular Active Networks in each local authority, Active Essex is well placed to turn the tide of inactivity. October 2014 will see the launch of a ‘Get ActiveEssex’ campaign which will run across the county. This will be followed by a series of ‘Get Active’ targeted programmes i.e. ‘Get Active through a summer of Walking’ planned for Spring/Summer 2015.
The Active Essex website www.activeessex,org provides up to date information on the campaigns and activities provided by the team and by partners, plus a comprehensive club and activity finder, which currently has over 2000 sport clubs and physical activity groups detailed. 34 Basildon and Brentwood Prevention Strategy
A priority for Essex County Council and Active Essex over the next 2 years will be to work with partners to ensure that health colleagues are provided with sufficient knowledge and training to signpost inactive people to the most effective and relevant opportunities to take part in physical activity that is most appropriate for them
Active Essex have provided Brentwood, and all other Local Authorities in Essex, with a Physical Needs Assessment to identify groups with low levels of activity. In Brentwood we will use this assessment to target these groups. Brentwood Borough Council will encourage residents to become more active by providing them with further information on where to access physical activity and how to be more active generally.
6.8 Immunisation
6.8.1 Introduction Immunisations can protect against infectious diseases and are one of the most cost-effective public health interventions that can be provided.
6.8.2 What works? Evidence base on immunisation The UK immunisation programmes are under constant review. Public Health England monitors the epidemiology of immunisation preventable illness and manages outbreaks. The Medicines and Healthcare Products Regulatory Authority (MHRA) monitor adverse effects associated with immunisations. The Joint Committee on Vaccination and Immunisation gives advice on immunisation practice in the light of UK epidemiology and the international research.
The Joint Committee on Vaccination and Immunisation supplies UK health departments with independent scientific advice on the effectiveness and cost-effectiveness of immunisation that might be used in the UK. The childhood immunisation programme reflects this advice. The current routine childhood immunisation programme consists of the following:
Age at which routine Disease protected against immunisation given 2 months Diphtheria, tetanus, whooping cough, polio and Haemophilus influenza type b (Hib) Pneumococcal disease Rotavirus 3 months Diphtheria, tetanus, whooping cough, polio and Haemophilus influenza type b (Hib) Meningococcal group C disease (MenC) Rotavirus 4 months Diphtheria, tetanus, whooping cough, polio and Haemophilus influenza type b (Hib) Pneumococcal disease Between 12 and 13 Haemophilus influenza type b (Hib) months of age Pneumococcal disease Measles, mumps and rubella (German measles) 2, 3 and 4 years of age Influenza 3 years 4 months of Diphtheria, tetanus, pertussis and polio age or soon after Measles, mumps and rubella (German measles) Girls aged 12 to 13 Cervical cancer caused by the human papillomavirus types 16 and 18. years of age Around 14 years of Tetanus, diphtheria and polio age Meningococcal group C disease (MenC)
Immunisations that are given to children at risk are as follows: Age at which routine Disease protected against immunisation given At birth, 1 month,,2 Hepatitis B months and 21 months of age
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At birth Tuberculosis 6 months or older Influenza
In addition to the immunisation given in childhood pregnant women are recommended immunisation against seasonal influenza and whooping cough in part to protect their unborn child.
Influenza is a significant cause of illness causing service disruption with increased numbers of people hospitalised and care homes closed due to local outbreaks. It can also strike informal and formal carers reducing care capacity at a time (winter) when demand is higher. For this reason influenza vaccination is recommended for vulnerable groups in the population: those with certain chronic illnesses, those over 65 years old or those who are pregnant. It is also recommended that frontline health and social care staff and informal carers are immunised. The seasonal immunisation needs to be repeated every year.
Pneumococcal immunisation protects against a common cause of pneumonia (Streptococcus pneumoniae). The groups at risk are similar but do not include pregnant women. In addition as it is less prone to cause illness in the healthy population immunisation of healthy carers and staff is not needed. The pneumococcal immunisation is only needed once in most groups but is repeated every 5 years in those with kidney or spleen disorders.
The King’s Fund used hospital episode statistics from the year 2009/10 to show that 2% of emergency admissions were due to influenza or pneumonia.4
Hepatitis B virus can cause a severe illness of rapid onset. It can also lead to a chronic illness leading through liver cirrhosis to liver failure or primary liver cancer. The main risk factors in adults are living in residential accommodation for those with learning difficulties, inmates in custodial institutions, people with a history of injecting drug misuse and people who change their sexual partners frequently.
6.8.3 The situation in Basildon and Brentwood Local monitoring of immunisation programmes in Essex shows that across all 5 NHS Clinical Commissioning Groups coverage of all routine childhood immunisation is at or very near the 95% coverage target, with the exception of immunisations given to between 3 years 4 months and 5 year of age. For the immunisation given between 3 years 4 months and 5 year of age range from 91% to 94% coverage with the average across Essex being 93%.
FIGURE 6.11 FIGURE 6.12
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Figure 6.11 shows flu vaccination coverage rates by GP practice for the 65+ population in 2013-14.
There is considerable variation in performance between practices. Nine practices (shown in red) had coverage rates statistically significantly lower than the target 75% coverage (at 95% confidence). Conversely 11 practices (shown in green) had coverage rates statistically significantly greater than the target 75%.
Figure 6.12 shows flu vaccination coverage rates for clinically ‘at risk populations’. Again, there is wide variation between GP practice populations.
6.8.4 Future Commissioning Intentions The local NHS in the form of the Essex Local Area Team has the major responsibility for delivery of national vaccination policy locally. This includes the provision of seasonal influenza immunisation and pneumococcal immunisation. Essex County Council has a public health responsibility to assure itself of the adequacy of arrangements in place and where necessary recommend changes to improve provision. In the flu season 2012/13 the coverage of flu immunisation in both the over 65 year age group and in the clinical at risk group was less than the national average.
In addition to this overview function Essex County Council has the responsibility to ensure that its front line members of staff and those in the services it commissions have access to seasonal influenza immunisation. In some cases were staff are working in hospitals there are arrangements with the hospitals occupational service. In other situations staff source the influenza immunisation from a commercial service or through there GP and can then claim their costs from the Council.
It is the employer who has the responsibility to ensure that front line care staff in privately run care homes are appropriately immunised. Essex County Council does not ask for information on the adequacy of immunisation in care staff.
Drug mistreatment and sexual health services are commissioned by Essex County Council. Each person accessing these services is assessed for risk for hepatitis B. Where there is an ongoing risk hepatitis B vaccination is recommended and some services are able to give it themselves. Hepatitis B is offered to all prisoners in Essex who have not already been fully vaccinated.
No strategic changes in those offered immunisation who are working aged adults or older people are envisaged. The NHS Essex Area Team will continue to the lead on the provision of seasonal influenza and pneumococcal vaccination with Essex County Council continuing to scrutinise the adequacy of provision. Innovations are being brought into the delivery of flu immunisation such as pharmacies being commissioned to provide NHS vaccinations across Essex.
There is scope working with others to improve the tactics used to implement immunisation policy. Firstly Essex County Council should bring increased focus onto immunisation of its front line social care staff. There is no collection of data on how many staff are vaccinated. Such data is needed to check that uptake is adequate and to highlight were it is not so that effective action can be taken both to protect the health of those receiving care from the Council and to protect council staff.
The appropriate use of immunisation should be promoted more widely. Employers commissioned by Essex County Council to provide care to its residents in the residents own homes or in care homes are expected to offer seasonal influenza to their staff and to facilitate residents being vaccinated by their GPs. There is no information as to whether this happens of not. If such information were available it would be possible to identify employers failing in their duty to residents and to support them to improve.
NHS Basildon and Brentwood will further incentivise GPs to reach 70% flu vaccination coverage for patients aged 65+ and clinically at risk groups by funding a stretched Public Health QOF as part of the Winter Pressures Resilience Funding.
Brentwood Borough Council will work with the CCG Brentwood Locality Group and local GPs to promote uptake of flu vaccination.
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6.9 Reducing the Prevalence of Smoking
6.9.1 Introduction Smoking is the single biggest cause of preventable death in the UK, and differences in smoking prevalence between affluent and deprived communities are the single biggest driver of health inequalities. Each year in Essex the costs to society of smoking are thought to be £322 million this includes the output lost from early death, lost productivity, costs to the health and social care services, consequences of passive smoking, smoking related fires and the cost of cleaning and litter as a result of discarded cigarettes.
6.9.2 What works? The evidence base on reducing smoking prevalence There is a wide body of published evidence relating to smoking and reducing smoking prevalence. A range of coordinated Tobacco Control measures including promoting smoke free environments, dissuading people from starting to smoke, increasing tax on tobacco, restricting the supply of smuggled and counterfeit tobacco and universal and targeted high quality smoking cessation services have been shown to be effective.
6.9.3 The current situation in Basildon and Brentwood In 2013-14, ECC commissioned stop smoking services helped in excess of 9,000 Essex residents to quit smoking. ECC has commissioned its stop smoking support services in line with the evidence base to support quitters from those population groups who experience highest risk from or the largest barriers to giving up smoking including: • Routine and Manual groups; • Pregnant mothers; • Children and young people (this also includes smoking education programmes in schools); • Black Minority Ethnic Communities (BME)
ECC has also developed a comprehensive Tobacco control programme and works in partnership with ECC trading standards and HMRC on tackling underage sales and illegal and illicit tobacco.
Figure 6.1 shows smoking prevalence by member practice population, calculated as a percentage of the practice population aged 16+ with their smoking status recorded who stated that they smoked.
FIGURE 6.1
Figure 6.1 may over-estimate smoking prevalence, as practice staff may be more likely to record patient’s smoking status if they smoke. However it shows considerable variation in prevalence by GP practice.
Figure 6.2 shows the percentage of recorded smokers in each member practice population who accessed an NHS stop smoking service and set a four week quit date. Figure 6.3 shows the percentage of the GP practice population recorded as a smoker who quit successfully at four weeks. In order to have a positive impact on smoking prevalence it is imperative that GPs proactively refer smokers to NHS stop smoking services, and that referred smokers quit successfully.
FIGURE 6.2 38 Basildon and Brentwood Prevention Strategy
FIGURE 6.3
In total, 674 patients registered to Basildon and Brentwood practices quit smoking for four weeks through an NHS service in 2013/14. Reduction in smoking prevalence at GP practice level (as measured by four week quits) was just under 1% in 2013/14.
6.9.4 Future Commissioning Intentions Essex County Council will continue to commission GPs and pharmacists to deliver stop smoking services through a lead provider model and will continue with wider programmes on Tobacco Control.
Basildon and Brentwood CCG will ensure that ‘Making Every Contact Count’ is a key requirement of all of their providers and is written into all contracts.
Environmental Health Officers from Basildon and Brentwood Borough Councils will continue to champion the implementation of the Health Act (2006) in promoting healthy lifestyles in Businesses. They will also seek to ensure that front line staff receive training in Making Every Contact Count.
6.10 Alcohol harm minimisation and treatment
6.10.1 Introduction Alcohol misuse is one of the major population wide public health issues facing the UK and is the third leading cause of disability in the developed world after smoking and hypertension. Approximately 15,000 deaths in England are caused by alcohol per annum – 3% of all deaths. Harmful and dependent drinkers are much more likely to be frequent accident and emergency department attenders, attending on average five times per annum. Between 20 and 30% of medical admissions, and one third of primary care attendances, are alcohol related. 39 Basildon and Brentwood Prevention Strategy
The physical harm related to alcohol has been increasing in the UK in the past three decades. Deaths from alcoholic liver disease have doubled since 1980 compared with a decrease in many other European countries . Alcohol related hospital admissions have increased by 85% over the past decade. Excess alcohol use is not limited to younger people and nationally 13% of adults aged 65 or over drink every day – the greatest percentage of any age group. Alcohol can interact with prescribed medication in dangerous ways, and can increase risk of falls and injury. Alcohol misuse is also linked to dementia, and it has been estimated that 21-24% of cases of dementia may have had heavy alcohol use as a contributing factor.
6.10.2 Evidence Base There is a strong body of published evidence relating to programmes that are effective in reducing demand on health services resulting from alcohol. Improving the effectiveness and capacity of specialist treatment programmes is highly cost effective delivering a net saving to the NHS of approximately £1,100 per dependent drinker treated.5 Provision of alcohol nurse liaison services in general hospitals (where dependent drinkers are identified and their entry to specialist treatment is facilitated) has also been shown to be highly cost effective.6 Intervention and Brief Advice Services (IBA) in Primary Care, A&E and specialist outpatient units (e.g. fracture clinics or sexual health services) for patients who are drinking at hazardous or harmful levels but are not yet dependent has been shown to be both effective and deliver a net saving to the NHS within one year.7
6.10.3 The situation in Essex The level of need in Essex is identified in table 6.1 below:
Table 6.1 Sensible / Non Increasing risk drinkers Binge High risk drinkers Dependent drinkers drinkers drinkers
South East 158,460 50,149 40,894 12,247 9,471 South West 182,517 57,011 46,769 15,393 11,904 West 132,574 41,162 33,638 9,349 7,229 Mid 173,403 55,689 45,161 12,121 9,373 North East 155,498 47,829 40,286 11,555 8,936 Essex 802,452 251,840 206,748 60,665 46,913
6.10.4 Future commissioning intentions ECC has recently commissioned or expanded the capacity of the following evidence based services Essex to reduce the overall harm caused by excess alcohol consumption and in particular, alcohol related admissions to hospital:
Identification and Brief Advice (IBA) – Evidence based interventions that support a reduction in the incidence of hazardous and harmful drinking and able to be delivered in a wide range of settings. The intentions is to continue the roll out of specialist training to health, social care, criminal justice and other public sector staff to ensure that wherever the public are engaged and where appropriate IBA is delivered effectively.
Alcohol Liaison Nurse Services (ALNS) and A&E Liaison Services - Specialist services located and operating within the acute hospital setting to support the hospital staff and identify and engage with patients accessing services through Accident and Emergency and Acute wards where alcohol is identified as a contributory factor. Also facilitating referrals to community based specialist services where required.
Care Management (Recovery Management) – Clearly identified as best practice by both the Department of Health and Alcohol Concern to effectively manage the delivery of evidence based recovery focussed treatment , support services and enhance outcomes for individuals.
Extended Brief Interventions and Psycho social Interventions (EBI and PSI) – Evidence based structured interventions to support increasing risk drinkers to address alcohol related physical and psychological functioning and to support dependent drinkers pre and post detoxification to build and maintain gains made.
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In–patient and Residential interventions (Detox and Rehab) – Evidence based medical and non-medical services accessed through an appropriate assessment and referral process provided for drinkers with significant dependency or health/social functioning issues where community provision is assessed as unsuitable.
Community prescribing for detoxification (Home Detox) – Community based medical interventions primarily commissioned for dependent drinkers who are assessed as suitable for community based medical interventions.
Criminal Justice Interventions – Specialist services delivered in both the prison and community settings to individuals where offending is alcohol related. Support the Police, Probation and Court services to identify relevant individuals and support access to the appropriate support and treatment provision (including both custodial and community sentenced individuals).
Specialist Liaison - In addition to the above specific commissioned provision the intention will be to provide explicit and named liaison leads from within these commissioned specialist services to:
i. Family Solutions Service teams ii. Adult and Children’s Social Care teams iii. Youth Offending Services/Teams
6.11 Strengthening Community Resilience
6.11.1 Introduction Resilience is about more than an ability to bounce back from a single damaging event. It is about possessing a set of skills and having access to the resources that allow people to negotiate the challenges we all experience. It’s also about the skills that allow people to overcome the more difficult circumstances that some of our population experience. This approach builds on concepts such as capabilities, empowerment and much of the research on Social Mobility.
The communities we live in and the relationships and networks we are part of are all important features of resilience. To succeed most people need close emotionally supportive relationships but also exposure and links to a wider group of people with different knowledge, talents and resources at their disposal. We know people copy behaviour that they commonly see, so a resilient community is a well networked one, but also one where there are positive social norms and challenges to destructive behaviour. Personal and community resilience are intertwined because support networks are stronger when made up of resilient individuals, and forming meaningful relationships takes confidence and other personal capabilities. Most residents in Essex have emotionally supportive networks already. These might be friends and family or community or faith groups. They know people they can turn to in challenging times for help, advice and guidance. However for other residents these relationships do not exist, and research suggests that these are key for overcoming adversity and for general well-being. We want to create structures and support networks that can help residents build the relationships they need.
In a county as diverse as Essex this means ensuring good community cohesion. Essential to building a resilient community is an understanding of the power of networks in spreading positive behaviours, knowledge and social norms and challenging destructive ones.
6.11.2 Evidence Evidence shows that broad networks of weaker ties (contacts with people we don’t know as well) can help residents to access a range of advice, skills, knowledge and connections. So for example in resilient communities people are more likely to know someone who can give them advice about how to apply to university, how to do some DIY or how to influence local decision making. In particular, it is more likely that employment opportunities will arise from numerous weak ties rather than fewer strong ones.8 The more people and the broader the range of people we interact with, the more resources and potential support we have at our disposal.
Behavioural science suggests new insights into the impact of the behaviours we see around us. We mimic what we see others do and in this way our social networks influence our ideas, emotions, health, relationships and so on.9
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NICE evidence demonstrates that peer support is a critical and effective strategy for ongoing health care and sustained behaviour change for people with chronic diseases and other conditions, and its benefits can be extended to community, organisational and societal levels. Overall, studies have found that social support: decreases morbidity and mortality rates increases life expectancy increases knowledge of a disease improves self-efficacy improves self-reported health status and self-care skills, including medication adherence reduces use of emergency services Additionally, providers of social support report less depression, heightened self-esteem and self-efficacy, and improved quality of life.
In 2010 the government policy 'Putting People First' stated that person centred planning must become mainstream. Guidance was issued to help Local Authorities use person centred thinking and planning to deliver the personalisation agenda, recognising the evidence that person centred planning empowered individuals to accept ownership of their health and wellbeing. Whilst variability of CCG specific delivery models is recognised, it is expected that the evidence for personal goal setting will be incorporated into how services are delivered.
6.11.3 Current Situation in Essex Following the Who Will Care? report there have been a number of initiatives developed that will support community resilience in Essex. These initiatives include increasing volunteering within the community and mobilising communities to start their own initiatives that will allow them to support themselves.
Currently in Essex there are a number of initiatives being put forward aimed at helping to strengthen community resilience and these are in different stages of implementation. This comes, in large part under our Outcome 7 Commissioning Strategy – Helping People in Maintain Independence.
Increasing numbers of volunteers Essex aims to develop and strengthen the infrastructure that supports employee volunteering, both within Essex County Council and across other organisations, in both the public and private sectors.
We are re-launching and reinvigorating ECC’s own employee volunteering scheme whilst also identifying ways to engage with business, emphasising opportunities for business to promote volunteering and demonstrate their corporate social responsibility. This in turn will promote awareness of the potential of volunteering. and may in turn increase volunteering in the community
This includes: • Revising our staff volunteering policy • Base lining of current ECC volunteering with regular reassessment • Internal ECC communications campaigns in conjunction with partners for example The Citizens’ Advice Bureau. • Developing mechanisms for engaging the business sector in volunteering, building onbest practice Research & Analyses of current private sector volunteering/ corporate social responsibility activity as well as potential activities for the future (organisations that do not volunteer employees) • ing with business on issues of corporate social responsibility • Targeted interventions and initiatives to promote volunteering
Providing networking opportunities to share best practices and experiences We are seeking to increase networking opportunities in order to further support mobilisation of communities. Activities include - Initiating & supporting networking opportunities (e.g. swap shop) & sharing ideas , best practice & lessons learned for community groups across Essex - Using these to communicate key messages about eg work under way to review procurement practice - Using the Who Will Care portal to share messages
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Providing training and toolkits to empower communities Supporting mobilisation of communities by providing training and toolkits to set up and run community-led activities but also to bid for funding.
Examples of proposed schemes include: - Business incubator training, available to voluntary groups & partners to build skills around bidding for funding. - Toolkit, to replicate countywide & large scale roll-out approaches & learn from experience
These will help communities become better adapted for bidding for funding, leading to them becoming self-sustaining and will increase the support they have access to.
Improving the “Essex Connects” portal, to provide better information advice and guidance to CVS’ Building on the existing Essex Connects information portal, to enhance information sharing across a wider range of community organisations across Essex and provide additional information including a schedule of events for residents. Essex connects is used by some of the CVS groups across Essex, the proposal is to ensure all CVS have access to it & to update the on-line information. There will be further opportunities to enhance the portal by developing an app to support mobile access to information around community & volunteer groups
This will increase the number of community initiatives and schemes by giving greater access to support for communities seeking to start their own initiatives.
Planning Civic Innovation sessions Civic innovation sessions promote creative innovation in public services. They are predicated on a commitment to openness and participation, and a trust in empowering people and communities. Civic innovation sessions bring together participants from the public and private sectors and members of the public to generate practical solutions to social policy challenges.
They are entrepreneurial in spirit, and are opportunities to problem-solve. Built around “coalitions of the willing” that include residents, academics, entrepreneurs, charities and public agencies a civic innovation session will look to develop new technologies, and to locate new areas for innovation and funding.
Community Agents Essex Community Agents Essex is an innovative scheme delivered in partnership with four voluntary sector organisations, Rural Community Council of Essex, British Red Cross, Age UK Essex and Neighbourhood Watch Essex working together to identify and support frail older people and their informal carers to source and implement solutions to the issues they face.
People contact social care and health when they find it difficult to navigate the system, resulting in people contacting services either too early or at a point of crisis. This scheme, through targeted outreach helps identify those people who are likely to need social care and/or health services at an earlier stage, helping them to connect and link back to support within their communities. As well as improving outcomes for individuals, the scheme will reduce demand for social care and health by supporting people to approach services at the most appropriate time.
The scheme comprises a network of 36 Community Agents, supported by 72 volunteers, a countywide Older People Voice Network and local Neighbourhood Watch co-ordinators. Together they work alongside established community groups and organisations to enable people to find practical solutions and support from within their own natural and community networks, addressing loss of confidence, social isolation, mobility issues and increasing frailty. The approach is person centred and builds on the strengths of the individual; this is a scheme building on what people can do, rather than on their issues, but recognises that as people become older and more frail, and particularly after a life change such as after a hospital visit, bereavement or start of an illness some additional help may be needed to help them gain or re gain their independence.
The primary aim of the scheme is to enable people to manage their own lives and remain independent in their homes for longer resulting in reduced demand for health and social care services. By doing so, this scheme will also build more resilient individuals and communities.
The scheme is aiming to support around 6000 people a year.
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6.11.4 Future Commissioning Intentions
GP Practice Based Social Prescription Social prescribing is a mechanism for linking residents with early interventions and prevention support within the community. These might include opportunities for physical activity, self-care management courses, arts and creativity, learning new skills, volunteering, mutual aid, befriending and self-help, as well as support with, for example, employment, benefits, housing, debt, legal advice, or parenting problems.
Social prescribing is usually delivered via primary care – for example, through ‘exercise on prescription ’or ‘prescription for learning’, although there is a range of different models and referral options. It is particularly appropriate for patients who present at GP surgeries, often frequently, with issues that are non-clinical and allows GPs and other practice staff to link patients with community and third sector resources that can help them solve their own problems.
ECC will use the Public Health Grant and if available Transforming Communities Award monies to commission social prescribing programmes in every borough/district in Essex in 2015/16.
Social Prescribers will be placed in GP hubs together with a circle of 10 trained volunteers per practice improving the relationship between GPs and the local community and the knowledge of primary care teams about the range of community assets available locally.
The initiative aims to:
build self-resilience to assist individuals to better manage their holistic health reduce demand on primary care services and GPs from high intensity users provide a practical mechanism to assist patients who present repeatedly with non-clinical issues
Individuals referred by GPs, nurses, clinicians, social care will develop a Personal Plan through a guided conversation to self-manage their care. Including support and activities from within the community and voluntary sector it is reviewed periodically and progress tracked.
Referral will be from those over 16 that have a non-clinical underlying cause and will address conditions such as low level mental health issues, teenage obesity, multiple long term conditions, and issues associated with bereavement, loneliness, social isolation, caring or domestic violence.
Basildon and Brentwood CCG have pledged to match fund resources provided by Essex County Council in order to extend the programme locally. We will build on a pilot scheme in 15 GP hubs in Pitsea North, Pitsea South and Laindon and link to the new practice based Care Coordinators where relevant.
Community Builders Subject to a bid to the Transforming Communities Award (TCA), ECC will commission Community Builders placed in community settings that will assist shape a sustainable infrastructure utilising an Asset Based Community Development (ABCD) methodology to start to build a more resilient and more active community that is aligned to local health needs and inequalities. They will: actively work with the local community’s existing assets and skills align a group of dedicated volunteers to GP practices provide a pathway to community and voluntary services and take a pro-active approach to driving up referral numbers offer volunteering opportunities through CVS’ to aid recovery and reduce dependence on medication and primary health services link to other existing projects such as Parish Safety Volunteers, through Essex Fire and Rescue and Essex Police, and Community Agents through Age UK, to maximise resources and synchronise efforts
Steering Groups will be identified in each locality made up of public health, CCG, Local authorities, CVS and other voluntary and community groups, SEPT, NEPT.
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The relevant CCG will be the accountable body for the investment acting as the convenor of the group. A delivery partner will be determined by the steering group in each locality through a tendering / commissioning process where appropriate.
The local CVS will undertake mapping of opportunities and curate a portfolio of quality support and activities and assist with the recruitment of volunteers. A coordinator will coordinate volunteers in each GP practice working closely with the CVS in order to access support for patients.
Local Authorities will assist with community development and mobilisation building capacity on the ground and maximising their own initiatives
Quarterly Reports will be reported to the Strengthening Communities Programme Board feeding directly in to the Essex Partnership Board.
Increasing numbers of volunteers We will review our volunteering programme internally and assess whether we have been successful in the launch. This will be reassessed regularly. We will consider this successful if the baseline of volunteers increases consistently.
Providing networking opportunities to share best practices and experiences We will be looking to continue a series of events into 2015 that will increase the ideas exchange and help network with partners and facilitate them networking with each other.
Providing training and toolkits to help communities In future we will review how communities have progressed and how training has been attended and received. Those using the incubator training will be reviewed to measure the impact the process has had on them.
Improving the “Essex Connects” portal, to provide better information advice and guidance to CVS’ This will be maintained and reviewed in order to see what impact it has had on the communities that have used it. It will also be an action point to measure how many CVS have used and updated the website. This will be indicative of its success through charities considering it effective.
Planning Civic Innovation sessions We will review the session secure additional funds for future events.
6.12 Promoting Self-Care: Information, Advice and Guidance
6.12.1 Introduction Information, advice, and guidance (IAG) are essential in supporting people, carers and families to exercise choice and control and make well-informed choices about their care and support. It also has a key role in promoting self-care, preventing or delaying people’s need for care and support, and educating people about their needs and the needs of others.
IAG can also be vital for professionals working with people with care needs, by keeping them informed of the latest practices and services available and helping them provide better quality support. Ensuring high quality IAG is a key requirement of the Care Act 2014, which states that local authorities must: “establish and maintain a service for providing people in its area with information and advice relating to care and support for adults and support for carers”. The service should address prevention of care and support needs, finances, health, housing, employment, what to do in cases of abuse or neglect of an adult, and other areas.
6.12.2 What works? Evidence base on IAG and Self Care Some self-management programmes that assist patients to develop an understanding of their condition and lives and cope with their symptoms when delivered with both education and practitioner review have been found to reduce hospitalisations in patients with asthma by up to 50% and reduced hospital admissions in patients with COPD by between 13% and 36% depending on disease severity. 10 11
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An American RCT study to test whether a self-care model for transitional care could improve outcomes in Medicare Advantage and Medicare fee-for-service populations in the US found that patients that received IAG relating to self-care for the condition that they were initially admitted to hospital for, were less likely to be readmitted to a hospital in general, and for the same condition that prompted their index hospitalization, at 30, 90, and 180 days versus control patients.12
6.12.3 The current situation in Essex Essex County Council commissions and funds a number of services that contain elements of information and advice, some of which are targeted and others which are more universal. ECC also funds one service to directly provide information advice and guidance; this is a service from Healthwatch Essex. Services containing an element of information, advice and guidance include: • Home from Hospital work undertaken by the CCGs • Community Dementia Support Services • Falls Prevention • Self-Directed Support Services • Housing Related Support Funded Services • Floating Support • Social Inclusion and Recovery
Basildon and Brentwood CCG currently co-commissions NHS 111 to provide health information and provide health information on their website.
Service user groups have identified that better information and advice is needed to help people manage their needs and to access services efficiently when they need to.
The Joint Strategic Needs Assessment for 2013 highlighted findings from local surveys on adult social care which suggested: • Key areas for improvement include better signposting to existing sources of information, advice and support. • There is a need for improved standards of follow-up after social care assessments. • Improvements could be made in how easy it is to find information
Only 52.6% of people in Essex said information on local services was very or fairly easy to find, which was consistent to – but slightly below - the national average (55.7%). The Tracker Survey has also made similar findings with the 2014 report suggesting only 15% of respondents feel informed about future proposed changes to health services, and just over half of respondents (51%) feel informed about local public services.
Accessibility has also been highlighted as a particular issue and the 2013 JSNA reported that engagement with planning groups highlighted the need to improve awareness and accessibility of information and services. The report suggested that visual impairment and deaf or hard of hearing awareness training is a key priority for all front line staff, in all service areas.
6.12.4 Commissioning Intentions We will review current IAG provision at an Essex and CCG locality level across health, local government and the third sector with a view to agreeing a joined up coordinated approach to commissioning future IAG provision, and shared agreed messages to the public in a range of appropriate formats. We will ensure that all written communication is fit for purpose, written in plain English and fits the principles set out in the Information and Advice strategy when finalised.
We will ensure that future contracts or funding arrangements will provide information in a variety of different formats
Information Portal Essex County Council will commission a web-based Information Portal to provide Essex citizens with information and advice relating to care and support that is accessible and proportionate to their needs.
46 Basildon and Brentwood Prevention Strategy
This information portal will support citizens to gain information on the health and care system and services available in their area, thus supporting prevention and wellbeing and self-management. It will meet the growing need to manage increased demand via the web channel by providing information on: • How the care and support system operates; • Potential choices and how to access these • Health information and advice • How to access relevant financial advice; • How to raise concerns about an adult with safety, care or support needs; • How to make plans to meet needs that may occur; • Sign posting to relevant sites that promote and support health and wellbeing • Directory of services eg assistive technology and CQC
Supporting Prevention In order to support the prevention agenda all partner agencies will: • Conduct regular campaigns on social care and health issues and promotion of local services and initiatives linking with local papers, newsletters and radio stations. • Encourage schools to include information on social care issues, their causes, and potential preventative activities into appropriate lessons and show students where they can access additional information if they need it. • Advertise local information services at all frontline services / ECC & Partner premises.
Workforce. We will ensure that all staff are aware of the information and advice requirements of the Care Act and take opportunities to provide proportionate and relevant information and advice to meet the needs of service users and carers. We will develop an e-learning package to train front line staff on ‘Making Every Contact Count’ allowing them to identify and make appropriate referrals of people into commissioned services.
Web GP Web GP is an innovative web-based IT solution that promotes self-care and reduces demand on primary and secondary health services by helping patients access the most appropriate NHS service for their clinical need. It integrates with a GP practice’s website and provides five additional services: 1. Symptom checkers help patients establish the right service for their problem 2. Self-help guides and videos help them solve a number of issues themselves 3. Sign-posting content provides awareness of other offers e.g. pharmacy and online counselling 4. 24/7 phone advice within 1 hour using a form on the website to request a call back from a 111 nurse 5. e-consults whereby patients use condition-based web forms to request advice and treatment from their own GP within 1 working day, potentially avoiding the need to attend the practice in person. (See: hurleyclinic.co.uk).
The website was developed by 30 GPs and specialists working together for 18 months. A core team of senior GPs (Lecturers in general practice, GPSIs, text book authors) worked closely with software programmers and practice mangers. The clinical governance elements were co-designed with clinical advisers from the medical defence organisations and the service was successfully operationalised across a variety of practice types (e.g. different practice sizes, clinical software systems and appetite for using technology).
Evaluation of the service which is already running in 133 GP practices in London found that for every 10 minute face-to- face appointment slot booked via Web-GP, a further 27 patients had successfully tried to help themselves using other resources. It also found that 14% of users would have attended A&E if the service hadn’t existed.
Following a successful bid to the NHS Primary Care Transformation Fund, Basildon and Brentwood CCG will commission web-GP in 42 of its 44 member GP practices.
NHS 111 We will develop a common and county wide view on the future of NHS 111 in terms of a localised versus an Essex wide approach for procurement in April 2016.
47 Basildon and Brentwood Prevention Strategy
7. Secondary Prevention
7.1 Health Checks
7.1.1 Introduction NHS Health Checks are one of the few mandated services that must be commissioned by the local authority using the Public Health grant. Checks must be offered to every person aged 40 to 74 once every five years, with further targets relating to the number of checks delivered. NHS Health Checks are a key mechanism for identifying those at risk of more serious ill health, for example because of poor lifestyles, and for case finding of patients with clinical risk factors for serious disease such as hypertension or high cholesterol. By identifying and offering both lifestyle modification programmes and pharmacological interventions for those at greatest risk, the aim of the programme is to prevent more serious acute and chronic conditions such as CHD, stroke and diabetes.
Successful performance on NHS Health Checks is particularly important to Basildon and Brentwood CCG as they are a key mechanism for improving the completeness of Hypertension registers – one of the three key local priorities in the 2013/14 Integrated Plan.
7.1.2 What works? Evidence base on Health Checks It is estimated that the programme nationally will prevent 1,600 heart attacks and strokes, at least 650 premature deaths, and over 4,000 new cases of diabetes each year. At least 20,000 cases of diabetes or kidney disease could be detected earlier; allowing individuals to be better managed and so improve their quality of life. DH, PHE, NHS England and the LGA have recently highlighted the importance of the NHS Health Check programme in addressing premature death, disability and reducing health inequalities.
In Essex It is estimated that in year each of the first five years of implementing the NHS Health Check programme
3416 additional people will complete a weight loss programme 1973 additional people will be taking statins 881 additional people will be compliant with an Impaired Glucose Regulation lifestyle 476 additional people will be diagnosed with diabetes 1473 additional people with be taking anti-hypertensive drugs 223 additional people will be diagnosed with chronic kidney disease 877 additional people will increase physical activity 63 additional people will quit smoking
7.1.3 The situation in Basildon and Brentwood Health Checks in Basildon and Brentwood are commissioned via GP practices and NHS community providers. All but two GP practices are signed up to deliver Health Checks. Performance against target in 2013/14 was variable between different GP practices.
7.1.4 Commissioning Intentions Essex County Council currently commissions a Lead Provider to support GPs in delivery of The NHS Health Checks programme. This includes the writing of Clinical searches to identify eligible patients, training of staff, Point of Care testing equipment and consumables, bank staff and administration of payments for Health Checks delivered and invitation letters sent. The lead provider also delivers an outreach service to support; areas of low uptake from patients, where GPs decline to offer Health Checks to their patients or to concentrate on geographical areas or cohorts that suffer high levels of health inequality.
NHS Basildon and Brentwood will raise the issue of low uptake of Health Checks with member practices and localities through locality managers. Regular performance on Health Checks will be provided to localities and member practices through the Public Health balanced score card
48 Basildon and Brentwood Prevention Strategy
7.2 Senior Health Checks
7.2.1 Introduction Senior Health Checks are a local initiative commissioned by Essex County Council Public Health team that extends the health check to those aged 75-84. They act as another key mechanism for practices to identify those at risk of serious disease by case finding hypertension or high cholesterol and intervening.
7.2.2 What works? Evidence base on Senior Health Checks Senior Health Checks focuses on case-finding among older adults aged 75-84 followed by initiation of evidence-based management of risk factors. Adults aged up to 74 receive five-yearly checks through the national NHS Health Checks, but there is no national scheme for those aged 75+. 42% of people aged over 65 have a chronic health condition, with 23% having two or more. A large proportion of these remain undiagnosed and thus unmanaged. There is strong evidence that substantial health gains can be made in the 75-84 age group through diagnosing and treating chronic health conditions (NHS NE Essex, 2010, and references therein). Based on published evidence, previous implementation in North East Essex and modelling, Senior Health Checks should deliver a return on investment over five years with gains to both health and social care. For Senior Health Checks, it is estimated that in Essex, around 4,130 new diagnoses of long term conditions or of high vascular risk could be made at 50% coverage of the eligible population group, and around 6,600 at 80% coverage. Evidence suggests that up to 370 emergency health events could be prevented or postponed over five years.
7.2.3 The current situation in Basildon and Brentwood As of September 2014, overall the CCG is on track to meets its end of year Senior Health Checks target, with over half of the annual target number of checks already delivered. However there is again very considerable variation between member practices, with the majority under performing and a minority over delivering. This is poor in terms of inequality between GP practice populations.
7.2.4 Commissioning Intentions A Public Health Business case approved by ECC commits to continue to commission GP practices to deliver Senior Health Checks in 2014/15 and 2015/16.
NHS Basildon and Brentwood will raise the issue of low uptake of Health Checks with member practices and localities through locality managers. Regular performance on Health Checks will be provided to localities and member practices through the Public Health balanced score card
7.3 Prevention of strokes through case finding and treating undiagnosed hypertension and improving the clinical management of circulatory disease
7.3.1 Introduction Stroke is a major health problem in the UK accounting for over 56,000 deaths in England and Wales per annum representing 11% of all deaths.13 Each year in England approximately 110,000 people have a first or recurrent stroke. Although the majority of patients survive their first stroke, many will have significant disabilities which impact on their quality of life and drives demand for continuing health and social care services. More than 900,000 people in England are currently living with the effects of stroke, with half of these being dependent on other people for help with every day activities
However, stroke is a preventable and treatable disease. Effective case finding (diagnosis) and clinical management of patients with clinical risk factors for stroke such as hypertension (high blood pressure), coronary heart disease (CHD) and a previous history of stroke, reduces the probability of emergency admissions due to stroke and the resulting ongoing health and social care costs that would have resulted in a proportion of these patients.
GP practice level hypertension registers across Essex are incomplete; an estimated 169,554 patients with hypertension are not on a disease register and therefore will not be getting appropriate clinical care to manage their disease putting 49 Basildon and Brentwood Prevention Strategy them at high risk of stroke, heart failure and myocardial infarction (heart attacks). In total, Essex hypertension registers only contain an estimated 58% of all people with hypertension in Essex.
7.3.2 What works? Evidence Base on Stroke Prevention A multiple regression analysis undertaken by the Public Health team has identified the key underlying risk factors for stroke in the population of Essex that can be modified by improvements in primary care quality to be:
- The completeness of GP practice based hypertension registers (hypertension case finding) - The percentage of patients on practice hypertension registers who have had their blood pressure monitored within the last nine months - The percentage of patients on GP practice hypertension, stroke and CHD registers with their hypertension controlled to under 140/90 - The percentage of patients on GP practice stroke and CHD registers recorded as taking an anti-platelet or anti-coagulant drug (drugs that thin the blood).
Using the coefficients from the model, the Public Health team developed a health economic modelling tool that calculates the number of emergency admissions that would be expected for different levels of:
1) Case finding for Hypertension 2) Effectiveness of clinical management of hypertension, stroke and CHD patients at GP practice level based on the above clinical biomarkers.
The tool works by comparing the difference in incidence of strokes in practice populations known to have good case finding and clinical disease management and practice populations where this could be further improved. The tool calculates the secondary health care and social care costs that could be saved by improving performance against case finding and clinical management although it does not account for additional costs within primary care associated with case finding of circulatory disease patients for example increase GP practice time in managing hypertension patients. It also calculates additional savings to both Health and Social Care resulting from the prevention of vascular dementia.
A pilot programme has been running for one year in Basildon and Brentwood. It has resulted in an additional 1744 patients with hypertension being diagnosed and hypertension register completeness being improved by 3%.
7.3.3 The situation in Basildon and Brentwood Local data extracted from SystmOne for South Essex or QMAS 2012/13 for North Essex shows the completeness of Hypertension registers for each CCG and Essex as a whole. It suggests there are 145,366 people with undiagnosed hypertension across Essex. Table 7.2 shows 2012/13 performance on the six circulatory disease management QOF indicators and the trajectory needed to reach 80th centile of performance in three years.
TABLE 7.1 Hypertension Number of Register undiagnosed Completeness patients with hypertension
Basildon and Brentwood 64.28% 21815 Castle Point and Rochford 63.74% 17481
Mid Essex 55.92% 40832 North East Essex 59.54% 35677 West Essex 57.97% 29561
Essex 59.67% 145366
50 Basildon and Brentwood Prevention Strategy
TABLE 7.2 2012/13 YR1 YR2 YR 3 Baseline BP4 89.02% 90.91% 92.81% 94.70% BP5 77.05% 79.60% 82.15% 84.70% CHD 6 87.90% 89.97% 92.03% 94.10% CHD 9 89.28% 91.65% 94.03% 96.40% Stroke 6 84.80% 89.20% 93.60% 98.00% Stroke 12 88.99% 90.53% 92.06% 93.60%
Output from the Public Health economic model suggests that if this performance is achieved then 1199 strokes and 334 cases of vascular dementia will be prevented, saving over £4M to the five CCGs in Essex and £2.4M to adult social care.
7.3.4 Future Commissioning Intentions ECC have approved a business case currently being rolled out through the five CCGs to commission GP practices to improve hypertension register completeness by 10% over three years and reach 80th centile national performance on the six QOF indicators listed above. Funding to support practices will be transferred to each CCG via a section 76 agreement. CCGs will then engage member practices to design local programmes to reach the specified outcomes of the project.
NHS Basildon and Brentwood CCG will provided monthly reports to GP practices and localities on their performance against the specified metrics with a view to encouraging learning and peer review and increasing performance.
7.4 Prevention of Strokes in Patients with Atrial Fibrillation through effective anti-coagulation treatment.
7.4.1 Introduction Atrial Fibrillation is a heart condition where the sufferer has an irregular and often abnormally fast heart rate. It can affect adults of any age but is most common in older people. It affects about 10% of people over 75. Having AF increases the risk of having a stroke by five times. Moreover, strokes in patients where AF is an underlying factor are more likely to be serious and patients that survive them are likely to have an average of 36% more permanent disability compared to patients who have strokes where AF was not a causal factor. As such, identification and treatment of AF is a key secondary prevention priority in terms of reducing strokes and the disability caused by them to our population, and in reducing demand and cost on secondary care and adult social care services.
7.4.2 Evidence Base Recognition and optimal treatment is of particular importance as strokes due to AF are highly preventable. NICE Clinical Guidelines 36 Atrial Fibrillation recommends manual pulse palpation should be performed to assess for the presence of an irregular pulse that may indicate underlying AF in patients presenting with any of the following: breathlessness/dyspnoea; palpitations; syncope/dizziness; chest discomfort; stroke/TIA.
It is important to risk assess patients such that appropriate pharmacological interventions can be made including anti- platelet or anti-coagulation drug therapy in order to reduce the risk of AF-related stroke, and premature deaths from AF-related stroke.
7.4.3 The situation in Basildon and Brentwood
Figure 7.3 shows the percentage of patients on GP practices’ AF registers who have a CHAD2 >=2 ie are rated as at high enough risk of a stroke to beshould treated with an anti-coagulant to reduce their stroke risk, who have not been prescribed one
51 Basildon and Brentwood Prevention Strategy
FIGURE 7.3
The left hand side of the graph shows a worrying level of performance with significant proportions of AF patients with a stroke risk that warrants anti-coagulation therapy, not receiving it. In total, 528 patients (20.4% of those on AF register) who need it are not being prescribed anti-coagulation therapy, and are therefore at unnecessarily high risk of stroke.
Table 7.3 shows the number of people treated with an anti-coagulant who had a CHAD2 score >1.
TABLE 7.3 NUMBER OF PEOPLE TREATED (QOF AF3 AND AF4; THOSE WITH A CHADS SCORE >1 TREATED) CCG 13/14 new activity
BB 2575 247 CPR 2276 286 Mid 3623 449 NE 3988 522 West 1296 379 Total 13758 1883
In total 1,883 more patients at high risk of a stroke were anti-coagulated in 13/14 compared to 2012/13 According to the NICE costing model, the additionalnumbers of people treated and its impact on stroke risk, we would expect to see 70 fewer strokes across Essex.
7.4.4 Commissioning intentions ECC is working with the five Essex Clinical Commissioning to assist local GP practices to identify and treat patients with AF with appropriate pharmacological interventions to reduce their stroke risk. Our aim is to ensure that there are no patients on AF registers who have not been offered anti-coagulation or anti-platelet therapy where appropriate.
NHS Basildon and Brentwood CCG will provided monthly reports to GP practices and localities on their performance against the specified metrics with a view to encouraging learning and peer review and increasing performance.
7.5 Improving Mental Health through early intervention
7.5.1 Introduction Mental ill health is the most important cause of disability in the UK, accounting for 23% of the total ‘burden of disease’.14 People with long-term conditions are at significantly greater risk of experiencing mental ill health problems such as depression or anxiety. Patients with heart problems have been found to have a significantly increased risk of depression or anxiety compared to the general population15 16.It is estimated that 33% of patients with CHD are depressed17.
52 Basildon and Brentwood Prevention Strategy
Older people (many of whom also have one or more long term conditions) are also at significantly greater risk of depression. It is estimated that one in four older people in the community will have depression18, 19with the risk increasing with age such that 40% of those aged 85 and older are affected20.
NICE Guidance21 estimates that that 62% of the population may be suffering from depression and anxiety which is not diagnosed. For those aged over 65 this issue becomes even more significant. Research suggests only 1 in 6 people aged over 65 suffering from depression or anxiety discusses their symptoms with a GP, and only 1 in 12 people recievetreatment. This would suggest almost 92% of older people with depression will remain untreated.22 CHD patients with depression also have a greater mortality rate.23
With poorer prognoses and increased morbidity it is unsurprising that having mental health problems leads to increased demands on health and social care services. It has been shown that in people suffering a long term condition, additional depression can be more detrimental to health than the long term condition itself.24 25 26
Research suggests that depression in older people is a pre-disposing risk factor for entering residential care. One study found that over a one year follow, older people with depression had a 42% increased risk of entering residential care compared to those who were not, even after other diseases were controlled for. 27 28. This suggests depression is a predisposing factor to residential care admission and opens the possibility ,that if the depression can be appropriately managed, admissions could be avoided or delayed and people helped to remain independent for longer.
7.5.2 What works? Evidence base. Treatment for depression and anxiety is relatively low cost and effective. Most people with mental health problems are managed in primary care, with only six percent of older people with depression receiving specialist mental health care.29 Older people consult their GP almost twice as often as other age groups.30 Mild depression will often respond to supportive treatments including exercise and social prescription whilst more severe cases respond to drug treatments and talking therapies provided through Improving Access to Psychological Therapies (IAPT) services.
7.5.3 The situation in south Essex The South Essex CCGs commission a local IAPT service. The South Essex Mental Health Strategy identified that GPs made over 16,000 referrals into the service in 2011/12. The current IAPT service delivers one to one therapy, group therapy, computerised cognitive behavioural therapy and biblio-therapy, and focuses on mild, moderate and severe non-psychotic conditions such as anxiety and depression. The first assessment occurs within the GP practice.
7.5.4 Future Commissioning Intentions
Depression screening in older people Modelling by Public Health suggests that there are likely to be 6725 patients aged 75+ on GP CHD registers across Essex with undiagnosed depression.
ECC have approved a business case to commission GPs to screen all of the patients aged 75+ on their CHD registers for depression in one year and offer appropriate treatment for those that screen positive. Further screening and treatment of new cases of CHD would also be commissioned in years two and three.
In addition, front line Social Care will be trained to screen all clients aged 65 and over receiving a service, for depression and make appropriate referrals to the client’s GP for those who screen positive.
It is clear that there are currently a large number of people with heart disease and who are known to Social Care and who may have depression which has not been diagnosed. Addressing this will mean additional activity in the first 12 months of the project while these existing cases are identified, screened and treated. In subsequent years only new “incident” cases will need to be identified with considerably lower demand on, especially, primary care. Additional disease registers could then be considered for depression screening.
GPs will be paid to screen all of the patients on their CHD registers aged 75+ and to re-screen and treat all referrals from front line social care staff who screened positive. Modelling by Public Health suggest that treating these patients for depression is likely to prevent/delay approximately 92 residential care admissions and deliver savings of £1.4M over three years. 53 Basildon and Brentwood Prevention Strategy
IAPT and IAPT+ CCGs in south Essex will work collaborative to commission an IAPT+ service. This will reduce waiting times for IAPT, improve recovery and outcome measures, increase the numbers of patients seen and supported in primary care, and improve links and support for people to maintain employment, social networks and housing. The successful delivery of this strategy should mean that more people will receive treatment from ‘IAPT plus’ and fewer will need referral to secondary care services.
7.6 Improving Housing and Homelessness Support
7.6.1 Introduction Housing is a key element to the prevention and wellbeing agenda. Supporting people to find and remain in accommodation most suitable for their needs, promotes individual independence and wellbeing and relieves costs and pressure on the Health and Social Care system, for example by reducing demand on residential care services or facilitating hospital discharge.
Homeless people are a highly vulnerable population known to have extreme health needs. Many homeless people are affected by a combination of physical illness, mental illness and addiction. They also face major barriers to accessing mainstream health care series.
7.6.2 Evidence Homeless people are known to die much earlier than the general population particularly from causes related to alcohol and infectious disease. Average age at death in homeless people is estimated to be 40 – 44 years1 (Office of the Chief Analyst 2010). A survey of homeless people in Essex identified major health problems in the including mental illness (41% had been diagnosed with mental illness), substance misuse (38% reported current drug use) and high rates of infectious diseases (including Hepatitis B, Hepatitis C, HIV and TB). They are also put at risk by an extremely high prevalence of smoking (74%) and very poor nutrition, with 46% of participants reporting that they usually had 1 meal or less per day
7.6.3 The current situation in Essex
How many homeless people are there? Estimates of the number of homeless people in Essex were made by consulting published data on ‘statutory homelessness’ (those accepted by local authorities as being owed a statutory duty to be housed), information on the number of places available in night shelters, refuges and floating support. This produced the following estimates: Homeless Category Estimated number Statutory homeless in temporary 2,500 accommodation Rough sleepers 57 Night shelters 53 Refuges 118 Floating support 210 Other hidden homeless ? Total 2,938 The number of ‘hidden homeless’ (people sleeping in squat or ‘sofa surfing’ in friends’ houses) cannot be estimated but may be quite large.
1 Note that average age at death is not directly comparable with life expectancy. Data on life expectancy for homeless people is not available. 54 Basildon and Brentwood Prevention Strategy
7.6.4 Current Provision and Future Commissioning Intentions
Housing Brokerage ECC are currently working to commission a Housing Brokerage service, which will start April 15. The intenton is to commission a single high-quality, County-wide Housing Brokerage Service which will broker housing solutions via a ‘single front door’ for a range of client groups. Service users will include adults with disabilities, mental health needs and/or substance misuse dependencies including where there is a co-existing criminal justice issue (i.e. offenders with complex and additional needs). This service, depending on available funding, may in the future also be rolled out to other client groups. The service supports Service Users to access housing that matches their needs more easily and where appropriate enables individuals to move on from residential care, hospital or Supported Housing which exceeds their level of need and to prevent people requiring such services through securing suitable accommodation to meet need, through both the social and private housing sector. This service was originally based upon the successful scheme in place within Learning Disability which has increased access to individual tenancies and led to more individuals taking charge of their own support needs and increasing their independence. This service will also include supporting people living in housing which does not meet their need or awaiting release from the criminal justice system or living in the community. This is a key way of lowering service demand, by ensuring people are able to access suitable independent housing in a timely way in line with need.
Crisis Response Service We will also develop our crisis response services to enable more people to live in their own homes and avoid unnecessary admissions to residential care. This work is progressing both with older people and adults with disabilities. Crises can cause individuals to be left in long term residential care, contrary to their needs and desire to be independent. Crisis response is being developed to stop the key factors of crisis causing long term residential care stays. This will be based around support at home for service users and with short term emergency placements that do not become long term residential placements. It is particularly noted that a large amount of crisis is based around carers.
There is no reporting tool fit for purpose and in the future we will develop a new system that will have the flexibility and ability to fast track the process where ithereis a crisis. This will also allow crisis situations to be identified and dealt with quickly.
We want to support people to develop daily living skills, maximise their work capacity and skills and, gain or retain employment status, connect with their local community and maintain and improve their mental health. We have also put £2.5m into ensuring there is accommodation and opportunity to develop for young people at risk. This includes foyer schemes, which provide residence for young people at risk but link the accommodation offer to compulsory education or employment, which the service users are supported in finding. This will ensure not only will they be less likely to need social care services by housing them but also by allowing them to develop, to be ready to work , and therefore to support themselves going forward. We want to support people to manage their own health and care needs. We are aiming to increase independence by identifying those at risk individuals who do not yet have social care needs. There is risk stratification planned by CCGs that will give a better view of those who are potentially in need of support. This greater oversight will be backed by practical interventions, such as ensuring handrails are present to reduce the likelihood of falls. This will work to help ensure people are at less risk of needing Health and Social Care.
Adults with Disabilities The People Commissioning Capital programme board will look at ways to increase accommodation for adults with disabilities, aiming to achieve 250 extra units, which will be supported by care arrangements. The nature of these care arrangements will be flexible, allowing for residents’ needs to be addressed individually.
ECC wishes to ensure that accommodation options are available to adults with disabilities to enable 249 people to either move on from registered care or avoid being admitted to registered care. We are currently commissioning 14853 units of supported housing with 485 units commissioned purely for adults with disabilities (both Learning and Physical or Sensory disabilities). These provisions are being protected to ensure that access is improved to Supported Housing. This will reduce the number of service users placed in residential care, which may be providing excessive service compared to their need. This reduction in residential care numbers will relieve pressure on the system as well as ensuring that service users do not become institutionalised and can reclaim independence.
Extra Care Housing for Older People
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Extra care housing is for people over the age of 55 who wish to live independently but have support needs. The attractive, self-contained housing is designed to enable older people to retain their independence in their own home for as long as possible. A number of factors contribute to this including flexible care and support services, the design of the building, the use of assistive technology and the provision of additional services including meals. This means that for many older people extra care housing will offer a viable and attractive alternative to residential care.
ECC will develop additional Extra Care Housing tenancies in Essex as an alternative to residential care. It is an aspiration that all new builds will be “ready” for any Assistive Technology. This has previously been approached using piecemeal providers, but we will review this to understand whether the scale of this can be increased.
Disabled Facilities Grant for Older People Basildon Borough Council and Brentwood Borough Council offer Mandatory Disabled Facilities Grants for home adaptions. Brentwood Borough Council also offers limited loans to vulnerable and elderly owner occupiers to make safe and maintain their properties to enable independent living. Such loans are repayable on sale of the property. Brentwood Borough Council will actively promote this programme through leaflets, links with care homes, road shows and GP surgeries.
Integrated commissioning across Basildon and Brentwood Basildon Borough Council, ECC and NHS Basildon and Brentwood CCG will seek to integrate the Older People’s Strategy including care needs, with local housing needs assessment and the care-coordination approach and develop a clear articulated view on future options to better support people to live independently.
Domestic Abuse ECC currently fund 3 providers to deliver refuge and domestic abuse outreach/resettlement support across Essex. Currently there are 110 refuge places and an average of 121 people receiving resettlement/outreach support. An approach to re-commissioning these services from September 2015 is progressing under the auspices of the Essex Domestic Abuse Commissioning Co-ordination Group. The approach will focus on re-commissioning of ‘community services’ to emphasise that services are more than just refuges. Linking up with commissioning of Independent Domestic Abuse Advocates in the future is also planned.
Young People (age 16-25) Supported Housing There are currently a range of ECC funded young people supported housing schemes, including foyers, across Essex providing support to young people at risk, teenage parents and young people leaving care. The services provide support to young people to enable them to develop the life skills needed to be able to maintain a tenancy and live independently thus reducing the reliance on social care. Support will also include enabling people to actively participate in the community and engage in meaningful activity, including employment, education and training. People are normally supported to move on within 2 years.
A review has been initiated to look at referral arrangements into services. This is being done with the view of ensuring appropriate access to services for people who are 16/17 and those with higher level and more complex support needs, including mental health needs. Consideration needs to be given to wider commissioning activity to develop a new service delivery model and required activity to implement new services from April 16. The approach will ensure there are a range of services in place to meet need and will explore all funding sources to ensure appropriate funding streams and to maximise available funding.
Older People Sheltered Housing There are currently a range of sheltered housing schemes for older people across the county, with ECC funding and average of 8685 units of accommodation. Most ECC funded schemes are provided by district, borough and city councils, with housing associations, Abbefields and Almshouses also providing some schemes. The majority of sheltered schemes are for people over the age of 55, with some having a higher age criteria. Increasingly more and more people are choosing to remain living in their own home for longer rather than moving into sheltered housing and some sheltered housing schemes are being used more as a housing option for the over 55 where there are long waiting lists for general needs social housing.
Other authorities have reviewed their approach to sheltered provision and taken radically different approaches, including the total removal of funding (e.g. Liverpool, Peterborough). ECC intend to explore options which from 2016- 17 could lead to a more flexible needs-led service which is tenure-neutral and focuses on developing community capacity as well as complementing other initiatives such as community agents and social prescription as well as looking 56 Basildon and Brentwood Prevention Strategy to better align spend with need across the County. Key strategic principles will be that a) services should promote community resilience and b) individuals in receipt of services should be expected to contribute where possible to the cost of those services. As part of the next steps for 2016-17 arrangements, it is also proposed that consideration also be given to reviewing the current distribution of spend on sheltered schemes across the county which is currently based on legacy arrangements. An analysis to be based on population figures; demographic projections and other factors (such as Indices of Multiple Deprivation) is proposed.
Home Improvement Agencies (HIA) There are currently 3 ECC funded HIA services across Essex. They provide advice, support and assistance to elderly, disabled and vulnerable people who own and live in their own property. They help people to repair, improve, maintain or adapt their home to meet their changing needs. The purpose of the service is to help people to remain independent, in their own homes, warm, safe and secure. HIA services are due for re-commissioning from July 2015. The approach to re-commissioning is being developed and this will involve consideration of alternative provision.
Brentwood Borough Council will promote services such as handyman and gardening support to assist older residents maintain independence.
Fuel Poverty Fuel Poverty is defined as needing to spend 10% or more of household income on heating. Living in a cold environment is associated with greater risk of falls, cardio-vascular disease and mortality, particularly in older people. Brentwood Borough Council offers and processes grants for insulation through Aran Services. If a resident doesn’t qualify for free assistance from Arran then Brentwood Borough Council Environmental Health team will consider offering a grant. Environmental Health has a fund to use for loft clearance, scaffolding etc. to facilitate residents to undertake insulation and renewable energy installations. Brentwood Borough Council will promote this programme through GP surgeries, Parish Council newsletters, press releases, leaflets and the radio.
Floating Support Floating Support is an ECC funded countywide service. Up to 2000 people can be supported at any one time. The table below provides a breakdown of referrals received during 2013/14.
Castle Epping Primary Client Support Need Basildon Brentwood Point Forest Harlow Rochford Uttlesford Braintree Chelmsford Colchester Maldon Tendring Total Percentage Older people with support needs 18 2 6 3 1 1 2 10 4 4 4 4 59 1% Older people mental health 10 0 0 2 3 2 0 3 2 0 0 1 23 1% Frail elderly 18 1 5 3 6 4 0 1 2 6 0 5 51 1% Mental health problems 219 31 57 29 42 31 25 107 150 205 38 163 1097 26% Learning disabilities 33 12 13 5 23 9 6 20 27 36 9 49 242 6% Physical or sensory disability 76 6 29 15 14 12 7 25 30 57 11 70 352 8% Single homeless with support needs 27 0 1 0 0 0 1 11 19 7 0 17 83 2% Alcohol misuse problems 15 3 6 8 5 5 4 4 2 6 0 4 62 1% Drug misuse problems 18 4 3 4 3 2 3 1 4 5 0 7 54 1% Offenders or at risk of offending 22 1 0 7 12 2 1 7 16 6 0 4 78 2% Mentally disordered offenders 4 0 0 0 0 0 0 0 0 1 1 0 6 0% Young people at risk 0 0 0 0 1 1 0 3 6 12 3 6 32 1% Young people leaving care 15 0 0 1 3 0 0 0 1 3 1 0 24 1% People at risk of domestic violence 44 7 9 11 10 10 7 6 16 11 4 10 145 3% People with HIV / AIDS 1 0 3 0 1 0 0 0 0 0 0 1 6 0% Homeless families with support needs 2 0 1 0 0 0 0 5 8 2 2 2 22 1% Refugees 0 0 0 0 0 0 0 0 0 0 0 0 0 0% Teenage parents 7 0 1 0 0 0 1 5 2 9 0 2 27 1% Rough sleepers 0 0 0 0 0 0 0 13 16 12 2 18 61 1% Gypsies & Travellers with support needs 2 0 0 0 0 0 0 0 0 1 0 1 4 0% Chaotic / Complex needs 248 17 50 12 11 25 15 265 293 402 95 427 1860 43% Total 779 84 184 100 135 104 72 486 598 785 170 791 4288 100% Percentage 18% 2% 4% 2% 3% 2% 2% 11% 14% 18% 4% 18% 100%
Flexible needs led support is provided by support workers to people who are living in general needs/independent accommodation or who are of no fixed abode and who require support to enable them to increase their daily living skills and to retain their home or to be supported to access suitable housing. Support workers will also support people to manage their health and well-being, actively participate in the community and to engage in meaningful activity as well as signposting and supporting people to access other relevant services to ensure needs are met. This service is a short to medium term service. The length of the support depends on individual need, some people may only require one off advice and assistance whilst others may require the support for a number of months and occasionally may require the service for up to 5 years. Over time the amount of support reduces down as needs are met and people’s independence increases until the support worker is able to ‘float off’.
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The initial contract term for this service comes to an end 31st March 15. The contract has the provision to extend on a 1+1+1 basis up to a further 3 years. The service provided is of a high quality and demand for the service continues to increase with providers continually looking for different and innovative ways to manage waiting lists and maximise the number of people that are supported at any one time.
The intention is to exercise the contract extensions as well as continuing to identify further funding opportunities to expand and complement the service.
Single Homeless and Homeless Families There is currently a range of ECC funded homeless provision across the county, including supported housing and night shelters. There are 274 units of accommodation for single homeless and 63 units of accommodation for homeless families.
The services are for people who require accommodation and many of whom will also have support needs which have contributed towards their homelessness. People can stay in the night shelters for up to 28 days and may stay in supported housing for up to 2 years, with many staying for a far shorter period.
It is intended to develop an Action Plan based partly on the Homelessness Health Needs Assessment (HHNA) carried out for the Joint Strategic Needs Assessment. In addition, it is intended to involve partners in Essex Housing Officers Group (EHOG) to consider current provision in terms of services and usage across the county. Commissioning intentions will then be developed with a view to re-commissioning from April 2016. Feedback has noted that the scope of the HHNA was limited to single homeless people so any further work would need to broaden to consider homeless families.
Private Sector Tenants Brentwood Housing Policy gives priority to those most in need. (Refer to Brentwood Housing Strategy 2013-16). The council will ensure that private sector tenants are provided with information concerning their legal rights to established legal standards. Environmental Health will signpost these services though the Council’s Healthier Brentwood web pages. The council will use housing regulations to take enforcement action against any landlords who offer sub-standard accommodation, including lack of heating, dampness etc.
7.7 Assistive Technology
7.7.1 Introduction Assistive technology (AT) describes any technology-enabled product or service designed to facilitate independence for people with health and social care needs, such as Long Term Conditions (LTCs) or the frail elderly. It is increasingly seen by policy-makers as a key building block of service redevelopment in order to address rising service demands
AT includes: Telehealth: the remote exchange of physiological and wellbeing data between a patient at home and medical staff to assist in diagnosis and monitoring (this could include support for people with lung function problems, diabetes, heart failure etc). Telecare: a combination of remotely monitored passive alarms, sensors, other equipment and services to help people live independently in their own homes. Telemedicine: the provision of consultation and other services by off-site health care professionals to those on the scene. Diagnosis and treatment advice can be given at a distance through methods such as videoconferencing and/or rapid transmission of digital files and images.
7.7.2 Evidence base There is some evidence that specific Telecare interventions can support the prevention agenda. One study suggested it could reduce falls in older people by 20% and reduce post fall hospitalisation rates. 31Another found that installing call systems in care homes can reduce falls and their associated health care costs by up to 50%.32An evaluation of telecare provision in Essex in 2009-10 reported that, across 240 randomly selected telecare users, for every £1 spent on telecare £3.82 was saved in traditional care, based on social worker report of the next best care scenario.
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7.7.3 The current situation in Essex During 2010/11 ECC funded 3540 service users; which equated to £296,695, whilst in 2011/12 funded 4030 service users, which equated to £339,565. The funding was for the monitoring and where provided the response service as well as the £35 installation charge. The telecare equipment, installation and replacement of faulty equipment is provided free of charge for service users assessed with needs which are moderate or above.
The equipment is provided by EES, commissioned through Essex Cares (contract renewed for 5 years). Progress has already been made in centralising the provision of equipment services across Essex, through the recent S75 agreement with 10 partners. The current equipment spend for the consortium is circa £17.5m, of which £8.5m is for ECC. Of this £8.5m, currently less than £1m is spent on AT (telecare equipment only).
7.7.4 Future Commissioning Intentions We plan to further develop the potential of assistive technology as a way of supporting vulnerable people. We are aiming to promote AT, supporting the social care workforce so that they understand what is available as well as improving visibility and uptake from the general public and service users. There is an aspiration to include an AT assessment when new service users first engage,. There is also a long term aspiration to ensure that new build homes are ready to take on assistive technology. Work is being conducted with Anglia Ruskin University to develop these ideas further. Essex is also currently investigating the feasibility of a single provider who may be able to develop and deliver our AT needs in their entirety.
Assistive Technology available to each resident The recent digital and technological revolution made a wide range of assistive technology available to our customers and our urgent priority is to: Have appropriate technology solutions which are consistently embedded within the remodelled referral pathways for our residents Work with our residents to raise awareness and to facilitate easy access to the market for technology solutions/products for them Enable and influence consistent delivery of integrated, mainstreamed, equitable and integrated assistive technology services across Essex Ensure provision of technology which will support sustainable housing – prolonging independent living for our most vulnerable older residents Utilise care monitoring data to inform future commissioning decisions, and enhance wellbeing and prevention
We have already started developing the Technology in Care Strategy which incorporates the inclusion of telecare, telehealth, telemedicine, and technology awareness. The strategy will be fully implemented county wide as soon as possible. Finally the overarching enabler to achieve our vision, is to work in an integrated manner with our partners to develop a service model that meets our high ambitions and aspirations. The process by which we will do this will involve: service and pathway reviews analysis of available data wide stakeholder engagement including, service users and carers, clinicians and other service providers market development critical review of relevant research financial and procurement modelling
7.8 Support to Carers
7.8.1 Introduction Carers form an integral part of ensuring that Health and Social Care needs are met. The delivery of many health and social care interventions rely on carers to ensure that they provide good outcomes for service users. Ensuring that the carers we and our service users rely on are supported, empowered and assisted will help us to provide our outcomes and healthier, more independent lives for service users.
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7.8.2 Evidence 146,211 adults in Essex provide informal care to relatives, friends or neighbours according to the 2011 Census, compared with 129, 236 reported in the 2001 Census. This represents a 13% increase in the number of carers in ten years. This is 10% of the population, which is similar to the proportion for England and the Eastern region. About 70% of carers in Essex were working-age adults (25-64 years old), 24% were elderly (65+ years old), and 6% were younger people (less than 24 years old).
The 2011 Census also showed us that people’s caring responsibilities were varied, with a large number of carers (22%) providing more than 50 hours of care per week, as shown below;
Figure 7.4
7.8.3 The Current Situation in Essex Support for carers is currently provided via two main routes – 1. Social care assessment and support • 32% of those assessed receive a service • 5% of those assessed (600 people) receive a cash payment • 3000+ carers currently have an emergency plan registered with ECC 2. Voluntary sector services • A wide range of respite and sitting services; information and advice; and emotional and practical support - funded via grants (ECC and NHS) • Low value grants which contribute to the costs of existing services
We understand too that informal networks of family and friends are formed around carers, and that these networks offer vital support of all kinds
7.8.4 Future Commissioning Intentions ECC recognises that we need to do things differently to improve outcomes for our carers. We have ambitious plans to achieve a new model of support for carers by 2017 which will operate at four levels:
• Community based and led activities - which support those who take on a caring role, whether or not they define themselves as carers, helping them to find solutions to issues and support from within their own communities and natural networks; • A locality level ‘first stop model’ - identifying needs and aspirations and providing, facilitating or co- ordinating support for carers in each CCG area • Social care assessments and support - in relation to joint assessments of the carer and cared-for and for those with complex needs • Professional awareness and engagement - improving the recognition and involvement of carers as expert partners in care, ensuring that the role of carers, including their contribution and support needs is factored into mainstream commissioning.
We want to get the new approach right, and we will work with carers and partners across the public, voluntary, community and commercial sectors over the next two years to do so. In the meantime, we want to ensure that carers in
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Essex have access to a range of services and support, which is why the first step in developing our new model, is the ‘Supporting Carers in Essex’ grant funding round.
Applications to this funding will need to have a clear focus on outcomes for carers and demonstrate how they will be achieved. We envisage that applications will deliver more than one outcome through the following themes:
Theme Outcome
1. Choice and Control Carers know what their options are now and for the future and are supported to plan for all stages of their caring role.
2. Respect and Recognition Carers are recognised, respected, valued and included as expert and knowledgeable partners by professionals.
3. Access to networks of support Carers are connected to local community support networks.
4. Good Health and Wellbeing Carers are able to maintain their health and wellbeing, both physically and emotionally, whilst managing their caring role.
5. Independence Carers are resilient and able to sustain a life of their own alongside their caring role.
7.9 Improving Offender Health
7.9.1 Introduction The increasing older population across Essex is also reflected in the prison system. In addition there is a perceived gap in the diagnosis of low level Mental Health/Personality Disorders and Learning Disability issues when compared to the predicted prevalence in the offender cohort. These individuals leaving the prison system with undiagnosed or untreated health and/or social care need can present a significant strain on the Health and Social Care system. Identifying and intervening early with these groups both within the prison system and on release during post sentence supervision and rehabilitation may lead to reduced social care need.
7.9.2 Evidence base Prisoners over 60 are the fastest growing group in the prison estate. The number of women prisoners aged over 50 has more than trebled (Prison Reform Trust, 2008). Older prisoners now represent around 12% of the total prison population and have a high prevalence of physical and mental disability (Ministry of Justice, 2014). Much research on older offenders in the criminal justice system comes from the prison estate. The national minimum standards for the care of older people in the community or in care homes do not apply in prison (HMIP, 2008). The Prison Reform Trust (Doing Time; The needs and experiences of Older Prisoners, 2008) has indicated poor regimes and lack of engagement with older people are leading to isolation in prison and a lack of planning for resettlement means that older people do not get the services they need on return to their community and experience anxiety about the future. Thematic work from the Inspectorate of Prisons (‘No Problems, Old and Quiet, 2004) found that none of their sampled prisons had a separate regime for older prisoners. Retired prisoners had not been asked about what they wanted to do during the working day. Where activities are not accessible, alternatives should be provided to avoid discriminatory practice. Older offenders’ needs are not restricted to their time in custody but also require specific resettlement plans, especially where they have served life sentences. The Inspectorate found that over a quarter (28%) of the prisoners sampled would be at least 70 years old on release. They would be unlikely to be seeking employment. Many will require health and social services support in addition to having to adjust to the outside world. Of course, not all older offenders are ill or infirm – but there is a strong encouragement to view age as a potential vulnerability
7.9.3 The Current Situation in Essex The table below demonstrates all services that are currently available to offenders within and released from the prison service. Whilst there are good provisions for drug, substance and alcohol abuse there is very little or no identification
61 Basildon and Brentwood Prevention Strategy services for learning disabilities, dual diagnosis or the other combinations of conditions. This leads many sufferers to serve time in prison without ever being diagnosed or referred for their condition.
7.9.4 Future Commissioning Intentions In response to: the new statutory duties under the Care Act in relation to Prisoners and Social Care need, the identification of Re-offending within the new ECC Outcome Framework (Outcome 4) the drive to improve pathways and provision for prisoners with wider Health needs, the inclusion of a Re-offending target within the Public Health Outcome Framework, and; the need to reduce re-offending as identified by the Essex Re-offending Board and Office of the Police and Crime Commissioner
4.7 Improving Mental Health in children through early intervention
4.7.1 Introduction Children and young people do not present or process mental distress or disorder in the same way as adults. The systems and structures of the family and school which surround children are not the same as those within which adults operate. The legislation which impacts on a child’s treatment changes depending on their age, capacity and competence. In the eyes of the law, an under 18 year old is still a minor for whom there are a range of safeguards in place.
“No health without mental health – delivering better outcomes for people of all ages” states the following in relation to working with children and young people:
‘Different approaches are required for children, young people and adults, although some interventions are effective in reducing distress and improving functioning across all age groups. Stigma and discrimination create barriers for people with mental health problems of all ages and their families and carers. The principles of the recovery approach, which
62 Basildon and Brentwood Prevention Strategy emphasises the equal importance of good relationships, education, employment and purpose alongside reduction in clinical symptoms, apply equally to children and young people.’
‘Getting the experience of care right for children and young people and involving them in the design and review of services are important both for their current and future health and their willingness to use services if they need them later in life. Services need to be appropriate to the child’s or young person’s developmental stage. Of particular importance is ensuring effective transition from children’s to adults’ services.’
Children, young people and families should experience effective transition between all services without discriminatory, professional, organisation or location barriers getting in the way.
4.7.2 What works? Evidence base.
No Health without Mental Health sets out a clear vision for supporting excellence of provision in mental health services centred around six objectives: More people will have good mental health More people with mental health problems will recover More people with mental health problems will have good physical health More people will have a positive experience of care and support Fewer people will suffer avoidable harm Fewer people will experience stigma and discrimination These objectives are applicable as much to services for children and young people as they are to those for adults and form the basis from which services should be developed
4.7.3 The situation in Essex
4.7.4 Future Commissioning Intentions The three Local Authorities, and seven Clinical Commissioning Groups (CCGs), are working in partnership across Southend, Essex and Thurrock to develop an improved response to children’s emotional wellbeing and mental health needs. It is recognised that each partner brings a unique and important contribution to this process and all have agreed to work together to integrate commissioning, take an outcomes based and innovative approach and to develop more integrated pathways across health, social care and education.
Partners recognise there needs to be fundamental changes to the current CAMH service model to ensure services are able to respond to current need, promote resilience and respond flexibly to future national and local changes to resource to support children and young people’s mental health, and allow local commissioners to make the most of the resources they receive.
The Health and Social Care reforms together with the current financial climate have given added impetus for an integrated commissioning approach via a joint procurement process for traditional CAMHS Tier 2 and 3 services between the 7 CCGs and the 3 local authorities to enable enhanced flexibility, integration and collaboration between services and Tiers
The overarching objective for an integrated EWMHS Tier 2 and Tier 3 service is to improve emotional wellbeing and mental health of children and young people by working in the community and offering assessment, interventions, and consultation to children and their families and carers, outreach to identify severe complex needs, and training and support for other professionals and agencies
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8. Tertiary Prevention
8.1 Reduce the risk of further falls in older people
8.1.1 Introduction Falls are a major cause of disability and the leading cause of mortality due to injury in older people aged over 75 in the UK.(1) Each year, a third of the population aged over 65 has a fall, and half of these people fall at least twice.(2) Annually, over 500,000 older people attend UK Accident & Emergency departments following a fall.(3) The financial impact of falls and fractures on the NHS & Social Care is significant, incurring the use of a range of health and social care resources and interventions.
8.1.2 What works? The evidence base on falls National Institute of Health and Care Excellence (NICE) Guidance CG16133 on Falls Prevention recommends the following:
Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s and considered for their ability to benefit from interventions to improve strength and balance.
Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service.
All older people with recurrent falls or assessed as being at increased risk of falling should be considered for an individualised multifactorial intervention. In successful multifactorial intervention programmes the following specific components are common (against a background of the general diagnosis and management of causes and recognised risk factors): strength and balance training home hazard assessment and intervention vision assessment and referral medication review with modification/withdrawal
8.1.3 The situation in Basildon and Brentwood For the population of Basildon and Brentwood in 2013/14 there were 497 inpatient stays relating to falls injuries including fractures. This includes 110 fracture neck of femur admissions. DH business case suggests that 1 in 8 hip fractures lead to care placement, so potentially 14 fracture related placements per annum for Basildon and Brentwood.
Figure 8.1 demonstrates that fractures are the third most common cause of unplanned care admissions in the population aged 75+ Basildon and Brentwood in 2013/14 accounting for 405 admissions.
An audit of ECC care home admissions suggests that maybe 66% of people placed in care have a history of falls; for the 2010/11 care placements of 2166 that equates to maybe ~ 1400 Essex placements having falls within the person’s history
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FIGURE 8.1
Using rates extracted from ‘public health outcomes framework’ for age-locality specific cohorts it is possible to determine the anticipated volume and growth in falls over the next twenty years, assuming no further success in Falls Prevention activity and consistant age specific morbidity (figures X,Y and Z). The population forecasts provided the baseline for these forecasts. Estimated volume of emergency hospital admissions for injuries as a result of falls were calculated for each district (by age bands 65-79 and 80+) and aggregated to CCG level:
FIGURE 8.2 Due to the anticipated large increase in over 65 population, this will impact on the volume of falls resulting in hospital admissions. Mid Essex CCG is expected to experience the greatest growth in falls (94.15% increase in annual falls after twenty years), whilst Basildon and Brentwood CCG will experience the smallest growth (whilst still rising by 65.72% after twenty years).
This growth results in an additional 1,395 falls (resulting in emergency admission) per year in Mid Essex by 2034 – on top of the baseline volume of 1,482 (so by 2034 Mid Essex can expect 2,876 falls per year).
Whilst still experiencing an increase, Basildon and Brentwood CCG should expect the smallest increase based upon demographic pressures.
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FIGURE 8.3
FIGURE 8.3
8.1.4 Commissioning Intentions ECC has commissioned an Integrated Falls Prevention Service
The provision of falls prevention services has been patchy across Essex and comprehensive services across the whole county have only been in place since August 2014. New services have started in Castle Point & Rochford, Basildon & Brentwood and West Essex CCGs, and services in Mid Essex have been expanded. Approximately £2.2m is invested in falls prevention of which £1.4m is new investment from 14/15. ECC will commission a further expansion of falls prevention services in 2015/16 across the county.
These services are based on the best evidence and recommendations as to effective interventions. They include: Comprehensive assessment of risk factors and general prevention advice Home hazard assessment Vision assessment and correction Medicines review Strength and balance training (1:1 or group) Provision of equipment & home modifications
Based on the risks identified at the assessment, each patient will have an individualised management plan. The risk assessment also checks for risk factors such as foot health, nutrition, incontinence, and osteoporosis and refers where appropriate to other services such as podiatry or dietetics.
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Services are provided in a variety of settings across the community and including – where necessary – in the patient’s home.
NHS Basildon and Brentwood CCG and ECC will seek to develop a proactive care pathway from the Ambulance service to commissioned falls prevention programmes for patients that have already had a fall. The CCG will also work with GP practices to develop falls registers at practice level and with BDC in terms of data sharing from telecare alarms to identify more proactively patients that have fallen.
Public Health will benchmark levels of falls locally with comparators to identify best practice and target rates.
ECC will work with BDC to identify how day centres can be used to best effect to deliver falls prevention / guidance in a more proactive way.
Brentwood Borough Council offers Mandatory Disabled Facilities Grants for home adaptations. It also offers loans to vulnerable and elderly owner occupiers to make safe and maintain their properties to enable independent living. Such loans are repayable on sale of the property. Council officers will contact and liaise with Papworth Trust concerning these grants and loans and the information that is available on these. They will also promote the scheme through local GPs to make patients' aware of the availability of grants/loans and provide a link to grants and loans from Healthier Brentwood webpage
8.2 Improve Continence Services
8.2.1 Introduction Incontinence can have a significant effect upon the quality of life of the individual concerned, causing an increased risk of urinary tract infections (UTIs), depression and social isolation. Incontinence may cause deterioration in the relationship between the individual and their family and/or carer as well as being a major contributory factor to falls and fractures. 34It is also cited as the second highest cause of admission to residential care. 35Therefore, the resource implications for Health and Social Care services are significant, and commissioning excellent continence care services is key to the prevention agenda.
8.2.2 What works? Evidence base on continence The National Institute for Health and Clinical Effectiveness has published numerous guidelines relating to adult continence care - CG40,36 CG49, 37CG97.38 There is plenty of guidance about, but there are clear deficits in implementation.39 Previous studies bemoan the lack of integration across acute, primary care, care homes and community settings, resulting in disjointed care for patients and their carers.40 Case studies from Nottingham and Oxford mentioned by the Department of Health41 found that co-ordinated, integrated continence services that aim to support people become more independent and reverse a potentially inevitable course towards more costly and intensive care are effective.
8.2.3 The situation in Essex In collaboration with CCGs, ECC completed an Essex-wide review of the current level of continence services and produced a position statement in April 2013, which provided a starting point for the development of an Essex-wide joint strategy for integrated continence care.
The development of an integrated continence service can support the local health and social care economy in: Substantially reducing the risk of admission to a care home from urinary and faecal incontinence (5%) Curtailing the spend on incontinence products by around 10% Reduction of 5% admission for urinary tract infection (UTI) Reduction of 10% in attendances at urology and gynaecology clinics Reduction of 5% in attendances at A&E for falls or dehydration.
In 2013, all five CCGs signed up to commissioning integrated continence services as part of the Integrated Public Health Business Case. Public Health has developed model with and for CCGs and to encourage their engagement and commitment to develop services. 67 Basildon and Brentwood Prevention Strategy
Amendments to service specifications in July 2013 including cascading of staff training in Care Homes to improve continence management and reduced waiting times to see continence advisors.
8.2.4 Commissioning Intentions South Essex and Mid Essex CCGs are implementing the agreed plan from October 2014. There has been delay in implementation in NE Essex and West Essex CCGs. An Essex-wide consistent continence care pathway has been agreed and will be in place from April 2015. Awareness raising with GPs will commence in February 2015 to improve early intervention, better referral and support.
Revised Public Health modelling suggests that the programme is likely to deliver £741,000 per annum from 2015/16.
8.3 Improve the Management of Stroke/TIA in Primary Care
In England, strokes are a major health problem. Every year over 150,000 people have a stroke and it is the third largest cause of death, after heart disease and cancer. The brain damage caused by strokes means it is the largest cause of adult disability in the UK.
People over 65 years of age are most at risk from having strokes, although 25% of strokes occur in people who are under 65. It is also possible for children to have strokes.
Smoking, being overweight, lack of exercise and a poor diet are also risk factors for stroke. Also, conditions that affect the circulation of the blood, such as high blood pressure, high cholesterol, atrial fibrillation (an irregular heartbeat) and diabetes, increase stroke risk.
Transient ischaemic attack (TIA), a related condition, where the supply of blood to the brain is temporarily interrupted, causies a 'mini-stroke'. TIAs should be treated seriously as they are often a warning sign that a stroke is coming. Up to 40 percent of all people who have experienced a TIA will go on to have an actual stroke. Most studies show that nearly half of all strokes occur within the first two days after a TIA. . 8.3.2 What works? Evidence Base on Stroke Management There is a large published body of evidence on management of stroke and stroke rehabilitation by NICE.4243. The 2014/15 Quality Outcomes Framework (QOF) Framework for Primary Care recommends that patients on GP stroke QOF registers have their blood pressure controlled, are treated with an anti-platelet or an an anti-coagulant and are vaccinated against flu. Pharmacological treatment with statins are also recommended for those with high levels of cholesterol.
NICE guidance also recommends the systematic referral of patients on stroke registers who smoke to NHS stop smoking services.
8.3.3 The situation in Basildon and Brentwood Figure 8.5 highlights that overall the CCG has a low percentage of Stroke/TIA patients being recorded as a smoker at 11.5% and wide variation amongst GP practices. This must be considered in the context of how well recorded smoking status is for each practice to identify if this accurately reflects the smoking status for Stroke/TIA patients in each practice.
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FIGURE 8.5
The trajectory set by the CCG board and CEG means that practices are expected to have 92.3% of their Stroke/TIA patients with a blood pressure recorded in the last 12 months. Figures 8.6 highlight that overall the CCG has 11 of its practices that are statistically significantly lower than the CCG trajectory.. The New surgery, The Gore and Dr Ainsworth and Nasah are outliers to 3 SDs from the CCG trajectory.
FIGURE 8.6
The CCG agreed trajectory for those on the Stroke register that are on aspirin, antiplatelet or anti coagulation therapy was set at 92.92%. Figure 8.7 shows there is a great deal of variation amongst GP practices with a large number of practices in Basildon and Brentwood not achieving the agreed trajectory.
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Figure 8.7
Analysis by Public Health in 2013 on risk factors for stroke in GP practice populations found a lower incidence of new strokes amongst practice populations on stroke registers that had higher rates of anti-coagulation and better controlled blood pressure.
8.3.4 Commissioning Intentions The data in this section identifies considerable opportunity for improvement in the clinical management of stroke in primary care. Improving management is likely to reduce the number of unplanned care admissions in this cohort of population. Public Health will support the CCG and member practices through its ‘core offer’ to improve clinical management of stroke in Primary Care by:
• Creating and publishing SystmOne reports at GP practice level that identify every recorded smoker, every patient with a BP >150/90 and every patient who is neither anti-coagulated nor exception reported. • Providing real-time data on performance on these metrics to GP practices and localities on a monthly basis.
Localities and member practices have committed to reviewing this data regularly and inviting patients identified within it to review as appropriate.
8.4 Increase the provision of Stroke Early Supported Discharge (ESD)
8.4.1 Introduction Early Supported Discharge (ESD) for stroke survivors aims to provide the same intensity of rehabilitation support as patients could expect in a hospital setting, but in the patient’s home, in order to maximise regaining independence as quickly as possible. It is an evidence-based, holistic, time-limited, clinical rehabilitation service, which includes (as required by the patient): nursing care, physiotherapy, occupational therapy, speech and language therapy, continence care etc. The service can deliver maximum benefits to both patients and the health and social care system if delivered in an integrated way, with health elements being co-ordinated with social care delivery.
ESD for stroke survivors aims to provide the same intensity of rehabilitation support as patients could expect in a hospital setting, but in the patient’s home. Delivery of ESD to 40% of stroke patients is a national standard for health services.
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8.4.2 Evidence Base NICE Guidance on Stroke Rehabilitation CG162 44recommends that ESD should be offered to patients with stroke who are able to transfer from bed to chair without assistance as long as a safe and secure environment can be provided.
Analysis by ECC’s Public Health team that compared demand data from across Essex estimated the impact of ESD on social care demand. Introduction of ESD for 40% of stroke patients, as per national standards, is projected to remove the need for post-stroke social care packages among 4% of stroke patients. Savings are based on the assumption that the average length of a social care package in Essex is 2.5 years. Achieving the 40% target across Essex was estimated to save ECC £1.964m per annum by 2016/17.
8.4.3 The situation in Essex Table 8.1 shows the current performance on Early Supported Discharge by CCG.
Table 8.1 CCG % of stroke discharge patients receiving early supported discharge Basildon and Brentwood 60% Castle Point and Rochford 20% Mid Essex 38.9% North East Essex 48% West Essex 34.1%
8.4.4 Commissioning Intentions In 2013, all five Essex CCGs pledged to deliver the 40% ESD target as part of their support for the Public Health Integrated Commissioning Business case. Public Health will work with CCGs to improve their data reporting by the end of December and will work with Castle Point and Rochford CCG and West Essex CCG to obtain a clearer understanding of the reasons behind apparent poor performance with a view to driving improvement.
8.5 Improve the Diagnosis and Management of COPD in Primary Care
8.5.1 Introduction Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. COPD is one of the most common respiratory diseases in the UK. It usually affects people over the age of 35, although most people are diagnosed much later. It is thought there are over 3 million people living with the disease in the UK, of which only about 900,000 have been diagnosed. This is thought to largely be due to those that develop symptoms of COPD not seeking medical help, often dismissing their symptoms as a cough. COPD affects more men than women, although rates in women are increasing.
8.5.2 What works? Evidence base on Diagnosis and Management on COPD
The National Institute for Health and Clinical Excellence (NICE) and the London Respiratory Team guidelines suggest that an effective approach to treating COPD is based around 7 key interventions: 1. Smoking cessation 2. Early diagnosis 3. Effective self-management 4. Responsible respiratory prescribing (RRP) 5. Pulmonary Rehabilitation service 6. Home Oxygen Assessment and Review service 7. Early supported discharge 71 Basildon and Brentwood Prevention Strategy
Figure 8.8 shows a COPD value pyramid showing cost per Quality-Adjusted Life Year (QALY) for each of the standard forms of COPD treatment Figure 8.8
Taken from: COPD Value Pyramid - Telehealth position so far (updated LRT value pyramid includes the positioning of telehealth based on available cost effectiveness data. The study included a majority proportion of people with COPD but did also include other conditions; 14 October 2013). http://www.networks.nhs.uk/nhs-networks/london-respiratory-network
8.5.3 The situation in Basildon and Brentwood
Diagnosis of COPD Improving the case finding of COPD is essential in encouraging smoking cessations, follow-up and appropriate treatment and immunisation. Figure 8.9 shows the current levels of completeness of GP Practice QOF COPD registers locally.
FIGURE 8.9
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There is a great deal of variation in the diagnosis of COPD amongst GP practices. There are a large proportion of GP practices with an observed rate of COPD that is statistically significantly less than expected suggesting there is likely to be significant under diagnosis of COPD within Basildon and Brentwood. There are also a few practices that have an observed rate of COPD that is statistically significantly greater than expected and practices may wish to review their registers to ensure other alternative appropriate diagnoses have been considered and eliminated.
Smoking and COPD Smoking is the most common risk factor for developing COPD. Recording the smoking status of those with COPD will aid the identification of current smokers to be offered smoking cessation advice and programmes. Figure 8.10 shows the prevalence of smoking on practice COPD registers, plotted around the CCG mean prevalence of smoking amongst patients on COPD registers which is 28.2%.
Figure 8.10
In some areas of Basildon and Brentwood almost half of all patients diagnosed with COPD still smoke. Three practices have a rate of their COPD population, recorded as smokers, that is statistically significantly greater than the CCG mean. It is to be noted that there is a wide variation in these figures and they must be considered in the context of how well recorded smoking status is for each practice to identify if this accurately reflects the smoking status for COPD patients in each practice.
Referral to the NELFT Community Respiratory Team The North East London Foundation Trust (NELFT) Community Respiratory Team has been commissioned to provide support in clinical management of patients with COPD. The team undertakes review of patients with COPD and provides proactive management within the community with a view to preventing unplanned care admissions.
Figure 8.11 shows the association between the percentage of patients of GP practice COPD QOF registers with an MRC score of 3+ referred to the NELFT Community Respiratory Team, and unplanned care admission rates for patients with COPD.
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FIGURE 8.11
Figure 8.11 demonstrates that levels of referral to the Community Respiratory Team is negatively associated with unplanned care admission rates in patients with COPD, and as such, low referral rates increases risk of unplanned care admissions for COPD. In total almost 10% of the variation in unplanned care admission rates for COPD amongst GP practice populations on the COPD register can be explained by variation in referral to the NELFT Community Respiratory team.
Figure 8.12 shows the rate of referral of patients on practice COPD registers with and MRC score of >=3 in 2013/14 to the NELFT Community Respiratory Team
FIGURE 8.12
Overall there is a very low rate of referral across the CCG of less than 10% of patients with clinically more serious COPD. However there is significant variation between GP practices. This suggests considerable potential to reduce unplanned care admission rates for patients with COPD by increasing referrals to the Community Respiratory team.
Referral of patients with COPD to Pulmonary Rehabilitation Figure 8.13 shows the percentage of patients on COPD QOF registers with an MRC score of 3 or more who were referred to pulmonary rehabilitation in 2013/14.
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Figure 8.13
There were very low levels of referral to Pulmonary Rehabilitation in 2013/14, with only 5.3% if all patients on CCG COPD QOF registers with an MRC score of 3 or more receiving a referral. Again, considerable variation in referral rates exists between GP practices. Low levels of referral increase the risk of unplanned care admissions.
COPD Unplanned Care Admission Rates by GP practice Figure 8.14 shows the percentage of unplanned care admissions for COPD at GP practice level that resulted in a length of stay of three days or fewer. It could be argued that an admission that lasts fewer than three days is potentially avoidable.
FIGURE 8.14
Across the CCG, almost 40% of admissions for COPD lasted three days or fewer, suggesting considerable potential for reducing COPD related unplanned care admissions.
8.5.4 Commissioning Intentions The data in this section identifies considerable opportunity for improvement in case-finding and clinical management of COPD in primary and community care. Improving management is likely to reduce the number of unplanned care admissions in this cohort of population. Public Health will support the CCG and member practices through its ‘core offer’ to improve clinical management of COPD in Primary Care by:
• Constructing and publishing SystmOne reports that assist in improving GP practice COPD register completeness by identifying at GP practice level, a list of patients not on the COPD QOF register that have risk factors for COPD, for example being over 50, being a smoker, being prescribed an inhaler etc.
• Constructing and publishing SystmOne reports that identify all patients on GP practice COPD registers with an MRC score of 3 or more that have not received a referral to the NELFT Community Respiratory team and/or not received a referral to Pulmonary Rehab 75 Basildon and Brentwood Prevention Strategy
• Providing monthly data sets to localities that show performance against these metrics.
Member practices have committed to review this data and offer appropriate clinical interventions to patients identified within them.
8.6 Commission integrated, preventative health and social care services aimed at frail elderly people
8.6.1 Introduction Risk on unplanned care admission increasing substantially with age, and rate of unplanned care admissions in those aged 75+ are significantly greater than any other population age band and this group are more likely to stay in hospital for longer compared to any other population group. A significant number of clients enter social care following an admission to hospital. As such, older people, particularly those with frailty are a key focus for prevention activity. Preventing unplanned care admissions in this population group will both improve the health and wellbeing of our older population and deliver substantial cost savings to the health and social care system locally.
8.6.2 Evidence Base: Integrating health and social care There is evidence from a recent review by The King’s Fund that integrating primary and social care reduces unplanned care admissions. 45One trial from Italy showed that integrated social and medical care for frail elderly people in the community was associated with fewer hospital admissions. A second study from the United States showed that elderly people with long-term conditions who received shared health and social care had fewer unplanned admissions than those receiving usual care. Data from Torbay shows that providing integrated care to the highest-risk older people, who require intensive support, has resulted in a reduction in hospital admissions. 46
The literature review by the Kings Fund found evidence is supportive of the concept of Integration of Primary and Secondary Care when integration occurs at a disease management and individual patient level rather than a systems level.29
One example of integrated care included the medical home concept in which the financial mechanisms provide an incentive for physicians to co-ordinate care over time and across sectors. In one health care system, a community-based advanced medical home for individuals with multiple chronic conditions, all-cause hospital admission rates declined by around 20 per cent whereas there was no change among other similar patients in the plan.
There is very little evidence to suggest that clinics provided by hospital specialists in primary care reduce hospitalisation rates when delivered in isolation.47
There is strong evidence from a systematic review of randomised controlled trials that an individualised discharge plan for hospital inpatients is more effective than routine discharge care that was not tailored to the individual. Re-admissions to hospital were significantly reduced by around 15 per cent for patients allocated to structured individualised discharge planning. 48
8.6.3 The situation in Basildon and Brentwood
Figure 8.15 shows the association between ECC rate of social care spend on the 75+ population at GP practice level.
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FIGURE 8.15
There is a weak association between unplanned care admission rates and rate of social care spend, (figure 8.15) suggesting that GP practice populations aged 75+ with high unplanned care admission rates also have greater social care costs and hence need (that qualifies for ECC funding). This may be because a significant proportion of social care assessments happen as a result of a hospital admission or it may be because practice populations with higher social care needs are more likely to have greater levels of morbidity and hence be at greater risk of unplanned care admissions.
Figure 8.16 shows the percentage of new client assessments that were undertaken as a result of a hospital admission compared to a community referral, by CCG population in Essex.
FIGURE 8.16
33.9% of social care new referrals followedr an unplanned care admission for Basildon and Brentwood patients. This is greater than that for Essex as a whole, and suggests further scope for more proactive referrals to social care from the community.
Figure 8.17 shows the percentage of new client assessments that were undertaken as a result of a hospital admission compared to a community referral by GP practice population.
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FIGURE 8.17
If large proportions of a GP practice population enter residential care as a result of hospital admission, there may be increased scope to reduce social care demand by reducing unplanned care admissions. Conversely, it could be argued that if a GP practice population has a high percentage of client assessments as a result of community referrals, that the practice MDT is referring proactively in order to prevent further deterioration
There is very considerable variation between GP practice populations in terms of the ratio of new client assessments undertaken in hospital as opposed to community. Malling Health, has the greatest percentage of new entrants to social care through hospital assessment (two thirds), whilst four GP surgeries have 100% of referrals via community
Hospital Reassessment A number of the population will have an unplanned care admission despite having some form of social care package already in place. A hospital re-assessment occurs when an existing social care package is re-assessed following an unplanned care admission.
Figure 8.18 shows rate of social care hospital reviews per 1000 patients aged 75+ by CCG.
FIGURE 8.18
Basildon and Brentwood CCG have a rate of hospital reviews that is both greater than the Essex average and that of the other CCG’s in Essex. Factors such as the suitability of social care originally put in place and the deterioration of the 78 Basildon and Brentwood Prevention Strategy individual thus leading to increased social care need may be necessitating the need to review a social care package currently provided.
8.6.4 Commissioning Intentions ECC in partnership with CCGs has develop an Older People’s Commissioning Strategy. We see the Essex health and social care system operating significantly differently in the future. In five years’ time the system will work in a more proactive way with older people. We will be identifying all people over the age of 75 and co-producing a holistic care plan which identifies preventative and enabling services which keep them well and active in the community for as long as possible. By taking this early intervention approach we anticipate a protracted delay in time before older people require more intensive health and social care interventions.
This means the role of social care and community health care will shift from just supporting people when they deteriorate or at times of crisis. The role of integrated social and health care services will be much more preventative, confidence building, informative, enabling and educative.
We recognise the individual is usually best placed to judge their well-being and actions needed to maintain their well- being. We will encourage greater self-responsibility, and provide information and support to enable people to take greater control over their lives. We will develop a change programme around consumer behaviour which is more closely linked towards more self-help.
Those eligible for personal care budgets will have access to a more varied, vibrant market of providers able and willing to deliver care tailored to individual needs. We expect greater numbers of older people with direct payments, accessing personal assistants and developing bespoke packages of health and social care that suit their individual needs. This means the Council may not block purchase high volumes of standard care as it once did, and instead see growth in micro-commissioning.
We will have mapped providers by locality, and will encourage providers to work collaboratively to support needs and share capacity at a neighbourhood level. This means exploring a hub and spoke model.
Through our early interventions programmes we will screen and offer older people a range of preventative services as a core offer. This package includes pathways to long term condition self-management courses, falls assessment, assistive technologies and Reablement.
Local communities will be supported to galvanise and offer local and innovative solutions to reduce isolation of older people.
8.7 Reablement
8.7.1 Introduction Reablement is one service on a continuum of intermediate care. This continuum spans acute and long-term care and responds to a range of health and social care needs. Other ‘intermediate’ services can include rehabilitation, rapid response and supported discharge teams.
Although there is no single delivery model for reablement, it is generally designed to help people accommodate illness or disability by learning or re-learning the skills necessary for daily living. These skills may have been lost through deterioration in health and/or increased support needs. Reablement is a time limited intervention, usually provided directly after an acute episode of worsening health, (for example after a stroke).
The focus of reablement services should be on promoting and optimising independent functioning rather than resolving health issues. It is about empowering clients to do as much for themselves as possible rather than doing things for them. Unlike other social care services funded by ECC which are means tested, reablement is provided free to all for 12 weeks.
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8.7.2 Evidence Base There is some evidence that reablement reduces long term social care costs. One study conducted in Edinburgh found that 62% of a cohort that were offered reablement no-longer needed a service after 12 weeks compared to 5% of the control group. Furthermore, 26% had a reduced requirement for care homes compared to 13% of the control group. 49 An Australian randomised control group study of 750 clients found that at one year follow up 14.2% of clients receiving reablement were receiving on-going care compared to 40.3% in the control group.50
Whilst reablement may reduce demand on long term social care services, there is no evidence that those receiving reablement have fewer unplanned hospital admissions.
8.7.3 The situation locally Figure 8.19 suggests that around 84% of the referrals made in Basildon and Brentwood will actually go on to reablement starts. This is a greater proportion than South East and West Essex. However, the largest proportion of reablement starts are in a hospital setting.
FIGURE 8.19
Figure 8.20 demonstrates the outcome of reablement services. Basildon and Brentwood has one of the lowest proportions of individuals ‘self-caring’ in Essex and the largest proportion in Essex requiring domiciliary care and Hospital. This suggests outcomes for those in Basildon and Brentwood are mixed with less than two thirds self-caring following reablement and almost a quarter requiring either domiciliary care or hospital Furthermore, the population in Basildon and Brentwood are in some cases experiencing worse outcomes compared to other areas in Essex.
FIGURE 8.20
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8.7.4 Commissioning Intentions ECC is procuring a new reablement service in 2016 which will be tailored to local need. ECC will also conduct a ‘deep dive’ into the data in this section to understand why outcomes in Basildon and Brentwood are poorer than elsewhere in Essex.
8.8 Sensory Loss
8.8.1 Introduction Sensory loss (or Sensory disability) refers to an individual who has lost or is losing their sight and/or hearing. This can come about in a number of ways;
Sensory disability from birth Degenerative sensory disability, which leads to a worsening condition over time Sudden sensory loss e.g. A sensory loss following an accident.
Sensory losses can be debilitating on their own however they are most debilitating when factored in with other disabilities or health and social care needs. Failing to recognise and acknowledge sensory disabilities in health and social care interventions can lead to a reduction in independence, increased social isolation and an increased risk of falls.
With the right information, advice, practical and emotional support, people with sensory impairments can lead independent, fulfilling lives but if support is not available at the right time or in the right format, people can become isolated, and lose skills and independence. Undiagnosed/ poorly supported sensory impairments are also a major contributing factor to falls in older people leading to admissions to acute services.
8.8.2 Evidence There are an estimated 180,000 people in Essex living with a sensory impairment (visual or hearing impairment). This is expected to grow to over 210,000 by the year 2020.
Around 70 percent of people with a sensory impairment are over 65 and 12,000 have dual sensory impairments (deaf blind).
8.8.3 The current situation ECC currently provides or commissions a range of specialist services for adults with sensory impairments. These comprise:
• ECC’s Sensory Assessment Team which provides a specialist assessment and care management service for people with complex sensory needs across Essex. • The Essex Cares Ltd Sensory Service which provides demonstrations and maintenance of specialist equipment and an up to 6 week reablement service for around 600 people across Essex. • Eight grant funded third sector providers who provide information, advice, guidance, equipment and social support in specific parts of Essex
(Separate services are currently commissioned for children and young people)
8.7.4 Future Commissioning Intentions Sensory impairment assessments will be part of all social care assessments, as this will ensure that the best intervention is in place for service users. There will also be work alongside CCGs to ensure that GPs are also identifying patients who have sensory disabilities as GPs are a more frequent contact for the population. We will also develop training and awareness for carers to help them identify sensory disabilities wherever possible.
Key trigger points for these assessments will be targeted as these are the occasions during which sensory loss is most likely to occur or be identified. The Key trigger points identified are linked to current health check and interventions;
40 year old health check will give an opportunity to see if there is a developing or degenerative sensory disability Incidents of trauma; by assessing the needs of someone who has suffered trauma, we can ensure that any sudden or developing disability is identified.
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Bereavement; by assessing the needs of someone suddenly living alone, we can ensure whether there is a sensory disability Over 75 single named care professional meetings can give opportunities to identify and monitor sensory disabilities. Essex Senior Health Check for 75-84 year olds.
These preventative measures aim at reducing need or preventing individuals from entering social care. There is a difficulty in trying to prove a negative effect has occurred and as such the success measures must be based on how the social care services have reduced need in the demographics that sensory disabilities intervene in.
New Sensory Disability Pathway Following a review of the current provision it was decided that a new Sensory Disability Pathway was needed. A stakeholder group decided upon a set of principles and outcomes that any new pathway should seek to adhere to and achieve. This can be seen in the table below;
Element Outcomes Currently Provided in this area (October 2014)
Pre diagnosis/ referral Good eye and hearing health is promoted in Essex. Mainly information and advice via Voluntary People know when they should have a sight and/or sector grant funded services. ( will end June hearing test, how/ where to get one and are supported 2015) to do so when necessary. Reablement staff, Support workers in residential , supported living and home care.
Diagnosis People get an appropriate diagnosis of their sensory Opticians, Ophthalmologists and Audiologists impairment. commissioned by NHS England Everyone eligible for a Certificate of Vision Impairment (CVI) receives one. Information, advice, People are provided with information, advice, guidance Voluntary Sector providers via grant funding guidance and emotional and emotional support to enable them to exercise that will end June 2015 support choice and control over their situation and maintain/improve their own independence. Information, advice, guidance and emotional support are available to everyone at the right time, the right place and in the right format to meet their individual communication needs. Registration/ Data All eligible people are offered registration, understand Essex Cares hold….. register collection its benefits and how to utilise them. Accurate information is gathered that facilitates effective ECC holds…….register planning and delivery of services and support. Reablement/ rehabilitation People with sensory impairments are provided with the Provided by Essex Cares- contract ends June equipment, training, skills and Information, Advice and 2014 Guidance they need in order to maintain or develop Also provided by Voluntary Sector providers their independence. via grant funding that will end June 2015
Social Care assessment People have their support needs assessed and a support ECC Sensory Assessment team carries out plan agreed without delay. assessments/ support planning for people Individuals have a person centred assessment of their with sensory impairment as a primary need. needs, which leads to an agreed support plan that WAA/ OP community teams carry out details what the individual and their family will do and assessments/ support planning for people what social care will provide to meet their eligible needs. whose sensory need is secondary to aged related/ other primary disabilities.
Ongoing support Ongoing support should be responsive to changing needs, providing the right support, at the right time, in the right place across Essex.
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Model to deliver the new sensory pathway A series of workshops has been held with stakeholders to begin to design the service model that will deliver the pathway. We are aiming to have the pathway fully in place to achieve the outcomes within 5 years. To do this, we have developed the following service model: Figure 8.21
Anyone, any age Any sensory impairment, irrespective of cause
Information, advice, guidance and emotional support cuts across all areas of the model
Specialist/ mainstream services with Specialist Sensory appropriate adjustment Interventions
Support, Advice, Mentoring
Diagnostic and Treatment Services
Communication Support Equipment Communicator Guides Signers
Reablement/ Integrated Rehabilitation Education /Training
Sensory
Co- Employment
ordination
Service Housing
Social Care Services
Transport
Other
The 7 elements will be embedded within the model
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8.9 Improving support to people with physical disabilities
8.9.1 Background A physical disability is a limitation on a person's physical functioning, mobility, dexterity or stamina. Other physical disabilities include impairments which limit other facets of daily living, such as respiratory disorders, blindness and epilepsy. Mobility impairment is a category of disability that includes people with varying types of physical disabilities. This type of disability includes upper or lower limb loss or disability, manual dexterity and disability in co-ordination with different organs of the body. Disability in mobility can either be a congenital or acquired with age problem. This problem could also be the consequence of disease. People who have a broken skeletal structure also fall into this category of disability.
Individuals with physical disabilities often experience stigma concerning their physical competence and bodily appearance. This leads to impairment in social interactions and devaluation of an individual.
8.9.2 The situation in Essex 123,415 adults in Essex are estimated to have a moderate or serious physical disability, a visual impairment, or a moderate, severe or profound hearing impairment. This is equivalent to 15% of Essex’s working age adult population. During the 2013/14 financial year, ECC worked with 4,546 adults of working age with a primary physical impairment. This represents a very partial view of the support needs of the overall population. Of the 4,546 support by ECC: • 58% were aged between 50 and 64 with the volume of people increasing in each age bracket
• The vast majority of new service users were not to ECC prior to engagement with Adult Services
• 55% are supported by an unpaid carer
• 860 are in receipt of homecare support
• 1036 received direct payments
• 225 receive either nursing or residential care
• 115 people accessed day services
• 2340 people were supported with equipment or adaptations
It must be noted that this is an incomplete view of physical impairment in Essex and that much is unknown about those who are not yet eligible for social care provision. The number of adults who will access our service in the future is likely only to increase.
This year there has been 1,225 new client assessments completed for adults aged 18-64 with a physical or sensory impairment. Projected forward for a full year effect, this would be 2,100 new client assessment for the year 2014-15, which is a 12% increase compared to last year at 1,875. Last year also saw a 38% increase in the volume of new clients, totalling a 55% increase in demand since 2012-13. Two years prior to this Essex has experienced a decrease in PSI new clients assessed to its lowest point. However this year, is estimated to be the second highest year for demand in the last 10 years.
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FIGURE 8.22 New Client Physical Disability Assessments 18-64 New Clients Physical & Sensory (18-64) 2005/06 1,935 2006/07 2,210 2500 2000 2007/08 2,020 1500 2008/09 1,890 1000 2009/10 1,940 500 2010/11 2,060 0 2011/12 1,780 2012/13 1,355 2013/14 1,875 2014/15 -Estimate * 2,100
% Change this year 12% PSI PSI Average % Change last year 38% % Change since 12/13 55% During 2013/14 Essex supported 475 service users per 100,000 population, exceeding the comparator average (442), Eastern England (445), and across England (455). Of the LA Comparator group Oxfordshire had the lowest number of service users per population and less than half than the number per population supported by Essex at 200 people, whereas East Sussex supported the highest rate of service users at 820 people per 100,000 head of population. Essex supported 33 more service users for every 100,000 people than the average in the comparator group.
FIGURE 8.23
As at 31st March 2014 Essex supported 325 service users per 100,000 head of population. This was above the average for the comparator group (314 service users per 100,000 head of population) and the rate of service users supported in the East of England (300 per 100,000 population). Essex’s rate of service provision at 31st march 2014 was higher than the average rate across England (305), 20 extra people were supported for every 100,000 head of population
8.9.3 Future Commissioning Intentions A new service offer for working aged adults with disabilities is being developed which is based upon the many strengths of service users and places a greater emphasis on the importance of community support and will focus on supporting independence rather than creating dependence as well as likely result in a reduction in residential care placements. This service offer will support our increasing independence programme that helps people with disabilities or impairments to live with the same life expectations, opportunities and outcomes as everyone else.
8.10 Improving support to people with learning disabilities
8.10.1 Background A learning disability affects the way a person understands information and how they communicate. Around 1.5m people in the UK have one. This means they can have difficulty understanding new or complex information, learning new skills or coping independently.
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A learning disability can be mild, moderate or severe. Some people with a mild learning disability can talk easily and look after themselves, but take a bit longer than usual to learn new skills. Others may not be able to communicate at all and have more than one disability. It is thought that up to 350,000 people have severe learning disabilities. This figure is increasing.
Some learning disabilities are diagnosed at birth, such as Down's syndrome. Others might not be discovered until the child is old enough to talk or walk.
8.10.2 Evidence base There is currently a national trend that is replicated in Essex that shows the number of individuals living independently with learning disabilities is increasing (See Table below). Supporting those with learning disabilities and their families to live independently and not in a care or acute setting is beneficial to the overall wellbeing of the individual. The ability to seek work and live supported in their own accommodation is an important part of overall health and wellbeing and socio-economic factors are found to account for around 50% of a person’s overall health.51
Delivering better outcomes for people with disabilities is also more cost effective for ECC in the short term as well as delivering reduced life-time costs.
2010/11 2011/12 2012/13 Essex 43.5 68.8 72.5 Statistical Neighbours 57.7 65.8 73.4 England 59.0 70.0 73.5
The table above shows the percentage of adults with learning disabilities that are living in their own homes or with their families (i.e. not living in registered care).
8.10.3 Current situation in Essex Essex currently provids a range of services for those living with learning disabilities, as well as their carers. These programmes of work currently include assessment and care management as well as residential care services. These services are designed not only to support those living with learning disabilities, but also their families and to ensure that not only are those living with learning disabilities provided support in accommodation but also allowing them to participate in everyday life, improve their self-esteem and skill-set through employment and have good overall health and wellbeing that leads to them remaining independent and out of a care or hospital setting. Services currently commissioned for Learning Disabilities include: Residential care Domiciliary care Supported living Day opportunities Supported employment services and; Short-breaks
Essex also grant funds the Essex Carers Network, which supports carers, including those carers of individuals with learning disabilities, and there are currently services available for the families of those living with learning disabilities to provide support and information, advice and guidance.
Essex fund short breaks for individuals living with learning disabilities, that seek to build their skills and confidence whilst also providing their carers with an opportunity to relax away from their responsibilities as a carer.
Learning disabilities also factor in other services, including sensory services, assistive technology and carers support which will help further the outcome of independent living and help individuals best manage their day to day lives Essex County Council (ECC) and the Northeast Essex Clinical Commissioning Group, Mid Essex Clinical Commissioning Group & West Essex Clinical Commissioning Group (north Essex CCGs) have agreed to integrate their commissioning arrangements for adult learning disability services. These integrated commissioning arrangements will be hosted by ECC.
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The implementation of this will contribute to the achievement of outcomes for adults with learning disabilities as detailed in Essex County Council’s Outcome Framework, the Adult Social Care National Outcomes Framework 2013/14, NHS Outcomes Framework 2013/14 and the Public Health Outcomes Framework 2013-16.
8.10.4 Future Commissioning Intentions There will be a continued drive towards integration of health and social care provision, ensuring that those living with learning disabilities will continue to be as independent as possible. The Council’s commissioning strategy, People in Essex can live independently and exercise choice and control over their lives notes that the Council wishes to pursue a course where as many people as possible are out of residential care and living independently as possible. There is also a desire to ensure that direct payments continue on their current trend, as they are the purest form of personalisation
8.11 Improve support and treatment of patients with more serious mental health problems to promote independence and prevent relapse.
8.11.1 Introduction Living with Mental Health Issues can lead to a reduction in independence and often result in a low level of wellbeing, social isolation, poorer physical health and a greater risk of experiencing health inequalities.
Long term residential care can limit the ability for an individual’s autonomy. Essex aims to look at an individual’s needs and establish what level of support they require. In terms of accommodation this could be in supported housing or by helping them to manage their own tenancy agreement in social or private housing.
8.11.2 The current situation in south Essex In 2011/12 there were nearly 8,000 people with functional mental health problems in secondary health care services. On average, each person received 12.5 face to face contacts per annum. There are currently a number of different services which provide this care. These include: - Outpatient services - Community mental health teams - Early intervention in psychosis team - Assertive outreach teams - Day care - Therapies and psychology - The voluntary sector - The independent sector. - The number of service users with mental health needs currently in residential care is 52. The table below shows the geographic split of these residential placements. We can also see, in the second table, the current net spend in terms of residential care for adults with mental health needs, and this is a figure we are keen to reduce. This will become possible, when we are reducing the number of residential care placements and increasing the number of residents living independently, away from traditional social care interventions. The percentage of service users currently living independently can be seen in the bottom table.
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Geographic split Mid North South West Other in Essex
Number of 36 162 52 46 54 service users in Residential Care
Number of Service users with Mental Health needs in Residential Care (Commissioning Strategy 7)
2010/11 2011/12 2012/13
Essex 820.0 740.0 725.0
Statistical Neighbours 581.3 494.7 575.3
England 810.0 755.0 755.0
Net Spend per 100,000 population on residential care for Adults with Mental Health Needs (PSSEX1)
2010/11 2011/12 2012/13
Essex 79.1 71.3 77.8
Statistical Neighbours 57.2 50.2 52.4
England 66.8 54.6 58.5
Percentage of Adults with Mental Health Needs living independently (ASC CAR)
Supported to Independence Supported to Independence services provide lower level interventions in a supported housing setting that meet a wide range of needs. Support workers work with service users to enable them to develop the skills to live independently, taking a planned and proactive approach to move-on, usually within 2 years. This element of the Pathway is a step down for people moving on from intensive enablement services and for those who do not require an intensive level of support. Services are for people who have both housing and support needs. If an individual is deemed appropriately housed then they should be signposted to floating support services.
All Supported to Independence services receive core Housing Related Support (HRS) funding to deliver safe and effective services. Providers are required to complete scheme information sheets which are shared with the Mental Health Trusts. If service users are eligible, and have needs over and above the agreed core HRS funding, they can have a personal budget to meet additional unmet needs. Service users will have choice and control over how they use their personal budget i.e. they may choose the support provider or choose another provider. If a service user has a personal budget which is lower than the core HRS funded element of the service they will not receive any funds as all their needs will be met by the service.
Some Supported to Independence schemes’ criteria require service users to be under the Care Planning Approach (CPA) whilst others will accept referrals for people who are not subject to CPA.
Intensive Enablement The intensive enablement service, provided by Metropolitan Housing, promotes recovery and move on towards independent living. The service provides intensive support for up to 18 months within a supported housing setting. The service supports people with complex mental health needs as well as a range of other needs, including; substance misuse, those with a history of anti-social behaviour, in need of medication or at risk of exploitation or harm.
The target group for this service are people who are moving from residential or in-patient care, or who are at risk of moving into residential or in-patient care and who have intensive support needs.
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People eligible for the service will have an assessed need for support to live independently or to develop their independence. People may never have held a tenancy, not be able to cook, have never paid bills, have no connections in the local community and have needs which challenge. People referred to the service will have a named care coordinator, be in receipt of secondary mental health services and meet Fair Access to Care eligibility criteria or be subject to s.117 (Mental Health Act, 1983 amended 2007). The criteria to access the intensive enablement service is based solely on an individual’s needs and is not based on the level of their indicative Personal Budget i.e. if an individual’s personal budget is lower than the cost of intensive enablement this will not prevent them from accessing the service.
Mental Health Housing Brokerage, benefits and debt advice. The brokerage service, currently running as a pilot until 31st March 2015 , has been set up to facilitate people to access a range of suitable housing options in line with need which promotes recovery and progression, supporting people to maximise their independence. The brokerage service is provided by One Housing and Family Mosaic.
The service identifies and brokers housing solutions for people with mental health needs who would otherwise be:
awaiting hospital discharge pending suitable accommodation in residential care and suitable for independent living and unable to move on unable to move on from supported to independence and intensive enablement schemes because of a lack of suitable accommodation to move on to living in housing which does not meet their needs. The service works with a range of landlords and housing providers, both in the social and private sector to promote access to a range of accommodation for people with mental health needs.
The service also ensures timely move on throughout all stages of the Mental Health Accommodation PathwayThe new commissioned service will also incorporate assertive in-reach/outreach to mental ill health treatment providers including in-patient units, community mental health teams and IAPT to identify and assist patients with debt or other money issues. Being in debt or being unable to claim benefits has been shown to increase significantly the risk of relapse for patients treated for existing mental health problems. A successful pilot run in Tendring showed significant benefit to patients in terms of specialist support to get debt written off and assistance in claiming the correct level of benefits. It will be rolled out across Essex as part of this programme.
Floating Support This element of the Pathway is delivered by the two generic floating support services: One Housing and Family Mosaic. The floating support services have extensive experience of working with people with mental health needs and are receiving an increasing number of referrals to their services for people with mental health needs. Currently 30% of referrals to floating support services are for people with mental health needs.
Floating support services support people using primary, secondary and tertiary mental health services by addressing three factors which are key to the successful management of mental ill-health: housing, income and debt.
The floating support providers have established links with Community Mental Health Teams (CMHTs), acute psychiatric units and other mental health services. Support workers will work with service users to address their needs and signpost to other relevant services as required.
Referrals to floating support services may be made via the MHJRPs or directly with the providers (see Essex Floating Support leaflet for further details).
8.11.4 Future Commissioning Intentions
Specialist Health Trainers People with serious mental health problems are also far more likely to engage in health damaging behaviour such as smoking, poor diet, lack of exercise or alcohol misuse. The Health Trainer Programme is an established national public health intervention that provides access to trained staff to work with individuals to support and empower them to change their lifestyles. ECC will review the current commissioning of its health trainer programme with a view to refocusing some of the resource to deliver a targeted health trainer programme aimed at patients accessing secondary care mental health services.
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Secondary health care community services CCGs will work with providers of secondary mental health care to re-design services in order to provide more intensive support for patients earlier on in their condition. They will also seek to move secondary mental health care provision into primary care where possible and appropriate. The design principles for secondary care will seek to:
- Develop clear, evidence based and efficient pathways - Deliver care in the least restrictive environment, reducing the need for residential and inpatient care - Provide rapid access back to specialist care when needed - Deliver regular multi-disciplinary reviews - Focus on improving holistic patient outcomes including social isolation, housing and employment - Provide a much greater focus on recovery and co-production - Deliver choice and personalisation including personalised mental health budgets - Integrate health and social care services - Employ a greater use of alternative provider options including the third sector - Reduce the use of Mental h Health Act procedures - .
Intensive Enablement ECC are commissioning 79 units of Intensive Enablement accommodation located across the whole of Essex, as detailed by the table below;
North East Mid
Russell Road Friary Fields Details: Clacton-on-Sea. 8 units of shared accommodation Details: Maldon, 6 units of self-contained accommodation
Mersea Road Pavilion Court Details: 6 units of shared accommodation (due to come on line Details: Braintree, 6 units of self-contained accommodation Jan 15) Neptune Court Additional units to be located Details: Chelmsford, 8 units of self-contained accommodation Details: Colchester, 6 - 8 units of shared or self-contained accommodation West South
Madeleines Basildon Scheme Details: Harlow. 8 units of self-contained accommodation Details: Basildon, 12 units of self-contained accommodation Availability: in progress, late 2014/early 2015 Additional units to be located Details: Epping Forest district, 6 units of shared or self-contained Additional units to be located accommodation Details: Rayleigh, 12-14 units of shared or self-contained accommodation
Mental Health Housing Brokerage ECC will commission a Mental Health Housing Brokerage programme aimed at people with mental health needs. This will also include debt and benefits advice. (See section 7.6 for more details).
Floating Support Floating Support will continue to be provided via Housing Related Support Services, and these will continue to be provided to those with Mental Health issues in need. (See section 7.6 for more details).
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8.12 Improving support to people with dementia
8.12.1 Introduction The term 'dementia' describes a set of symptoms which can include loss of memory, mood changes and problems with communication and reasoning. Symptoms occur when the brain is affected by certain diseases or conditions. The symptoms depend on dementia type.
Alzheimer’s Disease is the most common type of dementia. It is a progressive disease, meaning more and more of the brain is affected over time. Vascular Dementia is the second most common form, often occurring following a stroke. It progresses in a stepped way, meaning the symptoms remain constant for a while followed by a sudden deterioration.
Dementia is associated with complex needs and, especially in the later stages, high levels of dependency and morbidity. These care needs often challenge the skills and capacity of carers and services.
As the condition progresses, people with dementia can present carers and social care staff with complex problems including aggressive behaviour, restlessness and wandering, eating problems, incontinence, delusions and hallucinations, and mobility difficulties that can lead to falls and fractures. The impact of dementia on an individual may be compounded by personal circumstances such as changes in financial status and accommodation, or bereavement.
8.12.2 What works? The evidence base on dementia There is no good evidence that any intervention for the prevention or treatment of dementia reduces the risk of admission to hospital or residential care.2 With regard to prevention there is as yet no good evidence that dietary supplements such as B6, B1252 folate53, thiamine54, vitamin E,55 omega 356 or ginkgo biloba57are of any benefit. There is no good evidence as yet that aspirin58, Statins59 or hormone replacement therapy60 are useful in the prevention or slow the progression of dementia.
There is some evidence that anti-cholinesterase inhibitors and memantine may delay the time to institutionalisation for patients with Alzheimer’s disease.61This evidence has not been synthesised in a good quality systematic review. The degree of any delay in institutionalisation remains speculative.
A systematic review of case management of dementia patients found that three out of six good quality trials found a delay/reduced institutionalisation and one additional that found a significant delay in a subgroup (in one country of the three studied).62
There is limited good quality data on which interventions provide the best outcomes for patients with dementia and their carers. The use of anti-psychotic medication in patients with dementia has been shown to result in increased mortality.63 The avoidance of this class of medication and the use of non-pharmaceutical means of controlling distressing or potentially harmful behaviour has been advocated.64 In the absence of an adequate research evidence base it is pragmatic to follow expert opinion. This is set out in the NICE guidance. This gives guidance on: the care of patients with dementia (non-discrimination and valid consent) carers (assessment and support) coordination and integration of services (health and social care) memory services structural imagining services behavioural management training (of those in health, social care and voluntary sectors) acute hospital care
8.12.3 The situation in Basildon and Brentwood
Figure 8.24 shows the number of patients diagnosed with in Basildon and Brentwood from 2009-10 to date, as derived from GP QOF registers, and the modelled (expected) prevalence within the community.
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FIGURE 8.24
Figure 8.24 demonstrates that the numbers of patients with dementia is likely to increase over time, and that a significant amount of dementia remains undiagnosed.
Figure 8.25 shows the completeness of GP Practice QOF Dementia Registers, i.e. the number of patients on the register divided by the expected number of patients with dementia in each GP practice population.
FIGURE 8.25
Figure 8.25 demonstrates that in all but three GP practice populations, the numbers of patients on the dementia register is statistically significantly lower than the expected number of patients with dementia in the practice population. Across Basildon and Brentwood, only 50% of patients with dementia have received a diagnosis.
Figure 8.26 shows the expected number of patients with mild, moderate and severe dementia from 2009 to 2014. The ratio of mild:moderate:severe has remained relatively constant over the last five years, although the absolute numbers in each category have increased.
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FIGURE 8.26
Figure 8.27 shows the numbers of patients with dementia cared for in the community and in residential care over the last five years.
FIGURE 8.27
There has been an increase in both the numbers and proportion of patients with dementia cared for in the community. Conversely, the number of patients with dementia cared for in residential care has decreased.
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There are a number of services commissioned by ECC, B&B CCG and Basildon Council which supports people with Dementia and their carers in Basildon.
SEPT Older Peoples and Adults Community Social care assessment (client and carers) Mental Health Team Community nursing and therapy Memory Assessment Service Carers support services Older People Assessment In-patient Service Respite Challenging Behaviour In-patient Ward Dementia domiciliary care Dementia Physical and Mental Health Dementia Connection (Alzheimer’s Society and Reablement Intermediate Care Age UK Essex) Reablement at home and in residential care Handy persons, equipment, aids and homes adaptations Residential and nursing care GNS Sheltered accommodation and extra care Dementia Crisis Team Day opportunities, advocacy, information, Community Dementia Nurses advice Dementia Liaison Service Dementia Bereavement Counselling Community Careline Wardens Sheltered Accommodation Co-ordinators
8.12.4 Future Commissioning Intentions
A tripartite workshop between ECC, NHS Basildon and Brentwood CCG, and Basildon Council on dementia was held recently to discuss future opportunities for joint commissioning and potential new models of care for people with dementia locally.
The Basildon Partnership agreed a small multi-agency project group is formed to explore accommodation based care solutions for Basildon. We will require a dedicated project manager from December 2014 to help lead on this piece of scoping work, and project management of possible follow-up delivery plans.
Key outcomes to be achieved by end March 2015:
To undertake a baseline analysis of current local care practice, based on national quality markers. To better understand models of care villages, operational and design considerations and financial modelling. To explore how new accommodation based care models can be made financially strategically sustainable To undertake consultation and engagement with carers and people living with Dementia to understand their needs and preferences. To engage with front line staff on caring and supporting people with Dementia. To develop options for the future
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9. Strategy Implementation and Monitoring
Basildon and Brentwood CCG, Basildon Borough Council, Brentwood Borough Council and Essex County Council will develop a programme delivery function in order to integrate commissioning priorities and improve partnership working to deliver the commissioning intentions specified within this strategy. Opportunities for co-location of staff and pooled funding will also be explored.
The strategy will be monitored through ECC and NHS Basildon and Brentwood existing performance management processes and through the Basildon and Brentwood Health and Wellbeing Partnerships.
9.1 Workforce Planning
ECC, NHS Basildon and Brentwood CCG and Basildon and Brentwood Councils recognise that their workforces are one of their most valuable assets. Achieving the fundamental shift in behaviour required to deliver the prevention agenda set out in this strategy requires both commissioning and front line staff to work differently.
In order to develop staff across the organisation to become advocates for the prevention agenda we will undertake the following actions.
Making Every Contact Count Every day front line health, local government and third sector staff see tens of thousands of members of our community collectively. Making Every Contact Count (MECC) is about encouraging and helping people to achieve positive long- term behaviour change by: - Systematically promoting the benefits of healthy living - Asking individuals about their lifestyle and changes that they may wish to make, when there is an appropriate opportunity to do so, (for example when a patient, client or customer lights a cigarette or mentions smoking). - Responding appropriately to the lifestyle issue(s) once raised - Taking the appropriate action to either give information, signpost or refer individuals to the support they need.
ECC will commission an e-learning package to help staff to develop Making Every Contact Count skills. This will be open to all ECC staff, plus the wider health, local government and third sector workforce
Raising Awareness of the Prevention Agenda amongst our workforce In order to help promote the idea that the Prevention Agenda is everybody’s business, ECC will seek to undertake the following: - Include Prevention in the job descriptions of all staff - Include Prevention on all email strap lines - Publicise the Prevention agenda and this strategy on its intranet
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