The Greater Manchester Population Health Plan 2017-2021

Greater Manchester Health and Social Care Partnership Contents

Foreword...... 1 Summary...... 2 1 . Introduction ...... 4 1 .1 Wider strategic linkages...... 5 1 .2 Taking charge together of our health and wellbeing ...... 5 1 .3 Greater Manchester’s health challenge ...... 7 1 .4 Mental health and wellbeing...... 11 1 .5 Taking charge of our outcomes...... 11 1 .6 Primary care...... 13 1 .7 Acute and specialist healthcare...... 14 1 .8 Our Greater Manchester priorities ...... 14 1 .9 Our ‘whole system’ approach to population health...... 18 2 . Person and community-centred approaches...... 20 2 .1 Background...... 20 2 .2 What are person and community-centred approaches?...... 20 2 .3 The case for investment...... 22 2 .4 Approaches that are asset-based ...... 22 2 .5 Greater Manchester context...... 24 2 .6 Opportunity...... 26 2 .7 Plan...... 26 3 . Start Well ...... 30 3 .1 Background...... 30 3 .2 Greater Manchester context...... 32 3 .3 A new model of care for Early Years ...... 33 3 .4 Opportunity...... 33 3 .5 Smoking in pregnancy...... 37 3 .6 Better oral health ...... 37 3 .7 Developing Well (5-25 years) ...... 39 4 . Live Well...... 43 4 .1 Work and health ...... 45 4 .2 New model of primary care for deprived communities ...... 51 4 .3 Incentivising and supporting healthy behaviours...... 55 4 .4 Cancer prevention and early detection...... 70 4 .5 Scaling up our response to HIV eradication...... 74 5 . Age Well...... 79 5 .1 Housing ...... 80 5 .2 Nutrition and hydration ...... 84 5 .3 Falls ...... 90 6 . System reform ...... 97 6.1 System reform – Creating a unified population health system for Greater Manchester ...... 98 6 .2 Social value...... 102 7 . Next steps...... 107 7 .1 Scoping and delivering via a blended approach ...... 107 7 .2 Equality analysis and impact assessment ...... 110 7 .3 Delivery schedule ...... 110

The Greater Manchester Population Health Plan 2017 - 2021 Foreword

April 2016 was We’ve said before that that’s a huge a milestone in privilege - it gives us the chance to Greater Manchester’s make decisions locally about how best history. It marked the start to spend our £6 billion budget to bring of the era in which we the greatest, fastest improvement to take charge of health and the health and wellbeing of our 2 .8 social care in our region. million people . It gives us chance to focus on our people and communities, helping them to take control of and make decisions about their own health, looking after themselves and each other . And it gives us chance to strengthen the links between health, work and economic prosperity . Put simply skilled, healthy and independent people are crucial to bring jobs and investment, we therefore want to support as many people as possible to contribute and benefit from the opportunities economic growth brings .

It’s also a huge challenge as we seek to tackle the deep rooted health inequalities and high levels of long term conditions such as diabetes, which mean that Greater Manchester people not only have a shorter life expectancy, but can expect to experience poor health at a younger age than in other parts of the country . In turn this means many thousands of people here are not always able to benefit from that increased prosperity we want to bring to the region .

Our strategic plan, Taking Charge, set out our ambitious goals for everything from community health services, to hospitals, IT and our public sector buildings . This Population Health plan is our commitment to the people who live and work in the ten towns and cities of Greater Manchester - and that includes the carers, the volunteers and the workforce - that we will make changes which we know will work and at the right scale in order to help people have the best start in life, to live well and to age well .

With your support and assistance we can turn this bold and ambitious strategy into an effective plan to transform lives and achieve a healthier Greater Manchester .

Lord Peter Smith Chair GMHSC Strategic Partnership Board Leader of Wigan Council

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The Greater Manchester Population Health Plan 2017 - 2021 Summary To achieve the greatest and fastest improvement to the health, wealth and wellbeing of the Vision 2.8 million people who live in Greater Manchester

Person and community Start Well Live Well Age Well System reform Strategic framework centred approches

● Greater Manchester’s population is predicted to increase by 3%, with an ageing profile, and people aged over 70 predicted to increase by 15.2% by 2021. ● Greater Manchester has significant health inequalities both in relation to England averages and across Greater Manchester between local authorities and within them. ● Our life expectancy is below the national average, and we have poorer levels of healthy life expectancy . ● Rates of employment are lower – 70 .5% compared with 74% across England . Health Challenges ● Across the life course, risk factors that lead to illness and reduced life expectancy in general are worse than the respective England averages e .g . in 50% of all Greater Manchester local authorities smoking prevalence is significantly higher than the England average of 16.9%, and one in three children in Greater Manchester did not achieve a good level of attainment by the end of Reception . ● 9.8% of adults reported they had a long-term condition or disability that significantly impaired their everyday activities, compared to 8.3% across England.

● 90% wanted to improve their lifestyles, with most people citing being more active, eating healthier and tackling stress as their key areas of need . ● People were willing to take charge of their own health and wellbeing, but recognised their ability to do so was limited by the wider determinants of health such as income, transport and housing . Taking Charge ● While improving health and social care services was seen as important, people emphasised the role of personal and community support structures . Mental health was seen as equally as important as physical health . Together ● People recognised that one size does not fit all and that certain groups had additional needs e.g. LBGT. Consultation ● They emphasised the importance of self-confidence and self-efficacy in changing health-related behaviours. ● People highlighted the important legislative powers of local government and the role of public sector organisations in creating the right conditions for people to take charge of their own health, and the important role of staff as health ambassadors within local communities . ● They wanted greater use of behavioural insights to identify how people really behave, not how policy makers think they should .

● Our plan is aligned with the broader approach to reform across Greater Manchester that is predicated on: a new relationship between people and public services; connecting people to the opportunities of growth and reform; place-based integration of services and orientating the system towards early intervention and prevention . ● We are clear that change happens in communities, supported by localities . The priorities for change set out within this plan have been chosen to support the locality delivery described in each of the 10 locality plans . Wider strategic ● While the plan focuses on the programmes of work that the Greater Manchester Health and Social Care Partnership will deliver in collaboration with localities, linkages achieving a radical upgrade in population health will be dependent on both the priorities of this plan and the broader reform of services being taken forward across Greater Manchester . ● Nor can this plan be disconnected from the rest of our health and care transformation programmes, in particular the development of locality care organisations (LCOs) and the primary care strategy will lead to embedding more proactive, person-centred prevention and early intervention practice consistently into the design and delivery of community-based services .

Taking Charge Together Common theme in Quick wins Economics of prevention consultation locality plans Findings from Greater Manchester people, carers and Opportunities to implement An audit earlier this year of locality plans The ‘economics of prevention’ work was developed by New Economy staff conversations online and face to face, with over evidence-based local best highlighted areas for standardised approaches Manchester and Public Health England and group interventions by their 6,000 responses and 50,000 visits online about how practice at scale across other across Greater Manchester . gestation or notional rate of return in order to recognise that dividends for they might better take charge of their own health . parts of Greater Manchester . different interventions are likely to be realised over different time periods . Summary

Greater Manchester Population Health Plan Objectives Taking Charge Stronger Together

Person and community centered approaches Greater Manchester is a fairer, ● To build a Greater Manchester framework and support capacity and capability building for Start Well person and community centred approaches healthier, safer and more inclusive ● To work in partnership with VSCE sector to develop and test an exemplar social movement place to live focused on cancer prevention . More Greater Manchester children will reach a good level of development Reform health and social care with Start Well cognitively, socially and emotionally . ● To support localities to implement the core elements of the Greater Manchester Early improved access to quality, integrated Years model, including the development of an IMT proposition to improve data processes services . Greater independence, to track progress and allow earlier intervention . Fewer Greater Manchester babies will improved well-being and stronger ● To develop a sustainable, resilient and consistent Greater Manchester approach to communities . stopping smoking in pregnancy . have a low birth weight resulting in ● To implement evidence-informed interventions at scale in a targeted and consistent better outcomes for the baby and less manner across Greater Manchester to improve oral health and reduce treatment costs cost to the health system . Improve early years support for parents within 3-5 years . to give children the best start in life and help workless parents towards work . Live Well Live Well ● To build and test an approach to work and health that improves the integration and alignment of health, employment and other services . All people are valued and able to fully ● To test and evaluate the ‘focused care’ approach model in a number of deprived practices More Greater Manchester families in Greater Manchester with a view to supporting the future expansion and mainstreaming participate in and benefit from the city of the new care model, including exploration of sustainable funding mechanisms . will be economically active and family regions success . Support unemployed ● To develop a whole systems approach to lifestyle and wellness services, including incomes will increase . residents into work and enable innovative digital options for incentivising and supporting lifestyle behaviour change . progression into higher skilled, higher ● To deliver the cancer prevention workstream of the national cancer vanguard, testing paid roles . innovative approaches to awareness and behaviour change, social movement, cancer Fewer people will die early from screening uptake and lifestyle -based secondary prevention . cardiovascular disease . ● To roll out a lung health-check programme across Greater Manchester . ● To help develop a Greater Manchester city-region approach to eradicating HIV within a Greater Manchester is known for generation . excellent, efficient and value for money Fewer people will die from cancer . services . Encourage self-reliance and Age Well reduce demand on services . ● To facilitate the roll-out, testing and evaluation of an approach to tackling issues around poor quality housing . Fewer people will die from respiratory ● To facilitate the roll-out, testing and evaluation of an approach to tackle dehydration and disease . Create the conditions for growth malnutrition based on the nationally recognised work in Salford . and place Greater Manchester at ● To facilitate the roll-out ,testing and evaluation of fracture liaison services, integrated with the leading edge of science and locally designed falls prevention services in a number of Greater Manchester boroughs . Age Well technology . Expand and accelerate the commercialisation of research . System reform ● To develop a population health commissioning plan, and develop and test a proposal for a More people will be supported to stay new Greater Manchester population health function including future resourcing model . Collaboration and partnerships . Strong ● well and live at home for as long as Maximise the social value benefit from health and social care commissioning and collective and individual leadership . contribution of the voluntary, community and social enterprise sector . possible . 1. Introduction

That is why we are committed to achieving the greatest and “The greatest fastest improvement to the health, wealth and wellbeing of the wealth is health” 2 .8 million people who live here . Each of the towns and cities – Virgil of Greater Manchester is determined to do this by: helping people to take control of their own and their family’s health; Greater Manchester’s connecting people to the opportunities created by economic (GM) future success growth and reform; tackling the root causes of poor health; depends upon the health focusing on improving the health of the most vulnerable; and of its population. For providing excellent care for people when they need it . too long our city-region has lagged behind Our plan is unashamedly focused on people and communities . national and international Communities, both place-based and where people share a comparators when it comes common identity or affinity, have a vital contribution to make to to key health outcomes. health and wellbeing . We know that connected and empowered Deeply embedded health communities are healthy communities . That it is the assets inequalities, often between within communities, the skills and knowledge, the social communities little more networks and the community organisations that are building than a stone’s throw apart, blocks for good health and wellbeing . So we have put person have blighted individual and community-centred approaches at the centre of our plan . lives and acted as a drag on our economy. This plan sets out our approach to delivering a radical upgrade in population health . It is informed by the best empirical evidence and by the views of the people of Greater Manchester . It sets out the health challenges we face and our approach to population health at the Greater Manchester level .

We are convinced that the key to better population health is to get upstream of the impact of illness and disease in focusing on prevention and early intervention . We are also committed to a life course approach; we believe that from pregnancy right through to ageing we have multiple opportunities to enhance future quality of life .

We are clear that most change happens in communities, supported by local organisations, so the priorities for change set out within this plan have been chosen to add value to the local delivery described in each of the 10 locality plans . The plan then focuses on those programmes of work that Greater Manchester Health and Social Care Partnership (GMHSC Partnership) will deliver in collaboration with localities . It does not seek to duplicate those priorities that are best delivered at the locality level .

The choices we have made in the plan are based on the best available evidence of impact and seek to achieve a balance of short, medium and long-term improvements . There will be some programmes that we will work up in future years, and

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The Greater Manchester Population Health Plan 2017 - 2021 others that we will take forward through our of strategies that contribute to population commissioning plans and by working with health in this document . However, we have localities . signposted to the most important strategies and programmes of work for population health We know a lot about what we need to do to wherever possible . improve health and wellbeing and reduce health inequalities . The ambition of this plan Across Greater Manchester, we are clear lies in our desire to implement and embed that people’s lives do not neatly fit into public these proven approaches consistently at scale service sectors . Aligning our reform strategies across Greater Manchester in a way that has means we are placing people at the heart of never been achieved before . Right now, there what we do rather than expecting people’s are multiple examples of good practice across lives to neatly map to our organisational the conurbation but they tend to be small in boundaries . It also means that this is not scale and operating at the fringe rather than at just a traditional public health plan, in that it the heart of the health and social care system . seeks to draw on the widest possible range This plan will act as a key driver to re- of services and support options to help orientate the system towards prevention and people achieve the best possible health and a focus on population health and wellbeing . wellbeing outcomes . 1 .1 Wider strategic linkages Nor can this plan be disconnected from the rest of our health and care transformation The overall Greater Manchester Strategy, programmes and projects . Our aim is that ‘Stronger Together’, places reform of services people across Greater Manchester are able to to the public at the heart of our strategic access the right services, at the right time, in ambition . The subsequent Growth and the right way to help them tackle challenges Reform Plan, devolution agreements, and the they may face and to build on their strengths Health and Social Care Strategic Plan ‘Taking and assets . We must do this in collaboration, Charge’ have restated that commitment to across sectors so that people no longer have reshaping our services, supporting as many to navigate fragmented systems and services . people as possible to contribute to and This will mean that when we consider any benefit from the opportunities economic pathway of care, for any condition or group growth brings . of conditions, we will think about the whole The various elements of the overall Greater journey from prevention right through to Manchester strategy – Stronger Together, the specialist care . Greater Manchester Spatial Framework (the plan to manage the supply of land for jobs and 1 .2 Taking charge together of new homes across Greater Manchester) and our health and wellbeing the Greater Manchester Local Transport Plan, In order to develop the proposals in this together with more targeted strategies such population health plan, our starting point is as the Greater Manchester Alcohol Strategy, the views and experiences of local people . In the Greater Manchester Primary Care Strategy 2016, we engaged with Greater Manchester and The Greater Manchester Mental Health people including the “seldom heard”, carers, Strategy – all have important contributions to and health and social care staff by working in make to population health . It’s not possible, partnership with Healthwatch, the Voluntary nor is it appropriate, to reference the full range Community and Social Enterprise (VCSE)

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The Greater Manchester Population Health Plan 2017 - 2021 sectors and across all 37 public sector crowdsourcing (online conversations) and a organisations that form GMHSC Partnership . health snapshot online questionnaire . 50,000 visited our websites and more than 6,000 were involved in our conversations The engagement with seldom heard people, face to face from all walks of life in a led by a unique partnership between conversation specifically about health and Healthwatch and Greater Manchester wellbeing and how they might better take Voluntary, Community and Social Enterprise charge of their own health . This innovative (VCSE), sign-posted these groups to our engagement exercise generated feedback via online conversations . Their feedback included:

It’s all environmental: A range of factors commonly defined as wider health determinants were recognised as having either a direct impact on health or on people’s ability to adopt healthy behaviours such as healthy eating or exercise . Factors included income and costs, work and employment, transport, housing, skills and education, town and city planning, crime and community safety, pollution, social and cultural norms, climate and weather .

It’s all about people: People highlighted the role of social and community support structures, the harmful effects of social isolation and the importance of people as positive role models and motivators . VCSE groups and organisations were seen as key in facilitating social support and providing opportunities for creating meaningful connections .

It’s all in the mind: Mental health was given equal, if not more, importance as physical health . Self-confidence, a sense of self-efficacy (especially in relation to perceptions of behaviour change as possible, and likely to result in positive health impacts), and motivation all featured strongly in discussions .

It’s all relative: People emphasised the relative nature of health and wellbeing and referred to significant levels of diversity in relation to individual, social and cultural differences as well as transitions across the life course. ‘One size does not fit all’, and a particular focus was put on the additional access and inclusion requirements of particular communities, such as disabled, Deaf, lesbian, gay, bisexual and trans (LGBT) and young people, and people for whom English isn’t their first language.

It’s all about equality: Participants drew a direct connection between structural inequality and ill health, in line with mainstream theory on health inequalities . This suggests that addressing structural inequalities in society has to be at the centre of all health improvement work .

It’s all about knowledge: While participants generally reported good levels of knowledge about healthy living, they recognised an unmet need for accessible information for particular groups and communities, and for consistent messaging and education from a young age . Also, gaps in knowledge among professionals around particular issues and the needs of particular communities were highlighted .

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The Greater Manchester Population Health Plan 2017 - 2021 These conversations have given us a unique 1 .3 Greater Manchester’s health insight into the opportunities and barriers challenge that people are experiencing and the key messages and have been fundamental in Where are we starting? Greater Manchester shaping this population health plan . is the fastest growing economy in the country and is a great place to live and work for Overall, people are willing to take charge of many people . Yet people here die younger their health and wellbeing while recognising than people in other parts of England . Our that their ability to do so on an individual aspirations for good health need to recognise basis is limited by other factors, mainly time our starting point and also the challenges of to do this, place and confidence. While an ageing population and the inequalities that improvements to health and social care currently exist between the most affluent and services are seen to play a role in this, people most deprived parts of the local population . put more emphasis on improving personal and community support structures . To 1.3.1 Demographics find out more visit www.takingchargetogether. We have an ageing population . Between 2016 org uk. and 2021 the number of people aged over 70 living in Greater Manchester is predicted It follows that creating conditions in which to increase by 15 .2%, while the overall people are enabled to take charge of their population will increase by 3% (figure 1). own health and wellbeing will require a truly holistic approach based on radical Greater Manchester has a diverse population improvements of the physical and socio- and it is important to recognise how this economic environment and transformative diversity is dispersed across the areas as this grassroots community development . can lead to significant inequality. For example, the 2011 Census shows that local populations have different ethnic characteristics (see figure 2).

2016 2021 450,000

400,000

350,000

300,000

250,000

200,000

150,000

100,000

50,000

0 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80+ Age Figure 1: Demographic change over the next five years

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The Greater Manchester Population Health Plan 2017 - 2021 White Mixed / multiple ethnic groups Asian / Asian British Black / African / Caribbean / Black British Other ethnic group

Manchester

Oldham

Bolton

Trafford

Bury

Salford

Tameside

Stockport

Wigan

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 2: Greater Manchester cultural diversity

1.3.2 Life expectancy and Life expectancy varies between local deprivation authorities, but also within them . Published figures for the 2009-2013 period show that Around 680,000 Greater Manchester people there is considerable variation between live in areas that fall into the 10% most relatively small areas (middle super output disadvantaged areas in the country, and three areas or MSOAs) within each local authority . local clinical commissioning groups (CCGs) The MSOAs with the highest and lowest life are in the bottom 10 nationally for healthy life expectancies within each local authority are expectancy at birth . shown in figure 3.

Male Female

Highest MSOA life expectancy Lowest MSOA life expectancy Highest MSOA life expectancy Lowest LSOA life expectancy 90 90

85 85

80 80

75 75 Life expectancy inLifeyears expectancy inLifeyears expectancy

70 70

65 65

Figure 3: Life expectancy across the localities

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The Greater Manchester Population Health Plan 2017 - 2021 1.3.3 Work and health The benefits of work for your overall health Working age population and wellbeing are well understood; being in 1,759,800 good work is beneficial for your health. The

economic status of Greater Manchester’s Economically working age population is shown right . Economically active inactive 1,328,500 (75.5%) 431,400 (25.4%) Disability and long-term health conditions are not a total bar to employment, but the working Definition of economically active is a measure of age population who have health conditions the number of people employed or actively seeking employment and able to take up employment if it or illnesses lasting more than 12 months are came along (i .e . on Jobseeker’s Allowance) . less likely to be in employment than the total working age population . And employment Figure 4: Economic status of Greater Manchester’s population rates are lower in Greater Manchester than across England . In Greater Manchester, 70 .5% of the total working age population are 12 months are in employment compared with in employment compared with 74% across 65 .3% across England (Active People Survey, England; similarly, 59 .2% of those who have July 2015 to June 2016) . a health condition or illness lasting more than

Participation in the labour market, Greater Manchester, July 2015 to June 2016

Working age population with health conditions Working age population or illnesses lasting more than 12 months

Inactive, 24.5% 24.5% Inactive, 35.1% 35.1%

Unemployed, 5.0% 5.0% 59.2% In employment, 59.2% 5.7% 70.5% In employment, 70.5%Unemployed, 5.7%

In employment Unemployed Inactive Figure 5: Participation in the labour market

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The Greater Manchester Population Health Plan 2017 - 2021 1.3.4 Over the life stages

One in five adults in Greater Across almost all standard published measures Manchester smokes . Smoking of alcohol harm, including alcohol-related prevalence in 2015 ranged from mortality and alcohol-related hospital admissions, 15.1% in Stockport to 22.7% in Greater Manchester local authorities have Manchester . In 50% of Greater significantly worse figures than the respective Manchester local authorities, England averages . smoking prevalence is significantly higher than the England average of 16.9%. 35.5% of Greater Manchester children have dental decay, Smoking prevalence with an average in routine of 1.41 filled, and manual decayed or occupations missing baby is higher teeth in children . than across the general population, and The proportion of across Greater adults who are Manchester physically active it varies from varies from 45.0% 24.4% in Wigan to in Oldham to 57.7% 36.3% in Oldham . In in Stockport, Rochdale, Bolton and compared with the Oldham prevalence is England average of significantly higher than 57.0%. the England average of 26.5%. Around two-thirds of adults in Greater In 2016, one in three Manchester are children in Greater Manchester (over overweight or obese . The proportion varies from 12,700 children) did not achieve a 61.5% in Manchester to 69.7% in Rochdale, good level of development by the end compared with 64.8% across England . of Reception .

9.8% of adults in Greater Manchester reported they had a In 2015, 4.6% of the over- long-term condition or disability that limited their day-to- 65s in Greater Manchester day activities a lot, and a further 9.5% said that their day- were recorded as having to-day activities were limited a little, compared to England dementia . The England averages of 8.3% and 9.3% respectively . value is 4.3%.

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The Greater Manchester Population Health Plan 2017 - 2021 1 .4 Mental health and wellbeing health programme supports more people into work recognising the importance of good The importance of mental health and work to health; the person and community- wellbeing is a recurring theme of our plan centred approaches build self-efficacy and and we want to draw this out explicitly from resilience, basic building blocks for good the start . More than anything else, mental wellbeing; and the digital platform to support health and wellbeing is recognised by local behaviour change is built on the promotion people as fundamental to all our lives and to of self-efficacy and self-care using nationally the communities where we live . It underpins recognised patient activation measures . everything we do, how we think, feel, act and behave . It is an essential and precious Improving child and adult mental health, individual, family, community and business narrowing the gap in life expectancy for resource that needs to be protected and people with mental health conditions and enhanced . ensuring parity of esteem for people with mental health conditions are fundamental to Wellbeing is about lives going well, the unlocking the power and potential of Greater combination of feeling good and functioning Manchester communities . Shifting the focus effectively . It includes the positive emotions of care to prevention, early intervention of happiness and contentment, but also and resilience and delivering a sustainable such emotions as interest, engagement, mental health system requires simplified and confidence, empathy and affection, the strengthened leadership and accountability development of one’s potential, having some across the whole system . Enabling resilient control over one’s life, having a sense of communities, engaging inclusive employers purpose (e .g . working towards valued goals), and working in partnership with the third and experiencing positive relationships . sector will transform the mental health of Mental health and wellbeing is a key cross- Greater Manchester residents . cutting priority of the Greater Manchester strategic plan, ‘Taking charge of our health 1 .5 Taking charge of our and social care in Greater Manchester’ outcomes (‘Taking Charge’) . The Greater Manchester We’ve turned our ambition of achieving the Mental Health and Wellbeing Strategy greatest and fastest improvement to the focuses on early intervention and prevention, health, wealth and wellbeing of the 2 .8 million supporting people in communities and people into a set of high-level outcomes improving access to services . It takes a that are supported by all 37 organisations in ‘whole system’ view of how to address mental GMHSC Partnership . health and wellbeing and in doing so ensures we all have a role to play in transforming outcomes and the wellbeing of local people .

Aligned to this whole system approach, the principles and priorities of the Greater Manchester Mental Health and Wellbeing Strategy are embedded through every section of this plan, recognising that poor mental health cannot be tackled in isolation . The Early Years integrated new model of care supports secure attachment between parent and infant, preventing future problems; the work and

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The Greater Manchester Population Health Plan 2017 - 2021 What do we want to How will we know if we’ve succeeded? achieve?

START WELL More Greater Manchester Improving levels of school readiness to projected England rates children will reach a good will result in 3,250 more children starting school ready to learn, level of development (GLD) and ultimately better educational attainment by 2021 . cognitively, socially and emotionally . Fewer Greater Manchester Reducing the number of low birth weight babies in Greater babies will have a low birth Manchester to projected England rates will result in 270 fewer weight, resulting in better very small babies (under 2,500g) by 2021 . outcomes for the baby and less cost to the health system .

LIVE WELL More Greater Manchester Raising the number of parents in good work to the projected families will be economically England average will result in 16,000 fewer Greater Manchester active and family incomes children living in poverty by 2021 . will increase . Fewer people will die early Improving premature mortality from CVD to the projected from cardiovascular disease England average will result in 600 fewer deaths by 2021 . (CVD) . Fewer people will die early Improving premature mortality from cancer to the projected from cancer . England average will result in 1,300 fewer deaths by 2021 . Fewer people will die early Improving premature mortality from respiratory disease to the from respiratory disease . projected England average will result in 580 fewer deaths by 2021 .

AGE WELL More people will be Reducing the number of people over 65 admitted to hospital supported to stay well and due to falls to the projected England average will result in 2,750 live at home for as long as fewer serious falls . possible . Table 1: Life course strategic aims

Work is ongoing to develop a set of sub- work that is already underway to transform indicators that will enable us to monitor and integrate health and social care services progress against these high-level outcomes . in each of the 10 Greater Manchester boroughs . This thinking dates back to 2013 1.5.1 Place-based integration and when the Government issued a national locality working commitment to providing jointly delivered The ambitions within the ‘Taking Charge’ and co-ordinated health and community care health and social care plan are reflected in the services, with the explicit aim of improving

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The Greater Manchester Population Health Plan 2017 - 2021 the experience of patients, service users, recognises that our health, mental wellbeing their families and carers . In practice, this and ability to live independently starts with means that social workers, district nurses living well day to day, supported by our and GP practices – and in some cases wider families and wider community . The basic therapy services and the voluntary sector premise is that if people are supported to live – will work as a single team to co-ordinate well in their community, connected to family, their efforts to support an individual and their friends and activities in an environment in family to recover from ill health and maintain which they feel safe and included, they are independent living . more likely to sustain a good quality of life and less likely to see a deterioration in their health Some examples of how this should improve and independence . people’s experience of health and social care include the following . In Greater Manchester we are therefore ●● People will tell their story once, including positively extending the original concept of the role of any informal family carers, and integrated health and social care to recognise a ‘key worker’ will be responsible for co- the important role of family, community and ordinating the support needed . place in promoting the health and wellbeing of our population . ●● Medical, social and emotional needs will be identified in one process, leading to more timely and appropriate support from 1 .6 Primary care the people or services that are best placed High-quality primary care services – general to help . medicine, general dentistry, pharmacy and ●● Hospital discharge will be better co- optometry – have always had an essential ordinated from hospital to home, role in supporting population health . In many supporting more effective and rounded instances, contact with these professionals recovery, including emotional wellbeing is a natural opportunity to identify wider and adapting to being back in the home health issues or worries and intervene environment . positively at an early stage . Many prevention services such as immunisation and screening In Greater Manchester there are a number of programmes are already delivered through GP boroughs that are moving quickly towards practices nationwide e.g. flu immunisation, formalising these arrangements by creating cancer screening . Some health conditions new organisations called locality care such as diabetes, high blood pressure and organisations (LCOs), which means that cancer can be picked up early through regular public sector health and care workers will be eye or dental checks, while the advice and employed by one organisation and led by one support of pharmacists can help people to management team, which will be responsible self-care or better manage the medicine they for community care provision in that borough . need to take to stay well .

This goes beyond the traditional models However, primary care leaders in Greater of health and care we see now, and will Manchester want to embed ‘proactive, allow people and their carers to take more person-centred’ prevention and early control over their own health and be more intervention practice consistently in how easily connected into existing voluntary and they plan and deliver their services, which community support and to wider public sector should lead to fewer people needing planned services such as housing, employment, or emergency health and social care . The schools and the fire and police services. primary care strategy identifies some great A ‘place’ or neighbourhood approach examples of best practice in this area and

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The Greater Manchester Population Health Plan 2017 - 2021 highlights how they will scale up this work health and care service demand in the across their 2,000 points of delivery, such as short to medium term . The development of the commitment to roll out the Healthy Living consistent and best practice specifications, Framework* across all pharmacy, optical and which include prevention activities, will help dental practices by April 2018 . reduce variation in care, and through the development of the Health Education England Primary care is at the heart of Greater programme: Making Every Contact Count Manchester’s new integrated community care initiatives, evidence-based interventions can and the ambition for primary care mirrors the be delivered to people at a time they are principles described in the previous section receptive . Examples of such interventions about the importance of place and community include: smoking (implementing consistently and the broad range of factors that influence the National Institute for Health and Care good health, including the impact of inequality Excellence guidance on smoking harm on health and wellbeing . Taken together, reduction and including smoking interventions this is sometimes described as primary care in mental health and maternity services); adopting a ‘more than medicine’ approach i .e . alcohol (brief advice and care teams); and recognising the non-clinical support that gives cardiovascular disease (preventing strokes in people the confidence to improve their health people with atrial fibrillation). and wellbeing . This will mean: The scaling up of such interventions across ●● enabling different consultations, including different organisations will maximise the health coaching and shared decision impact and benefits for Greater Manchester making and support work being undertaken across ●● expanding the primary care workforce to the wider system in primary care and include health trainers and neighbourhood neighbourhoods and communities . and community connectors to provide support to people in the community 1 .8 Our Greater Manchester priorities ●● connecting people to non-clinical support (community assets) . This would We know that poor health and disadvantage include exploring opportunities for social are inextricably linked and that disadvantage prescribing in primary care to refer starts before birth and accumulates throughout patients to ‘cook and eat’ sessions or life . We have therefore structured our housing energy and efficiency measures. programme using the Start Well, Live Well, Age Well approach . Furthermore, we want 1 .7 Acute and specialist to bring to life our conviction that connected and empowered communities are healthy healthcare communities with some programmes that There are thousands of contacts with acute cross the age range. And finally we need care and specialist care services in Greater to adapt and change our systems to fit our Manchester, and hence many opportunities population health ambitions . Putting all that for primary and secondary prevention together, we developed five work programmes, interventions to support improving the which we have tested extensively with the population’s health . Standardising acute Greater Manchester system . and specialist care is one of the themes of the Greater Manchester health and social 1. Person and community-centred care reform programme . This offers some approaches transformational opportunities to support The capabilities of the public are population health improvements and reduce extraordinary . They understand communities’

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The Greater Manchester Population Health Plan 2017 - 2021 needs and can identify solutions because years of life to give us the best opportunity they are those communities; they are experts to successfully reduce health, educational by experience . Their support is vital to and social inequalities . By establishing a developing a sustainable healthcare system framework for the delivery of appropriate and culture that delivers for all . services at the right time, we will support children and families to become healthier, Person and community-centred approaches resilient and empowered . mean putting the comprehensive needs of people and communities, not only diseases, Our Early Years new delivery model is based at the centre of health systems, and on universal and targeted services, using empowering people to have a more active evidence-based assessments to identify and role in their own health . We aim to put people intervene effectively to avoid or minimise and communities at the heart of what we do, escalation of need . In addition, this Start Well concentrating on what is most important to population health programme is focused on them, what skills and attributes they have to two key drivers of poor Early Years outcomes offer, and what strengths exist naturally in the and inequality i .e . smoking in pregnancy and people and places we serve . poor oral health where scaling up evidence- based interventions at Greater Manchester The VCSE sector will play a central role level could enable rapid improvements in in the leadership and delivery of this work health outcomes and deliver economies of programme, which aims to develop an scale . infrastructure across Greater Manchester to reliably and consistently deliver social models Another recognised area for intervention is our of support to enable people to live better . The desire to focus on the health challenges for programme includes: children and young people aged 5-25 years, ●● developing the capacity and capability with mental health and wellbeing a specific across Greater Manchester to support the focus for this population group . This area of embedding of person and community- work will be developed further in the next centred approaches into the reform of the stage of the plan under a Developing Well system theme . ●● developing a Greater Manchester 3. Live Well framework for action that provides a consistency of approach but also allows This programme focuses primarily on flexibility to respond to local needs the opportunities to improve the health of Greater Manchester residents in mid- ●● developing an exemplar social movement adulthood, taking into account the pressures focused on cancer prevention . and priorities upon this large working age population . Live Well recognises that good 2. Start Well work is an essential prerequisite of health, Building on the principles of early intervention wellbeing and socio-economic outcomes . The and prevention, the aim of the Start Well wealth of evidence to support employment as programme is to deliver integrated early a route to achieving good health and mental intervention and prevention services for wellbeing, and the relevance of good levels children across all localities in Greater of health in retaining stable and meaningful Manchester . We know that disadvantage employment, makes the work and health starts before birth and accumulates proposal a critical component within our throughout life, so we have developed a population health plan . new care model for early years that focuses on action in pregnancy and the earliest Alongside the influence of meaningful

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The Greater Manchester Population Health Plan 2017 - 2021 work on the mental and physical health of integrated local wellbeing services for those individuals and families, we also recognise people who need a bit more support . the undermining impact of poverty and socio- economic deprivation on health and emotional The final elements of the Live Well programme wellbeing . These inequalities can range from focus on addressing two conditions where greater prevalence of unhealthy lifestyle early identification and treatment can have a choices to poorer access to health and care very positive impact on quality of life, health services, all of which have a negative impact outcomes and life expectancy . These are on health and wellbeing outcomes, leading to HIV and cancer . The link between lifestyle shorter life and healthy life expectancy . Our risk factors and cancer is also very well proposal to create a new model of primary documented, and there is a clear opportunity care for deprived communities seeks to give to make the link between lifestyle and reduced health practitioners the time and capacity cancer risk in later life . to offer greater continuity of care and target 4. Age Well their service towards medical needs more effectively, but also to connect individuals to Greater Manchester is leading the way in its the wider support services in their community efforts to promote healthy ageing, creating that could help make a difference to their a vision for a society where older age is lives . This will include a focus on some of our seen positively and people in later life are most vulnerable groups, including the traveller empowered to secure a healthy future and communities, homeless people, offenders, good quality of life for themselves . Our and asylum seekers and refugees . specific Age Well proposals aim to support people to maintain good health, wellbeing Lifestyle and health behaviour presents one and independence for as long as possible and of the biggest challenges to good health and the programme focuses on interventions that, wellbeing in adulthood and the accumulated when delivered consistently and effectively at effects of those choices contribute scale, will enable this to happen . significantly to the ill health experienced in later life as we age . Our population continues Evidence shows that improving the quality to suffer higher than national instances of and suitability of the home environment heart disease, diabetes and other lifestyle- can be effective in preventing and reducing related illnesses . An important component demand for health and social care . Equally, of our Live Well strategy is therefore to find enabling people to manage their health new and innovative methods to stimulate and care needs can allow them to remain and incentivise healthier behaviours in in their own homes for longer . Creating a adulthood . However, achieving population- home environment that supports people’s scale changes in behaviour, which have often independence – which is often incredibly become normalised over many years, can be important for older people – and remains difficult to achieve quickly and needs different connected to their local community, friends approaches . The programme will therefore and family, also has a positive effect on utilise the natural opportunities in adulthood emotional wellbeing and can reduce the risk and new thinking to stimulate ‘whole system’ of social isolation . approaches to smoking, alcohol, physical We acknowledge that suitable housing activity and obesity . actually benefits all people at every stage of In addition, we will develop digital platforms their life course; however, our evidence to for lifestyle and wellness to support individual date has found that interventions directed behaviour change, and we are working with towards the older population can return localities to develop a set of standards for particular benefits.

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The Greater Manchester Population Health Plan 2017 - 2021 Malnutrition and dehydration are estimated Greater Manchester therefore has the chance to be very prevalent in the older population to take a co-designed approach to radically but are often hidden or unnoticed . Left reframe the role of population health in the unchecked, they can undermine mobility, context of a devolved system, creating a steadiness (leading to falls), healing and unified population health system across recovery, mental alertness and energy levels . 10 localities that is better able to achieve Outcomes are therefore much worse for improved health outcomes for the people of older people who are malnourished and the Greater Manchester . same is true of dehydration . The Age Well programme is therefore focusing on this In addition to creating a unified leadership issue and will work with Greater Manchester system for population health, we need to boroughs to implement community-level, create a unified approach to commissioning locally led programmes of support to improve population health that enables us to awareness and understanding of the impact commission services at the right spatial of malnutrition and dehydration . level, in collaboration with one another, and to improve population health outcomes and Falls are a commonly recognised problem in health inequalities as well as contributing to older age that requires a system response a more sustainable public health, health and to manage and address effectively, but care system . this is also an area where there is a lot of independent evidence of what works . We have a number of programmes of work Fracture liaison services, which identify underway to do this, namely: people at risk of injurious fracture and then ●● the development of a population health co-ordinate services and appropriate care for commissioning plan that brings together the individual, are well evidenced and cost the NHS England commissioning effective and are included in the programme responsibilities set out in Section 7a of the for that reason . Health and Social Care Act 2012, together with local government-commissioned 5. System reform for population health population health services and the new It is clear that an ambition of this magnitude service models set out in this plan around the delivery of the Greater Manchester ●● the development and testing of a proposal Population Health Plan requires the support of for a new Greater Manchester population a population health system that is organised health leadership system serving localities, to deliver at pace and scale . CCGs and Greater Manchester structures that is future-proof and financially We therefore need to build a single population sustainable health system across the Greater Manchester ●● reviewing how public sector spend can economy – one that maximises both the produce a wider benefit to the community impact and the capacities of a small and i.e. the social value benefit to the people specialist public health workforce, but also of Greater Manchester from public sector supports the embedding of the pursuit of commissioning and procurement and population health as being everybody’s maximising the contribution made by the business and sees collaboration across a VCSE sector . range of sectors and wider communities – between NHS organisations, local authorities, the third sector and other local partners, as well as patients and the public working together as population health systems .

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The Greater Manchester Population Health Plan 2017 - 2021 1 .9 Our ‘whole system’ thriving population to economic growth and approach to population prosperity, and, equally, the contribution of economic growth to a healthy population . health Our aim is to ensure we have a mutually Figure 6 sets out our ‘whole system’ approach reinforcing cycle between our growth and to population health, recognising the central health ambitions across all our Greater importance and contribution of a healthy and Manchester plans .

Economic Growth - Public Service Reform

Population Health

Starting Well Community Services

Living Well

New Models of Primary Care Acute and Specialised Services Ageing Well Local Care Organisations

Mental Health Person and Improvements Community Centred Enhanced role Standardisation, consolidation Approaches of Voluntary and Community Sector and improvement of services

Supporting self-care System Reform and role of carers

Figure 6: ‘Whole system’ approach

During 2016 we have: ●● taken a collaborative view on the ●● swiftly set out our five transformation work outcomes we are seeking to achieve programmes – person and community- across Greater Manchester, ensuring centred approaches; Start Well; Live Well; all the work we do is focused on Age Well; and system reform supporting the achievement of the Greater Manchester strategic outcomes that will ●● developed a set of proposals, which we improve the life chances of people in will deliver with the system Greater Manchester . ●● developed programme governance to support decision making and delivery The remainder of this document provides ●● aligned our programme to other a comprehensive delivery plan for those transformation work that forms ‘Taking programmes of work to be led by GMHSC Charge’ Partnership and, where appropriate, signposts to other Greater Manchester-led pieces of ●● built cohesion across the wider public work contributing to population health . service reform programmes, ensuring decisions we take together are cognisant of broader activity across our system

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The Greater Manchester Population Health Plan 2017 - 2021 This plan was constructed by looking at…

1 Taking Charge Findings from consultation with 50,000 Together Greater Manchester residents about how consultation they might better take charge of their own health

2 Quick Wins Opportunities to implement evidence- based local best practice at scale across All principles other parts of Greater Manchester underpinned by the evidence base Common themes An audit earlier this year of locality 3 where possible in locality plans plans highlighted areas for standardised approaches across Greater Manchester or

utilising 4 Economics of The ‘economics of prevention’ work was innovation prevention developed by New Economy Manchester to test new and Public Health England on groups’ approaches to interventions by their gestation or service delivery notional rate of return in order to recognise that dividends for different interventions are likely to be realised over different time periods

5 Work already Work already underway which now underway aligns with the population health themes and programme .

Figure 7: ‘Whole system’ approach

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The Greater Manchester Population Health Plan 2017 - 2021 2. Person and community-centred approaches

Patients, peers and Our starting point is that health and care services need to work communities represent a alongside individuals, carers, families, social networks and thriving huge resource. Whether communities . This means working in ways that are ‘person and in terms of effective community-centred’ – in other words, approaches that put people behaviour change at and communities at the heart of their health and wellbeing . scale, high-quality volunteering, informal We want our health and care system to support people to have networks of care, the knowledge, skills and confidence to play an active role in impactful models of managing their own health and to work with communities and their voluntary sector practice assets . For this vision to become reality, person and community- or growing social centred ways of working need to become widely understood enterprises, there is a and valued as core to the whole health and care system, not just significant opportunity ‘nice to have’ . This requires systematic change in the way people within Greater access, interact with and experience health and care services, and Manchester to support wider support . people living with long- term conditions, prevent 2 .1 Background ill health and reduce The NHS Five Year Forward View sets out how the health service costs. needs to change, and argues for a more engaged relationship between health and care services and patients, carers and citizens . NHS England funded the Realising the Value programme, an 18-month programme led by innovation charities Nesta and The Health Foundation to support this vision . Realising the Value strengthened the case for change, identified evidence-based approaches that engage people in their own health and care, and developed tools to support implementation across the NHS and local communities . Two organisations based in Greater Manchester were involved in Realising the Value, and the findings and tools can be built on to deliver the ambitions set out in this Greater Manchester plan . 2 .2 What are person and community-centred approaches? Approaches that are person and community centred include a very broad range of practice, ranging from ‘more than medicine’ support that complements and enhances clinical care for people with long-term conditions (such as peer support) to everyday community activities that enable people to improve their health and wellbeing (such as a local football team or gardening club) . Many of these activities can be enjoyed and engaged in by all citizens, whether or not they have health conditions . They can happen in formal health and care settings, people’s own homes and in the wider community . 20

The Greater Manchester Population Health Plan 2017 - 2021 Hospital

GP

Formal health and Care and Shared care support decision setting planning making

Social prescribing

Health Centre

Health coaching

Care Home

Self management Support

Personal budgets Community Peer support Centre Health trainees Bridging Volunteer roles health roles Group based Community activities navigators Asset- Health based Champions approaches Community Home

Community Source: Realising the Value hubs Timebanking (2016) Ten key actions to put people and communities at the heart of health and wellbeing

Figure 8: Common examples of person- and community-centred approaches

People can access person and community- ●● Personal budgets: Giving people control centred approaches in a number of ways, over how the money allocated for their such as the following . health and care is spent .

●● Personalised care and support planning: A ●● Social prescribing: People can receive a systematic process in which people with ‘social prescription’ as a way to connect long-term conditions and their carers work to services and groups outside of formal in partnership, very often with health and health or social care . social care professionals, to identify their ●● treatment, care and support needs . Bridging roles, such as health trainers and community navigators: Roles undertaken

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The Greater Manchester Population Health Plan 2017 - 2021 by people, often drawn from the local represent a 7% reduction in A&E attendance, community, who work with individuals to planned and unplanned admissions, and connect them with local services and help outpatient attendances . them to navigate these services . More recently, the Realising the Value Although wide-ranging and varied, these programme has undertaken economic approaches are all focused on genuinely modelling that suggests that implementing putting people and communities at the heart person and community-centred approaches of health . And for years there has been at scale has the potential to contribute to sustained work by many to work in this efforts to slow the demand pressures on way . There is now strong enthusiasm for the system . Realising the Value used this this to become the norm across health and economic modelling to develop a tool for care, rather than the experience of the few . commissioners, to assess the potential impact And there is a growing – and increasingly of commissioning person and community- convincing – body of evidence from research centred approaches in a local area . This will and practice that these approaches lead to help localities within Greater Manchester that better outcomes and significant benefits for want to commission these approaches to individuals, services and communities . build their business case for doing so . 2 .3 The case for investment 2 .4 Approaches that are asset- There is a strong moral and ethical case for based person and community-centred approaches The family of person and community-centred for health and wellbeing: put simply, it is the approaches described above are all asset- right thing to do . It enables people to have a based, or strengths-based . This means they voice, to be heard, to be connected and to have a different starting point to traditional have the opportunity to choose how best to health and care services . Fundamentally, they live their lives, and gives them the support to ask the question ‘what makes us healthy?’ do so . rather than ‘what makes us ill?’

The other key rationale for these approaches Person and community-centred approaches is that they ‘work’. They can lead to significant focus on what is important to people, what benefits for individuals, services and skills and attributes they have, the role of their communities . They can improve individuals’ family, friends and communities and, given health and wellbeing and reduce demand on all this, what they need to enable them to live formal services such as unplanned hospital as well as possible . This includes enabling admissions, and they can also contribute to people to: wider social outcomes such as employment ●● look after themselves better, including and school attendance . understanding their condition, managing There is a clear financial imperative to embed their symptoms and improving their these changes into the fabric of Greater diet, and education tailored to particular Manchester . conditions ●● have meaningful relationships that help In 2013, Nesta’s ‘Business Case for People them improve their health and wellbeing Powered Health’ calculated that the NHS through, for example, peer support could realise savings of at least £4 .4 billion networks and community groups a year if it adopted self-care innovations ●● that involve patients, their families and work collaboratively with professionals, communities more directly in the management such as collaborative consultations and of their long-term conditions . These savings health coaching .

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The Greater Manchester Population Health Plan 2017 - 2021 I understand my situation and can look after myself

I have meaningful relationships with others that help me stay healthy and well

I am working with supportive professionals

Source: At the heart of health; Realising the Value of people and communities (Nesta, 2016)

Figure 9: What defines this way of working

While our health and care system is getting 2.4.1 Co-production, volunteering better at drawing on the strengths and assets and social movements for of individuals and communities to improve health and maintain good health, we know that there The only way to understand and support what is still some progress to be made . matters to people and communities is to work We all have a role in making this happen – with them, in a variety of ways . including community-based and voluntary ●● Carers. We need to recognise and value organisations, faith communities and social the role of carers, who are a huge asset enterprises . Many faith-based groups have and resource; by supporting the lives of long-established traditions of providing social, the people they care for, they sustain and emotional and spiritual support that can be support the wider health and care system . an important part of health and wellbeing, ●● Volunteers. Volunteers are an increasingly and we are committed to working closely with important part of the health and care these groups . Social enterprises play a role in workforce and there is evidence that incubating new ideas in health and wellbeing, high-quality, well-supported volunteering and in some cases work with people to build can benefit patients and health and care their confidence and capability to get back services, as well as having reciprocal into work . benefits for people who volunteer.

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The Greater Manchester Population Health Plan 2017 - 2021 ●● Co-production. The most successful long-term condition, and this number examples of person and community- is increasing . People within this cohort centred approaches in practice are are often frequent users of health those developed by people and services, accounting for 50% of all GP communities, working with and alongside appointments and 70% of all inpatient bed commissioners and policymakers, to co- days . design and co-deliver solutions that work . ●● Around 70-80% of all people with long- Support and training is needed to support term conditions would benefit from good co-production . support to manage their condition(s) . ●● Social movements. Social movements ●● While we often provide great care, at times happen when people come together to we focus on people’s problems rather than fight for their rights, solve problems, shift looking to their capabilities and resources . how people think, support each other ●● Too many people are going into residential and demand what they need . There are and nursing care, particularly from incredible stories in health of the power hospital, in part because of a lack of clear of passionate people working together and planned alternatives . to drive change . For example, over the ●● Earlier, community and family-based last few decades the disability rights support could help people to maintain and movement and HIV/AIDS campaigns improve their health and wellbeing . have challenged social attitudes and have transformed the way the health Greater Manchester has a rich history system responds to these issues . The of working in these areas and has many breast cancer movement has addressed examples of best practice that could be the deep cultural stigma associated with drawn on, such as those below . the disease, given women the words to explain their experiences, and changed 2.5.1 The Wigan Deal the culture of care . The value of people The Wigan Deal has been successful in taking getting involved in social movements in forward a community-centred approach . this way was recognised in the NHS Five Driven by the critical need to find fiscal Year Forward View . savings, Wigan proposed ‘The Deal’ with its residents and businesses, creating an 2 .5 Greater Manchester context informal agreement that through cooperation We want to enable more people to take has addressed the financial pressures control of their own health and wellbeing, while improving resident collaboration and and to help others within their communities engagement in the use and delivery of to do the same . In ‘Taking Charge’, we set services . out our view that changing the relationship between people and public services is vital 2.5.2 People Powered Health in if we are to enable people to prevent and Stockport manage long-term health conditions, maintain Stockport has demonstrated the potential of their independence, improve their health and mobilising communities to help deliver care wellbeing and, in doing so, live happier and over a number of years, embarking on an healthier lives while also reducing demand on ambitious programme as a selected vanguard services . site to include social action at the core of the developing new care model . The Stockport We know the following . approach has four core strands . ●● Over 560,000 people (30%) of adults in Greater Manchester have one or more

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The Greater Manchester Population Health Plan 2017 - 2021 ●● Workforce and organisational culture: 2.5.4 Realising the Value Adopting person-centred practice within a Realising the Value was a programme funded strengths-based approach, working with by NHS England to enable the health and people and communities to co-design care system to support people to have the solutions to meet rising demand . knowledge, skills and confidence to play an ●● Develop place-based health and active role in managing their own health and community networks of support: Bridging to work with communities and their assets . the health and care service model to the At the heart of the programme were five sites communities in which people live to grow that exemplify the best of approaches of more resilient communities with access to this kind . Two of these sites were in Greater targeted prevention . Manchester: ●● Promote social action/health as a social ●● Unlimited Potential with Inspiring movement: Recognise and include the Communities Together: Unlimited resource of the people both within and Potential works to deliver, with local outside of the system as part of the people, a range of asset-based solution . approaches in a health and wellbeing ●● Commission differently: Alignment and context in Salford, such as ‘Salford collaboration over cost and competition as Dadz’ – finding new ways to improve the primary drivers . wellbeing of fathers experiencing severe and multiple disadvantages Stockport is a national exemplar in this ●● Big Life Group with Being Well Salford: area, particularly in terms of being a model Big Life delivers health coaching to of social action led ‘from the inside’ – from anyone who wishes to make changes to commissioning teams themselves . Stockport two or more of their lifestyle behaviours; is currently working to spread the learning this includes low mood, isolation and from its approach more widely . anxiety . 2.5.3 Health as a Social Movement 2.5.5 People Powered Results and NHS England’s Health as a Social Elective Care Rapid Testing Movement programme aims to support (ECRT) programme social movements in health and care, and is currently working with six new care model NHS England and Stockport Together vanguards, two of which are in Greater worked with Nesta on a 100-day innovation Manchester: programme to improve elective care . The programme aimed to test ways of improving Stockport Together (multispecialty community patient experience of, and speeding up provider), which aims to support social access to, elective care, by better managing movements in Stockport, Oldham and demand . Challenge focus areas included Tameside boroughs and across Greater gastroenterology, cardiology and respiratory, Manchester, building on the People Powered and orthopaedics . Teams were made up of Health programme to ‘hard-wire’ social action representatives from across the health and into a transformed health and care system care system, including GPs, consultants, nurses, VCSE representatives, mental health The Greater Manchester Cancer Vanguard, professionals and representatives from the which will apply at scale a multi-faceted council and social care . approach to nurture a social movement across the entire cancer prevention spectrum that is ultimately self- sustaining .

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The Greater Manchester Population Health Plan 2017 - 2021 2.5.6 Arts, health and social action organisational and clinical processes; Greater Manchester has a long history workforce development; and the relationships of interest and action in arts and health . between clinical professionals and the people Engaging in arts activity can help people and communities they serve . to make social connections, enable self- Putting people and communities genuinely in expression, create the conditions for social control of their health and healthcare requires action and enable people to have more power a shift away from a traditional biomedical over their lives . We intend to position the model of health towards a model that takes strong inter-relationship between arts and into account the expertise and resources of individual and community health as one of people and their communities . In order for the key foundations of building sustainable this shift to happen, we will need to support a and resilient communities across Greater cultural shift across the system and underpin Manchester . As part of the next iteration of this with a willingness to identify and ‘unblock’ the Greater Manchester Population Health system barriers and engage system levers at Plan we are committed to further developing both a Greater Manchester-wide and a locality a programme of activity on arts in healthcare level . and social care, and in social action on wellbeing, and aim to embed this approach By engaging differently with the people we in commissioning of health and social care serve, we can start to learn what resources, services and commissioning for wellbeing in physical and social, are available to support Greater Manchester . this agenda . We can identify and better support grassroots initiatives through different These activities are further strengthened with commissioning processes . We can help to a well-developed, varied and diverse voluntary build links to better utilise available assets . sector in each area and various Greater And we can learn from carers, patients, Manchester umbrella organisations . families and volunteers what more we can do Our challenge now is to make this form of to support them to start, live and age well . engagement between the public and public A further opportunity that GMHSC Partnership services a common and defining feature has begun to explore is the contribution of across the whole of Greater Manchester . housing and the home environment to asset- based working and our people and place- 2 6. Opportunity based agenda . Evidence suggests that the The capabilities of the public are right home environment can: improve health extraordinary; they understand communities’ and wellbeing and prevent ill health; enable needs and can identify solutions because people to manage their health and care they are those communities; they are experts needs; and allow people to remain in their of experience . In Greater Manchester we own homes for as long as they choose . This recognise their support is ‘mission critical’ to area of work will be developed more in our developing a sustainable health and social next iteration of the population health plan . care system and culture that delivers for all . 2 .7 Plan We want to work with our partners across the system, including the VCSE sector, A radical upgrade in population health brings to implement high-impact person and with it a need for radical action and solutions community-centred approaches at scale – one of which is, as we have described, to across Greater Manchester . Delivering this shape a new relationship with the people of will require changes in: commissioning; Greater Manchester .

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The Greater Manchester Population Health Plan 2017 - 2021 The VCSE sector will play a central role in the The project will seek to: leadership and delivery of this project . We ●● identify a group of ‘explorers/enablers’ want to mobilise communities and networks who can help to seek out the best practice to support people on their terms . This will and strengths to build capacity and complement medical care by developing sustainability from the start an infrastructure to reliably and consistently ●● develop an offer for explorer roles to skill deliver social models of support to enable them to do this work people to live better . ●● bring together the organisational The Public Health England (PHE) 2015 report development community across health ‘A guide to community-centred approaches and social care in Greater Manchester to for health and wellbeing’ emphasises that: act as a network of supporters . “Community engagement is more likely to ●● provide tools and resources to assist require a ‘fit for purpose’ rather than ‘one places to understand the conditions for size fits all’ approach.” This is crucial for success and assess readiness how we deliver across Greater Manchester, ●● build a menu of development programmes recognising that the form and function of and tools to support shared decision our plan must allow the local flexibility that making, strength-based conversations, responds to the specific characteristics of quality improvement, team coaching each local community . and consultancy support, which support 2.7.1 Objectives systems to understand which approaches are likely to be most effective and in what A number of objectives have been identified circumstances at a Greater Manchester level to support ●● build place-based support teams and a the development of person and community- network of skilled facilitators/enablers to centred approaches locally . These include: support places ●● Objective 1: To help build capability and ●● develop system capacity through capacity within localities, recognising approaches such as ‘skills pools’ and the need for a consistent approach while ‘time banks’ . allowing sufficient flexibility for localisation ●● Objective 2: To build a Greater Objective 2: To build a Greater Manchester Manchester framework for person and framework for person and community-centred community-centred approaches approaches . ●● Objective 3: To support a strong system This project will seek to: leadership commitment to the approach ●● map and capture existing practice on ●● Objective 4: To work as part of NHS asset-based approaches across Greater England’s Health as a Social Movement Manchester national exemplar programme to test and ●● bring together the 10 localities across spread effective ways of mobilising people Greater Manchester to share best practice in social movements that improve health within a system-wide learning event outcomes . ●● define key principles to develop a Greater 2.7.1.1 Approach to delivering Manchester framework for action that objectives describes consistency of approach, including evaluation Objective 1: To help build capability and capacity within localities, recognising the ●● develop a platform to enable localities need for a consistent approach while allowing and local and national partners to connect sufficient flexibility for localisation. with Greater Manchester against an

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The Greater Manchester Population Health Plan 2017 - 2021 agreed framework that provides some To develop a network of 20,000 cancer consistency of approach champions by August 2019 . ●● gain agreement from the system to adopt ●● Work in partnership with the third sector and implement the framework to develop an exemplar social movement, ●● launch the framework to cement support focused on cancer prevention . across the system for this way of working ●● Apply at scale a multi-faceted approach with people and communities to nurture a citizen-led social movement ●● from the evidence, identify existing and across the entire cancer prevention exemplar communities that offer the spectrum . potential to invest and build a network of ●● Develop a network of 20,000 cancer best practice champions and expert patients to provide ●● develop a network of delivery leads with a ‘more than medicine’ approach . third sector partners to test and spread ●● Demonstrate ‘what works’ using rigorous innovative solutions . evaluation approaches . ●● Support spread by identifying approaches Objective 3: To ensure a strong system that could be scaled or adapted and leadership commitment to the approach . adopted in other communities . This project will seek to: ●● work with the VCSE sector in Greater 2.7.1.2 Target outcomes for 2016/17 and Manchester to co-produce the leadership 2017/18 model for this work The programme will work towards achieving ●● work with system leaders to sign up to a five key outcomes: statement of commitment to demonstrate ●● Outcome 1: Localities have more local strong support to self-care/person and capability, appropriate for their needs and community-centred approaches assets ●● work with system leaders to develop a ●● Outcome 2: A Greater Manchester road map to delivery that will feed into the framework for action agreed by system framework for action leaders to support local implementation, ●● connect with work underway through the building on work already underway in each Greater Manchester leadership framework, locality the nine leadership expectations and the ●● Outcome 3: An agreed roadmap wider Greater Manchester workforce, for delivery with strong leadership enabling work to inform the development commitment to deliver of the existing and future workforce . ●● Outcome 4: The development of a mass social movement across the entire cancer Objective 4: To work as part of NHS prevention spectrum that is ultimately England’s Health as a Social Movement self-sustaining, to include an army of national exemplar programme to develop, cancer champions networking across the test and spread effective ways of mobilising conurbation, driving the cancer prevention people in social movements that improve agenda health outcomes . ●● Outcome 5: Digital opportunities tested and evaluated

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The Greater Manchester Population Health Plan 2017 - 2021 2.7.1.3 Programme of work – scope This programme will work with system leaders from across Greater Manchester and partner organisations, including the VCSE sector, to influence and support ways of working at locality level . With an initial focus on asset- based approaches, it has the potential to develop and spread across wider reform and at all levels of the system .

The scope of the social movement work specifically includes all people of Greater Manchester, community groups, charities and volunteers linked to cancer-related activities . The project will also need to connect to Greater Manchester’s broader communications work and the digital platform work linked to the proposed Greater Manchester Lifestyle Hub . Similarly, it has the potential to link to the wider Greater Manchester Cancer Vanguard prevention projects, including the lifestyle-based secondary prevention work, the large-scale social marketing project, and the enhanced screening offer for Greater Manchester residents .

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The Greater Manchester Population Health Plan 2017 - 2021 3. Start Well

One of the most important The aim of the Start Well programme is to deliver integrated foundations for building early intervention and prevention services across all localities caring, productive and in Greater Manchester . We know that disadvantage starts healthy families and before birth and accumulates throughout life so we have communities is the developed a new care model for Early Years that focuses action nurturing of children in early in pregnancy and the earliest years of life to give us the best life. In other words, helping opportunity to successfully reduce health, educational and children to get a better social inequalities . Greater Manchester is leading the way in start is good for them and efforts to prioritise Early Years with significant progress see good for all of us. We are across all 10 localities . all instinctively motivated to care for and protect 3 .1 Background our children and promote their future wellbeing. This It is much more difficult and costly to repair the damage motivation is increased done by child maltreatment in later life than to prevent it during pregnancy and when during the Early Years . It is estimated that 40% of public a child is most dependent funds are currently being spent on problems that could have in early life. However, been prevented earlier . People who suffer adverse events in sometimes this motivation childhood achieve less educationally, earn less, and are less can be missing or frustrated healthy, making it more likely that the generational cycle of as a result of internal inequality is repeated . factors such as mental health problems or external The Marmot Review report ‘Fair society, healthy lives’ (2010) factors such as poverty. recommended that ‘giving every child the best start in life’ was We need to connect to the the highest priority to tackle health and social inequalities . In deep motivation of parents 2013, the WAVE Trust report, ‘Conception to age two – the and provide extra support age of opportunity’, agreed that the Early Years are the crucial to parents when this is phase of development and the time when early intervention challenged. will reap great dividends for society . The way in which we support very young children (0-2 years) shapes their lives and ultimately our society . These reports clearly identify the window of opportunity from pregnancy to age five that establishes the foundations for life, including physical and mental health, social and communication skills, behaviour and future academic success . Indeed, it is not an exaggeration to say that the prosperity of Greater Manchester is dependent on our ability to support the development of the very young much more effectively .

We know that investing in early education is vital to addressing the social gradient in children’s positive early experiences . Studies have shown that, by age three, children from low- income families are exposed to an average of 30 million fewer words than children from the most affluent families. Children within affluent families also hear twice as many unique words and twice as many ‘encouraging’ as ‘discouraging’

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The Greater Manchester Population Health Plan 2017 - 2021 3. Start Well

conversations . This work highlights the impact of savings to the public sector will importance of integrating early education be realised up to 10 years after the Early services and that later interventions, although Years period . In the longer term, a failure to important, are considerably less effective effectively intervene to address the complex where good early foundations are lacking . needs of an individual in early childhood can result in a nine-fold increase in direct public Early Years investment is proven to be the costs. Significantly, the organisations that best route to overcoming intergenerational benefit most from the interventions are not inequalities . Figure 10 illustrates the rates the organisations that traditionally fund the of return on investment for education and services . Devolution arrangements provide an training over a person’s working life . The opportunity to address this . The devolution earlier the investment is made, the higher the commitment to integrated partnership return on this investment . working provides significant incentives to A great deal of work has been undertaken invest in transformational reform, removing in Greater Manchester to understand the those barriers that precluded investment in costs and benefits of intervening in the Early preventive approaches, particularly those Years . This work shows that while there will where investments provided benefit to other be significant short-term gain, the principal agencies .

Figure 10: The Return on investment over a life time by education and training

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The Greater Manchester Population Health Plan 2017 - 2021 Every £1 invested in quality early care and education saves taxpayers up to £13 in future costs .

For every £1 spent on early years education, £7 has to be spent to have the same impact in adolescence .

Source: Centre for Research in Early Childhood (2013) The impact of early education as a strategy in countering socio-economic disadvantage Figure 11 Impact of investing in early years

3 .2 Greater Manchester context necessary to negotiate early childhood and flourish in primary and secondary school, We want every child in Greater Manchester further education and employment . to have the best start in life . This means that every child grows up in an environment that In Greater Manchester we have set ourselves nurtures their development, derives safety an ambition of supporting every child to and security from their parents/care givers, reach a good level of development (GLD) and can access high-quality Early Years services closing the gap between Greater Manchester and has a belief in their goals and their ability and England . Table 2 sets out percentages to achieve them . Our ambition is that every of children reaching a GLD at age five for the child in Greater Manchester acquires the skills period 2013 to 2016 .

% achieving a good level of 2013 2014 2015 2016 development (GLD) Bolton 48 54 61 65 Bury 51 56 66 69 Manchester 47 53 61 64 Oldham 41 52 57 61 Rochdale 42 50 57 63 Salford 53 57 61 65 Stockport 54 62 68 69 Tameside 42 52 58 63 Trafford 61 69 73 73 Wigan 38 55 64 67 ENGLAND 52 60 66 69 North West 50 58 64 67 Greater Manchester 47 56 62 66 Table 2: percentage of children reaching a GLD at age five for the period 2013-2016

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The Greater Manchester Population Health Plan 2017 - 2021 Table 2 shows that GLD for Greater performance and the national average for the Manchester in 2016 is 66% compared to 69% following selected outcomes: nationally . However, nearly one in every two ●● to improve the percentage of children children in receipt of free school meals is not achieving a GLD at the end of the Early reaching a GLD . Raising overall attainment Years Foundation Stage for the most disadvantaged and vulnerable ●● to increase the percentage of children groups of children is a challenge for every achieving age-related expectations at locality; however, we are encouraged by the 2-2½ years (measured using the ‘Ages fact that the gap between Greater Manchester and Stages Questionnaire’ (ASQ 3) and the England average has reduced from ●● 5% to 3% over the period . to increase the percentage of two- and three-year-old children who take up their 3 .3 A new model of care for free entitlement in schools and settings that are judged ‘good’ or ‘outstanding’ Early Years by Ofsted (with a particular focus upon At the heart of the health and social care vulnerable groups) reform ambitions is the recognition that we ●● to improve the percentage of children in need to see a significant shift in activity; receipt of free school meals who achieve shifting the balance from reactive, crisis a GLD at the end of the Early Years services to preventative services that help Foundation Stage reduce escalation of need . The Start Well ●● to reduce the number of full-term babies Early Years Strategy was approved by the with a low birth weight Greater Manchester Strategic Partnership Board in June 2016 and sets out the Greater ●● to increase breastfeeding rates at 6-8 Manchester vision for transformational system weeks change and a long-term and sustainable shift ●● to reduce the rates of smoking at time of from expensive and reactive public services to delivery prevention and early intervention . The strategy ●● to reduce levels of overweight and obesity aims to reduce duplication and make more at age 4-5 years efficient use of resources to achieve better ●● to reduce the number of decayed, missing outcomes wherever possible within existing and filled teeth in children aged five budgets, including a vision for integrated ●● to reduce attendance at Accident and leadership, commissioning and delivery . Emergency for children aged 0-4 years The need for targeted and specialist services ●● to protect vulnerable children and families is acknowledged; however, the strategy by ensuring that all general practices recognises the requirement for a core meet national targets for childhood universal offer to all Greater Manchester routine vaccinations and pre-school flu families in the Early Years to identify abuse, vaccinations neglect, developmental delay, and special ●● to improve parent and infant mental health educational needs and/or disability at an early ●● to safely reduce the number of looked- stage to ensure swift access to support and after children (LAC) . interventions . The overall objective of this work is to 3 .4 Opportunity increase the number of Greater Manchester The Greater Manchester devolution children who are school ready, and over agreement, the transfer of health visiting the next five years we intend to close the and Family Nurse Partnership (FNP) gap between current Greater Manchester commissioning to local authorities, free early

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The Greater Manchester Population Health Plan 2017 - 2021 education places for disadvantaged two-year- year . Take-up of two-year-old places across olds, the Early Years pupil premium grant, the 10 localities varies, with an average the Greater Manchester Children’s Services 71% of eligible children taking up their free Review and the development of integrated entitlement across Greater Manchester with a services for 0-19 years present a golden local variance of 63-85% (2015) . window of opportunity to ensure a concerted approach to improving child development . The Greater Manchester Early Years delivery model presents a unique opportunity to To reduce the steepness of the social develop system-wide transformation that gradient in child development, actions must supports a sustainable shift from expensive be universal, but with a scale and intensity and reactive public services to prevention and that is proportionate to the level of need . early intervention . The model aims to reduce The universal components of the Greater duplication and variation and achieve better Manchester Early Years Delivery Model outcomes within existing budgets; however (EYDM) were fully implemented prior to the the challenge of implementing the Early transfer of the commissioning responsibility Years model at scale alongside diminishing for health visiting to local government in in local authority budgets is recognised and October 2015 . Numbers of health visitors in understood . Greater Manchester rose by 57% between 2013 and 2015, with substantial increases in 3.4.1 Programme of work – scope the delivery of evidence-based assessments The Greater Manchester EYDM is an ongoing and an additional 40% investment of £13 universal and targeted pathway based on million from NHS England . During the same consistent, integrated age-appropriate period FNP programmes were implemented in assessment measures promoting early every Greater Manchester locality, increasing intervention and prevention, implemented access by almost 300%. Significant workforce through assertive outreach and improved transformation to identify need earlier has also engagement with families with young children been delivered . This increase was urgently from pre-birth to school . Assessments will required to meet universal requirements; be evidence-based, timely and ongoing from however, there is still a significant amount of pre-conception to five years (see diagram unmet need in localities . A self-assessment below) . Services will identify needs early and undertaken within localities has identified intervene effectively to minimise the escalation that each locality is well placed to build of need . This is reinforced by a series of upon this strong foundation by implementing evidence-based interventions supporting the evidence-based targeted interventions short and long-term benefits. Implementation identified as part of the Greater Manchester of the EYDM has progressed at different rates Early Years delivery model . across all areas of Greater Manchester .

There have been significant changes to There is a requirement to focus on the provision of free early education during remodelling existing Early Years services the last three years, including new places within budgets that are under pressure . This for two-year-olds and an Early Years pupil requires new multi-agency delivery models, premium for the most disadvantaged three reducing commissioned activity with no and four-year-olds . Since September 2014, evidence base, and moving public sector 55% of two-year-olds in Greater Manchester money associated with poor outcomes have been entitled to 15 free hours of free into programmes that rapidly improve the early education per week for 38 weeks of the performance across Greater Manchester .

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The Greater Manchester Population Health Plan 2017 - 2021 The Greater Manchester Early Years Delivery in receipt of a proportionate multi-agency Model comprises three key components: tailored response relevant to their level of need . The EYDM has the full engagement 1 . an eight-stage assessment pathway (see of all authorities but commissioning, service below) delivery and provision remain inconsistent 2 . a range of multi-agency pathways across Greater Manchester, with progress 3 . a suite of evidence based assessment hard to evidence . To increase momentum tools and targeted interventions . there is a need to develop a new approach to commissioning Early Years services across When the EYDM is fully implemented across Greater Manchester, specifically integrated Greater Manchester to a standard of the commissioning of the Greater Manchester highest performing localities, families will be EYDM .

Figure 12: Greater Manchester eight-stage pathway

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The Greater Manchester Population Health Plan 2017 - 2021 Figure 13 below sets out the universal, targeted and locally determined components of the Greater Manchester Early Years delivery model of integrated provision .

1: Core model elements 2: Core model elements 3: Core model elements Universal entitlements within Evidence-based targeted Evidence-based targeted ALL localities interventions/entitlements interventions/entitlements within ALL localities within ALL localities Use of agreed evidence-based Use of agreed evidence-based universal assessment tools (e g. . targeted assessment tools ASQ3, EPNDS) Greater Manchester 8-stage New Delivery Model assessment pathway Maternity services Family Nurse Partnership High-needs pathway for vulnerable pregnant women requiring intensive Core Greater Manchester offer: support, including pathway for including stopping smoking in pregnant teenagers not accessing pregnancy, PIMH pathways FNP . Antenatal and Newborn Screening Specialist screening and intervention Unicef Baby Friendly Initiative: Breastfeeding support (best Acute, Community, Neonatal Units practice = peer support service) and Children‘s Centres Health Visiting core offer Health Visiting targeted / early help offer Childhood routine immunisations BCG vaccination Free early education entitlement for Free early education entitlement for Communication -friendly all 3 and 4 year olds . the most disadvantaged environments / Raising Early Achievement in Literacy (REAL) Speech , Language and Well-Comm Parent and Child Interaction Communication programmes and / Therapy / Elklan / initiatives (Greater Manchester Communication-friendly intervention pathway to be ratified). environments Evidence- based parenting Incredible Years Baby (0-1 Bm) Solihull Parenting Groups / programmes, including Solihul Incredible Years Toddler Family Partnership Model approach (18m-30m) / Baby Steps antenatal Greater Manchester antenatal programme / Mellow Parenting Incredible Years Pre-school parent preparation guidance and / Perinatal PEEP / Triple P / (30m-7 years) classes Baby Links Nurturing / Video Interactive Guidance Children ‘s Centre core offer Children ‘s Centre targeted offer Communication-friendly environments PIMH & Attachment (Greater Neonatal Behavioural Assessment Manchester intervention pathway Scale to be ratified) Neonatal Behavioural Observation

Figure 13: Early Years delivery model

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The Greater Manchester Population Health Plan 2017 - 2021 The Greater Manchester EYDM will require universal carbon dioxide (CO2) monitoring integrated commissioning arrangements to at antenatal booking . Across Greater include a local commitment to commission Manchester the implementation of CO2 and deliver all core model elements (1) and monitoring is variable . (2) within each locality, delivered by multi- disciplinary integrated teams . If evidence- Smoking cessation services are based local targeted variations are in place commissioned by local authority public it is recognised that there may be a desire health teams on behalf of their populations . to retain these at the expense of specific Localities can have several providers of core model elements (2); the model intends maternity services, which may not be to support this flexible approach. Examples commissioned by coterminous CCGs . of these are listed within local elements (3) . Initiatives such as the Saving Babies’ Significantly, any services agreed as core Lives care bundle provide opportunities for components (1) and (2) of the model should collaborative commissioning approaches . not be decommissioned at a local level . A single Greater Manchester evidence- based pathway for stopping smoking in 3 .5 Smoking in pregnancy pregnancy is needed to support systematic collaboration between CCG commissioners, Smoking is ‘the single biggest modifiable risk local authority commissioners and maternity factor for poor birth outcomes and a major service providers to ensure consistent high- cause of inequality in child and maternal quality provision and access across Greater health outcomes’ (NHS England National Manchester . Maternity Review, 2016) . A recent North West review that focused on child deaths 3 .6 Better oral health under one year identified that smoking was Good oral health in children means freedom the most prominent modifiable risk factor from pain and discomfort, confidence associated with infant mortality . A concerted, to smile, talk and socialise without collaborative effort to reduce smoking in embarrassment, to attend school and pregnancy will save babies’ lives, improve be ready to learn . It also means that the childhood development and narrow health requirement for urgent or routine clinical care and social inequalities . is greatly reduced . The most common reason Parental smoking quadruples the chance for young children to be admitted to hospital of children becoming smokers . A system- is for the extraction of decayed teeth, with wide approach to smoking cessation in many also attending A&E due to dental pain . pregnancy to target the most vulnerable will Improved clinical care pathways would mean lay the foundations for securing a smoke-free that many children who may ultimately receive environment not only in pregnancy but for general anaesthetic for dental treatment children throughout their childhood years . would be cared for through appropriate early Smoking prevalence in the under-20s is intervention within primary care . reported to be two to three times higher than To achieve the fastest improvement in the overall rates, and this translates through into oral health of young children we need to higher smoking rates among young mothers . implement a co-ordinated programme of The identification of women who are smoking universal and targeted interventions across at their booking visit is key if services are Greater Manchester . There is a strong going to be able to support a woman to quit evidence base for population-level oral health smoking . The NHS England ‘Saving Babies improvement interventions employing a range Lives Care Bundle’ guidance recommends of measures, at scale, to achieve maximum

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The Greater Manchester Population Health Plan 2017 - 2021 population coverage and reduce inequalities . addition, there are marked inequalities both The current cost to the Greater Manchester within and between localities, ranging from health system of treating tooth decay in 50% in Oldham, to 22% in Stockport . Due children is approximately £19 million per year . to persistently high levels of tooth decay in Enabling the most effective use of resources five-year-olds, Oldham, Salford, Rochdale and to support evidence-based programmes Bolton have recently been highlighted as four will require bold decisions to decommission of the 13 ‘priority areas’ for child oral health in activities that are not supported by the England . evidence base . In order to reduce tooth decay in five-year- When oral health is poor, children experience olds to the England average within five years, pain, infection, sleepless nights and absence we need to ensure the following . from education that affect their ability to learn, thrive and develop . Parents must also take 1 . Oral health is on everyone’s agenda: Our time off work to care for their children . Tooth ambition is that every child in Greater decay is strongly associated with deprivation Manchester has accessed preventively- and chaotic lives, with some of the most focused dental services by the age of vulnerable children facing very poor oral 12 months . To achieve this we need health . Risk factors include poor nutrition, greater integration between Early Years high consumption of sugar and lack of access services and dental services, with clear to fluoride due to starting toothbrushing late pathways to support facilitated access to or infrequently . professionally delivered prevention and early intervention . In 2015, 36% of Greater Manchester five- year-old children had experienced tooth 2 . The Early Years workforce has access to decay, compared to 27% in England . In evidence-based oral health improvement training .

Figure 14: Clinical effectiveness of oral health initiatives

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The Greater Manchester Population Health Plan 2017 - 2021 3 . Oral health data and information is used to and delivering a sustainable mental health the best effect by all stakeholders . system in Greater Manchester, requires simplified and strengthened leadership and 4 . Population-level oral health improvement accountability across the whole system . interventions that have the strongest The Greater Manchester stakeholder survey evidence base are delivered at scale . for the Greater Manchester Mental Health 5 . Child oral health improvement is Strategy reported that mental health should communicated effectively: Opportunities be embedded within the school curriculum as are identified to communicate oral part of a wider health and wellbeing approach health information as part of broader in schools . There is a requirement for every communications . school and college to identify when a young person may be struggling and to intervene 3 .7 Developing Well (5-25 years) early and effectively to nurture and support young people’s mental health and resilience, While Greater Manchester is taking a focusing on key attributes such as self- pioneering approach to prioritising the Early esteem and empathy . This is vital as 75% Years, we acknowledge the requirement of all adult mental health problems start by to address population health challenges in the age of 18 and only 25% of young people children and young people aged 5-19 years . with mental health problems get access to Scoping the requirements for 5-25 year olds the right support . Improving child and adult will require significant partnership working and mental health, narrowing social, educational engagement with schools, further education and health inequalities, and ensuring parity of and higher education establishments and the esteem with physical health is fundamental to community and voluntary sector . We intend the overall future health and wellbeing of our for this work to be incorporated into phase communities . two of the population health planning process . This will be captured under the theme of To support this we have drafted five Developing Well . Initially, we will champion key asks of schools, colleges and the aspirations of the Greater Manchester universities to support the establishment Children’s Services Review led by the Greater of Greater Manchester standards for local Manchester directors of children’s services . implementation . These are: The review aims to support the development 1 . encouraging young people to develop of a clear Early Help offer for 5-19 year olds healthy lifestyles in all Greater Manchester localities that 2 . supporting young people (and their helps children and young people achieve families) in developing core resilience to better outcomes and reduces demand for tackle problems and face issues targeted and specialist services . Further work is required to establish the key priorities for 3 . working with other community young people aged 19-25 years; the initial organisations to provide a strong support area of focus will be on young people who network for children and young people remain within education . 4 . being a good employer in proactively supporting the health and welfare of staff Mental health and wellbeing is a key priority 5 . getting involved in Greater Manchester across GMHSC Partnership, where it is a work on health and care of young people, cross-cutting theme across all workstreams . so that they can benefit from best practice The implementation of this workstream will be and mutual support across the region . delivered via the Greater Manchester Mental Health Strategy . Shifting the focus of care to prevention, early intervention and resilience,

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The Greater Manchester Population Health Plan 2017 - 2021 3.7.1 Plan 3.7.1.2 Approach to delivering objectives 3.7.1.1 Objectives Objective 1: Implement the core elements of It is now well understood across Greater the Greater Manchester Early Years model Manchester that investing in new models within all 10 Greater Manchester localities . for Early Years services is the right thing to do from a moral, economic, financial, The programme will seek to: performance and resilience perspective . ●● identify local gaps in the delivery of the The next stage of the work will seek to give Early Years model and develop locality confidence to system investors that the Early implementation plans Years model will deliver improved outcomes . ●● formulate investment proposals to pursue ●● Objective 1: Fully implement the core and agree funding options elements of the Greater Manchester Early Years delivery model within all 10 Greater ●● update the cost benefit analysis model Manchester localities . ●● undertake a commissioning options ●● Objective 2: Develop a sustainable, appraisal resilient and consistent set of Greater ●● develop an engagement strategy around Manchester interventions to stopping achieving the aspiration of the Start smoking in pregnancy . Well Early Years Strategy. Specifically, it ●● Objective 3: Develop information will seek to scope the vital contribution management technology (IMT) proposition of schools, community and voluntary to improve data processes to track organisations and a public health progress and allow earlier intervention . maternity workforce in achieving the objectives of the Start Well Early Years ●● Objective 4: Implement evidence- Strategy . informed interventions at scale in a targeted and consistent manner across Objective 2: Develop a sustainable, resilient Greater Manchester to improve oral health and consistent Greater Manchester approach and reduce treatment costs within 3-5 to stopping smoking in pregnancy . years . The programme will seek to: ●● Objective 5: Develop a clear Early Help ●● scope current approaches to offer for 5-19 year olds in all Greater commissioning stop smoking services in Manchester localities that helps children pregnancy and young people achieve better outcomes and reduces demand for ●● review the evidence and formulate targeted and specialist services . This sustainable investment proposals objective will be delivered via the Greater ●● commission a Greater Manchester Manchester Children’s Services Review approach to stop smoking services in led by Greater Manchester directors of pregnancy to ensure consistency . children’s services . Objective 3: Develop IMT proposition to ●● Objective 6: Develop a consistent Greater improve data processes to track progress and Manchester approach to improving allow earlier intervention . the mental health and wellbeing of children and young people in education . The programme will seek to: This objective will be delivered via the ●● work with the Greater Manchester- implementation of the Greater Manchester Connect data and information programme Mental Health Strategy .

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The Greater Manchester Population Health Plan 2017 - 2021 to identify the potential scale, impact and ●● evaluate the effectiveness of a programme efficiency savings promoting attendance at local dental ●● explore the opportunities identified within practices before a child’s first birthday. capturing data, storing data and sharing This programme will involve partnership data working between health visitors and local dental practices to promote delivery ●● identify localities to test a proof of concept of evidence-based prevention . This ●● develop a Greater Manchester model programme will be tested and evaluated that will realise efficiencies and enable in priority localities where levels of the workforce to spend more quality time dental decay in young children remain working with families . consistently high . Objective 4: Implement evidence-informed Objective 5: Develop a clear Early Help offer interventions at scale in a targeted and for 5-19 year olds in all Greater Manchester consistent manner across Greater Manchester localities that helps children and young to improve oral health and reduce treatment people achieve better outcomes and reduces costs within 3-5 years . demand for targeted and specialist services . The programme will seek to: This objective will be delivered via the Greater Manchester Children’s Services Review led ●● commission a co-ordinated oral health by Greater Manchester directors of children’s improvement programme across all of services . Greater Manchester that focuses on increasing access to fluoride via: The programme will seek to: • supervised brushing in all Early Years ●● develop a Greater Manchester integrated settings health and Early Help strategy • promotion of brushing with fluoride ●● engage a wide range of key stakeholders toothpaste in the home environment via around the development and ‘take home’ packs and information implementation of the strategy and what it • toothpaste distribution by health visitors means for their organisation and school nurses as part of the checks ●● develop locality implementation plans to undertaken in the 0-5 year old age meet the objectives of the strategy . groups Objective 6: Develop a consistent Greater ●● ensure that child oral health is seen as Manchester approach to improving the mental everyone’s agenda, with child oral health health and wellbeing of children and young improvement messages communicated people in education . effectively by all stakeholders Via the implementation of the Greater ●● create links between Early Years and Manchester Mental Health Strategy the dental services, in order to facilitate programme will seek to identify opportunities access to preventively-focused dental to: care for all Greater Manchester infants by the age of 12 months . This will be ●● implement mental health-promoting achieved by a programme of training and activities for children and young people updates to all key health and Early Years integrated into normal school life staff across Greater Manchester

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The Greater Manchester Population Health Plan 2017 - 2021 ●● introduce mental health promotion and mental health issues into the school policy and mandatory curriculum subjects

●● offer mental health liaison at all Greater Manchester schools, providing support for teachers when working with children and young people at key life stages .

3.7.1.3 Target outcomes for 2016/17 and 2017/18 Year 2016/17: ●● Early Years delivery plans developed in all localities ●● Investment proposals developed to deliver core Early Years model in pioneer localities ●● Investment proposition developed for a Greater Manchester stop smoking in pregnancy service ●● Investment proposition developed for a Greater Manchester oral health improvement programme

Year 2017/18: ●● Greater Manchester stopping smoking in pregnancy service commissioned ●● Investment proposals developed in remaining localities ●● IMT rolled out in initial areas ●● Evaluation process developed to give confidence in investment

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The Greater Manchester Population Health Plan 2017 - 2021 4. Live Well

As stated previously, this The programme of work will include addressing key wider plan is focused around determinants of health such as work, focusing on whole system those key points and approaches to the key lifestyle risk factors of smoking, physical stages in people’s lives inactivity, obesity and alcohol that are driving premature when mental and physical mortality, inequality and illness, and developing new service health can be most strongly responses that support general practices to work differently influenced. The aim of with people who face severe disadvantage . In addition, work is the Live Well theme is focusing on two key mid-adult life diseases that impact on our to support adults to be population – cancer and HIV . healthier, empowered and more resilient; key here will The programme of work outlined in the ‘System reform’ chapter be connecting people to of this plan to create a unified population health commissioning the opportunities created system for Greater Manchester will also contribute significantly by economic growth and to the delivery of Live Well . By moving away from a fragmented reform, behaviour change Greater Manchester approach to commissioning more strategic at scale to respond to the and collaborative approaches at the right spatial level, we rise in chronic disease, and have the potential to improve at scale the response to the key a real focus on reducing lifestyle risk factors for midlife adults . health inequalities. Greater Manchester is leading the way in its work on adult health improvement, forging groundbreaking strategic partnerships with national bodies such as Sport England to develop insight-led radical new propositions to address our high levels of physical inactivity, and with philanthropic and charitable organisations, focusing on our shared aims of tackling health inequalities . There is a wide range of activity already underway across the system that complements and enhances the projects in the population health plan . They include:

●● local care organisations: The new locality care organisations (LCOs), which each of our 10 localities is developing, have a crucial role in delivering proactive, preventative, population healthcare to consistently high standards

●● primary care strategy, which encourages a population- based approach to improving health and care through the delivery of place-based care and includes specific proposals on oral health and the introduction of a Greater Manchester Pharmacy Healthy Living Framework

●● ‘Greater Manchester Moving: the blueprint for physical activity and sport in Greater Manchester’, (2015), the foundation to drive forward work across the system to increase physical activity

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The Greater Manchester Population Health Plan 2017 - 2021 ●● Greater Manchester Combined Authority’s Offender health alcohol strategy, which continues to take The Greater Manchester devolution forward a programme of work, including agreement made a commitment to greater licensing, regulation and compliance, and collaboration in the planning and delivery of alcohol awareness campaigns a range of justice provision . An increased ●● the Greater Manchester sexual health role in commissioning offender management partnership, which since its inception services is enabling Greater Manchester to 13 years ago has driven significant build improved pathways through services, improvements in sexual and reproductive tackling the challenges that can occur at health outcomes and service quality . transition points in the system . Recent developments include cluster Greater Manchester is developing plans for an commissioning arrangements and integrated health and justice pathway, across proposals are currently being developed all points of the criminal justice system, to secure further improvements and including consideration of mental health economies of scale by seeking to (including child and adolescent mental health commission sexual health services at a services), substance misuse and learning single Greater Manchester level . disabilities . As an example of these new ways As identified above, a key element of the of working, Greater Manchester has recently Live Well work programme will be advancing become the first area in the country where equality and reducing health inequalities, the NHS and police and crime commissioner and therefore focusing on some of our most have worked together to jointly commission vulnerable groups, including the Traveller integrated police custody healthcare and communities, homeless people, offenders, liaison and diversion services . This is an asylum seekers and refugees . This work optimal model that will operate within police will build on and align with activity already custody, at court and in the community for underway across the system . those at risk of entering the criminal justice system . Asylum seekers and refugees Homelessness Greater Manchester has one of the largest populations of asylum seekers and refugees Homelessness is increasing across in the country . It is recognised that this Greater Manchester, in terms of statutory community holds a range of health needs, homelessness and also rough sleeping, both physical and mental . Greater Manchester which has been the most evident and visible . has been working with the North West We have also seen increasing movement Strategic Migration Partnership and other and transience of some elements of the stakeholders, such as the Home Office, local homeless community, reflecting the economic authorities and providers, to better define and and social conditions in some boroughs, understand how the needs of asylum seekers and which is increasingly requiring a cross- and refugees are assessed . boundary response . Plans are being put in place to develop a Greater Manchester GMHSC Partnership has recently secured homelessness prevention system that will funding from NHS England to improve access operate across local government geographical to routine primary care and address the boundaries . This means a focus on more barriers that many asylum seekers experience effective, proactive investment in prevention in accessing healthcare, leading to increased and driving down reactive costs . Local pressures on emergency services and poorer services will be integrated in a place-based health outcomes . way to provide people with an individually

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The Greater Manchester Population Health Plan 2017 - 2021 tailored pathway, based on their needs, to There is strong evidence that re-employment promote sustainable life chances . leads to improved self-esteem, improved general and mental health, and reduced 4 .1 Work and health psychological distress and minor psychiatric morbidity . The magnitude of this improvement 4.1.1 Background is more or less comparable to the adverse There is a strong association between effects of job loss . The exception to this can worklessness and poor health . Being out of be young people . work can lead to poor physical and mental health, across all age groups, with major ●● Unemployed young people are particularly impacts for the individual concerned, their affected by ‘scarring’, when, a bad early partner and family . Getting back into work experience in the labour market can last improves people’s health, as long as it is good for 20-30 years and restrict ability to quality work . progress . ●● Young people who are not in education, There is strong evidence that unemployment employment or training (NEET) for a is generally harmful to health, linked to: substantial period are less likely to find ●● increasing death rates by 1 .5 to 2 .5 times work later in life, and more likely to ●● higher mortality experience poor long-term health . ●● poorer general health and long-term Staying in work is key to improving outcomes . limiting illness National Institute for Health and Care Excellence (NICE) evidence indicates that ●● increased alcohol and tobacco those out of work with a health condition for consumption 6-12 months have a 2% chance of returning ●● lower levels of physical activity to employment, and after two years are more ●● higher rates of medical consultation, likely to die than return to employment . medication consumption and hospital The Government published the ‘Work, health admission rates . and disability: Improving lives’ Green Paper Being in work and having a purpose in in October 2016, which recognises the life have a positive effect on wellbeing . importance of work as a health outcome, Conversely, being out of work can result in and the need to give this greater focus within health harms such as the following . health services . It sets ambitious targets to halve the gap in the employment rate for ●● One in seven men develops clinical those living with long-term health conditions depression within six months of losing or disability in relation to non-disabled people . their job . The Department of Health and Department ●● Prolonged unemployment increases the for Work and Pensions (DWP) established the incidence of psychological problems from joint Work and Health Unit to lead the drive 16% to 34%, with major impacts on the for improving work and health outcomes for individual’s partner . people with disabilities and long-term health conditions, as well as improving prevention ●● Young people are particularly at risk . and support for people absent from work Suicides attempts are 25 times more through ill health and those at risk of leaving likely for unemployed young men than the workforce . employed young men, with mental health problems in general much higher among The NHS Five Year Forward View gives a unemployed populations . clear statement on the need for the NHS to do

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The Greater Manchester Population Health Plan 2017 - 2021 more to help people to get into, and remain ●● In Greater Manchester, mental health and in, employment. It sets out the fiscal impact musculoskeletal issues are the main health of health-related absence and benefit claims problems cited by workless claimants of to employers and taxpayers, and the low sickness-related benefits. The Greater employment rate of people with mental health Manchester Working Well programme problems . The role of employers, and the NHS demonstrates that 68% of clients state in supporting employers, is identified as key to that poor mental health is their biggest supporting a healthier workforce and reducing barrier to employment and 62% cite long-term costs . physical health, while 41% state that both mental and physical health issues are 4.1.2 Greater Manchester context equally considered the largest barrier to Very high rates of health-related worklessness employment . have persisted in Greater Manchester ●● Of the Greater Manchester economically regardless of the economic climate, and the inactive population, 26% are out of work number of health-related benefit claimants due to long-term sickness, compared to has remained high even during times of 22% in England as a whole . Levels are economic growth . highest in Rochdale (32%), and lowest in Greater Manchester health and social Stockport and Trafford (20%) . Temporary care devolution, as demonstrated in the sickness accounts for 3 .4% of the vision document ‘Taking Charge’, presents Greater Manchester economically inactive opportunities to further test and embed population, well above the England approaches that integrate employment and average of 2 .3% . health . It is well understood that employment ●● In 2015, nearly a third (31%) of the Greater is a key determinant of health at strategic Manchester working-age population had level . Despite this, there is still further work a health condition or illness lasting more needed to make sure it is given the priority it than 12 months, compared to the England should have in relation to patient care . This average of 29% . However, the Greater includes a recognition that more should be Manchester average masks considerable done around early interventions to improve variation across localities, ranging from employment outcomes for those residents 27% in Manchester to 37% in Tameside . at risk of falling out of work due to health or ●● Data from the 2011 Census shows that disability and those recently unemployed or 7 .4% of the Greater Manchester working- inactive due to health or disability . age population reported that they had The scale of the challenge in Greater a long-term health problem or disability Manchester is significant. There are that limited their day-to-day activity ‘a approximately 225,000 people in Greater lot’ . There is similar variance by locality, Manchester claiming out-of-work benefits, ranging from 5 .6% in Trafford (equal to the and of these, 140,000 claim as a result of a England average) to 8 .7% in Rochdale . health condition . Since 2012, unemployment ●● It is estimated that less than 30% of in Greater Manchester has been reducing presenting issues at GP surgeries actually overall, but disability-related worklessness require clinical intervention, and 70% of has not . There are a further 200,000 families appointments are actually down to issues in work and reliant on Working Tax Credit to around wider social determinants (‘social move them out of poverty . The cost to Greater prescribing’); furthermore, this figure rises Manchester of worklessness and the impact in more deprived areas . of low pay has now reached over £2 billion a year .

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The Greater Manchester Population Health Plan 2017 - 2021 Strong progress has been made with the offer, and those who are economically Government to co-design testing of an inactive with health conditions and get alternative approach to welfare to work . The little in the way of support from Jobcentre Working Well programme assists those with Plus . It is recognised that there are differing health-related barriers, and other complex characteristics within this population group benefit claimants, to secure and sustain that need to be considered, for example, employment . Notwithstanding Greater the needs of older workers, or those with Manchester Working Well’s success, it is particular disabilities . We will be working critical to note that Working Well, and its closely with all partners including the Centre successor the Work and Health programme, for Ageing Better, and disability and equalities will not have the capacity to address the groups, to test and learn what works for issue of health-related worklessness at the whom . scale required to make the impact we need in the numbers of claimants within Greater In work but at risk: The current national Manchester . offer is not meeting local need . The national Fit for Work service, which is available to The new DWP/Greater Manchester Work employers, employees or GPs to refer to once and Health programme aims to deliver to the person has been off sick for four weeks, circa 20,000 claimants over five years, which has struggled to engage general practice or reaches only a small proportion of those with receive referrals from employers; neither does health conditions that need support to return it provide rapid access to treatment . to work . There is a need to focus on what can be achieved at scale through a greater In contrast, there is evidence from the focus on work as a health outcome by taking Manchester Fit for Work service that a different approach to integrating the support demonstrates that an earlier intervention offer from the health and social care system offer that meets GP and patient need can with Jobcentre Plus and other key partners . be effective . The local service has 86% of Manchester GP practices making regular 4.1.3 Opportunity referrals and is achieving effective outcomes using a biopsychosocial approach . The return Our ambition is for work for health to be on investment demonstrated in an initial cost given the priority it should have in relation benefit analysis (CBA) suggests that this to patient care and approaches to improve model offers good value for money . population health within Greater Manchester . A systematic approach to integrate We will test the approach at a wider scale healthcare provision with programmes in conjunction with discussion around the designed to address the social and economic devolution potential of the national scheme . determinants of health will better support health outcomes for the individual, and Out of work: Currently the most significant realise the ambitions set out in the GMHSC gap is systematic support for those Partnership Strategic Plan: Taking Charge of with health conditions who are recently our Health and Social Care . unemployed, or economically inactive, such as those in the Employment and Support In terms of the opportunities available when Allowance (ESA) group and who do not looking at the different segments of the meet the access criteria for Working Well . population, key areas to focus on are those In Greater Manchester the majority of such employees who become ill and are at risk of claimants are in the Employment and Support falling out of employment, those newly out of Allowance (ESA) Group (84,430) and therefore work who need an enhanced health support are unlikely to get much in the way of support .

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The Greater Manchester Population Health Plan 2017 - 2021 Greater Manchester health and employment system

Referral - Multiple channels GP’s and Primary / Secondary Care Job Centre Plus Self Referral Employers

Co-ordinated access in Greater Manchester Health and Employment Support

Distance from the labour market

IN WORK IN WORK BUT AT RISK RECENTLY UNEMPLOYED RETURN POSSIBLE WITHIN LONG TERM 15 MONTHS ECONOMICALLY INACTIVE

Development required Programme Gap Programme Gap Programme in place Programme Gap Greater Manchester work & health programme (currently Greater Manchester Working Well)

Integrated health and work offer capable of delivering at a neighbourhood level: Key features: • Referral and triage . Biopsychosocial Assessment . Action Planning, Advice & Case Management . Integration and co-ordination with locality ‘eco-system’ . • Reassessment and progress measurement on range of health and well-being, work and skill outcomes . Developing the role of employers • Provides condition management, self-care, lifestyle change, confidence-building, patient activation, self-efficacy. Social determinants support: debt, housing, social connection, Employer Engagement volunteering, learning, skills and work . Public sector leadership on workplace health and well-being Improving occupational health Additional components in work Additional for out of work side Integrated at neighbourhood Hub level Incentivising business leadership for employee at risk Co-ordination with JCP work coaches/DEA health Rapid access to MSK and mental health Onward referral for intensive support Greater Manchester Employer Support (SME’s) treatment programmes e .g . Skills for employment, Social value in procurement HR and employment advice Co-ordinates in work support offer Develop Greater Manchester approach to Advice and support to GPs Facilitate access to Work and Health multiple standards Facilitation of return work for employer / programme for longer term support (e.g. Disability Confident, Workplace Well- employee being Charter) Careers advice/brokerage if RTW not viable

140,000+ Greater Manchester residents out of work with health conditions of Impact of poor health on economy / 114,598 Greater Manchester fit notes which Greater Manchester work and health programme will reach 26,000 and a productivity / cost to health annually relatively small proportion are expected to move into sustained work. Figure 15: Health and employment

There is no coherent pathway for those with work . Local examples from Salford, Bury and health conditions to access employment Manchester demonstrate that a trusted health and skills support, condition management and work pathway from primary care can be and other social determinants, at the scale effective and well-used by GPs for those in or required . out of work with a health condition, and offer potential to enhance the proposals set out in Improving The ‘Work, health and disability: the Green Paper . lives’ Green Paper proposes steps to address earlier intervention for people making new Cost benefit analysis claims for benefit/Universal Credit as a Initial cost benefit analysis of the Manchester result of a health condition . This presents Fit for Work (in-work) and Healthy Manchester opportunities for collaboration between (out-of-work) models suggests that they Greater Manchester and the Government to offer good value for money . For a relatively improve support across the spectrum of out- low unit cost per client, significant fiscal of-work claimants . benefits were delivered, including reduced worklessness and associated benefit For both of these priorities, two of the payments (flowing to government), and key system interfaces at these critical reactive cost savings (flowing to local risk points are Jobcentre Plus and NHS partners) associated with reduced mental primary/secondary care services that hold health disorders, GP and physiotherapy responsibility for issuing fit notes and appointments, and alcohol dependency . The for treating those with long-term health gross five-year fiscal return on investment for conditions . In most cases, there is little the in-work service was an estimated 1 .25, clinicians can offer to support a return to

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The Greater Manchester Population Health Plan 2017 - 2021 and 1 .35 for the out-of-work service; for both other services, to ensure that the target group services, payback (when the benefits begin can access the support they require at an to outweigh the initial investment) should early stage and before falling into long-term be achieved in four years . The wider public unemployment . It also aims to give individuals value delivered by the Manchester services the tools to manage health conditions in the incorporates increased economic output longer term, build resilience and know where and reduced costs to employers, along with to go for other support when they need it . softer social benefits related to improved individual well-being – the public value return The programme is set up to achieve the on investment was estimated at £5 .74 for the following core objectives . In-work service and £2 .36 for the Out-of-work . Objective 1: Develop a work and health When scaled up across further localities, the support model that addresses the needs of fiscal return on investment reported above the identified cohorts, underpinned by data, is likely to increase, not least due to the evidence and cost benefit analysis, and economies of scale and potential efficiency secure endorsement by stakeholders across savings that delivery on a Greater Manchester Greater Manchester . platform might generate Objective 2: Scope and determine the extent of current local work and health support Opportunities still to be scoped The significant efforts made at both delivered within Greater Manchester, tested Manchester and Greater Manchester level against the work and health model described to move people back into employment will under Objective 1, scope procurement and not achieve maximum gain if the work is not delivery options and Greater Manchester/ ‘good work’ . The role that employers can play locality approach . is critical and significantly under-developed, Objective 3: Support a number of localities both in terms of protecting health, supporting to implement the work and health model . skills development and career progression, and promoting longer, healthier lives . There Objective 4: Develop a business case is an economic case for stronger leadership that builds on the robust evaluation of across public, private and third sector implementing the model to support the partners at Greater Manchester and locality future expansion and mainstreaming of the levels . programme across the whole of Greater Manchester, based on the evidence . Further work will take place over the next 12 months to scope the opportunities to support 4.1.4.1 Approach to delivering employers to provide ‘good work’, and objectives employees to stay well in work . Objective 1: Define the work and health 4.1.4 Plan support model that addresses the needs of the identified cohorts, underpinned by data, The vision of this programme is to ensure that evidence and cost benefit analysis, and agree Greater Manchester has effective prevention appropriate funding mechanisms . and early intervention systems in place that support as many adults with health conditions The programme will seek to: as possible to return to, and remain in, ●● undertake detailed cohort analysis and good quality work . In order to do this, the modelling programme is to build and test an approach to work and health that improves the integration ●● define and agree the key features that and alignment of health, employment and need to be in place to deliver effective services to the cohort

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The Greater Manchester Population Health Plan 2017 - 2021 ●● define the metrics through which to ●● provide a forum for sharing intelligence, measure success analysis, perspectives and outputs related to the implementation of the model . ●● develop a CBA model ●● undertake a communication and Objective 4: Develop a business case engagement exercise with Greater that builds on the robust evaluation of Manchester stakeholders implementing the model to support the future expansion of the programme across the ●● pursue and agree funding options, whole of Greater Manchester, based on the including: evidence . • The national Work and Health Innovation Fund The programme will seek to: • Greater Manchester Transformation ●● collate analysis from implementation sites Fund . from across Greater Manchester Objective 2: Scope and determine the extent ●● update and further develop cost benefit of current local work and health support analysis delivered within Greater Manchester to the ●● defined cohort, tested against the defined collate local lessons learned to inform work and health support model . future development of the model for wider Greater Manchester adoption The programme will seek to: ●● gain agreement from the system to ●● work with localities to identify the ‘as is’, expand the work and health support taking into account local place-based model to ensure coverage of remaining delivery models Greater Manchester boroughs ●● hold discussions with localities where no ●● produce and agree a plan for Greater offer is currently in place to understand Manchester-wide coverage . appetite for implementing model and agree participation 4.1.4.2 Outcomes ●● undertake an options appraisal of the The programme will work towards achieving appropriate procurement and funding four key outcomes . models to progress implementation with ●● Outcome 1: A work and health support participating localities . model that addresses the needs of the identified cohorts, has been developed, Objective 3: Support a number of localities to endorsed by stakeholders and is build on existing services or implement new supported through an agreed investment provision to address gaps in service for the approach . cohort . ●● Outcome 2: The ‘as is’ support service The project will seek to: landscape for the target group is ●● secure and put in place agreements with understood and locality appetite to test an a number of localities to implement the at scale new approach model has been model and test locally explored . ●● undertake a procurement exercise or ●● Outcome 3: A number of Greater implement agreed funding arrangements Mchester boroughs are implementing and testing the model for agreed cohorts and ●● provide programme management and participating in evaluation . delivery support to assist localities to develop

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The Greater Manchester Population Health Plan 2017 - 2021 ●● Outcome 4: A business case and plan ●● people who have a health condition who for refinement and extension of a Greater are economically active and would benefit Manchester-wide roll-out of the model has from integrated health and a wider support been produced and agreed . offer to move closer to the labour market . 4.1.4.3 Programme of work – scope 4 .2 New model of primary care Overall the programme will work to the for deprived communities following principles: 4.2.1 Background 1 . Early intervention when employees become We know that people experiencing multiple ill and risk falling out of employment disadvantages are more likely to have poor 2 . Early intervention for those with a health health, alongside a range of other challenges condition who have become recently including homelessness, worklessness, unemployed or are long-term economically substance misuse, mental illness, poverty, inactive to support them to make a return violence and abuse . to work Tackling these inequalities in health requires 3 . Support for employers to provide ‘good universally proportionate services to address work’, and for employees to stay healthy the larger part of the inequalities gradient . and productive in work There is also a need for tailored provision for the most disadvantaged communities, where There are significant gaps within the system multiple social determinants of ill health, offer for each of these areas . Prevention clustering of risk behaviours, and early impact from leaving the labour market is key . NICE of multi-morbidities come together . These evidence indicates that those out of work with communities often experience (statistically) a health condition for 6-12 months have a 2% significant differences from the rest of the chance of returning to employment, and after population . two years are more likely to die than return to employment . Intervention through services can widen health gaps if attention is not focused on Population in scope inequalities in access and outcomes . Often We are looking to test and evaluate it is the most disadvantaged that make the approaches that address the work and health least effective use of services and this can be needs of the following groups of working age exacerbated if they are offered poor levels of adults: service (the ’inverse care law’) . This mismatch of need and demand can be portrayed as ●● employed people who have been off sick those ‘missing’ from services . for two weeks or more, and who require a biopsychosocial intervention to return to People who face severe disadvantage need work as quickly as possible genuine opportunities to transform their ●● employed people who are at work but lives; opportunities that help the individual struggling with health conditions, and overcome all aspects of the disadvantage so are at risk of going off sick and require a that they can reach their full potential in life . biopsychosocial intervention to remain Too often, people struggle to get the support effective and productive in work . This they need and there is a strong chance that particularly includes those who are self- the disadvantages they face will become employed, or work for small and medium- more severe . This means that when they do sized enterprises (SMEs) . present to support agencies, the focus is on

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The Greater Manchester Population Health Plan 2017 - 2021 managing problematic behaviours and the may be the underlying factors contributing risks these present rather than addressing to the challenges faced by residents and the person’s underlying issues . This can agreeing what action to take through asset- escalate the severity of problems even further . based conversations with the residents they Rather than responding to what the person are working with . is experiencing, a range of disconnected services are delivered, each tackling individual This work is having a positive impact . Early problems . This means that people who most analysis has highlighted that up to 70% of need support find it difficult to navigate a referrals across public services are generated complex structure of help, meaning they by other parts of the public sector . Currently access services late or not at all . people are assessed and referred, passed around the system rather than being helped 4.2.2 Greater Manchester context to directly address the challenges they are facing . By working in a new way, by In spite of Greater Manchester’s increasing intervening early and collaborating in our economic prosperity, health inequalities approach we can cut down that referral persist, with 20% of our population across the system and reduce the likelihood (680,000 people) living in the 10% of most of issues escalating for the people we are disadvantaged areas nationally . working with . Across Greater Manchester, we are Health and social care services are already developing models of place-based integration engaged in this work . However, there is of services intended to identify early those scope to increase that involvement, drawing people at risk of developing more complex in a wider range of health and social care issues that, over time, could place significant services. Early work has identified the value pressure on services and lead to poorer of mental health professionals being full-time outcomes for individuals or families . members of these teams . GP engagement Each locality across Greater Manchester is in place-based integration models has been in the process of implementing an approach invaluable in those areas that have trialled to place-based integration . Based on the work with GPs . The link into social care will learning from these early adopter sites, be fundamental to the success of this new district-wide roll-out plans will then be way of working . By aligning our population developed . By April 2017, plans will be in health strategy with Greater Manchester’s place for place-based integration across each approach to place-based integration we have part Greater Manchester . the capacity to enrich our collective approach to new models of support . Through Greater Manchester’s place-based integration work, teams are being brought Through place-based integration models together from a wide range of organisations, there is significant opportunity to address bringing together the police, local authorities, issues that contribute to poor population health, housing and fire services, the voluntary health outcomes . Alongside this, there is also sector, and others as needed . They are opportunity to build system-wide alignment working with local residents in a new way . with other elements of our health and care Rather than assessing and referring across transformation work, such as social care . the system, place-based teams are working Work is ongoing to support further integration together to agree how they can actively and alignment of the health and social care work with people to address the range of programme with place-based integration challenges they may face . They are sharing by: developing a health and social care offer information, taking time to understand what

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The Greater Manchester Population Health Plan 2017 - 2021 in a broader place-based early intervention complex problems, and greater GP stress . model; supporting localities to identify the Furthermore, people’s medical needs specific health and social care services and are intimately interwoven with emotional, interventions that could strengthen place- psychological, financial and social problems. based integration in their locality; supporting the development of a cross-sector Early Help Focused care is a model that has been strategy in each locality; and ensuring this work developed in Greater Manchester from is reflected in and informed by locality plans. the work of Hope Citadel Healthcare CIC . It is a response to the frustration GPs feel We will ensure the Greater Manchester place- when seeing patients experiencing multiple based integration roll-out delivers on our disadvantage, knowing they cannot do much Greater Manchester-wide reform ambitions, in a 10-minute appointment but recognising including the delivery of our health and social great need . Often these patients are the care strategy . Our goal is to ensure people most invisible to the normal workings of the will no longer need to navigate fragmented NHS but they are often very expensive . They systems and services . present late with significant conditions, and they turn up frequently and randomly at acute 4.2.3 Opportunity services . General practice has a pivotal role to play in Focused care is a systemised, standardised supporting the most disadvantaged and in holistic approach now operating in eight GP place-based integration of services . GPs are practices in Greater Manchester . The model usually the first point of contact with NHS has been shown to change both patient and provision, although this is set against the clinician behaviour and has led to improved context of the capacity challenge associated outcomes and improved engagement and with serving populations who have a lower utilisation of services . healthy life expectancy and experience more years of living with multi-morbidities . In essence, focused care is a holistic approach that: Being able to provide preventative interventions and continuity of care are seen ●● makes the invisible visible and keep them as the two key assets that GPs can deploy . visible GPs have repeated contact with their patients ●● uses a clinical case discussion across and are therefore ideally placed to understand disciplines and agencies, by people who the underlying causes of poor health, whether know the patient medical or social . ●● keeps the responsibility for the patient at However, delivering effective primary care the GP surgery; the promotion of the value in the poorest communities is challenging . that these are our patients and we will do Some diseases are more prevalent in our best for them practices serving deprived populations, ●● recognises the importance of relationships particularly mental health conditions, and and that trust is a valuable commodity there are higher levels of A&E attendances, emergency hospital admissions and primary ●● uses a focused care practitioner to enable care usage among these communities . households to be supported by mutually Consultations in these practices are agreed plans characterised by: higher demand, greater ●● fosters close working relationships with time constraints, greater psychological and other agencies . physical morbidity, more multi-morbidity, less enablement reported by patients with

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The Greater Manchester Population Health Plan 2017 - 2021 It has been likened to a Macmillan The programme will seek to: Cancer Support service for very deprived ●● identify an agreed number of suitable communities. Early cost benefit analysis practices serving the most deprived areas suggests a 3:1 return on investment can be and providing a good geographical spread achieved . across Greater Manchester 4.2.4 Plan ●● work with SHF to develop an appropriate The vision for this programme of work is delivery vehicle for focused care to ensure that Greater Manchester has an ●● work with SHF and New Economy effective system in place to meet the needs of Manchester to develop outcome the most disadvantaged in our communities . framework and key success measures . We have developed a unique collaboration with the Shared Health Foundation (SHF), Objective 2: Test the focused care approach an initiative of the Oglesby Charitable Trust to facilitate general practice involvement in (OCT), which is seeking to tackle health place-based integration . inequalities across Greater Manchester . The programme will seek to build on the We will develop new service responses that testing of the model as described in Objective support general practice to work differently 1 by: for people who face severe disadvantage by enabling genuine opportunities for people to ●● documenting and developing the general transform their lives, opportunities that help practice contribution to the health and the individual overcome all aspects of the social care offer in a broader place-based disadvantage so that they can be and do the early intervention model things they value in life . ●● supporting the development of a cross- sector Early Help strategy in each locality The programme is set up to achieve the following core objectives: ●● ensuring this work is reflected in and informed by locality plans . ●● Objective 1: Provide proof of concept for the focused care approach by testing the Objective 3: Develop a business case model in 10 deprived practices in Greater to support the future expansion and Manchester mainstreaming of the new care model, ●● Objective 2: Test the focused care including exploration of sustainable funding approach to facilitate general practice mechanisms . involvement in place-based integration The programme will seek to: ●● Objective 3: Develop a business case ●● develop a cost benefit model to support the future expansion and mainstreaming of the new care model, ●● pursue and agree funding options, including exploration of sustainable including Social Impact Bonds, the funding mechanisms . Greater Manchester Transformation Fund and Life Chances Fund . 4.2.4.1 Approach to delivering objectives 4.2.4.2 Outcomes Objective 1: Provide proof of concept for the The programme will work towards achieving focused care approach by testing the model three key outcomes: in an agreed number of deprived practices in Outcome 1: A systemised, standardised Greater Manchester . holistic approach that supports behaviour

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The Greater Manchester Population Health Plan 2017 - 2021 change in both patient and clinician, resulting excessive consumption of alcohol, poor diet in improved outcomes and improved and low levels of physical activity . engagement and utilisation of services . As outlined in the NHS Five Year Forward Outcome 2: The focused care approach View, the future health of the nation, the to facilitate general practice involvement in sustainability of the NHS and future economic place-based integration and appetite to scale prosperity all now depend on a radical up has been explored and is understood in upgrade in prevention and public health . localities . Over a decade ago, the Wanless Review in ‘Securing our future health: Taking a long- Business case and plan for Outcome 3: term view’ warned that unless the country Greater Manchester roll-out procured and took prevention seriously we would be faced agreed . with a sharply rising burden of avoidable illness . That warning has not been heeded – 4.2.4.3 Programme of work – scope and now we are facing a crisis in our health Overall the programme will work in the and social care services . following way . Despite improvements in population health, Focused care has no acceptance criteria . 70% of us still engage in two or more lifestyle In an environment of social complexity and risk factors . Rather than the ‘fully engaged ‘chaotic-ness’, referral criteria are not helpful . scenario’ that Wanless spoke of, one in five There is no single clearly defined population adults still smokes . A third of people drink group affected . For example, a single mother too much alcohol . A third of men and half of with four children might actually be thriving women don’t get enough exercise . Almost in life while a single man in his 50s may not two-thirds of adults are overweight or obese . be . Experience has shown that often patients These patterns are influenced by, and in turn on focused care don’t meet criteria for other reinforce, deep health inequalities that can services, or have been rejected for other cascade down to generations . For example, services . Patients in this cohort often end up smoking rates among routine and manual being passed from pillar to post . workers range from 15 .8% in Bromley to 36 .3% in Oldham . Population in scope Focused care has a case load of 50 The number of obese children doubles while households per two days of focused care children are at primary school . Fewer than time . In previous analysis this represents one in 10 children is obese when they enter about 2-4% of a deprived practice list per Reception. By the time they are in their final year . The equation used is two days of year, nearly one in five is obese. focused care per 2,500 patients on a list . As our population’s health risk gets worse, the 4 .3 Incentivising and supporting burden on our health and social care system increases . To take just one example from healthy behaviours the Five Year Forward View – Diabetes UK 4.3.1 Background estimates that the NHS is already spending People’s health behaviours are widely known approximately £10 billion a year on diabetes . to affect their health and risk of mortality . Almost three million people in England are Close to half of the burden of illness in already living with diabetes and another developed countries is associated with the seven million people are at risk of becoming four main unhealthy behaviours: smoking, diabetic .

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The Greater Manchester Population Health Plan 2017 - 2021 Our current health challenges require ●● 270,000 adults smoke every day widespread behaviour change . We need ●● 560,000 adults binge drink (consume behaviour change at scale to respond to twice the daily recommended alcohol the rise in chronic disease . New types of levels at least once a week or once approaches are needed that reduce unhealthy a month among men and women, behaviours, such as smoking, and increase respectively) healthy behaviours, such as physical activity . In particular, we need to find effective ways to ●● 677,600 adults are physically inactive (less help people in lower socio-economic groups than 30 minutes of physical activity per to reduce their multiple unhealthy behaviours, week) . as evidence indicates that reductions in Evidence from the King’s Fund: Clustering of unhealthy behaviours achieved to date are unhealthy behaviours overtime (2012) also mostly confined to the higher socio-economic estimates that approximately 1 .4 million adults groups, who respond better to social in Greater Manchester (circa 70%) will engage marketing campaigns . in two or more of these unhealthy behaviours . 4.3.2 Greater Manchester context The same study also highlighted that over time inequalities regarding multiple lifestyle Evidence supports the need to upscale risks have increased, with those from the behaviour change support services across lowest socio-economic groups and with the the conurbation . There are just under two least education being three to five times more million adults aged over 19 living in Greater likely to have all four risk behaviours than Manchester . Among these it is estimated that: professionals . ●● 730,000 adults regularly consume less We also know from the ‘Taking Charge’ than four portions of vegetables and/or engagement that 90% of people want to fruit per day improve their lifestyles, with most people citing being more active, eating more healthily and tackling stress as their key areas of need .

Figure 16: Greater Manchester population engagement responses to improving their lifestyle

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The Greater Manchester Population Health Plan 2017 - 2021 This engagement process also generated new insights into the Greater Manchester population, which enabled us to group Greater Manchester people into one of six personas detailed below . However further ethnographic research is required to explore and refine these typologies further.

Figure 17: Greater Manchester population personas

4.3.3 Smoking Smoking is also the biggest single contributor Despite good progress made in recent years, to health inequalities . More than half of the there are still over 423,000 adult smokers inequity in life expectancy between social among the city-region’s circa 2 .8 million classes is linked to higher smoking rates population . This is well above the England among poorer people . In Greater Manchester average (about 20% in Greater Manchester people in routine and manual (R&M) groups versus 17% nationally) and equates to around are far more likely on average to smoke than 63,500 more smokers than if at the England the general population, and R&M smoking average . rates in Greater Manchester are higher than the R&M England average . Smoking is by far the biggest single cause of ill health as well as early death in Greater Smoking prevalence remains lower than Manchester and in England . Figure 18 average in Black and minority ethnic groups, illustrates the scale and diversity of the particularly in women, however, other tobacco deaths caused by smoking in England . Our use, such as oral and chewing tobacco and Greater Manchester figures across localities shisha use, is higher in some groups than in for smoking-related cancers, respiratory the general population and is a concern in and circulatory disease are higher than the some areas of Greater Manchester such as England average, consistent with our higher Oldham and Bolton and Manchester . The than average smoking rates . highest use of other tobacco products is in Manchester at 17 .6% of the population and this extends to shisha use in the wider population .

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The Greater Manchester Population Health Plan 2017 - 2021 Figure 18: Variety of deaths caused by smoking

Figure 19 (‘Smoking Still Kills’, ASH 2015) to £1,739 per smoker) . This includes illustrates the social divide in smoking increased costs of health and social care, rates in England that is reflected in Greater lost productivity, and house fires caused by Manchester . cigarettes .

Smoking also has significant economic Research by ASH also shows that cutting impacts in Greater Manchester at societal, smoking rates has the potential to lift some of systems, family and individual levels . The Greater Manchester’s poorest families out of societal/systems costs of smoking are poverty, as shown in Figure 20 . estimated to be £785 million a year (equating

Figure 19: Data from Smoking Still Kills

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The Greater Manchester Population Health Plan 2017 - 2021 4.3.4 Alcohol Alcohol is inextricably linked with premature mortality – particularly through the causal link with at least seven types of cancer, including liver, bowel and breast cancer – and causes 80% of liver disease deaths .

Greater Manchester mortality rates are among the highest in the country in relation to alcohol-specific conditions (see figure 21).

Lower socio-economic status (SES) is associated with higher mortality for alcohol- attributable causes, despite lower socio- economic groups often reporting lower levels of consumption . People living in the most deprived decile are twice as likely to die from alcohol harm (16 .1 per 100,000) than those living in the least deprived (8 .3 per 100,000) .

The demands placed on the NHS as a result of alcohol, both in terms of attendance at A&E departments at busy times and in terms of the Figure 20: Smoking and poverty impact on availability of beds, are significant. The rate of admissions for alcohol-related conditions has doubled nationally in a decade Sustained action is also needed to reduce the and is continuing to rise . Over 2014/15, there supply of, and demand for, illegal tobacco, were over one million admissions in England, which is cheap and unregulated . Its low including 66,790 across Greater Manchester . price undermines high taxation that is key The rate of admissions per 100,000 people to encouraging ‘cut-downs and quits’ (the is higher than the England average in all World Bank estimates a 10% price rise leads 10 Greater Manchester localities, and a to circa 4% less consumption) . The illegal disproportionate number relate to young trade also makes it easier for children to people; there were 956 under-18s admitted start and keep on smoking, and is linked to to hospital due to alcohol, a rate of 52 .1 per low-level and organised crime/terrorism . In 100,000 compared with the England rate of Greater Manchester, illicit tobacco can be 36.6 (see figure 22). purchased for as little as £3 for a standard pack compared to the legitimate price of £7 The combination of crime, worklessness for a standard retail pack of cigarettes . and health and social care costs to Greater Manchester arising from alcohol-related harm While only 17% of respondents to the ‘Taking are estimated at approximately £1 .2 billion, Charge’ engagement exercise wanted to equivalent to £436 for every man, woman and smoke or drink less, we know from YouGov child living in Greater Manchester . polling that actually the majority of those who smoke in Greater Manchester want to quit (only 10% of smokers don’t want to quit) and two-thirds are supportive of efforts to tackle smoking .

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The Greater Manchester Population Health Plan 2017 - 2021 Alcohol-specific mortality (persons) 2012 to 2014 Directly standardised rate – per 100,000

Figure 21: Alcohol mortality in the Greater Manchester region (CI=Confidence intervals)

Persons under 18 admitted to hospital for alcohol-specific conditions

Figure 22: Alcohol-related under-18 hospital admissions in the Greater Manchester region

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The Greater Manchester Population Health Plan 2017 - 2021 4.3.5 Physical inactivity and obesity ●● Between the upper National Statistics Doing less than 30 minutes of physical activity Socio-economic Classification (NS SEC) per week is one of the top 10 causes of early 1-4 and the lower NS SEC 5-8, levels of mortality . Greater Manchester has a high inactivity rise from 24% to 49% . level of inactive population – around 677,600 Physical activity programmes at work can residents (31% of the population versus the reduce absenteeism by up to 20% and on England average of 27 .1%), with an estimated average physically active workers take 27% cost to health services in Greater Manchester fewer sick days . Nationally 131 million days of £26 .7 million per year (2013/14 prices) were lost due to sickness absences in 2013, related to the main chronic diseases (heart and 15 million days in the North West . A 20% disease, diabetes, CVD and cancer) that could reduction in the North West would reduce this be prevented by exercise . by three million days . Furthermore, research Levels of inactivity vary between localities, suggests that participating in 3 x 30 minutes ranging from 22-33% across the 10 boroughs of activity per week could translate to an of Greater Manchester, and also across average increase in earnings of 7 .5% due to various under-represented groups . improved productivity, social capital/networks and motivation to perform . ●● More than one in three females (35%) is inactive, compared to one in four males As well as being a risk factor for premature (26%) . death in its own right, leading increasingly inactive and sedentary lifestyles – linked to ●● More than double the number of disabled time, work and more reliance on travelling people (56%) are inactive compared to by car – has also contributed to the steady non-disabled people (25%) . rises seen in levels of obesity . While everyone would benefit from being more active ●● Levels of inactivity range from 16% every day, this is especially true in Greater between the ages of 16-25 and 49% for Manchester, with 65% of adults and 28% of those aged 65 and over .

Figure 23: Levels of inactivity in the Greater Manchester region

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The Greater Manchester Population Health Plan 2017 - 2021 Obesity prevalence and consumption of fruit and vegetables of children by Greater Manchester borough

Source: Public Health Outcomes Framework http://www .phoutcomes .info/search/childhood%20obesity#page/0/ gid/1/pat/103/par/E45000008/ati/102/are/E08000001 Figure 24: Obesity prevalence in the Greater Manchester region

children classified as overweight or obese, Pakistani ethnicities, compared to the other which is significantly worse than the UK ethnic groups . It affects our mental health too average . and can stop us from fulfilling our potential and living a full and happy life . Bury, Oldham, Rochdale and Wigan have significantly higher levels, with between 67% Being overweight or obese is the main and 69 .5% of adults living with excess weight modifiable risk factor for type 2 diabetes, and obesity . which is also on the increase and is a serious and incurable condition that has lifelong For children and young people, 22% of pupils health implications . Currently 90% of adults in Greater Manchester are starting school with type 2 diabetes are overweight or obese . in Reception with excess weight, which There are currently five million people in increases to over 35% when leaving primary England at high risk of developing type 2 school . These are much higher rates of diabetes . In Greater Manchester, currently childhood obesity than the rest of the country, 164,000 people have type 2 diabetes and at according to the most recent National Child least the same number of people are at risk of Measurement Programme (NCMP) data . developing it . Obesity impairs lives . It raises the risk of If these trends persist, one in three people serious physical health conditions such as will be obese by 2034 and one in 10 will diabetes, heart disease, stroke and cancer . develop type 2 diabetes . However, evidence Prevalence of obesity is higher among shows that many cases of type 2 diabetes are women of Black Caribbean, Black African and

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The Greater Manchester Population Health Plan 2017 - 2021 preventable . There is also strong international Greater Manchester should be a UK leader in evidence that demonstrates how behavioural becoming smoke free . Building on evidence interventions, which support people to from New York and other cities our approach maintain a healthy weight and be more active, will be: can significantly reduce the risk of developing ●● the condition . helping significantly more smokers to quit, working in partnership with smokers Obesity is widespread and appears to be and a renewed commitment to meet their increasing, but it can be very difficult to needs, to help them quit in whatever address at a whole-population level at the way works for them; greater investment scale that is needed in Greater Manchester, in targeted year-round mass media and and many approaches have already been social marketing campaigns to educate tested . This plan presents an opportunity to and motivate quit attempts; and working think differently about how to address its root across all sectors to exploit every contributors – food and physical activity . opportunity to help smokers quit

4.3.6 Opportunity ●● creating more smoke-free spaces . The mayor could lead the way for Greater Devolution in Greater Manchester provides Manchester by making the public places the opportunity to look at whole system controlled by Greater Manchester innovative approaches to these major health authorities smoke free risks, in order to fully harness the positive potential health impacts of the third sector, ●● exploration of how further freedoms and local government, employers and local flexibilities for Greater Manchester can communities themselves . reduce smoking prevalence through, for example, use of bye-laws for smoke-free We will develop comprehensive, broad-based spaces; consulting on raising the age of and hard-hitting Greater Manchester action at tobacco sales to 21; introduction of a multiple levels and across sectors to address Greater Manchester licensing scheme for the major lifestyle risk factors, working in tobacco retailers and wholesalers partnership with key national lead agencies such as Sport England and Public Health ●● launching a fresh crackdown on the England . trafficking in, and selling of, illegal tobacco . A key principle behind the development of these new approaches will be building on The GMCA’s Greater Manchester Alcohol the assets and skills we have in Greater Strategy 2014–2017 continues to take forward Manchester, whether as individuals or a programme of activity across 11 strategic communities, including forging stronger priorities, seeking to: support a focus on partnerships with charitable and voluntary growth and reform; promote effective practice sector organisations . within Greater Manchester; and challenge the status quo on key national policy issues . Work is already underway in the following Work taken forward through the strategy has areas . contributed to a range of business areas, The Greater Manchester Cancer Board has including the following . made reducing smoking a key focus within Licensing, regulation and compliance – the emerging Greater Manchester Cancer Greater Manchester authorities are promoting Plan and is sponsoring work to develop a the effective and consistent use of licensing/ comprehensive Greater Manchester Tobacco regulatory tools and powers, with a best- Control Plan . The board believes that

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The Greater Manchester Population Health Plan 2017 - 2021 practice toolkit devised, strong lobbying for for sport and physical activity at a Greater change in respect of the 2003 Licensing Act, Manchester level, placing the customer first and a suite of devolution ‘asks’ tabled with and central to all thinking and delivery while government . contributing to the strategic priorities of Greater Manchester, particularly regarding Alcohol campaigns and awareness raising – health, economic growth and social wellbeing . supporting the principle of local democratic leadership on public health, work through The MoU will: the strategy has maximised the impact of ●● Greater Manchester campaign activity (with a have a framework that provides particular focus on protecting young people fundamentally different propositions from the harm of alcohol advertising) . This to enable healthier, more resilient and has complemented local targeted campaigns empowered residents to take charge of to reach priority groups such as middle-aged their own wellbeing, including supporting drinkers and female drinkers, and specific inactive neighbourhoods and communities programmes looking at the issue of drinking at ●● develop an insight-led, behaviour-change home . approach to sport and physical activity, New solutions to addressing the key drivers starting with the individual and their of avoidable ill health – a Communities in communities and designing and delivering Charge of Alcohol (CICA) programme is sport and physical activity according to being developed, which recognises that the their specific needs and wishes citizens of Greater Manchester will be active ●● have shared metrics, performance participants in supporting and enabling their measures and a robust cost benefit own better health outcomes, and seeks to analysis for all joint areas of work, which establish a new network of health champions . will specifically include decreasing the Parallel, asset-led work is also pursuing fresh number of inactive people, increasing collaboration opportunities with Greater participation of under-represented groups Manchester universities and unions in respect and increasing the number of people of building a culture of responsible attitudes taking part in sport and physical activity towards alcohol . At the locality level, Greater more regularly Manchester’s recent status as a Home Office initiative: Wave 1 Local Alcohol Action Area ●● demonstrate impact across government’s has provided continued impetus to address five outcomes for sport and physical alcohol health harm through effective, activity – physical health, mental recovery-oriented treatment, with a greater wellbeing, individual development, social/ focus on early intervention and prevention . community development, and economic development . ‘Greater Manchester Moving: The Blueprint for Physical Activity and Sport’ was established We recognise that work needs to be in 2015 as the foundation for a social developed at a Greater Manchester level to movement to reduce inactivity and increase address the significant challenges related to physical activity across Greater Manchester . obesity . We need to build on the best practice Subsequently, in 2016 a memorandum of already underway such as the NHS Diabetes understanding (MoU) was signed between Prevention Programme (NHS DPP) . The Sport England, the GMCA and the NHS in NHS DPP is a joint commitment from NHS Greater Manchester . This provides an agreed England, Public Health England and Diabetes framework to explore the delivery of both the UK to deliver at-scale, evidence-based, Government’s and Sport England’s strategies behavioural interventions for individuals

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The Greater Manchester Population Health Plan 2017 - 2021 identified as being at high risk of developing health services from lifestyle-related long-term type 2 diabetes . Framing the problem posed conditions . by obesity in the context of diabetes is one important element of a wider programme Our role as public sector employers to address obesity, but this needs to sit We also want to ensure that, as a public alongside collaborative approaches targeting sector and major employer accounting for the achievement of higher levels of physical over 18% of all jobs in the region, we are activity in the general population as the a positive role model for workplace health, ‘norm’, and innovative approaches towards innovating and implementing best practice food and nutrition . A focus on socio-economic to support our 219,400 staff to stay healthy and wider inequalities must form part of this . and serve as health champions in their local communities . From April 2017, all areas of Greater Manchester will start to offer behavioural 4.3.7 Plan interventions to people at risk of developing type 2 diabetes . This follows Salford leading 4.3.7.1 Objectives as a demonstrator site, Bury, Oldham The objectives of this programme are and Rochdale being early adopters and a to develop Greater Manchester-wide successful bid led by the Greater Manchester approaches to tackle the main lifestyle risk Strategic Clinical Network to incorporate a factors, i .e . smoking, physical inactivity, further eight areas in to the NHS Diabetes alcohol, poor diet and obesity, including Prevention Programme (NHS DPP) . Those developing innovative approaches that can be people identified and found to be applicable tested at scale . will be invited to attend an evidence-based course that either delays the possibility of Objective 1: To develop a comprehensive developing type 2 diabetes or prevents it Greater Manchester Tobacco Control Plan altogether . that is fully aligned to the Population Health Plan priority themes and wider reform agenda . Lifestyle and wellness services Objective 2: To support the development and The drive to more person-centred wellness implementation of a refreshed and integrated and lifestyle services, which recognises that GMCA Substance Misuse Strategy . many of our Greater Manchester population have multiple unhealthy lifestyle risk factors Objective 3: To develop a comprehensive and requires person-centred approaches plan to reduce inactivity and increase that address the psychosocial and wider participation in physical activity and sport determinants of health, has been around for a that is aligned to the Population Health Plan number of years; however, progress has been priority themes and wider reform agenda . slow . In addition, the reach of such services Objective 4: To develop a comprehensive into the populations most at need is limited plan for better nutrition and healthy weight and more work needs to be done to extend that is fully aligned to the Population Health such service offers into the C2DE cohort Plan priority themes and wider reform agenda . (the three lower socio-economic groups) with particular focus on 40 to 60-year-olds . Objective 5: To develop a whole systems Devolution offers us an opportunity to deliver approach to lifestyle and wellness services, a radical upgrade in lifestyle behaviour change including testing innovative service delivery support that delivers innovative approaches models for incentivising and supporting at scale to drive long-term behaviour changes lifestyle behaviour change, and to: and reduces current and future demand on

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The Greater Manchester Population Health Plan 2017 - 2021 ●● work with a pathfinder local provider ●● develop and secure transformation to test out and develop an effective funding to resource key elements of plan . delivery model aimed at promoting a radical upgrade in self-care and lifestyle Objective 2: To support the development and prevention, which can be tested at scale in implementation of a refreshed and integrated parts of Greater Manchester GMCA Substance Misuse Strategy . ●● develop and test an innovative incentives- The project will seek to: based digital platform to support lifestyle ●● secure full support of the Greater behaviour change at scale aimed at Manchester health and social care system Greater Manchester’s public sector to the process of refreshing the strategy workforce and defining an integrated suite of shared ●● develop standards and a performance priorities framework for Greater Manchester ●● leverage support for all relevant integrated wellness services to ensure workstreams within the Greater a more standardised offer for Greater Manchester Substance Misuse Review Manchester residents – with the ultimate aim to ensure that ●● develop the role of wider primary care in substance misuse service delivery for supporting lifestyle behaviour change drugs, alcohol and new psychoactive substances is better co-ordinated and 4.3.7.2 Approach to delivering delivering the best possible outcomes objectives across Greater Manchester Objective 1: To develop a comprehensive ●● embed strategic dialogue on alcohol harm Greater Manchester Tobacco Control Plan in the wider context of devolution, and that is fully aligned to the Population Health promote collaborative commissioning Plan priority themes and wider reform agenda . through a recognition of alcohol as a cross-cutting priority in other Population The project will seek to: Health Plan theme areas . ●● develop a costings model that includes staffing costs and non-pay budget to Objective 3: To develop a comprehensive secure services of an expert reference plan to reduce inactivity and increase group participation in physical activity and sport that is aligned to the Population Health Plan ●● utilise best evidence and modelling priority themes and wider reform agenda . analysis for Greater Manchester to identify the key components of a comprehensive The project will seek to: plan ●● engage with all key sectors, organisations ●● engage with all key sectors, organisations and localities to identify their contribution and localities to identify their contribution to a Greater Manchester plan to a Greater Manchester plan ●● develop an insight-led, behaviour-change ●● produce a detailed plan and approach to sport and physical activity, implementation timeline starting with the individual and their communities ●● work with New Economy Manchester to carry out cost benefit analysis to ●● produce a detailed plan and support bid to Transformation Fund and implementation timeline to drive the development of evaluation framework for outcomes of the MoU plan

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The Greater Manchester Population Health Plan 2017 - 2021 ●● develop opportunities to secure Greater This project will seek to: Manchester and national resource to ●● use national exemplars and local good enable delivery of key elements of plan, practice to document a replicable and which would include having shared scalable model that can be tested at scale metrics, performance measures and a in parts of Greater Manchester robust cost benefit analysis for all joint areas of work . ●● develop a costings model that includes staffing costs and non-pay budget to Objective 4: To develop a comprehensive secure services of an expert reference plan for better nutrition and healthy weight group that is fully aligned to the Population Health ●● Plan priority themes and wider reform agenda . secure local provider partners to be part of the trial The project will seek to: ●● work with New Economy Manchester to ●● develop a costings model that includes develop an initial cost benefit analysis staffing costs and non-pay budget to based on work to date and to support secure services of an expert reference development of transformation bid group ●● develop a business case to support ●● utilise best evidence and modelling the adoption and testing of the new analysis for Greater Manchester to identify model across two or three localities and the key components of a comprehensive secure monies from Greater Manchester plan Transformation Fund ●● engage with all key sectors, organisations ●● support a number of localities to and localities to identify their contribution collaborate to implement the described to a Greater Manchester plan model, recognising the local variations that may be required ●● produce a detailed plan and implementation timeline ●● develop a business case that builds on the evaluation of testing the model to support ●● work with New Economy Manchester expansion of the project across other to carry out cost benefit analysis to parts of Greater Manchester . support bid to Transformation Fund and development of evaluation framework for plan 4.3.7.3 Programme of work – scope The proposal is to develop a three-tiered ●● develop and secure transformation behaviour-change support offer across funding to resource key elements of plan . Greater Manchester (see figure 25). This is Objective 5: To develop a whole systems in effect a hub and spoke model. The first approach to lifestyle and wellness services, two tiers, including a web portal and virtual including testing innovative service delivery telephone support, can be provided at a models for incentivising and supporting sector level and will integrate with the third lifestyle behaviour change . tier, which is the locality-based lifestyle and wellness service offer . Objective 5.1: Work with a pathfinder local provider to test out and develop an effective A key principle is that of proportionate delivery model aimed at promoting a radical universalism, where the service response will upgrade in self-care and lifestyle prevention, be according to need . which can be tested at scale in parts of The primary audience for the service will Greater Manchester . be the target demographic for the Public

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The Greater Manchester Population Health Plan 2017 - 2021 Health England One You lifestyle campaign . ●● undertake consumer research to ensure This is C2DE aged 40-60, because evidence that the incentives package is attractive to suggests a strong link between unhealthy the target audience behaviours and social class and NICE ●● work with developer and New Economy to identifies the 40-60 age group as a key carry out cost benefit analysis to support window of opportunity to engage adults in bid to Transformation Fund their own health to prevent disease in later life . This enables Greater Manchester to ●● develop a costings model that includes capitalise on the current national campaign of staffing costs and non-pay budget to focus (One You) and prioritise digital content secure services of an expert reference to support its delivery . group ●● develop and secure transformation Objective 5.2: Develop and test an innovative incentives-based digital platform to support funding to resource the development, lifestyle behaviour change at scale aimed at commissioning and evaluation of a pilot Greater Manchester’s public sector workforce . programme for Greater Manchester public sector staff The project will seek to: ●● evaluate service model to inform further ●● secure an existing developer to develop roll-out . a bespoke incentivised digital health platform to support at scale self-care, and pilot the programme with Greater Manchester public sector staff

Proposal: three-tiered Greater Manchester wellness support offer

Tiers 1 and 2: Greater Manchester Wellness Hub Tier 3: Local Tiers 1: Web portal Tier 3: Local Wellness Wellness service offer Self-assessment tool(s) service offer • Lifestyle • PAM • Cancer risk assessment Gateway to virtual / telephone Tier 3: Local support Tier 3: Local Wellness • Tailored signposting to web Wellness information, social media groups service offer and local non-commissioned service offer services • Incentive packages • Quality-assured Apps Tier 3: Local Tier 3: Local Wellness Wellness service offer Tiers 2: Virtual / telephone support service offer

• Telephone assessment of motivation and goals • Patient activation level Tier 3: Local Tier 3: Local Wellness Wellness service offer Personal action plan agreed, Referral to Tier 3 local service offer including signposting to other services if need is greater support services and if meets referral criteria

Tier 3: Local Follow-up support by: Feedback to practitioner Tier 3: Local Wellness • Telephone if person was referral Wellness service offer • Text into the virtual/telephone service offer • Email support service • Live chat

Figure 25: Three-tiered Greater Manchester wellness support offer

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The Greater Manchester Population Health Plan 2017 - 2021 4.3.7.4 Programme of work – scope The project will seek to: This is a more basic service delivery model ●● define key standards and performance in comparison with the lifestyle and wellness metrics that describe a consistency of hub described above . approach and quality against which services can be commissioned, monitored Its central feature is the provision of an online and evaluated incentives package that rewards participants for undertaking health promoting behaviours ●● gain agreement from the system to such as screening or quitting smoking . adopt and implement the standards and performance framework It would take the form of a digital platform, with an interactive directory and incentivised ●● launch the framework to cement support health platform (see figure 26). across the system for this way of working .

Such a platform could also support other Objective 5.4: Develop the role of wider digital offers, such as Orcha, a Wakelet page primary care in supporting lifestyle behaviour for community champions to collect and share change . content, and access to managed social media The project will seek to: options . ●● develop the role of the primary dental care Objective 5.3: Develop standards and setting in delivering brief interventions, a performance framework for Greater particularly focusing on smoking cessation Manchester integrated wellness services to and reduction of harmful drinking (both ensure a more standardised offer for Greater significant risk factors for mouth cancer as Manchester residents . well as other health conditions)

Level 03 The Offer Directed to support services according to their responses For example if they wish to give up smoking they would receive smoking cessation support. If they want to be more active they would be directed to health trainers in their area. If they are due an assessment they would be given details of health checks/screening programmes etc.

Incentivised Health Section Incentivised programme to be rolled out to public sector staff across the area. The number of staff working in the public sector who would benefit from this programme is 120,000.

When you complete the assessment you are classed as a bronze member with some basic retail or other benefits for logging on to the site. The more you engage with the site and show actions for improving your health such as linking wearable tech and logging your activity levels you increase your points.

You will also increase points by having a health assessment or cancer screening and also signing up to support your community in some way as a volunteer. The more you do the more points you get to rise to silver and gold to unlock more attractive benefits such as cinema tickets, retail vouchers. This scheme is like a loyalty card scheme.

A New User Sign Up/Register Interactive Initial questions Connects to wearable technology such as Fitbit Uses data from application such as Fitbit, Garmin, Nike Running & Apple Watch. • Do you smoke? • How much do you drink? • How regularly do you have your health checked? • How much activity do you do in a Social Media Support week? Such as Manchester Breast Cancer Support or Mummys Support. • How much sleep do you get? • How long hours do you work? • How stressed are you (would be a stress test) • How healthy is your diet? Health App Section Download health and care apps. This would be managed by the Orcha platform.

Positive patient/community stories Develop a page on Wakelet for community champions.

Figure 26: Infographic for incentives based digital platform

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The Greater Manchester Population Health Plan 2017 - 2021 ●● facilitate the roll-out of the Healthy Living affected by cancer at some point in their lives, Framework to all pharmacy, optometry, which is particularly alarming given evidence dental and general practice providers . suggesting that 42% of the country’s most common cancer cases could be preventable . 4.3.7.5 Target outcomes for 2016/17 and In the last five years, almost 600,000 cancer 2017/18 cases in the UK could have been prevented Outcome 1: Comprehensive Greater by modifications to lifestyle factors. Manchester Tobacco Control Plan produced The NHS Five Year Forward View signalled a that is fully aligned to the Greater Manchester continued focus on improving care, treatment Population Health Plan priority themes and and support for everyone diagnosed with wider reform agenda cancer . It set an ambition to improve Outcome 2: Refreshed and integrated GMCA outcomes across the whole pathway, Substance Misuse Strategy developed and including: implemented ●● better prevention Outcome 3: Comprehensive physical activity ●● swifter diagnosis plan produced aimed at reducing inactivity ●● better treatment, care and aftercare . and increasing participation in sport and physical activity, and fully aligned to the In 2015, following the publication of the Greater Manchester Population Health Plan NHS Five Year Forward View, NHS England and wider reform agenda established the Independent Cancer Taskforce to look at how cancer services Comprehensive plan for better Outcome 4: are currently provided and to set out a vision nutrition and healthy weight produced, linked for what cancer patients should expect from to the Population Health Plan priority themes the health service . The taskforce produced and wider reform agenda a report, ‘Achieving World-Class Cancer Outcome 5a: New delivery model tested Outcomes – A Strategy for England 2015- and evaluated with pathfinder local provider, 2020’, which included 96 recommendations to aimed at promoting a radical upgrade in help transform the care that the NHS delivers lifestyle prevention and self-care for all those affected by cancer .

Outcome 5b: Innovative incentives package A plan has now been launched to deliver to support lifestyle behaviour change for these changes . It is designed to increase public sector workforce tested and evaluated cancer prevention, speed up diagnosis, invest in technology, improve patient experience and Outcome 5c: Greater Manchester will have help people living with and beyond cancer . a standards and performance framework for lifestyle services agreed by all commissioners As part of this plan, new models of care to support localities piloted by the National Cancer Vanguard will aim to radically improve patient outcomes 4 .4 Cancer prevention and early and save thousands of lives every year by detection developing new models of care that are ambitious and transformational, and provide 4.4.1 Background replicable models for cancer care nationally Cancer survival rates are at their highest, with that will act as blueprints for the NHS . Its key more than half of those diagnosed living for at objectives are to: least 10 years . However, it is estimated that ●● improve rates of earlier diagnosis and by 2020 more than one in two people will be detection

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The Greater Manchester Population Health Plan 2017 - 2021 ●● improve patient outcomes Clearly we will not be able to sustain comprehensive health and social care ●● reduce variation coverage unless we take more concerted ●● improve patient experience action on prevention . Rising numbers of cancer cases that could be prevented should The National Cancer Vanguard is led by be seen as unacceptable . It is within our The Christie, The Royal Marsden and control to prevent many cases of cancer University College London Hospitals . The and we should seize this opportunity . More three organisations will lead a local delivery than four in 10 cases of cancer are caused system – Greater Manchester Cancer, Royal by aspects of our lifestyles that we have Marsden Partners and University College the ability to change . Tobacco remains the London Hospitals Cancer Collaborative – main risk factor, followed by obesity, alcohol which comprises health organisations in their consumption and physical inactivity . area, including clinical commissioning groups, NHS acute trusts, community services and Earlier diagnosis of the disease is also hospices, that will develop and trial new essential if we are to take meaningful steps models to improve cancer care along the in improving survival for our patients . The patient pathway . key here is a strong focus on improving the uptake of the three national cancer screening 4.4.2 Greater Manchester context programmes . Screening contributes to A key commitment in ‘Taking Charge’ is to reducing incidence and improving outcomes deliver improvements in our cancer services for those patients whose cancers can be and outcomes, with a particular focus on treated at an earlier stage . England’s existing reducing premature mortality from cancer by cancer screening programmes already save 1,300 fewer deaths by 2021 . This is based on thousands of lives each year . However, the transformation of our health and social there is potential to do better, to reduce care system towards prevention and earlier the considerable variation in uptake of intervention . these programmes and further develop the programmes by introducing new tests . Half of people born since 1960 will be diagnosed with cancer in their lifetime, With increasing numbers of people surviving and every 30 minutes someone in Greater their primary cancer, we also need a stronger Manchester is told they have cancer . The focus on preventing secondary cancers . incidence of cancer is growing at a rate of about 2% per annum; in 2013, 14,500 people 4.4.3 Opportunity were diagnosed with cancer in Greater In 2015 Greater Manchester was designated Manchester . This means the burden of as part of the National Cancer Vanguard . cancer on our health and social care system The two-year vanguard programme will is growing . There were 89,200 GP referrals allow the testing of clinical innovations for suspected cancer to Greater Manchester and a new approach to the commissioning hospitals in 2014/15, up from 77,800 the of cancer and delivery for the Greater year before. The National Audit Office Manchester population . It began delivery in estimates cancer-related costs for the NHS April 2016 . Central to the Greater Manchester in England – extrapolating from these costs programme is a prevention workstream, for Greater Manchester gives approximate which incorporates primary and secondary costs of £335m in 2012/13, rising to £650m prevention projects as well as a focus on by 2020/21 (acknowledging that these do not screening . capture all costs, such as those incurred by primary care) .

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The Greater Manchester Population Health Plan 2017 - 2021 In summer 2016 a new Greater Manchester ●● Objective 1: To develop new Greater Cancer Board was established to oversee Manchester-wide social marketing all cancer activity in the area, and it will strategies for cancer to scale up develop a five-year cancer plan to transform prevention and earlier detection services and re-orientate the system towards ●● Objective 2: To apply at scale a multi- prevention and early detection . This is faceted approach to nurture a social an opportunity for Greater Manchester movement across the entire cancer to strengthen and build on the work of prevention spectrum that is ultimately the National Cancer Vanguard and other self-sustaining, as part of the national pilot innovations such as the Macmillan Cancer programme Health as a Social Movement Improvement Partnership (MCIP), led by the three CCGs in Manchester . ●● Objective 3: To improve access to, and uptake of, three national cancer screening As identified above we want to reduce programmes (bowel, breast, and cervical) premature mortality from cancer by 1,300 among the eligible population of Greater fewer deaths by 2021 . On average, over Manchester residents a three-year period from 2012-14, cancer ●● was responsible for 7,571 deaths in Objective 4: To develop a Greater Greater Manchester and half of those were Manchester-wide service model that preventable . The main driver of premature increases tailored lifestyle support for mortality and health inequalities in Greater those surviving cancer, focusing on Manchester is related to tobacco . Despite reducing the chance of secondary cancer significant improvements made in recent (metastasis) years to reduce smoking, smoking rates in Furthermore, through the MCIP work the three Greater Manchester are significantly higher Clinical Commissioning Groups in Manchester than in the rest of England and 21% or about are pilot testing an innovative service that 450,000 adults still smoke . This equates to aims to detect lung cancer earlier . The pilot around 70,000 more smokers than if Greater service offers people at high risk of lung Manchester was at the England average . disease an opportunity to attend a lung health Smoking also significantly contributes to check . If the pilot of the MCIP lung health health inequalities, as smoking rates among check is shown to be successful we will roll it our poorest families are twice the Greater out across Greater Manchester to transform Manchester average . Therefore a key focus our lung cancer outcomes . of work for the Greater Manchester Cancer Board will be tobacco control . 4.4.4.2 Approach to delivering objectives 4.4.4 Plan Objective 1: To develop new Greater 4.4.4.1 Objectives Manchester-wide social marketing strategies The overall objectives of the programme are for cancer to scale up prevention and earlier to effectively deliver the cancer prevention detection . workstream of the National Cancer Vanguard In Year 1 the project will seek to: by April 2018, testing and evaluating innovative approaches to awareness and ●● work in partnership with PHE/Cancer behaviour change, social movement, cancer Research UK (CRUK) to test out, deliver screening uptake and lifestyle-based and evaluate a major bowel screening secondary prevention . This includes four key campaign to improve uptake, featuring objectives . mass media (TV, outdoor media etc) and direct mail

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The Greater Manchester Population Health Plan 2017 - 2021 ●● commission additional behavioural ●● demonstrate ‘what works’ using rigorous insights research into Greater Manchester evaluation approaches to gain a deeper understanding of the ●● support spread – in Year 3, identifying core behavioural attitudinal barriers and approaches that could be scaled motivators for our population or adapted and adopted in other ●● use the insights gained to amplify the communities CRUK/PHE campaign activity to nudge ●● explore the digital opportunities that would further Greater Manchester audiences into support mass involvement, such as social participation media approaches . ●● undertake evaluation to inform future national and local campaign activity . Objective 3: To improve access to, and uptake of, three national cancer screening In Year 2 the programme will: programmes (bowel, breast, and cervical) among Greater Manchester’s eligible ●● commission primary and secondary population . qualitative and quantitative research to segment, profile and prioritise our smoking The project will seek to: population ●● increase the effectiveness of the initial ●● using the above audience profiling and invites letters through the application of behavioural insights, design a social innovative behavioural insight techniques . marketing programme This will involve running randomised control trials over a six-month period to ●● co-ordinate delivery and evaluation of test out the different approaches Greater Manchester social marketing programme ●● commission health equity assessments (HEAs) for all providers of cancer ●● undertake evaluation to inform future screening services to identify inequities campaign activity . in service usage and test out service Objective 2: To apply at scale a multi-faceted changes based on findings of HEAs approach to nurture a social movement ●● design and test out innovative patient across the entire cancer prevention spectrum engagement approaches to improve that is ultimately self-sustaining, as part of the people’s experience of screening and to national programme to pilot Health as a Social increase uptake of screening and self-care Movement . ●● evaluate different approaches to inform The project will seek to: local and national roll-out . ●● work in partnership with the third sector Objective 4: To develop a Greater to develop an exemplar social movement Manchester-wide service model that –focused on cancer prevention increases tailored lifestyle support for those ●● apply at scale a multi-faceted approach surviving cancer, focusing on reducing the to nurture a citizen-led social movement chance of secondary cancer (metastasis) . across the entire cancer prevention The project will seek to: spectrum ●● develop and test out an effective delivery ●● develop a network of 20,000 cancer model of lifestyle-based secondary champions and expert patients to provide prevention as part of the vanguard‘s new a ‘more than medicine’ approach aftercare pathways for breast, urology and colorectal cancer

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The Greater Manchester Population Health Plan 2017 - 2021 ●● develop and roll out a locality-based, 4 .5 Scaling up our response to lifestyle behaviour change support offer HIV eradication with a focus on Greater Manchester-wide access to exercise referral programmes 4.5.1 Background for cancer survivors, providing increased A 2015 report by Public Health England (PHE) access to tailored physical activity estimated that 103,700 people were living programmes with HIV in the UK in the year 2014 . Once ●● develop and test a digital platform (tech people are diagnosed they are able to receive bundle) to enable cancer patients to very effective treatment . However, nationally access professionally approved secondary 17% of people living with HIV are unaware of prevention self-management content, their status . Furthermore, 40% of adults newly mobile applications, managed social diagnosed with HIV were diagnosed late, after support networks and links to locality- they should have started treatment (PHE, based prevention services 2014) . ●● evaluate different approaches to inform Late diagnosis reduces health outcomes for further roll-out . HIV-positive people, as well as increasing the likelihood of onward transmission of HIV . In 4.4.4.3 Outcomes addition to the negative effects of late HIV The overall objective is to make a significant diagnosis on an individual’s and population’s contribution to reducing the number of health, it also makes an impact upon the premature deaths due to cancer by 1,300 public purse; the lifetime treatment cost of fewer deaths by 2021, through improved living with HIV is estimated to be around prevention and earlier diagnosis . More £360,000 . Late diagnosis increases further the specific outcomes include: cost of HIV treatment by 50% . ●● Outcome 1: Increased uptake of bowel It is well recognised that HIV symptoms are screening (+10% in first timers and +3% in frequently missed . As a consequence, many non-responders) people that have been diagnosed with HIV have previously presented at a healthcare ●● Outcome 2: Increase in smoking quitters setting but HIV diagnosis had been missed . ●● Outcome 3: The development of a mass Furthermore, while HIV is a condition that social movement across the entire cancer can affect all population groups, some prevention spectrum that is ultimately communities are more disproportionately self-sustaining, and spread of effective affected by HIV . approaches to other communities/areas ●● Gay, bisexual and other men who have ●● Objective 4: Improved uptake to the three sex with men (MSM): Across the UK, one national cancer screening programmes in 20 gay men is living with HIV . In large (bowel, breast, and cervical) among the cities like Manchester, the figure is more eligible population of Greater Manchester likely to be one in 10 . A total of 44,980 residents gay, bisexual and other men who have sex ●● Objective 5: The development of lifestyle with men are living with HIV (prevalence of support offer for cancer survivors in 4 .8%) . Greater Manchester with a focus on ●● People from Black and minority ethnic secondary prevention of cancer groups (BME) made up 40% of HIV- positive individuals accessing treatment and care in Greater Manchester in 2015, a substantial over-representation compared

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The Greater Manchester Population Health Plan 2017 - 2021 to the proportion of BME groups in the ●● 90% of all PLHIV on ART will have durable Greater Manchester population as a whole viral suppression . (16%) . 4.5.2 Greater Manchester context ●● Transgender population: One worldwide meta-analysis of 39 studies from 15 There is clear synergy with a city-region countries found that transgender women approach to eradicating HIV within a had an HIV prevalence rate of 19% – 49 generation and the vision of transforming times higher than that of the general population health in Greater Manchester; population . In high-income countries the to deliver the greatest and fastest possible prevalence was 22%, with the highest improvement to the health and wellbeing of rate among transgender women of colour the 2 .8 million people of Greater Manchester . (aidsmap, 2016) . In particular, a city-region approach fits with Late diagnosis of HIV is a key public health the Greater Manchester objective to transform issue as identified within the Public Health our health and social care system to help Outcomes Framework . If someone has a late more people stay independent and well and HIV diagnosis, they are 10 times more likely to take better care of those who are ill . It does die within the first year of diagnosis compared this by preventing onwards transmission to people diagnosed promptly (PHE, 2014) . of HIV, both through earlier diagnosis and identification of undiagnosed people living It has also been recognised that further with HIV; across Greater Manchester there progress needs to be made in improving early are estimated to be 984 people living with diagnosis of HIV; nationally, there is a need undiagnosed HIV . These individuals are very to increase and target HIV testing in order much a part of the ‘missing thousands’ (i .e . to improve early diagnosis and to reduce those that are unknown to the system, but onward transmission by getting people onto live and work in the community) identified treatment . Early diagnosis results in earlier within Greater Manchester priorities . An treatment (National Institute for Health and innovative, ambitious programme of upscaling Care Excellence, 2016) . of HIV testing and associated interventions, particularly targeted at and with those We have an opportunity in Greater communities most at risk of acquiring HIV, is Manchester to strengthen a city-region an opportunity for Greater Manchester . approach to eradicating HIV within a generation, by adopting a similar approach to The Fast-Track Cities Initiative complements the Fast-Track Cities Initiative . and adds value to the Greater Manchester focus on Health as a Social Movement The Fast-Track Cities Initiative aims to build through utilising the assets of communities, upon, strengthen and leverage existing HIV supporting people to talk about the programmes and resources in ‘high HIV importance of HIV testing and sharing burden’ city-regions to strengthen local AIDS people’s stories of how they maintain their responses, including attaining the Joint United wellbeing . This is focused upon communities Nations Programme on HIV/AIDS (UNAIDS) taking charge of their own health . 90-90-90 targets: ●● 90% of all people living with HIV (PLHIV) Reducing late diagnosis of HIV is a key Public will know their status Health Outcomes Framework indicator . Upscaling targeted HIV testing is a key ●● 90% of all PLHIV will receive sustained mechanism to achieve this . A combination antiretroviral therapy (ART) approach to prevention is a key part of the Fast-Track Cities Initiative, which includes not

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The Greater Manchester Population Health Plan 2017 - 2021 only testing but also pre-exposure prophylaxis ●● Compared to other people living with (PrEP), prompt access to treatment and HIV, people who died of an AIDS-related support with adherence . cause in 2014 had the highest mean number of outpatient visits (5 .8) and spent ●● 4,922 HIV-positive Greater Manchester the greatest mean number of days as residents accessed treatment and care inpatients (19 .6 days) . in 2014, a 5% increase on the number reported in 2013 (4,682 individuals) . 4.5.3 Opportunity ●● It is estimated that one in six people living There is opportunity to develop a city- with HIV in the UK is yet to be diagnosed . region approach to eradicating HIV within a ●● This means there could be approximately generation . Greater Manchester devolution a further 984 people living undiagnosed and closer integration and collaborative with HIV in Greater Manchester . approaches present opportunities for cross- sector partnership working to eradicate HIV ●● Overall prevalence of HIV in Greater within a generation, with public, voluntary Manchester is 2 .78 per 1,000 population, and private sectors developing an ambitious (significantly higher than the England rate programme to identify the missing 984 people of to 2 1. per 1,000) . living with HIV . ●● Two local authorities in Greater Manchester, Manchester (5 .83 per 1,000 Deeper exploration of the barriers and population aged 15-59) and Salford (4 .8) enablers of reducing late and undiagnosed have an adult prevalence of over two per HIV across Greater Manchester will help 1,000 population, the threshold at which formulate a Greater Manchester strategy to the British HIV Association recommends eradicate HIV within a generation . Shared routine testing for all medical admissions Greater Manchester system leadership will and new GP registrants . provide opportunities for analysis of how both more frequent and earlier HIV testing, at scale ●● The dominant mode of HIV exposure and targeted at those communities most at is men who have sex with men (MSM) risk, could be implemented . at 57% of new cases, followed by heterosexual sex, representing 37% of This Greater Manchester-wide city-region new cases . approach will also encompass transferable learning for addressing other health priorities ●● The predominant route of infection for and inequalities . This would include the new cases in 2014 was MSM (57%) but similar challenges with early diagnosis of this varied across local authorities, with hepatitis B and hepatitis C, which this Greater the majority of new cases in Stockport, Manchester approach can also help to tackle . Bury and Trafford being among MSM (71%, 62%, and 62% respectively) while There are pockets of existing or recent best in Wigan a higher proportion of new cases practice in individual Greater Manchester were acquired heterosexually (56%) . boroughs, which could be more fully explored ●● People from BME groups made up 40% to identify areas that could be scaled up via of HIV-positive individuals accessing a Greater Manchester approach . Regarding treatment and care in Greater Manchester community-based HIV testing, LGBT in 2015, a substantial over-representation Foundation is working in partnership with compared to the proportion of BME health equalities charity BHA, local PHE teams groups in the Greater Manchester and sexual health commissioners to provide population as a whole (16%) . point-of-care HIV testing in community settings, churches etc . This approach is

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The Greater Manchester Population Health Plan 2017 - 2021 particularly targeting those most at risk of Greater Manchester city-region approach acquiring HIV infection; gay, bisexual and to eradicating HIV within a generation . other MSM and Black African communities . The project is currently in its delivery phase 4.5.4.2 Approach to delivering but it is proving to be successful and there are objectives opportunities to explore scaling up provision Objective 1: Review and map out current and replicability in its community-led and HIV testing approaches across Greater focused approaches . Manchester, to inform the ambition of eradicating HIV within a generation . A city-region approach and Greater Manchester strategy also provides The project will seek to: opportunities to explore associated enablers ●● for eradicating HIV within a generation . These describe a Greater Manchester vision could include evaluation of access to post- around reducing undiagnosed and late exposure prophylaxis (PEP) and exploration of HIV diagnosis how partner notification is currently working in ●● work with the Greater Manchester Sexual Greater Manchester . Health Network, mapping out current HIV testing methods and associated 4.5.4 Plan interventions 4.5.4.1 Objectives ●● utilise data within the public health domain The objectives of this programme of work are to inform future HIV testing approaches to help develop a Greater Manchester city- ●● develop a costings model for the possible region approach to eradicating HIV within expansion of HIV testing services, targeted a generation . It would facilitate the roll-out, at Black African and gay, bisexual and testing and evaluation of an approach to other MSM communities, across Greater tackling issues around undiagnosed and Manchester late diagnosis of HIV . The project would be ●● develop and secure transformation informed by existing good local practice, funding to fund roll-out to adopt and test including the current PHE community-based the model . point of care test project, access to HIV testing within healthcare settings and PEP . Objective 2: Develop a business case The project is set up to achieve the following that builds on the robust review and core objectives . mapping exercise of HIV testing provision ●● Objective 1: Review and map out current and associated interventions, and which HIV testing approaches and related demonstrates the economic and health interventions across Greater Manchester, benefits of a Greater Manchester city- to inform the ambition of eradicating HIV region approach to eradicating HIV within within a generation . a generation . To then pilot and evaluate a Greater Manchester city-region approach to ●● Objective 2: Develop a business case eradicating HIV within a generation . that builds on the robust review and mapping exercise of HIV testing provision The project will seek to: and associated interventions, and which ●● provide a forum for sharing intelligence, demonstrates the economic and health analysis, perspectives and outputs related benefits of a Greater Manchester city- to the implementation of the model region approach to eradicating HIV within a generation . To then pilot and evaluate a ●● collate HIV data from a range of sources for analysis across Greater Manchester

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The Greater Manchester Population Health Plan 2017 - 2021 ●● develop cost benefit analysis for a city- gay, bisexual and other MSM, Black African region approach to eradicating HIV within and trans communities . a generation, particularly the upscaling of HIV testing The new delivery model would be a city- region approach to eradicating HIV within ●● collate lessons learned in targeting HIV a generation . It would be a cross-sectoral testing for Black African and gay, bisexual collaboration, with the key driver being and MSM communities in order to inform evidence-led interventions . This city-region future development of HIV testing models approach would also capture wider benefits across Greater Manchester and learning for other health issues, and how ●● explore different sustainability and these can be tackled Greater Manchester investment models . wide . Central to the new approach is an evidence- 4.5.4.3 Target outcomes for 2016/17 and led delivery model . System leadership and 2017/18 the development of a shared response to The programme will work towards achieving eradicating HIV within a generation will enable three key outcomes . greater analysis and exploration of the barriers ●● Outcome 1: Through partnership working and enablers to reducing late diagnosis . across Greater Manchester and mapping of current practice, a Greater Manchester- wide HIV strategy for eradicating HIV within a generation, has been developed . ●● Outcome 2: A model to increase HIV testing and associated interventions has been developed . ●● Outcome 3: A business case and plan for the Greater Manchester-wide roll-out of the model has been produced and agreed and a Greater Manchester pilot implemented .

4.5.4.4 Programme of work – scope Greater Manchester residents who are currently living with undiagnosed HIV are the primary target cohort who would benefit from this intervention . It is estimated that 984 people are currently living with undiagnosed HIV across Greater Manchester . Thus, the programme would seek to target, reach and work alongside this key population group, through a community-led, assets-based approach .

The specific sub-groups within this proposal, who are intended to benefit most from this programme, are those communities that shoulder a disproportionate burden of HIV;

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The Greater Manchester Population Health Plan 2017 - 2021 5. Age Well

Greater Manchester is They include the following . leading the way in its efforts ●● In September 2016 Greater Manchester achieved European to promote healthy ageing, creating a vision for a Innovation Partnership on Active and Healthy Ageing society where older age is reference site status . seen positively and people ●● The Greater Manchester Ageing Hub and the national in later life are empowered Centre for Ageing Better have agreed funding that will to secure a healthy future support the work of the hub to work to achieve a world- and good quality of life for class age-friendly city-region . themselves. There is a wide range of activity already ●● The collaboration between Salford Royal NHS Foundation underway that complements Trust and the Haelo innovation and improvement science and enhances the projects centre, through Dementia United, aims to make Greater in the Greater Manchester Manchester the best place in the world to live for people Population Health Plan. with dementia and improve the lived experience of people with dementia and their carers .

●● Greater Manchester Centre for Voluntary Organisation (GMCVO) has established and continues to lead the Big Lottery funded Ambition for Ageing programme, which aims to tackle at a community level the risks to health and wellbeing presented by social isolation and loneliness in older age .

●● The developing Greater Manchester adult social care strategic proposals identify ‘support for carers’ as one of eight priorities, recognising that many carers are in later life themselves and can experience poor wellbeing due to health, economic and wider factors .

The aim of the Age Well theme in this plan is to promote active ageing and implement preventative and early intervention services to enable people to stay well and healthy in their own homes . We have focused on supporting people currently in early older age (65-75+) to maintain good health, social and emotional wellbeing, independence and quality of life for as long as possible, while also managing the current pressures associated with people who are very old (80-85+) where the challenge is to identify appropriate support and positive risk management to restore daily functioning and independence as far as possible or desirable . Our focus is on age-associated issues within the health, social care and housing sectors that are ‘modifiable’, based on evidence and effective interventions, and which will enable more people to stay well and live independently at home for as long as possible as they age .

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The Greater Manchester Population Health Plan 2017 - 2021 The individual programmes of work within demand for health and emergency services . Age Well highlight common issues affecting Inadequate housing causes or contributes health and wellbeing in older age that cross to many preventable diseases and injuries, all ethnic and social groups . But each one including respiratory, nervous system and will recognise the cumulative effect, over a cardiovascular diseases and cancer . Poor lifetime, of social or economic disadvantage housing is estimated to cost the NHS at least and how this can manifest in the earlier onset £600 million per year . of physical and emotional ill health . These inequalities will be taken into account by In England and Wales trends in excess winter effectively targeting all three projects towards deaths have decreased by about 30% since the people who need support the most, which 2008/09, when there were 36,450 deaths will include disadvantaged individuals and attributable to all causes . In 2010/11 there communities . were 25,700 excess winter deaths . The majority of these occurred among those aged The three programmes of work have a good fit 75 and over . with the creation of locality care organisations (LCOs) and can be incorporated on a longer- From estimates of the Excess Winter Mortality term basis into the usual practices adopted Index (EWM Index) by the Office for National and support offered through integrated Statistics, circulatory diseases caused 37% of health and social care teams . Current cost excess winter deaths in 2009/10 . Respiratory benefit analysis modelling suggests that diseases came in second and accounted there is a good case for each proposal to for 32% . Cold homes are one contributor to release savings back into the local health this, and increase the risk of cardiovascular, and social care system and for this reason respiratory and rheumatoid diseases as well we are suggesting that a central bid to the as hypothermia and poorer mental health . Transformation Fund is made for each project, Older, retired people are particularly at risk . to pump-prime the roll-out the proposals Around 1 .8 million homes had damp problems across Greater Manchester, with a view to in 2009 . Privately rented homes were most them being locally financially sustainable after likely to experience damp problems: 15% a given number of years . compared to 8% of owner-occupied homes and 10% of social housing . Twelve per cent 5 .1 Housing of poor households lived with damp problems 5.1.1 Background compared with 7% of other households . Poor housing is a driver of health inequalities, There is evidence that interventions to and those living in poverty are more likely to improve the quality and suitability of the home live in poorer housing or precarious housing environment can be effective in preventing, circumstances or lack accommodation delaying and reducing demand for social care altogether . Generally speaking, the health of and health care; can enable people to manage older people, children, disabled people and their health and care needs; and can allow people with long-term illnesses is at a greater people to remain in their own homes for as risk from poor housing conditions . long as they choose . There are substantial health benefits associated with improvements Direct effects of cold homes on a person’s to housing conditions; for example, cavity wall health can include: heart attacks, stroke, insulation can deliver improvements equating respiratory disease, flu, falls and injuries, and to a health saving of £969 . hypothermia . The indirect effects are poor mental health and risk of carbon monoxide One in three people aged over 65 and half of poisoning . This in turn can lead to greater those aged over 80 fall at least once a year .

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The Greater Manchester Population Health Plan 2017 - 2021 Falls are the commonest cause of death from wellbeing . Ensuring homes are safe, warm injury in the over-65s, and many falls result in and dry can: fractures and/or head injuries . Falls cost the ●● NHS more than £2 billion per year and also delay and reduce the need for primary have a knock-on effect on productivity costs care and social care interventions, in terms of carer time and absence from work . including admission to long-term care settings Unsuitability of housing and the need for ●● suitably adapted property can also prevent prevent hospital admissions a timely transfer of care for patients back ●● enable timely discharge from hospital and to their home from hospital . In a six-month prevent readmissions to hospital period in 2015, 916 days were reported as delayed waiting for adaptations; a potential ●● enable rapid recovery from periods of ill cost of £732,800 per year, assuming the cost health or planned admissions . of an acute bed to be £400 per day . The ‘home’ becomes a vital component in Housing plays a critical role in helping older developing successful integrated services . people and adults with disabilities or mental The role that the housing sector can play health problems to live as independently in assisting people to live independently as possible, and in helping carers and the for longer is often underestimated and wider health and social care system offer unrecognised by commissioning bodies . support more effectively . Evidence shows The provision of adaptations to the home that Government investment in specialised through Disabled Facilities Grants (DFGs) is housing for these groups is cost effective, a statutory requirement for local authorities . with a positive impact on health and social The funding stream recently became part care spend through for example, the of the Better Care Fund . The Care Act 2014 prevention of falls, or a reduction in the placed a responsibility on local authorities to levels of readmittance to hospital . Poor or ensure suitability of the living environment and inappropriate housing has been shown to recognised that preventative services such as put the health and wellbeing of people at ‘handyperson’ schemes can play a key role in risk . Evidence also demonstrates that a wide ensuring people are able to live independently variety of outcomes are better for those living for longer . in specialised housing compared to regular housing . 5.1.2 Greater Manchester context The lack of an adequate supply of specialised Housing growth is a priority for Greater housing means people are not able to make Manchester and having the right type of suitable housing choices, and are forced to homes to meet the needs of the population stay in less suitable accommodation when, is fundamental to this . The emerging Greater given the opportunity, they may wish to Manchester Spatial Framework highlights move . Furthermore, there is a lack of public the increasing ageing population and awareness of the wider variety of housing provisions that will need to be put in place to models or solutions available . accommodate the changing demographic .

In terms of the national policy context, the The Greater Manchester Low Carbon Hub recent ‘Memorandum of Understanding to has a priority to reduce fuel poverty through support joint action on improving health retrofitting existing homes with energy- through the home’ (2014), recognises that the efficient measures and behaviour change. home environment is essential to health and More generally, local authority housing

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The Greater Manchester Population Health Plan 2017 - 2021 officers and registered providers recognise housing information and advice, for older the contribution that providing good-quality and disabled customers . One main source of housing can have on an individual and their grant funding for the sector’s activities, the ability to live independently . However, this Disabled Facilities Grant (DFG), is now part also has an impact on the health and social of the Better Care Fund (BCF), and the HIA care system by reducing demand for health sector has a central role in the Government’s and social care through the integration of ambition for an integrated health and care housing interventions . system that promotes wellbeing at home and can provide a preventative response to By aligning our housing priorities with the reduce, delay or remove the need for costly vision for health at a Greater Manchester institutional alternatives . strategic level, we will be able to achieve: Integrating a home improvement agency ●● a better quality of life for our residents by model into a much larger jigsaw will ensure 2020 and assist with closing the health a greater range of resources, products and inequalities gap services can be deployed to keep a person ●● a clear focus on prevention and re- living healthily at home . For health trusts and enablement clinical commissioning groups, HIAs provide ●● promote self-care at home and improve ‘home-readying’ services to ease hospital community resilience discharges, prevent readmission and provide the means to better self-manage health ●● support effective discharge from hospital . conditions .

Greater Manchester-wide schemes focused Across Greater Manchester, different on fuel poverty and energy efficiency have approaches have been taken to been successful in the past, ensuring the understanding the extent of poor-quality delivery of a baseline offer of insulation, housing and also the level of interventions boiler replacements, energy switching available . About half of the local authorities and behaviour-change advice to residents run a home improvement agency; however, in Greater Manchester . However, these some are more comprehensive than others . programmes have been reliant on Government A number of local authorities use Age UK’s funding, which has ceased, and now the handyperson service . There are best practice emphasis is to work with private sector energy examples within Greater Manchester including companies, which have an obligation to assist Manchester Care and Repair, Bolton Care and vulnerable households . However, this tends Repair and St Vincent’s Homecare and Repair . to be restrictive and cannot deliver at the same scale as when Government funding was Discussions have been undertaken with available . health, strategic housing, registered providers and the Low Carbon Hub on the concept of a 5.1.3 Opportunity Greater Manchester HIA model, and there is The next decade will see dramatic growth broad support . in the number of older people seeking help The establishment of a Greater Manchester to remain at home as long as possible, home improvement agency model, which while local authorities and health and social builds on existing models in operation, would care conversely face continuing pressure to ensure that all districts are able to provide a reduce costs and seek efficiencies. Home basic offer to older and disabled residents, improvement agencies (HIAs) carry out small while also providing a single access point handyperson jobs and project-manage larger for health and social care professionals to repairs and adaptations, as well as providing

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The Greater Manchester Population Health Plan 2017 - 2021 refer into . Procurement of adaptations and a The project will seek to: handyperson service for Greater Manchester ●● describe a Greater Manchester vision is also likely to lead to efficiencies. There is around tackling issues of poor quality also scope to link Greater Manchester Fire housing and a Greater Manchester HIA Service Safe and Well checks into the model . ●● work with Greater Manchester districts Targeting of customers most likely to be that already have an HIA in operation to living in unsuitable housing, suffering from carry out an initial cost benefit analysis respiratory diseases, at risk of falls etc, and in based on the findings to date and agree receipt of homecare packages, would ensure metrics for evaluation of future Greater resources are spent where most needed . Manchester implementation sites 5.1.4 Plan ●● develop a costings model that includes staffing costs, service provision and 5.1.4.1 Objectives interventions, and identify sources of The objective of this programme of work funding is to help facilitate the roll-out, testing and ●● develop and secure transformation evaluation of an approach to tackling issues funding to fund roll-out in totality for all around poor-quality housing based on the agreed localities to adopt and test the work already taking place across Greater model . Manchester, in line with the other Population Health Plan proposals aimed at promoting an Objective 2: Support a number of localities in effective response to population ageing . The implementing the described model . project is set up to achieve the following core The project will seek to: objectives . ●● secure and put in place agreements with ●● Objective 1: Develop and document a a number of localities to implement the replicable and scalable model, which can model and test locally be tested at scale in a cluster of districts in Greater Manchester ●● provide programme management and delivery support to the initial and roll-out ●● Objective 2: Support a number of model across each of the boroughs (this localities in implementing the described could be shared across more than one model, recognising the local variations borough) that may be required ●● provide a forum for sharing intelligence, ●● Objective 3: Develop a business case analysis, perspectives and outputs related that builds on the robust evaluation of to the implementation of the model . implementing the model to support the future expansion of the project across the Objective 3: Develop a business case whole of Greater Manchester based on the that builds on the robust evaluation of evidence implementing the model to support the future expansion of the project across the whole of 5.1.4.2 Approach to delivering Greater Manchester based on the evidence . objectives The project will seek to: Objective 1: Develop and document a replicable and scalable model, which can ●● collate analysis from implementation sites be tested at scale in a cluster of districts in from across Greater Manchester Greater Manchester . ●● update and further develop cost benefit analysis developed for the model

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The Greater Manchester Population Health Plan 2017 - 2021 ●● collate local lessons learned to inform ●● referral mechanisms future development of the model for wider ●● home safety checks e .g . Safe and Well Greater Manchester adoption checks . ●● gain agreement from the system to fully There is also scope to include: roll the model out to the remaining Greater Manchester boroughs ●● home from hospital/hospital discharge services ●● produce and agree a plan for Greater Manchester-wide roll-out . ●● hoarding service ●● community equipment 5.1.4.3 Target outcomes for 2016/17 and ●● 2017/18 community alarm and assistive technology services The programme will work towards achieving three key outcomes: ●● falls prevention .

●● Outcome 1: Partnership working It will be important that referrals are enabled with existing HIAs and New Economy into and out of the service by housing, health Manchester has developed a replicable and social care workers . Self-referral and self- and scalable model, which can be funding will also be integral to the model . tested at scale in other parts of Greater Funding sources are likely to be varied, with Manchester using transformation funding a management fee taken from DFG funding ●● Outcome 2: A number of Greater being the core and sustainable contributor . Manchester boroughs have implemented Other sources of funding could include the model bidding for grants, private sector and fee generation . Transformation funding is likely ●● Outcome 3: A business case and plan for to be required to develop the scalable model the Greater Manchester-wide roll-out of and kick-start delivery . the model produced and agreed 5 .2 Nutrition and hydration 5.1.4.4 Programme of work – scope 5.2.1 Background The Greater Manchester HIA model would be available to all older people aged 60-plus and There is a good evidence base, drawing on disabled people across Greater Manchester . the literature and operational experience, It is envisaged that there would be a core relating to the role of nutrition and hydration in service and a menu of options that localities supporting good overall health, independence can adopt/commission . and avoidable deterioration in older age . The risk and prevalence of malnutrition increases Within the scope of the service, the intention with age so we should expect the rate of is to include: malnutrition to rise as the population ages ●● delivery of Disabled Facilities Grants (NICE) . Some experts place the potential (DFGs) prevalence of malnutrition at as much as ●● handyperson service 40% of the 65+ population . NICE guidance for commissioners (2012) estimates the ●● fuel poverty/energy efficiency measures following prevalence in different settings: ●● home improvements 30% of hospital admissions, 35% of care ●● project management/’handholding’ service home residents, 10-14% of people living in ●● advice and assistance – fuel poverty, sheltered housing . housing options, benefits

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The Greater Manchester Population Health Plan 2017 - 2021 However, the King’s Fund: Making our health 5.2.2 Greater Manchester context and care systems fit for an ageing population In Greater Manchester, the effects of report, observed in its 2014 report on the malnutrition and dehydration do seem to be readiness of the health and care system recognised in parts of the health and social to respond to an ageing population that care system. It is seen or identified at point of malnutrition is often regarded as a ‘minor’ hospital admission, often as a complicating factor in maintaining independence and factor alongside a wider set of clinical issues, wellbeing, alongside issues like foot health, and the Greater Manchester Directors of visual and hearing impairment, incontinence Adult Social Services Group also recognise and oral health (King’s Fund, 2014) . it as in issue for people with eligible social What is perhaps different about malnutrition care needs, in particular those people living in and dehydration is that it can go unnoticed long-term residential care . and therefore untreated – the majority (93%) There are pockets of relatively recent work of people at risk of malnutrition live in the focusing on food and nutrition in individual community, it often develops over the medium Greater Manchester boroughs (certainly work to long-term and there is rarely a specific, in Salford as part of the MTF national pilot and treatable ‘symptom’ associated with it until it in Manchester relating to care homes), but becomes very severe . Yet it can undermine it would seem that this issue does not have mobility, steadiness (leading to falls), healing a high or consistent profile across Greater and recovery, mental alertness and energy Manchester . Given the impact it can have levels . Outcomes are therefore much worse on individuals and the care system, this is for older people who are malnourished and a potentially missed opportunity that could the same is true of dehydration . provide a strong focus for collaboration at a In terms of the national policy context, the Greater Manchester level . Malnutrition Prevention Programme overseen The analyses below by the Salford public by the Malnutrition Task Force (MTF) is a health team in 2015 show hospital admissions Department of Health funded scheme to across Greater Manchester where malnutrition help the one million older people in England has been coded in the hospital admission suffering from or at risk of malnutrition . record, with a breakdown by gender . The The pilot programme was part of the overall trend between 2010 and 2015 appears Government’s response to the Francis Report to be rising, which could be a reflection of the into the failings at the Mid Staffordshire ageing population, or an independent increase Foundation Trust (see ‘Recommendation in the rate of malnutrition, or a combination 241’ on the Department of Health website) . of both . The analyses give us an insight into The report revealed that patients, many of hospital admissions where malnutrition has them older, had been unable to eat or drink been explicitly recognised, but it is important properly and that nutrition and hydration was to appreciate that this cannot be used to not treated as a priority . The programme gauge overall prevalence, which is estimated aimed to engage whole communities – local to be much higher (see previous sections) . NHS trusts, local authorities, GP practices, care homes and the third sector to come together to tackle malnutrition . The aim is to significantly reduce the number of people aged 65 and over in these areas who are malnourished . The pilot areas were Gateshead, Salford, Purbeck in Dorset, Kent and Lambeth and Southwark .

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The Greater Manchester Population Health Plan 2017 - 2021 The Greater Manchester Population Health Plan 2017 -2021 86

Rate per 100,000 population Rate per 100,000 population May 2010 to April 2011 10 15 20 25 30 35 10 15 20 25 30 35 40 45 50 0 5 0 5

44 Bolton Bolton 59 178 66 92 161 78 39

19 Bury Bury

21 Hospital admissions relating to malnutrition, Greater Manchester, 71 12 31 May 2011 to April 2012 46 34

Hospital admissions related to malnutrition by gender, 15 Manchester Manchester 58 68 194 54 May 2010/April 2011 86 177 105 45 Figure 28::Hospitaladmissionsrelating tomalnutrition bygender May 2010/April 2011 Oldham

Oldham 24 74 12 17 May 2012 to April 2013 28 53 46 22 Greater Manchester, Rochdale Rochdale 21 65 13 19 68 Figure 27:Hospitaladmissionsrelating tomalnutrition 36 Male 44 26

- 43 Salford Salford May 2014/April 2015 Female 161 53 May 2013 to April 2014 55 89 139 60 38 - October 2015 Stockport Stockport 19 105 34 53 35 104 68 22 Tameside Tameside 31 May 2014 to April 2015 99 26 9 48 71 56 25 Trafford

Trafford 23 91 28 41 41 89 47 17

26 May 2015 to October 2015 Wigan 119 Wigan 33 42 65 147 100 59 Manchester Manchester Greater

Greater 308 1157 347 368 1055 551 638 308 5.2.3 Opportunity from these settings, care homes in particular, A number of reports and guidance sourced and the more rapid physiological effects around food, hydration and nutrition refer of dehydration generally and on more frail to the very good availability of nutritional older people specifically, may point towards guidelines, yet there clearly remains a gap a stronger emphasis on hydration in these between knowledge and application, which settings . is confounded by the wide range of individual Salford has emerged as already leading and and environmental factors that can contribute developing local good practice in the area of to the development of malnutrition, usually malnutrition in particular and, as referred to over a long period of time . above, is a pilot site for a whole community In the community, the potential solution is to approach to prevention under the national raise individual, family, carer and practitioner Malnutrition Prevention Programme . The site awareness and promote a stronger has developed the Salford Together Nutrition understanding of the particular groups of Armband, which is gaining traction nationally older people that may be especially at risk and has been rebranded as PaperWeight © of malnutrition and hydration – they might Armband . The Salford team have been typically include men, people living on their nominated by Barbara Keeley MP for a public own, those who are recently bereaved and health excellence award due to their work . people with a psychological or cognitive The armband is a simple and non-intrusive impairment . NICE,2012: ‘Nutrition support in way of gauging potential malnutrition by adults QS24, suggests that nutritional support measuring the non-dominant upper arm . is an ongoing process involving the following Importantly, this has proved to be a way of steps: opening up a conversation, through a wide range of community contacts with older 1 . Raising awareness people, about food and nutrition in a non- 2 .Screening threatening way and providing access to high- 3 . Recognising malnutrition or the risk of quality, tailored information about relevant malnutrition local services, support and advice on the topics . 4 . Documenting nutritional support goals in a management care plan Kirstine Farrer, one of few consultant 5 .Treatment dieticians nationally who is based at Salford 6 . Reviewing nutritional care to identify and Royal, and partners in Salford (including respond to changes in nutritional status . Age UK Salford and local integrated care programme colleagues) have already done Steps 1-3 are equally applicable to the much of the thinking on ways to open identification of dehydration. In care home up conversation on malnutrition, having settings, and domiciliary care arrangements developed their own local scheme during the such as home care or extra care, although past three years . They are now continuing to the same issue of promotion and awareness- pilot work in care homes and have developed raising is important, because the groups an e-learning package designed to improve of older people being supported by these understanding of nutrition and hydration arrangements are likely to be much more among practitioners and care staff working vulnerable – needing more support with in the community and also relevant hospital food and drink at mealtimes, alongside very staff . specific dietary needs – the issues may need to be approached in different ways . The approach is relatively simple and likely The higher numbers of hospital admissions to be replicable across other boroughs

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The Greater Manchester Population Health Plan 2017 - 2021 – delivered through effective project 5.2.4 Plan management at a Greater Manchester level; supported by local buy-in to ensure that it 5.2.4.1 Objectives fits and reflects existing local provision; and The objectives of this programme of work with expertise and learning from colleagues at are to help facilitate the roll-out, testing Salford . and evaluation of an approach to tackle dehydration and malnutrition based on the New Economy has undertaken initial indicative nationally recognised work in Salford, in line analysis of the Salford Malnutrition Pilot to with the other Theme 1 proposals aimed at understand the financial case for the initiative. promoting an effective response to population This analysis suggests that the gross fiscal ageing . The project is set up to achieve the return on investment over a five-year period following core objectives . is 3 .20 and the net present budget impact is around £800,000 . The long-term cashable ●● Objective 1: Using the Salford approach, fiscal return on investment is estimated at develop and document a replicable and 2 .69 . scalable model, which can be tested at scale in other parts of Greater Manchester The costs comprise staff input (predominantly ●● Objective 2: Support a number of GP capacity in screening elderly patients), localities in implementing the described resource and distribution of materials, and model, recognising the local variations project management costs including initial that may be required outlay on programme design. The benefits are driven by the significant reactive cost ●● Objective 3: Develop a business case savings from a reduction in falls associated that builds on the robust evaluation of with addressing malnutrition and dehydration implementing the model to support the – this includes savings from non-elective future expansion of the project across the admissions, residential care admissions and whole of Greater Manchester based on the a reduced need for intermediate care, re- evidence enablement and home care . Considerable benefit is also anticipated from reduced GP 5.2.4.2 Approach to delivering appointments and a reduction in the use of objectives enteral feeds and nutritional supplements . Objective 1: Using the Salford approach, develop a replicable and scalable model, Further work will need to be undertaken to which can be tested at scale in other parts of test these emerging findings with partners Greater Manchester . and to replace national level assumptions with additional local evidence . As they stand, the The project will seek to: cost benefit analysis (CBA) outputs should ●● describe a Greater Manchester vision be considered as indicative and subject to around tackling issues of malnutrition and change. To reflect plans for scaling up more dehydration widely across Greater Manchester, the CBA can be re-run on a multi-locality footprint . It ●● work with Salford to carry out an initial is likely that this will increase the return on cost benefit analysis (CBA) based on the investment through cost efficiencies related to findings to date and agree metrics for procurement and savings in the project design evaluation of future Greater Manchester phase . implementation sites

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The Greater Manchester Population Health Plan 2017 - 2021 ●● develop a costings model that includes vigilance of malnutrition and dehydration staffing costs, plus all the materials, a in the community; and reduce the impact working budget and funds to secure the of malnutrition and dehydration on the services of an expert reference group quality of life, health and care outcomes of older people ●● develop and secure transformation funding to resource two to three localities ●● implement a financially sustainable to adopt and test the model . approach, using transition funding to mainstream good preventative practice, Objective 2: Support a number of localities in which can then continue to be overseen implementing the described model . and developed in the medium to longer- The project will seek to: term by a local multi-disciplinary expert reference group . ●● secure and put in place agreements with a number of localities to implement the 5.2.4.3 Target outcomes for 2016/17 and model and test locally 2017/18 ●● provide programme management and The programme will work towards achieving delivery support to roll out the model three key outcomes . across each of the boroughs (this could be ●● Outcome 1: The partnership working with shared across more than one borough) Salford and New Economy Manchester ●● provide a forum for sharing intelligence, has developed a replicable and scalable analysis, perspectives and outputs related model, which can be tested at scale in to the implementation of the model . other parts of Greater Manchester using transformation funding Objective 3: Develop a business case that builds on the robust evaluation of ●● Outcome 2: A number of Greater implementing the model to support the future Manchester boroughs have implemented expansion of the project across the whole of the model Greater Manchester based on the evidence . ●● Outcome 3: A business case and plan for The project will seek to: the Greater Manchester-wide roll-out of the model produced and agreed ●● collate analysis from implementation sites from across Greater Manchester 5.2.4.4 Programme of work – scope ●● update and further develop cost benefit This proposal is intended to be implemented analysis developed for the Salford model across community and allied healthcare, ●● collate local lessons learned to inform social care (public and independent sector) future development of the model for wider and voluntary sector services delivered within Greater Manchester adoption a locality, which are already in contact with older people in the normal course of delivering ●● gain agreement from the system to fully their services or support . roll the model out to the remaining Greater Manchester boroughs The proposal and model for delivery

●● produce and agree a plan for Greater ●● The model is designed explicitly to be a Manchester-wide roll-out community-level preventative approach ●● ultimately embed the use of the that can be applied in a wide range of care PaperWeight Armband into routine contact and health scenarios with older people . with older people; improve awareness and It does not require clinical expertise

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The Greater Manchester Population Health Plan 2017 - 2021 to use the armband, so it has wide the community, including family carers . application across the social care and It can also be used/promoted at one- health workforce based in the community . off community events or alongside Although the armband and its associated preventative interventions targeting older resources could be used in secondary people e.g. 65+ flu clinics. care settings, that is not the focus of this proposal as it is expected that secondary 5 .3 Falls care practitioners are likely to have 5.3.1 Background more direct experience of malnutrition and dehydration and more tools at Falls, osteoporosis and fragility fractures are their fingertips to identify and assess it three sides of the same problem . Falls can clinically . happen to anyone at any time, but they are more common among older age groups and ●● The target group to be identified, strongly associated with chronic conditions . prompted and supported to benefit from Falls are a major cause of disability and the the intervention will largely be an older leading cause of mortality due to injury in cohort of adults living in their own homes people aged over 75 in the UK . Annually, in the community, some of whom may around 35% of people aged 65 and over be experiencing signs of mild frailty, and will experience one or more fall and this rate many are also likely to have co-morbidities doubles for those living in care homes . Falls that they are managing medically . A key are implicated in the majority of fractures sub-group will be older people living in a in older people . Most of these are fragility care home setting, where the emphasis fractures affecting the pelvis, wrist, upper arm of the intervention may be more tailored or hip . Around half of all women and one in six to that environment e .g . training for men will experience a fragility fracture in later residential care staff . life. Fragility fracture is often the first indicator ●● The chief purpose of the model is of undiagnosed osteoporosis . to embed better awareness and Falls-related injuries range from minimal to understanding of malnutrition and serious, including loss of confidence. Falls can dehydration in older age and introduce increase isolation and reduce independence, a simple tool, which doesn’t require any with around one in 10 older people who fall specialist or clinical knowledge to apply becoming afraid to leave their homes in case (the PaperWeight Armband), to prompt they fall again . Falls trigger over 40% of its identification. The Salford model admissions into nursing and residential care was overseen and implemented by a and are the commonest reason for referrals cross-sector team who also collectively into intermediate care . designed and produced the materials used . A multi-disciplinary team, which is Hip fracture is the most serious consequence jointly committed to the implementation of a fall, the commonest reason for older of the project, creates shared ownership people to need emergency surgery, and the and disperses leadership, both of which most common cause of accident-related strengthen the model . death in older people . Around 30% of over- ●● In practice, a local project co-ordinator 65s experiencing a hip fracture will die within takes lead responsibility for introducing a year, and a quarter will need long-term the PaperWeight Armband, and its care . Hip fracture patients take up 1 .5 million associated support materials, to a wide hospital bed days each year and cost the range of practitioners who regularly NHS and social care £1 billion . This one injury come into contact with older people in carries a total cost equivalent to about 1% of the whole NHS budget . 90

The Greater Manchester Population Health Plan 2017 - 2021 5.3.2 Greater Manchester context will also be key . There is much to learn and ‘Taking Charge’ sets out our ambition to share from existing practices across Greater reduce falls-related injurious falls admissions Manchester and beyond, and we will seek to in older people to the England average, facilitate that and collaborative approaches resulting in 2,750 fewer serious falls . All where possible . locality plans across Greater Manchester 5.3.3 Opportunity have identified falls as a priority issue and/or an area for development . An understanding Given the ambition set out in ‘Taking Charge’ of key deliverables right across Greater there is now an opportunity in Greater Manchester will be vital to ensure we are Manchester to support the development maximising all our potential to reduce injurious of integrated systems geared to falls and falls and we collaborate where possible . fragility fracture prevention, informed by the Ensuring falls pathways are in place that link available evidence . A Greater Manchester falls acute and urgent care services to secondary programme could utilise the Department of falls prevention will be key to intervening early Health (DH) model for a systematic approach and restoring independence . Work with care to falls and fracture prevention as set out homes, where falls prevalence is much higher in Figure 29 . Falls and osteoporosis are than in the general 65+ population, will also essentially long-term conditions and this be needed and exploring how we can scale needs to inform preventative approaches in up relevant physical activity interventions parallel with other long-term conditions .

A systematic approach to falls and fracture prevention - four key objectives

Stepwise Objective 1: Improve outcomes and improve implementation Hip efficiency of care after hip fractures - by - based on size fracture following the 6 “Blue Book” standards . of impact patients

Non-hip fragility Objective 2: Respond to the first fracture, fracture patients prevent the second - through Fracture Liaison Services in acute and primary care .

Individuals at high risk Objective 3: Early intervention to restore of 1st fragility fracture or independence - through falls care pathway other injurious falls linking acute and urgent care services to secondary falls prevention .

Objective 4: Prevent frailty, preserve Older people bone health, reduce accidents - through preserving physical activity, healthy lifestyles and reducing environmental hazards .

Source: Falls and fractures: Effective interventions in Health and Social Care, 2009, DH . Figure 29: Falls and fractures

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The Greater Manchester Population Health Plan 2017 - 2021 A Greater Manchester approach around falls 5.3.3.2 Fracture liaison service (FLS) could aim to: Sustaining a fragility fracture at least doubles ●● reduce the incidence of falls the risk of a future fracture . A study of the Glasgow FLS established that 80% of re- ●● reduce the severity of injuries fractures that occur over a three-year follow- ●● ensure effective treatment and up period happen during the first year after rehabilitation for those who have fallen . the initial (post-index) fracture, with 50% of re-fractures having occurred during the first Two high-impact changes have been 6-8 months. A significant proportion of fragility identified for Years 1 and 2, in keeping with fractures are recurring fractures that could the stepwise implementation suggested in the have been prevented if steps had been taken model above . These centre around reducing to diagnose and treat osteoporosis after the variation in, and improving the quality of, initial or index fracture and to address any hip fracture care outcomes (to be delivered falls risk . This leads to a situation where “hip through Theme 3) and testing the potential fracture is all too often the final destination of of fracture liaison services integrated with a 30-year journey fuelled by decreasing bone local falls prevention services across Greater strength and increasing falls risk” . Manchester through the delivery of this plan . These two areas are now described below: An FLS will systematically identify, treat and refer to appropriate services all eligible 5.3.3.1 Hip fracture care patients over 50 years old within a local Quality in hip fracture care is incentivised population who have suffered fragility through a best practice tariff (BPT) . The fractures . An FLS is regarded as clinically and National Hip Fracture Database (NHFD) economically efficient. An FLS in an acute captures a range of clinical audit data in setting can intervene in 50% of future hip relation to hip fracture care by provider site . fracture cases and, in a primary care setting, Comparative data for achievement of BPT increase compliance with NICE guidance on shows some sub-optimal care and variations secondary prevention of osteoporotic fracture across Greater Manchester . This component by up to 64% . These reductions are realised of the programme will drive up improvements quickly and certainly within three years of the in hip fracture outcomes, implementing commencement of relevant drug treatment . relevant recommendations from the ‘NHFD It is generally recognised that, in the absence Annual Report 2016’, and seek to: of follow-up (which an FLS can provide), compliance with treatment is generally very ●● support quality improvement poor . ●● implement relevant NICE guidance and quality standards Interventions to reduce future fracture risk in patients who have already broken a bone ●● review and revise the whole hip fracture takes priority over primary fracture prevention pathway beyond acute care, and bring due to: into scope rehabilitation, intermediate care ●● and community care . the 2-3 fold greater risk of fracture (any skeletal site) following index fracture This element of the Greater Manchester Falls ●● 50% of hip fractures occurring in patients Programme will be taken forward by the who have previously sustained a fracture Greater Manchester MSK and Orthopaedics Programme within Theme 3 . ●● achieving the same reduction in fracture incidence through primary prevention would necessitate identification and assessment of 5-6 times more patients .

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The Greater Manchester Population Health Plan 2017 - 2021 A secondary fracture prevention strategy will setting within each of Greater Manchester’s achieve substantially greater fracture risk hospital sites, and are subject to decision- reduction for any investment of resources making around service configuration. Findings than can be achieved through primary fracture are presented here in isolation from other prevention . strands of the Age Well workstream, but in future will be considered as part of a wider Fracture liaison services originated in acute portfolio of work . settings . However, more models are emerging within community-based settings, which Opportunities still to be scoped support the drive for care closer to home . Work is still needed to develop and agree A community model can be more easily further opportunities at Greater Manchester facilitated with a ‘reporting radiographer’ to complement the work at a locality level to approach rather than case finding in acute reduce injurious falls in older people . Work will fracture care, which some earlier models take place over the next 12 months to further adopted . This also maximises opportunities define these pieces of work in collaboration to identify vertebral fractures . Wigan, for with localities . Initial areas for consideration example, currently has a community-based are described in the sections below . FLS+ that has an extended role into primary care . Wigan’s FLS is also integrated with its 5.3.3.3 Falls care pathway falls prevention service on the basis of the Ensuring falls pathways are in place that link inter-relationship between falls, osteoporosis acute and urgent care services to secondary and fragility fractures . falls prevention is key to intervening early and restoring independence . High-level predictive CBA undertaken by New Economy suggests an overall gross All locality plans have identified falls as fiscal return on investment of 2.26 with a net an issue or area for development . An present budget impact of £11 .2 million over understanding of key deliverables right five years. While there is a significant increase across Greater Manchester will be vital to in benefits as the target cohort increases over ensure we are maximising all our potential time, it is anticipated that the investment in to reduce injurious falls and we collaborate FLS across Greater Manchester will have where possible . There is much to learn and been ‘paid back’ during the first year of share from existing practice across Greater activity . Manchester and beyond in relation to multi- factorial risk assessments, falls pathways The largest benefits created by the FLS are and falls prevention practice . For example, those pertaining to prevented hip fractures . Stockport has developed a falls pathway that These benefits include savings as a result of supports the implementation of relevant NICE both a reduction in acute care presentations guidance . and the circumvented need for residential care. The most significant costs of the FLS The rate of falls in care homes is almost are those associated with staffing. However, three times that of older people living in the there are also costs linked to the increased community and 30% of hip fracture hospital number of patients prescribed medication, admissions are from a care home . Scotland and to a lesser extent, those likely to undergo and Derbyshire have developed good practice bone scans . toolkits .

Findings reflect indicative reactive savings Work could include steps to: that could be made through the provision of ●● identify and share examples of practice fracture liaison services based in an acute from across Greater Manchester

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The Greater Manchester Population Health Plan 2017 - 2021 ●● stimulate collaborative approaches to 5.3.4 Plan implementing relevant NICE guidance on falls prevention 5.3.4.1 Objectives ●● work with localities to identify toolkits The objectives of this programme of work and best practice around falls are to help facilitate the roll-out, testing prevention in care homes, and share for and evaluation of fracture liaison services implementation . integrated with a range of locally designed falls prevention services in a number Evidence-based physical activity programme of Greater Manchester boroughs . The for falls prevention programme is set up to achieve the following core objectives . Poor gait and balance is the most significant intrinsic risk factor for a fall . The most ●● Objective 1: Using national guidelines effective component of multi-factorial and learning from developments locally interventions is therapeutic exercise . Any in Wigan, develop and document a therapeutic exercise should be individually replicable and scalable model, which can prescribed, focus on building strength and be tested at scale in other parts of Greater balance, be progressive, and meet the right Manchester dosage criteria to sufficiently reduce falls ●● Objective 2: Support a number of risk . FaME, Otago, and LiFE are all evidence- localities in implementing the described based therapeutic exercise programmes, model, recognising the local variations which variously reduce falls risks by at least that may be required 35% and up to 54% . Compliance, however, is known to be problematic and, ideally, activity ●● Objective 3: Develop a business case needs to be sustained beyond the initial that builds on the robust evaluation of therapeutic phase . implementing the model to support the future expansion of the model across the Delivery requires instructor training in one whole of Greater Manchester based on the of the evidence-based programmes, with evidence . relevant prerequisites . Instructors can come from a number of backgrounds, including 5.3.4.2 Approach to delivering physiotherapists, occupational therapists, objectives sports scientists, and registered exercise Objective 1: Using national guidelines and professionals . There are varied approaches learning from developments locally in Wigan, to, and provision of, falls prevention physical develop and document a replicable and activity programmes and we need to scalable model, which can be tested at scale understand, learn and share from all Greater in other parts of Greater Manchester . Manchester districts . The project will seek to: Work could include steps to: ●● work with Wigan and the National ●● identify and share delivery models Osteoporosis Society to carry out an initial ●● facilitate an asset-based approach to build cost benefit analysis based on the findings capacity for physical activity interventions to date and agree metrics for evaluation of for falls prevention future Greater Manchester implementation sites ●● work with localities to identify options to scale up therapeutic physical activity ●● develop a costings model that includes programmes for falls prevention . staffing costs, plus all the materials, a

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The Greater Manchester Population Health Plan 2017 - 2021 working budget and funds to secure the 5.3.4.3 Target outcomes for 2016/17 and services of an expert reference group 2017/18 ●● secure transformation funding to roll out The programme will work towards achieving fracture liaison services in a number of three key outcomes . localities, which align with new models of ●● Outcome 1: Transformation funding care locally . secured, via a robust business case, for Objective 2: Support a number of localities roll-out of fracture liaison services in ‘early in implementing the described model, implementer’ sites recognising the local variations that may be ●● Outcome 2: A number of Greater required . Manchester boroughs will have developed The project will seek to: and implemented an FLS ●● secure and put in place agreements ●● Outcome 3: A business case and plan for with those ‘early implementer’ sites for the wider roll-out of FLSs across Greater provision of fracture liaison services Manchester will be developed ●● provide programme management and delivery support to the early implementer 5.3.4.4 Programme of work – scope sites An FLS is typically developed around a fracture liaison co-ordinator, usually a nurse ●● provide a forum for sharing intelligence, specialist, in collaboration with and supported analysis, perspectives and outputs related by a metabolic bone disease specialist as to the implementation of the model . named lead clinician . Objective 3: Develop a business case The FLS and care pathway will provide that builds on the robust evaluation of specialist secondary fracture prevention implementing the model to support the future assessment and management to all patients expansion of the project across the whole of over 50 years old . The service will promote Greater Manchester based on the evidence . co-ordination between acute, community and The project will seek to: primary care to ensure that care is seamless and consistent . This integrated approach will ●● support evaluation of FLS provision include: ●● collate analysis from implementation sites ●● case finding in fracture clinics, emergency from across Greater Manchester departments, inpatient wards and ●● update and further develop cost benefit outpatient clinics analysis developed for original model ●● triage and assessment of identified ●● collate local lessons learned to inform patients by co-ordinators/specialist nurses future development of the model for wider ●● diagnosis of osteoporosis using DXA Greater Manchester adoption scans ●● gain agreement from the system to fully ●● initiation of treatment for fracture risk roll the model out to the remaining Greater reduction in line with agreed guidelines Manchester boroughs ●● appropriate pharmacological treatment ●● produce and agree a plan for Greater Manchester-wide roll-out . ●● identification of the ‘modifiable faller’ and referral to a falls prevention service

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The Greater Manchester Population Health Plan 2017 - 2021 ●● liaison with the patient’s GP with the aim The service will be available to all patients of optimising long-term treatment over the age of 50 years who have suffered a fragility fracture, with the primary aim of ●● telephone follow-up of patients to provide preventing subsequent fracture. The figure education and support in primary care below provides an overview of an FLS and its ●● promotion of FLS to relevant hospital key interfaces . teams in order to maximise case finding In some more recently established services, ●● specialist clinic support for secondary case finding is via diagnostics with reporting care clinicians in managing complex and radiographers identifying patients and rare bone conditions notifying the FLS . ●● a database of patients assessed through the service to support follow-up and quality reporting .

Figure 30: FLS framework

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The Greater Manchester Population Health Plan 2017 - 2021 6. System reform

It is clear that an ambition ‘Population health systems: Going beyond integrated care’ of this magnitude around (King’s Fund 2015) identified that population health is affected the delivery of the by a wide range of influences across society and within Population Health Plan communities . Improving population health is not just the requires the support of a responsibility of health and social care services, or of public population health system health professionals . Instead, it requires co-ordinated efforts that is organised to deliver across population health systems . at pace and scale. Making this shift towards population health requires collaboration across a range of sectors and wider communities – between NHS organisations, local authorities, the third sector and other local partners, as well as patients and the public working together as population health systems .

Greater Manchester has the chance, therefore, to take a co- designed approach to radically reframe the role of population health in the context of a devolved system, creating a unified population health system across 10 localities and Greater Manchester that is better able to achieve improved health outcomes for the citizens of Greater Manchester .

Our system reform proposal will therefore look to create a leadership, governance and delivery model with clear lines of accountability and responsibility for achieving Greater Manchester’s population health ambitions that delivers financial sustainability and is able to future-proof against further funding changes .

In addition, the reform proposal will include the development of a unified approach to commissioning population health. This will take into account Section 7a (public health functions agreement) commissioning, local authority regulatory commissioned public health services, as well as the commissioning intentions and approaches arising from the new models of care outlined in the plan .

The final aspect of the system reform programme is looking at how public sector spend can produce a wider benefit to the community i.e. the social value benefit to the people of Greater Manchester from public sector commissioning and procurement and maximising the contribution made by the voluntary, community and social enterprise (VCSE) sector .

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The Greater Manchester Population Health Plan 2017 - 2021 6 .1 System reform – Creating model) across Greater Manchester or within a unified population sectors in Greater Manchester, with managed deliberate intent, would enable better public health system for Greater health leadership on aspects of population Manchester health management . In Greater Manchester, we have a shared There is an opportunity therefore to build commitment to the most ambitious approach a single population health system across yet in England to place population Health the Greater Manchester economy – one at the heart of public service reform and that maximises both the impact and the economic growth . Rebalancing our economy capacities of a small and specialist public also requires rebalancing our public services . health workforce, but also that supports the Since the implementation of the Health and embedding of the pursuit of population health Social Care Act 2012, public health leadership as being everybody’s business . This requires; has become fragmented and capacity is ●● a step-change in the way already devolved dispersed across local authorities, the work public health leadership capacity is of the Greater Manchester Directors of organised across Greater Manchester Public Health Group, PHE and NHS England, ●● resulting in fragmentation of health protection, the realignment and re-orientation of PHE intelligence architecture and commissioning resource and capacity functions . This has created duplication ●● building on the devolution of NHS England and overlap and limited the capacity to commissioning resource . effect significant change across Greater Manchester . In addition to creating a unified leadership system for population health, we need to In July 2015, Greater Manchester signed a create a unified approach to commissioning memorandum of understanding (MoU) with population health that enables us to PHE with an ambition to create a unified commission services at the right spatial level, public health system . This provides an in collaboration with one another and enabling opportunity to support and add value to us to improve population health outcomes local working by reducing the fragmented and health inequalities as well as contributing nature of public health leadership in Greater to a more sustainable public health, health Manchester and drive the necessary and care system . prevention and integration that will be central to improving outcomes in a landscape of We want to move away from focusing on diminishing resources . organisations and separate areas of spend with a single-service planning approach, 6.1.1 Opportunity which results in a fragmented approach to commissioning health, social care Reforming how public health functions and public health services . We want to are delivered within Greater Manchester is focus on integrated strategic planning to now a critical part of the wider devolution achieve cumulative impact and outcomes, transformation, and needs to be reformed in creating economies of scale across Greater partnership across all public services in order Manchester with integrated delivery around to deliver Greater Manchester’s ambition of a individuals and families at neighbourhood well population and productive workforce . level . Sharing of public health capacity (which is about embedding knowledge, skills and expertise across society in a place-based

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The Greater Manchester Population Health Plan 2017 - 2021 We intend therefore to: ●● ensuring far closer alignment at Greater Manchester level with the locality plans 1 . Create a leadership, governance and delivery model with clear lines of ●● ensuring any proposed Greater accountability and responsibility for Manchester population health resource achieving Greater Manchester’s population needs to do what only makes sense health ambitions to do at Greater Manchester level and still produces functionality and 2 . Look at extending commissioning at services that are timely and sufficiently Greater Manchester level of activity to relevant, reflective of or flexible to local improve health that achieves additional requirements and integral to locality care impact and is complementary to that at organisation development . locality level 3 . Strengthen health protection functions, 6.1.2 The plan to be commissioned and organised on Work has already been underway since a Greater Manchester footprint with the signing of the MoU to move towards additional responsibilities aligned to wider reforming the system to achieve a unified Greater Manchester resilience and civil leadership across the population health contingency arrangements system . The devolution of NHS England 4 . As agreed in the MoU, establish, where Section 7a commissioning resources to appropriate, a pooled budget to which all Greater Manchester as outlined in the Greater councils contribute to commission Greater Manchester Delegation Agreement was the Manchester-level activity and a district first opportunity taken to unify public health level budget for district activity commissioning . 5 . Ensure all local authorities have ready and The agreement saw the transfer of relevant effective access to all the necessary public resources to Greater Manchester Health and health experience and skills to ensure Social Care Partnership (GMHSC Partnership), they can fulfil their statutory requirements, as well as the responsibility for commissioning and identify an appropriate public health screening (cancer and non-cancer), presence in each local authority area immunisation and vaccination programmes, 6. Set standard commissioning specifications and child health information services . required for ensuring the delivery of Screening and immunisation programmes a population health approach across are the largest public health interventions providers . in Greater Manchester, delivering high- quality services across the whole life course In doing this we will work to a core set of that reduce the burden of disease and principles, such as: save lives . A population health team within ●● subsidiarity – the principle that decisions Greater Manchester Health and Social Care should always be taken at the lowest Partnership was established with embedded possible level or closest to where they will staff from NHS England (NHSE) and Public have their effect, for example in a local Health England, namely NHSE public health area rather than for a whole country commissioners and PHE assigned staff . A PHE relationship manager has been assigned ●● looking in the first instance at functions as an associate within GMHSC Partnership’s where there are sensible economies of wider leadership team as the interface scale and where genuine added value is between PHE and the Greater Manchester demonstrated population health team .

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The Greater Manchester Population Health Plan 2017 - 2021 The ‘Greater Manchester Commissioning sexual health network, which have Strategy: Commissioning for reform’ (October worked collaboratively to successfully 2016) signalled the intent to take a new produce a single service specification approach to commissioning that would for genitourinary (GU) and contraception overcome the barriers of fragmented decision and sexual health (CASH) services that is making and overlapping or duplicated being used consistently across Greater investment, and to address the longstanding Manchester, and have also established challenge of co-investment . Using the Greater sector-based recommissioning of core Manchester Commissioning Strategy as a services . framework, we will develop a commissioning ●● We want to look at how best to replicate plan that will be co-created with the system, the approach taken to the successful recognising that there are significant work underway under the leadership of variations that currently exist across and the Association of Greater Manchester within the ten boroughs, towns and cities Authorities (AGMA) wider leadership of Greater Manchester . We will look to the team, the Police and Crime Commissioner development of the emerging LCOs to ensure for Greater Manchester, local authority how best we can commission and deliver executives and directors of public services that meet our population health health, which is delivering a co-ordinated outcomes through the LCO models . approach to commissioning substance Work is already underway across Greater misuse (for drugs, alcohol and new Manchester to align commissioning intentions psychoactive substance) to deliver the and we intend to learn from that work and best possible outcomes across Greater successful approaches being taken . Manchester . ●● We want to continue to commission More recently we have seen the production services on a Greater Manchester of a set of high-level proposals – covering footprint for Section 7a services (screening population health commissioning, and immunisation) as it is the most population health intelligence systems effective way to deliver at scale with a and population health policy, strategy and lean workforce . Devolution provides an workforce functions – for taking forward opportunity to align these programmes a unified population health system for with the emerging LCOs and explore new Greater Manchester with broad stakeholder opportunities for workforce planning and engagement . to build on social and digital innovation to enable people to take charge of their Further work is now needed to develop own health . We have the opportunity of those high-level proposals into a set of identifying further opportunities to expand evidence-based options that will lead to a set the commissioning portfolio as need of decisions and then a period of managed dictates . transition . It is the intent that we ensure that any proposed Greater Manchester population ●● We will ensure future commissioning health resource needs to do what only makes and procurement approaches will take sense to do at Greater Manchester level and more of a social value approach and be still produces functionality and services that rooted within the needs of the GMHSC are timely and sufficiently relevant, reflective partnership and public service reform . of or flexible to local requirements, and ●● We need to build on existing work, integral to locality care organisation (LCO) such as the work undertaken by the development . sexual health commissioners and

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The Greater Manchester Population Health Plan 2017 - 2021 6.1.3 Objectives commissioned population health To deliver the plan we want to achieve the services following core objectives . ●● Identify commissioning plans and ●● Objective 1: Develop a population intentions, including planned cluster health commissioning plan that brings level commissioning; PH grant together the NHS England commissioning commissioning plans . responsibilities set out in Section 7a of the ●● review alignment of locality Health and Social Care Act 2012, together commissioning plans with Greater with local government-commissioned Manchester Theme 1 transformation population health services and the new programmes service models set out in this plan ●● identify any standard operating models ●● Objective 2: Develop and test a proposal and options for replicability on Greater for a new Greater Manchester population Manchester footprint health function serving localities, CCGs ●● review wider considerations for LCO and Greater Manchester structures models and pooling of commissioning ●● Objective 3: Develop a model for future budgets resourcing of population health in Greater ●● determine different commissioning Manchester approaches currently in use Approach to delivering the objectives e .g . outcomes-based, alliance, Objective 1 – Develop a population health neighbourhood level and best fit for commissioning plan that brings together the purpose . NHS England commissioning responsibilities 2 . Based on the activities outlined above, set out in Section 7a of the Health and further develop a set of options for Social Care Act 2012, together with local inclusion in the commissioning plan for government-commissioned population population health . health services and the new service models set out in this plan . The population health 3 . Undertake an assessment and review of commissioning plan will be a coherent vison stakeholder support underpinned by an and plan for population health commissioning understanding of implementation issues, in line with Greater Manchester’s including resource requirements and the Commissioning for Reform Strategy . risks and barriers that will need to be addressed, with an outline timetable for The programme will seek to do the following . change . 1 . With key stakeholders across the system, Target outcomes for 2016/17 and 2017/18 undertake an in-depth review of the ‘as is’ ●● approach to commissioning for population Outcome 1 – January 2017: The health, and: production of a set of proposals for inclusion in the commissioning plan ●● analyse current and planned population ●● health commissioning arrangements Outcome 2 – March 2017: A supporting implementation plan that has been co- ●● identify different population health designed with stakeholders across the commissioning approaches currently system in use e g. . outcomes based, alliance ●● neighbourhood level Outcome 3 – 2017: An agreed programme of activity to ensure a ●● review current contracts and spend managed transition into a new way of for Section 7a services and council- working

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The Greater Manchester Population Health Plan 2017 - 2021 Objectives 2 & 3: Develop and test a 3 Undertake an assessment and review proposal for a new Greater Manchester of stakeholder support for the different population health function serving localities, options, with clear recommendations CCGs and Greater Manchester structures, made on the shape and distribution of and develop a model for future resourcing of population health functions within Greater population health in Greater Manchester . Manchester . This will be underpinned by an understanding of implementation The programme of work will seek to do the issues, including resource requirements following . and the risks and barriers that will need to 1 . With key stakeholders across the system, be addressed, and an outline timetable for undertake an in-depth review of the ‘as is’ change . approach to determine the evidence base for the production of a set of proposals, 6.1.3.1 Target outcomes for 2016/17 and and: 2017/18 Outcome 1 – January 2017: The production ●● determine the scope of services that fall of a set of evidence-based proposals for currently within Greater Manchester’s creating a unified leadership system for remit (aligned with NHSE public health population health across Greater Manchester Section 7a commissioning intentions 2017/18) and those at the locality level Outcome 2 – March 2017: A supporting ●● map and review current provision implementation plan that has been co- of those functions at various levels designed with stakeholders across the system including Greater Manchester, cluster, Outcome 3 – 2017: An agreed programme of locality and neighbourhood activity to ensure a managed transition into a ●● benchmark cost and quality for key new way of working public health functions ●● assess current workforce provision and 6 .2 Social value future provision 6.2.1 Background ●● review current public health expenditure Social value asks the question: “If £1 is spent and determine any wider implications on the delivery of services, can that same £1 of changes to the grant such as the be used to also produce a wider benefit to the residual business rates pilot across community?” This involves looking beyond Greater Manchester . the price of each individual contract or activity and considering the collective benefit to 2 . Based on the activities outlined above, a an area . A social value approach includes small number of options for a new Greater consideration of the social, environmental and Manchester population health function economic wellbeing of a place and its citizens serving localities, CCGs and Greater during the planning, commissioning and Manchester structures will be developed delivery of services, buying of goods or the and tested . It is intended that those options procurement of works . will maximise both economies of scale and scope while staying true to the principle However, the same argument about gaining of subsidiarity embedded within the wider benefit can also be applied to business devolution framework . We intend to look in and non-commissioned VCSE activity, thereby the first instance at functions where there increasing the whole economic footprint of are sensible economies of scale and where Greater Manchester . genuine added value is demonstrated .

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The Greater Manchester Population Health Plan 2017 - 2021 Since January 2013, all public bodies have which are to stimulate growth in the economy had to consider social value as part of their and reform the way in which public services commissioning activities under the Public are delivered . Services (Social Value) Act 2012, both as part of contract specifications and as ‘added The Greater Manchester Police and Crime value’ . Under the Act, social value is an Commissioner (PCC) has also produced enabler that delivers additional benefits for a social value policy, which echoes the suppliers and partners across all procurement principles of the GMCA policy, and the AGMA and commissioning activity . Procurement Hub is currently in dialogue with the PCC and other partners to identify how a It is a legal obligation for local authorities consistent approach can be taken to social and the NHS to consider the social good value policy and measurement . . that could come from the procurement of services before they embark upon it . The Act Furthermore, the Manchester Growth allows authorities to choose a supplier under Company provides capacity building support a tendering process that not only provides the to local businesses, particularly SMEs, around most economically advantageous service but the generation of added value and wellbeing one which goes beyond the basic contract outcomes through being a responsible terms and secures wider benefits for the employer, undertaking sound environmental community . practices and contributing towards local economic gain . The themes of social value fall broadly into three categories: economic (local jobs and Social value is an enabler that delivers growth), social (resilience and strong voluntary additional benefits for suppliers and partners and community sector), and environmental across all procurement and commissioning (clean and protected environment) . The activity . Social value should be used to spectrum of potential activities and measures underpin the core objectives of the Greater within these categories is wide and varied, Manchester ‘Stronger Together’ and ‘Taking enabling individual authorities to match Charge’ objectives by stimulating growth in them to priorities and, to some extent, the the economy and reforming the way in which resources they may have to support this work . public services are delivered . It can be used to increase the spending power of every Furthermore, recent EU procurement pound spent in Greater Manchester . regulations have increased the emphasis on achieving wider societal goals through 6.2.3 Opportunity procurement and commissioning, and with An opportunity exists to derive relevant these regulations embedded within public social, environmental and economic value sector procurement, Greater Manchester is from everything that we do, in our business, now able to better commission social value . in service delivery, commissioning and procurement; to use the huge purchasing 6.2.2 Greater Manchester context power of the Greater Manchester devolution The Greater Manchester Combined Authority partners to obtain the greatest benefit for local (GMCA) Social Value Policy approved in people . November 2014 provides a consistent approach across each of the Greater The proposed approach to social value Manchester councils . The GMCA Social Value across Greater Manchester is to use this Policy sets out how social value is used to duty to increase the spending power of every underpin the core objectives of ’Stronger pound spent in Greater Manchester, therefore Together: Greater Manchester Strategy 2013’, maximising the social value benefit to the

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The Greater Manchester Population Health Plan 2017 - 2021 people of Greater Manchester from public ●● Objective 2: To develop the GMCA sector commissioning and procurement, Social Value Policy to cover health and as well as increasing purposeful activities wellbeing outcomes described in the in the business sector and maximising the Greater Manchester Strategic Plan ‘Taking contribution made by the VCSE sector . Charge’ for implementation across all public sector procurement in Greater The longer-term impacts of this approach Manchester will be to reduce dependency on, and demand for, public services, and contribute ●● Objective 3: To embed social value towards increased economic growth in into the culture of the health and social Greater Manchester . This is a £6 billion care workforce, through values-based opportunity to create local economic, social discussion, training, awareness raising and environmental benefit, if all procuring and participation in service design to organisations were to adopt a common maximise social value benefits approach, and follow similar processes ●● Objective 4: To put in place a number in relation to procurement, contract of enabling activities that will maximise management and delivery of outcomes . the co-production of social value from the expenditure of health and social 6.2.4 Plan care budgets, including work with NHS Objectives providers, the VCSE sector and relevant Our research shows that there is a great deal parts of the business sector . of work ongoing across Greater Manchester to develop social value approaches in Approach to delivering objectives commissioning, procurement, business, The activities that will deliver these objectives voluntary and community activity and social will all take place within the period April 2017 enterprise – the proposed programme will to March 2019, and can be summarised as seek to ensure that all Greater Manchester follows . health and social care commissioning and Objective 1: To understand and embed procurement maximises social, environmental social value in Greater Manchester Health and and economic wellbeing . Furthermore it will Social Care Partnership (GMHSC Partnership) put in place arrangements for health and commissioning and seek to work with CCG wellbeing outcomes to be realised from wider partners to scale up this work across the public, private and third sector investment . health care economy . This will involve culture change across all devolution partners and significant effort into ●● Provide training for commissioning staff co-production of social value outcomes . around social value ●● Undertake a review of current practice The objectives of the work supported through and policy and undertake a procurement the Theme 1 population health programme spend analysis will be: ●● Develop a social value framework ●● Objective 1: To understand and embed through which GMHSC Partnership can social value in Greater Manchester continuously monitor the social value of its Health and Social Care Partnership suppliers commissioning and seek to work with CCG partners to scale up this work across ●● Develop a toolkit for practitioners to use the healthcare economy when commissioning social value

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The Greater Manchester Population Health Plan 2017 - 2021 ●● Identify, test and share good practice ●● Develop a small number of thematically in return on investment in a healthcare or geographically focused projects that commissioning situation engage the workforce in activities to generate more social value; including ●● Work with CCGs to look at how this employee volunteering schemes, work could be scaled up across Greater wellbeing activities and energy-efficiency Manchester projects Objective 2: To develop the GMCA Social Objective 4: To put in place a number of Value Policy to cover health and wellbeing enabling activities that will maximise the outcomes described in the Greater co-production of social value from the Manchester Strategic Plan ‘Taking Charge’ expenditure of health and social care budgets, for implementation across all public sector including work with NHS providers, the VCSE procurement in Greater Manchester . sector and relevant parts of the business ●● Further develop the existing GMCA sector . Social Value Policy for procurement ●● Build capacity for the devolution partners activity across all public sector partners, to monitor, report and be accountable to include the strategy and outcomes for their own social value as employers described in ‘Taking Charge’ of local people, in their own right and ●● Work with partners to agree a clear spenders of public money description of what social value means in ●● Work with the Greater Manchester Social Greater Manchester for all of the partners Value Network to roll out a series of in Greater Manchester devolution information-sharing and networking events ●● As required, work to support and embed throughout the programme the revised policy into custom and ●● Develop a web portal/website for the practice across the Greater Manchester programme to allow the consistent sharing reform partners, including the health and of practice case studies, documentation, social care system policies and other information Objective 3: To embed social value into ●● Provide a health and social care the culture of the health and social care perspective in wider discussion around workforce, through values-based discussion, social value in Greater Manchester training, awareness raising and participation in service design to maximise social value 6.2.5 Outcomes (2017 - 2019) benefits. The following ‘signs of progress’ will be ●● Build from and roll-out the existing Greater evaluated to demonstrate the difference that Manchester Commissioning Academy this proposal has made over the two years of work to embed the single methodology for its operation . commissioning social value across health ●● Social value is embedded in GMHSC and social care into practice commissioning arrangements ●● Support individual leadership and ●● Social value framework model tested in responsibility in social value across GMHSC rolled out to interested CCGs the health and social care workforce, embedding a culture of ‘social value is ●● Increased understanding of social value everyone’s business’ through a series of and how to maximise its achievement interactive service design events through commissioning and procurement among the partners in Greater Manchester health and social care devolution

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The Greater Manchester Population Health Plan 2017 - 2021 ●● Achievement of the outcomes in the Greater Manchester Strategic Plan ‘Taking Charge’ as ‘added benefits’ from investment outside of the health and social care budget ●● Increased volume of ‘purposeful’ business sector activity in Greater Manchester that targets Greater Manchester population health outcomes ●● The development of a values-based culture in both the health and social care workforce and the operational leadership of the devolution partners ●● Increased ability of the partner organisations in health and social care devolution to monitor, report and be accountable for the social impact that they generate ●● Increased return on investment/value for money in health and social care expenditure ●● Evaluation work carried out as part of this programme will put in place a comprehensive dashboard and methodology for measurement of these outcomes

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The Greater Manchester Population Health Plan 2017 - 2021 7. Next steps

7 .1 Scoping and delivering via a blended approach Over the coming months there will be a concentrated effort to mobilise a core team that will drive delivery and implementation of the Population Health Plan’s aims and objectives, realising the outcomes and benefits that are to be delivered through the initiatives identified and those that are burgeoning within the localities .

There are some fundamental principles for delivery: 1 . Governance will be transparent . 2 . GMHSC Partnership will provide enabling and oversight as a minimum capability . 3 . Implementation will be a blended-delivery model based on the party best placed to deliver the business and social impact . 4 . Delivery will be driven through an alliancing model, where each member contributes and takes specific responsibility in delivery .

7.1.1 Governance will be transparent To maintain momentum and also to hold to account the system partners, it is important to have good governance across the system . A Theme 1 Executive Board, with membership from providers and commissioners from health and social care across Greater Manchester, has been established to organise, direct and ensure delivery of the work set out in this plan as well as to oversee the deployment of any transformation resource and the achievement of investment deliverables . Each of the programme areas outlined in this plan has its own delivery arrangements, which will bring together resources from across the system to enable delivery .

The Theme 1 Executive Board has direct lines of reporting and accountability into the Transformation Portfolio Board, which reports directly into the Greater Manchester Strategic Partnership Board Executive and the Greater Manchester Strategic Board . Resources are being allocated across the system, such as a dedicated senior responsible officer (SRO) plus operational support in each of the localities, to support the implementation of the plan . The GMHSC Partnership team will be supporting the SROs in the wider leadership and delivery, and has invested in an enabling portfolio/programme/project

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The Greater Manchester Population Health Plan 2017 - 2021 management office (PMO). All localities, 7.1.2 GMHSC Partnership will through the submission of their locality plans, provide oversight and enabling have aligned their local priorities with the as a minimum capability commitments laid out in this plan . As many localities will embark upon the As we move into delivery we will seek to delivery and implementation of the initiatives it define and design a localised light-touch is anticipated that there will be a requirement governance model that will provide autonomy for a core capability that will be able to to implement and rigour in oversight to enable support the localities . These core capabilities effective decision making and progress are the enablers in Figure 31 that will be monitoring without creating unyielding required for all the initiatives implemented . bureaucracy . The benefit of providing these centrally is that it will enable a specialist function to develop that can be deployed and allocated to each initiative, creating the rapid transfer of knowledge and learning quickly between initiatives. This will also have the benefit of reducing project overhead costs as these are carried centrally instead of by each project .

Figure 31: High-level governance

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The Greater Manchester Population Health Plan 2017 - 2021 7.1.3 Implementation will be 7.1.4 Delivery will be driven through blended, based on the party an alliancing model - where best placed to deliver the each member contributes and business impact takes specific responsibility in Throughout the Population Health Plan we delivery have identified a number of initiatives that Due to the multiple parties involved in the are either ready for scaled deployment delivery of each initiative, the approach to or concept testing i .e . ‘piloting’ . To be commencing each project will need to be able to generate the changes and reform established clearly . This will include clear proposed, it will be necessary for the terms of reference, objectives and benefits, entirety of Greater Manchester community and a clear schedule and profile. It is members to work collectively in the important that responsibility and scope is delivery of the volume, scope and scale clear from the outset and that the accountable of the work ahead . We believe that the parties are clear on their role and remit . most opportune means to achieve this is through a blended responsibility for delivery A full project initiation approach and structure by GMHSC Partnership, localities, the will be developed for all stakeholders to voluntary, community and social enterprise critique and endorse in the early part of (VCSE) sector and the Greater Manchester 2017 . This process of engagement with Combined Authority, as proposed in Figure 31 stakeholders will also enable all parties to and Figure 32 . reach a consensus on leadership roles and responsibilities .

Figure 32: Transformation funding application development phases

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The Greater Manchester Population Health Plan 2017 - 2021 7 .2 Equality analysis and impact 7 .3 Delivery schedule assessment A detailed delivery scheduled will be In alignment with the Greater Manchester developed and held for monitoring by the Strategic Plan, this Population Health Plan is GMHSC Partnership core team as an enabling to be delivered with the ongoing commitment capability . A high-level schedule has been to advance equality and reduce health outlined in Figure 33 and will be developed inequalities . The aim is to ensure that equality in greater detail in collaboration with all the and diversity are prioritised in the design of delivery partners . the new system, and are embedded into the structures and delivery frameworks governing key relations between GMHSC Partnership, Greater Manchester Combined Authority and the VCSE sector . Working under the guidance of the expanded remit of the Greater Manchester Equalities Group, the Population Health Plan will seek to assess the equality impact of this plan and within each initiative to ensure they seek to mitigate and minimise any inequalities through their development and implementation

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The Greater Manchester Population Health Plan 2017 - 2021 7.3.1 High-level schedule

Figure 33: High-level schedule

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The Greater Manchester Population Health Plan 2017 - 2021 To find out more or get in touch with us please go to:

Website: www.gmhsc.org.uk Email: [email protected] Twitter: @GM_HSC