Bromley Health & Wellbeing Board s Strategy
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- Chloe Lamb
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1 Bromley Health & Wellbeing Board s Strategy
2 CONTENTS 1. Executive Summary 3 2. Introduction 4 3. National & Local Policy Context 6 4. Borough Profile 7 5. Factors affecting health 9 6. Integrating Health Care with Social Care Health and Wellbeing Themes Key Health priorities in Bromley Priority Interventions 14 o Health & Wellbeing Priority Diabetes o Health & Wellbeing Priority Hypertension o Health & Wellbeing Priority Obesity o Health & Wellbeing Priority Anxiety & Depression o Health & Wellbeing Priority Children with Complex Needs and Disabilities o Health & Wellbeing Priority Children with Mental & Emotional Health Problems o Health & Wellbeing Priority Children Referred to Children s Social Care o Health & Wellbeing Priority Dementia o Health & Wellbeing Priority Supporting Carers Partners & Contacts 41 Appendix 1 Summary of National Policy Context Appendix 2 Summary of Local Policy Context 2
3 1. EXECUTIVE SUMMARY The Bromley Health and Wellbeing Board s first strategy outlines the top priorities for improving health and wellbeing of people living in the Borough. The strategic vision for the strategy is to: Live an independent, healthy and happy life for longer This will be achieved by improving the quality of life and wellbeing for the whole population, and for those with specific health needs, leading to an increase in life expectancy in the targeted areas. In the first sections of this strategy we outline the context and health and wellbeing key facts in Bromley. In the later sections we summarise how the Joint Strategic Needs Assessment 2011 (JSNA) has informed the priorities that we need to focus on to deliver our outcomes. In the next sections we look at each of the nine Health and Wellbeing priorities in detail. Exploring the issue, local implications, what is currently in place to support the area, plans in place for the coming year to address gaps, how the priority will be monitored/ measured (including which relevant partnership group) and any policy linkages that may impact on the priority. The final section identifies the key partners and broader strategy documents where health and wellbeing are also addressed. The 2012 Health and Wellbeing priorities are: o Diabetes o Obesity o Hypertension o Anxiety and Depression o Dementia o Children with Mental & Emotional o Support for Carers Health Problems o Children Referred o Children with Complex Needs and to Social Care Disabilities During the early part of 2012 the partnership groups were consulted on the priorities relevant to them. Whilst this is a three year strategy it is planned that the Health and Wellbeing Board will refresh it annually informed by the six monthly monitoring reports from the relevant partnership groups and reflecting the latest JSNA findings. A good JSNA and Health and Wellbeing strategy are crucial to enabling Health and Wellbeing Boards to achieve a vision for the future, as they underpin the shared understanding and joint action needed to approve outcomes across the board and at a local level. 3
4 2. INTRODUCTION This is a new era for public health, with radical reform of the NHS. Local government and local communities will be at the heart of improving health and wellbeing for their populations. Reforms include the creation of a new national public health service Public Health England. PCTs will be replaced by GP Clinical Commissioning Groups which will be responsible for the majority of NHS budgets. Public Health functions (health improvement, tackling health inequalities and health protection) are to be transferred from the NHS to local government. These changes present an opportunity for public health to be better integrated with areas such as social care, transport, leisure, planning and housing etc. Health and Wellbeing Boards will act as the main strategic vehicle to achieve this integration. Under our plans local innovation will replace central control. People and communities will drive directly the change we need to build a stronger, healthier Britain. Secretary of State for Health, 2010 The Health and Wellbeing Board for Bromley brings together the leaders of local health and care systems with local people, to understand what local communities need and to develop the best strategies to meet those needs. The Board works to join up services across the NHS (through Bromley Clinical Commissioning Group CCG), public health, social care and children s services. It takes the lead on developing a shared understanding of local needs (through the JSNA) and setting the priorities for health and wellbeing in Bromley through this the first Joint Health and Wellbeing Strategy for Bromley. The development of the JSNA and the Health and Wellbeing Strategy has been led by London Borough of Bromley and Bromley CCG What is the Health and Wellbeing Strategy? It is a statutory document aiming to respond to the health, social care and well-being issues in a strategic manner in accordance with the proposed Health and Social Care Act It brings together those areas which impact on health and wellbeing into a single co-ordinated framework. The strategy will guide the various agencies in Bromley as they tackle the major public health and wellbeing challenges to improve the health of the population and reduce health inequalities. It sets out the commitment to help individuals, families and communities make a positive choice to lead a healthier lifestyle, whilst also doing all we can to address the crucial wider determinants of health. It will identify and bring together a number of overarching priorities for 4
5 action. From these, more detailed plans will be developed and delivered. Bromley Clinical Commissioners have developed an integrated plan arising out of the JSNA and this H&WB strategy. It also important to note, that many plans and strategies that have an influence on health and well-being are already in place. What are the aims of the Health and Wellbeing Strategy? This strategy aims to improve and protect the health and wellbeing of all who live and work in the borough, and sustain Bromley as a healthy place to live, work or visit. We aim to tackle gaps in health inequalities and achieve real and measurable improvements in the health and well-being of residents. Our vision is for a healthier Bromley, where everyone is able to benefit from improvements in health and wellbeing. This strategy has been jointly developed by Public Health consultants, local authority agents, Clinical Commissioners and GP advisors, NHS representatives, local health and voluntary organisations. The strategy details how the Bromley Health and Wellbeing Board intend to work with cross-sector partners, including local residents, voluntary organisations and community groups, to reduce health inequalities and improve the health and wellbeing outcomes of our local communities and workforces. The purpose of this strategy can be summarised into the following points: Setting out the vision of what we want to achieve for health and wellbeing across the Borough Identifying key priorities for improving health and wellbeing Working in Partnership The World Health Organisation (WHO) defines health as a state of social, physical and mental well being and not merely the absence of disease. UK government policy is now focusing on health in this wider, more holistic way, making it clear that improving health is everyone s responsibility. Emphasis is on the prevention of illness rather than just the treatment of disease. This takes health beyond the realm of solely the NHS and into the community. There is increasing emphasis on the need for partnerships, a shared health vision / agenda, as well as a specific leadership role for local government and for people to engage with their own health. Driving and influencing the delivery of health care in the borough Providing an inclusive, overarching and co-ordinating framework which integrates with other local strategies Improving the quality of life, increase life expectancy, reduce health inequalities and promote mental and physical wellbeing for our residents Engaging with local partners and communities to ensure local needs are being met. 5
6 3. NATIONAL & LOCAL POLICY CONTEXT This strategy fits into a much bigger picture, namely the policies and programmes of the Government. Our general approach is shaped by national policy and thinking, and by local policy and practice. At a national level there is increasing recognition of the critical importance of health and wellbeing to people s quality of life and long-term prosperity. This is reflected in the developing policy and legislative framework which sets out the government s vision for transforming the country s health and social care system. The aim of this national policy framework is to develop a greater emphasis on preventative health care services, promoting healthier life styles, greater independence and choice for service users. The government has set out its strategic direction for the future of health and social care within the white paper Healthy Lives, Healthy People: Our strategy for public health in England and Equity and Excellence: Liberating the NHS. This vision is underpinned by the approach to developing local health services through the Commissioning Framework for Health & Well-being and Choosing Health: Making Health Choices Easier. underlying social and economic determinants of health and wellbeing. Secondly to provide services which are customerfocused, personalised and sensitive to each individual s needs. Users of health services are to be supported and encouraged to have greater choice and control over the type of services they receive. Service provision is to be redesigned to increase local accessibility and improve the quality of the individual s experience. These themes have informed the development of this Strategy and will influence the future provision of health and wellbeing services across the borough. Appendix 1 lists some of the relevant national policies key to shaping our approach towards health and wellbeing, with an accompanying summary. Whilst this strategy outlines the nine priority areas in some detail these are underpinned further by a range of strategies, plans and action plans that can be seen listed in appendix 2. These activities are informed by two critical goals. Firstly to create a more integrated approach to delivering health care services which reaches beyond the treatment of illness to actually preventing the causes of ill-health and addressing the 6
7 4. BOROUGH PROFILE Located in south-east London, Bromley is the largest London borough in the city. Although Bromley is a relatively prosperous area, the communities within Bromley differ substantially. The northeast and northwest of the borough contend with similar issues (such as higher levels of deprivation and disease prevalence) to those found in the inner London Boroughs we border (Lambeth, Lewisham, Southwark, Greenwich), while in the south, the borough compares more with rural Kent and its issues. Bromley is ranked 217th out of 354 local authorities in England in terms of deprivation (1st is the most deprived). Key Facts: Population Bromley has a population of 306,361 (2011 estimate). It has the lowest average population density in London, with 60% of the borough being protected Greenbelt or Metropolitan Open Land. The number of older people in Bromley is expected to increase from 16.2% of the population in 2011 to 17.2% in The pattern of population change in the different age groups is variable between wards, with some wards such as Bromley Town experiencing a large rise in the proportion of young people and Biggin Hill experiencing a large rise in the over 75s estimates show that 14.9% of the population are made up of BME groups. Key Facts: Employment 78.7% of Bromley s working age population is economically active. 36.7% of the working age population are either managers or in professional occupations. The unemployment rate in Bromley has decreased from 9,300 in 2008/09 to 7,600 in 2009/10 There is higher unemployment in Penge and Cator, Crystal Palace and the Crays than in the rest of Bromley. These wards are also experiencing benefit claimant counts higher than the sub-regional average and closer in level to the inner London wards. Key Facts: Life expectancy Bromley has lower all cause mortality rates and infant mortality rates than the national average. Bickley, Copers Cope, Crystal Palace and Penge & Cator have the highest rates of mortality in the borough, with the lowest rates in Biggin Hill and Shortlands wards. Life expectancy has been consistently low in Crystal Palace and Penge & Cator wards for both men and women, additionally in Mottingham & Chislehurst North for men. 7
8 Key Facts: Ill-health The three main causes of death from in Bromley have been cancer, circulatory disease and respiratory disease. Although coronary heart disease is still a major cause of death, the mortality rate in Bromley has fallen to less than half the 1993 level, in line with the trend for England & Wales as a whole. Diabetes is now the most prevalent chronic disease in Bromley, with 13,307 people on the diabetes register in This reflects a continuous rise in prevalence over the last 8 years from 1.6% to 5%. The prevalence of obesity is rising, and the characteristics of the Health Acorn group Possible Future Concerns (the predominant group in Bromley) promote the rise in obesity levels. Although health and well being in Bromley is generally considered to be good there are still areas that could be improved. The 2011 Bromley Joint Strategic Needs Assessment highlighted demographic changes, with the number of over 65's rising and people with dementia set to increase significantly over the next 30 years inequalities in life expectancy in key population and geographic areas, the main causes of death are cardiovascular disease (coronary heart disease and stroke) and cancer growing rates of obesity in adults and children 8
9 5. FACTORS AFFECTING HEALTH Health is not just about the presence of disease or illness (be that physical or mental), but also about how well people are. Wellbeing can be defined as a positive physical, social and mental state. Vast improvements in public health have meant that the biggest threats to our lives now are diseases that usually occur later in life. The onset of diseases that occur earlier in life are at least partly linked to the way we live our lives. Good health and wellbeing brings many benefits for all of us. Healthier people tend to be happier, tend to play an active role and contribute to society and the economy through their families, local communities and workplaces. Conversely, poor health and wellbeing puts a huge strain on individuals, the NHS, the economy and society. To maintain good health and wellbeing it is important to ensure the right social, economic and environmental factors are in place. amongst young people is particularly important with half of all lifetime mental illness starting before age 14. Poor mental health in childhood affects educational attainment, increases the likelihood of smoking, alcohol and drug use and has consequences for poorer physical health in later life. The following diagram outlines what determines good health in terms of layers of influence, starting with the individual and moving to the wider society. An individual s health is impacted heavily by their position within society i.e. their income, educational attainment, social class, their ability to have control over their life and to lead a life they value. Social influences on health and behaviour are important for understanding health inequalities and can have life-long consequences. Positive and negative experiences accumulate over people s lives and have lasting effects on health outcomes. This gives greater significance to taking a life course approach to public health and ensuring we get the early years of life right. Mental health and wellbeing are also critical dimensions of health. We know that mental ill health is responsible for a high proportion of the overall burden of ill health and prevalence has been rising. We also know that mental health and wellbeing are important factors for physical health. Focussing on mental health Source: G Dahlgren and M Whitehead, Policies and strategies to promote social equity in health, Institute of Futures Studies, Stockholm,
10 The factors affecting health and well-being fall into five main areas: 1. Those which are fixed - such as age, gender and hereditary factors 2. Social issues - such as employment or poverty 3. Environmental factors - such as air pollution, green space and housing 4. Lifestyle issues - such as smoking, exercise or diet 5. Access issues - such as access to education, leisure and transport etc. Factors which are not fixed can potentially be modified to achieve a positive impact on an individual s health. These are the factors that the Council will target in order to protect and improve the population s health. The following diagram is a health map produced by the Department of Health to show how various factors influence health. There is evidence to suggest that living in materially deprived neighbourhoods contributes to worse health for individuals. Children born and brought up in families with low levels of educational attainment, material disadvantage or in lower socio economic groups are likely to experience worse health in later life. This is significantly avoidable and fundamentally unfair Sir Donald Acheson, Chair, Independent Inquiry into Inequalities in Health,
11 6. INTEGRATING HEALTH CARE WITH SOCIAL CARE The Government s commitment to bringing health and social care together is reflected in its vision for adult social care in which services are more personalised, preventative and focused on outcomes. The Government has introduced separate frameworks of outcomes for adult social care, public health and the wider NHS. The diagram on the right illustrates the overlap between the three frameworks. Social Care & Public Health: Maintaining good health and wellbeing. Preventing avoidable ill health or injury, including through reablement or intermediate care services and early intervention Public Health NHS and Public Health: Preventing ill health and lifestyle diseases and tackling their determinants Understanding of the reciprocal relationship between health and social care is essential to ensure that they operate as a whole system of care. Integrated health and social care offers three benefits for the user: better outcomes for service users and patients; making limited resources go further; and improving people s experience of health, care and support. People want services that feel joined up, and it can be a source of great frustration when that does not happen. Integration means different things to different people but at its heart is building services around individuals, not institutions DH/DCLG, 2010 Social Care Social Care, NHS and Public Health: The focus of JSNA: shared local health and wellbeing issues for joint approaches NHS Social Care & NHS: Supported discharge from NHS to social care. Impact of reablement or intermediate care services on reducing repeat emergency admissions. Supporting carers and involving in care planning The relationship between public health, social care and acute services (Department of Health, 2010) 11
12 7. HEALTH AND WELLBEING THEMES To live an independent, healthy and happy life for longer The desire to improve the health and wellbeing of a population will ultimately manifest itself at the individual level as the ability for a person to live independently, healthily and happily for longer. This can be achieved by addressing the three main components of health and wellbeing: 1) increasing life expectancy, 2) improving quality of life and 3) improving wellbeing. The themes are interrelated as an improvement in one area will lead to an improvement in another. Improving Quality of Life Increasing life expectancy Improving Wellbeing These themes can be differentiated for those with specific health needs as well as the whole population. For example, the strategy aims to improve the quality of life and wellbeing for those who are living with long term conditions but recognises that it may be beyond the scope for these interventions to increase the individual s life expectancy. The following table lists the various sub themes within the three overarching themes. Increasing Life Expectancy Improving Quality of Life and Wellbeing for the Whole Population Improving Quality of Life and Wellbeing for those with specific health needs Primary causes of premature mortality: Cardio Vascular Disease (CVD) Cancer Respiratory Disease Secondary causes of premature mortality: Smoking Obesity o Unhealthy eating o Physical inactivity Alcohol and Substance Misuse Poor mental health Social inclusion within communities Supportive social networks Clean and safe environment Housing quality and affordability Education attainment & aspiration Employment opportunities Income maximisation Crime reduction Care pathways Care of long term conditions Acute care primary & secondary Social care o Older people o Carers o Disabilities o Mental Health o Dementia End of Life Care 12
13 8. KEY PRIORITIES The key themes and priorities to improving health in Bromley have been identified using the 2011 Joint Strategic Needs Assessment, which provides detailed analysis of trends and issues impacting on health. This process has highlighted areas that need to be addressed in order to tackle some of the most pressing issues facing residents today. In order to decide where best to focus our efforts to improve the health of the population it is helpful to use a prioritisation framework. A simple way of considering the relative priority of different health issues is to consider the burden in terms of the numbers of people affected, and then whether the problem is improving or worsening over time. The highest priority is allocated to the issues creating the highest burden which seem to be worsening over time. The table on the right has been populated to show the relative priorities of the key issues. The red box represents the highest priority issues according to this framework. Using this framework for the burden of ill health, the key priorities covered in this strategy are outlined in the box below. In section 9 each of these priorities is outlined in terms of the implications and what action will be taken in the coming year. Each year the strategy will be refreshed and all areas in the 4 boxes will be considered and reported as part of the JSNA process. During the first year the links between the priorities will be included as part of the routine reports from the Health, Social Care and Housing Board. LIFE EXPECTANCY CORONARY HEART DISEASE/STROKE CANCER SMOKING FOUNDATION STAGE ATTAINMENT NARROWING ATTAINMENT GAP FOR VULNERABLE GROUPS SUICIDE IMPROVING DIABETES HIGH BLOOD PRESSURE OBESITY ANXIETY/DEPRESSION CYP COMPLEX NEEDS/ DISABILITY CYP MENTAL HEALTH & EMOTIONAL PROBLEMS CYP REFERRALS SOCIAL CARE DEMENTIA SUPPORT FOR CARERS ATRIAL FIBRILLATION TEENAGE PREGNANCY HIV LIVER DISEASE SELF HARM COMPLEX CARE & TRANSITION FOR PEOPLE WITH PDSI APPROPRIATE HOUSING WORSENING In the next 5 years we aim to: slowdown the rise in the number of new cases of diabetes; continue to slow the rate of increase of people diagnosed with hypertension; raise awareness on the links to obesity, diabetes and hypertension; ensure that the Bromley working for wellbeing service only covers 15% of the population; support children and young people with emotional and mental health issues at the earliest possible stage provide a fully integrated pathway for people with dementia and their carers that reduces unnecessary hospital/ residential admissions; 13
14 9.1 PRIORITY INTERVENTIONS In order to tackle these priorities a series of interventions will be needed. These will be delivered at three different levels to drive change: population, personal and community health. Population Health Some interventions can be instituted directly at population level. They are sometimes referred to as health protection measures. They are usually societal changes aimed at influencing behaviour or making healthy choices, easy choices. Many of the outcomes identified fall into this category e.g. immunisation/ screening programmes offered by the NHS. Personal Health Some treatments, therapies and technologies are now highly effective at the personal level. As well as being effective at the individual level, such measures can also add up to a population level effect when part of a comprehensive approach to behaviour change. Community Health Individuals will only choose to use and benefit from certain behaviours and treatments if they fit with the cultural and belief system of their own community. Community development is a process of facilitating community awareness of the factors and forces that affect their health and quality of life, and ultimately to help to empower them 14 with the skills needed for taking control and improving those conditions in the community that affect their health and wellbeing. Partners from the community, voluntary, faith and business sectors play a key part in promoting community health. The strategy and its subsequent interventions will be underpinned by a set of core principles which are listed in the box below: CORE PRINCIPLES: 1) Maintain cost and resource effectiveness 2) Ensure equity of access 3) Support independence 4) Be efficient and non-bureaucratic 5) Adhere to clinical safety 6) Use evidence based interventions 7) Promote community engagement 8) Meet quality standards 9) Promote personal responsibility 10) Consider points of life course to ensure optimal effectiveness 11) Take a holistic approach to care 12) Consider the needs of the nine protected populations
15 9.2 Health & Wellbeing Priority - Diabetes What is the issue? Diabetes is a long-term condition that has been on a steep increase over last 10 years. There were 4,846 people on the Bromley diabetes register in 2002, as compared with 13,307 in This reflects a continuous rise in prevalence from 1.6% to 5.0%. This rise has particular significance because diabetes is classed as a vascular disease which is often a precursor to heart disease or stroke. In addition, patients with diabetes experience various complications of their disease, including renal failure, vascular complications (ulcers and amputations) and eye problems potentially leading to blindness. Diabetes is currently the single commonest cause of blindness among the working age population in the UK as well as end stage renal failure requiring renal replacement therapy. The foot problems caused by diabetes are one of the leading causes of disability and the need for social support. What are the implications for Bromley? Impact on patients with diabetes - Increased mortality: approximately 10% of patients with diabetes will die of diabetes related conditions - Increased morbidity: renal and eye disease, heart disease, stroke, depression - Reduced quality of life, ability to earn a living and independence Impact of services - Increased use of emergency services - Significant long-term management and interventions such as use of primary and community care, renal dialysis - Significant use of hospital services: 20% of people with diabetes are admitted to hospital every year for care directly associated with diabetes or its complications - High cost: approximately 10% of the NHS budget is spent annually on diabetes. Diabetes-related complications increase healthcare cost five-fold, social services costs four-fold, triple personal expenditure and double the need for carers. What are we currently doing? The majority of patient with diabetes are managed in primary care. However, some more complex patients and newly diagnosed patients with Type 1 diabetes are managed by specialist diabetes service. This service is based within the community provider with good links and joint working with primary care. This model of services has been developed and implemented in Bromley Diabetes Network Group oversees the development of diabetes services and monitors the service against quality standards. It also leads on training initiatives for health professionals across the primary and community care. What do we intend to do? Bromley Diabetes Network Group intends to develop an action plan to address the issue of significant increase in the incidence and prevalence of diabetes in Bromley. Because there are inequalities in prevalence of diabetes, prevention and early identification will help to reduce inequalities in health. 15
16 What are the gaps that need to be addressed? Prevention of diabetes - Identification of people at risk of developing diabetes and appropriate and timely management Services for people with diabetes - Improved management of patients with diabetes in primary care - To continue to develop the interface between primary and community services - Improved management of diabetes complications particularly vascular complications - Improved in-patient care of patients with diabetes shown by undertaking a patient survey - Paediatric services for children with diabetes: availability and capacity of nursing support Training of health professionals - To continue to assess the needs for training and develop training programmes for all health professionals involved in diabetes care. What are the expected outcomes? - Halt the rise in incidence and prevalence of diabetes - Reduction in complications of diabetes - 10% reduction in mortality associated with diabetes for people aged under 75 years - Improved medicines optimisation - Improved hospital care for patients with diabetes with consequent reduction in hospital stay - 10% improvement in identification of those at risk - 20% improvement in glycosylated Haemoglobin levels - Improved in-patient care of patients with diabetes shown by undertaking a patient survey - Improved support for children with diabetes and their parents How will we monitor and measure success? These outcomes will be routinely monitored alongside the related process measures by the Diabetes Network Group. What policy linkages are there? 1. NICE Clinical Guideline. Prevention of Type 2 Diabetes population and community interventions May Department of Health, Putting Prevention First - NHS Health Check: Vascular Risk Assessment and Management, Best Practice Guidance Healthcare for London: Diabetes guide for London, Diabetes National Service Framework, Department of Health 2001 and
17 9.2 Health & Wellbeing Priority - Hypertension What is the issue? Hypertension is one of the most important preventable causes of heart disease and stroke. It is a major risk factor for ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension is usually associated with a progressive rise in blood pressure. There are currently over 47,000 people with diagnosed hypertension in Bromley. The prevalence of hypertension has been rising over the last 6 years, but more slowly in the last 3 years. Hypertension affects more people than any other condition and should be considered as a long term condition. Despite it being so common it rarely presents with symptoms, therefore giving the perception of hypertension being a benign condition. It is more frequent in individuals who are obese or older and is also related to salt and alcohol intake as well as stress. What are the implications for Bromley? - The risk associated with increasing blood pressure is continuous, with each 2 mmhg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke. - New NICE Guidance for hypertension recommends changes in: o How to diagnose o How to treat o Treatment of older people - Hypertension is the only condition where it is now more cost effective to treat rather than not to treat. - People with hypertension should have cardiovascular risk managed; however, they are excluded from the National NHS Health Check programme. What are we currently doing? Blood pressure control - The prevalence of recorded hypertension (17.9%) is higher in Bromley than the national average; however, recorded prevalence of hypertension in Bromley is only 47.8% of the estimated prevalence. - 76% of people with hypertension achieve a QOF 1 standard of 150/90 mmhg, which is lower than the average for London and England. - When compared to the 2006 NICE Hypertension guidelines 40% of people with hypertension achieve a target of 140/90 mmhg. Cardiovascular risk management - As part of QOF people with newly diagnosed hypertension should have a face to face cardiovascular risk assessment. This is a new indicator and as yet no results have been published. 1 The Quality and Outcomes Framework (QOF) is a system for the performance management and payment of general practitioners (GPs) in the National Health Service 17
18 What do we intend to do? Refocus the work of the existing cardiovascular working group to address the issues of under diagnosis and treatment of hypertension in Bromley. This group to develop and action plan to include: - Making hypertension everyone s business through awareness raising campaigns and the expansion of vascular checks - Increased awareness of implications of hypertension - Driving the implementation of new NICE guidance What are the gaps that need to be addressed? People with hypertension have a higher mortality than people without hypertension, and the gap is widening. Therefore earlier identification and better control of blood pressure and other risk factors would improve outcomes. How will we monitor and measure success? Regular monitoring of agreed outcomes within action plan, along with observations of QOF and future audits of hypertension management in primary care. What policy linkages are there? 1. NICE. Hypertension Clinical management of primary hypertension in adults (CG127) Aug Department of Health, Putting Prevention First - NHS Health Check: Vascular Risk Assessment and Management, Best Practice Guidance Bromley JSNA (2011) Unlike many other long term conditions many people do not understand the significance of hypertension. Often there is under treatment of hypertension in older people both within Bromley and nationally. What are the expected outcomes? - Increase in the recorded prevalence of hypertension from 48% of estimated population to 55% of estimated population - Increased blood pressure control from 74% to 79% - Reduction in complications of hypertension and maintaining the downward trend for stroke mortality - Increased cardiovascular risk management by increasing the number of eligible people invited for NHS checks from 7% to 20%. 18
19 9.3 Health & Wellbeing Priority - Obesity What is the Issue Obesity is a key risk factor for circulatory disease and cancer, and also for diabetes, which is a precursor to circulatory disease. Obesity has an attributable risk for Type 2 diabetes of 24%. Therefore, any changes in the prevalence of obesity will have significant impact on the prevalence of diabetes. In Bromley there are rising levels of both adult and childhood obesity. In addition, diabetes and hypertension (which are also strongly associated with obesity) have been identified in the JSNA as conditions affecting a significant proportion of Bromley s population which are worsening. Data collected for Bromley as part of the National Child Measurement Programme (NCMP) show rising trends in the prevalence of obesity and overweight in children in Reception Year and Year 6. Childhood obesity levels are below the London and national level. What are the implications for Bromley? Obesity is a major risk factor for circulatory disease, diabetes and cancer, and is strongly associated with hypertension. Circulatory disease and cancer are the causes of 62.3% of the deaths in Bromley. Diabetes and hypertension have been identified in the JSNA as key health priorities since their prevalence has been rising over recent years. A failure to tackle obesity has serious implications: An increase in demand for healthcare services; A reduction in life expectancy; An adverse effect on the lives of individuals. The Foresight Report: Tackling Obesities: Future Choices includes a model for estimating the costs of overweight and obesity to the NHS. The results for Bromley are shown in the table below: Estimated annual costs to the NHS of diseases related to overweight and obesity 80.1m 85.7m Estimated annual costs to the NHS of diseases related to obesity 43.4m 49.8m Estimated Annual cost for physical inactivity 3,575,280 These costs relate only to the NHS, but social care costs are higher for the obese, and there are other economic impacts related to lost earnings attributable to obesity. What are we currently doing? A Healthy Weight Programme Board was set up in April, 2010 to oversee the implementation of a local healthy weight programme. This board reports into the staying healthy partnership group. The Healthy Weight Programme Board has developed a Healthy Weight Strategy to deliver a five year vision to reduce the rising trend of obesity in adults and children by
20 Pro-Active Bromley is a Community Sport and Physical Activity Network (CSPAN) established as a strategic, independent alliance of partners who are active in sustaining and increasing participation in sport and physical activity in the London Borough Bromley. Members of the healthy weight programme board are represented on a number of the Pro-Active groups. Current health spending on obesity ( ) includes: Approximately 274,000 for community services ( 71,025 children, 203,079 adults). Approximately 177,000 on prescribing for adults. Lite for Life had 158 participants of who 18 achieved 5% weight loss at a total cost of 61, 000 What do we intend to do? There are a number of subgroups working on the priority areas within the strategy which include the development of a pathway for the management of adult obesity and work to capitalise on opportunities to create an environment in Bromley which will support the achievement of healthy weight. Work is also being done to understand what motivates and deters people from losing weight through social marketing techniques. In addition, there are numerous campaigns and messages being delivered at national level through Change4life which is now a well recognised brand in the workplace and at home. There are also key workstreams to address the increasing trend of childhood obesity: Focus on early years and children to ensure there is more emphasis on prevention with our providers and partners; Ensure the environment plays a key role in helping children to stay healthy. What are the gaps that need to be addressed? The key gaps in adults include: Improving the recording of BMI and identification of obesity to 70% of the practice population; Having a more effective adult weight management pathway by increasing the: o capacity of the service to cover 3% of the obese population in 2012/13; o efficiency of the service from 11% to 30% o cost effectiveness of the service by reducing the average cost per person by 50% Having a more effective pathway for managing people with the combination of obesity, diabetes and hypertension. The key gaps in children include: Having an effective weight management pathway for children; Increasing Health Education Nutrition for the Really Young (HENRY) support for families with young children; Increasing the amount of healthy weight support being offered to schools and colleges; Increasing the uptake of school meals. 20
21 What are the expected outcomes? By 2016 we will have achieved: Reducing the prevalence of obesity in adults from 21% to 18% and children (reception) from 8% to 7% and year 6 from 17% to 13%; Increased the: o capacity of the weight loss service to cover 3% of the obese population in 2012/13; o efficiency of the weight loss service from 11% to 30% o cost effectiveness of the weight loss service by reducing the average cost per person by 50% o HENRY increase the number of trained health visiting staff from 50% (2011/12) to 90% in 2015 Increasing participation in physical activity and sport in adults (maintain physical activity participation 20% and increase by 1% annually) and children (maintain 3hrs of physical participation activity in children aged 5-16 years 53% and aim to increase by 1% annually What policy linkages are there? 1. Healthy weight, healthy lives: a call for action on obesity in England (2011) 2. Bromley JSNA (2011) 3. Proactive Bromley Strategy (2011) 4. NICE (2006). Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. How will we monitor and measure success? The Healthy Weight Programme Board will be accountable for the delivery of outcomes related to healthy weight. Success will be measured by progress towards achieving the targets as detailed above and also by our ability to: 1. monitor progress from baseline. 2. demonstrate a reduction of health inequalities. 3. sustain effective programmes. 4. learn and propose recommendations to ensure our healthy weight programme continues to develop. 5. ensure Bromley gains national recognition as an exemplar of healthy weight best practice. 21
22 9.4 PRIORITY Health & 3 Wellbeing OBESITY Priority -Depression and Anxiety (mental health) What is the issue? Good mental health and resilience are fundamental to our physical health, our relationships, our education, our training, our work and to achieving our potential. Moreover, good mental health and wellbeing also bring wider social and economic benefits. Improved mental health and wellbeing is associated with a range of better outcomes for people of all ages and backgrounds. These include improved physical health and life expectancy, better educational achievement, increased skills, reduced health risk behaviours such as smoking and alcohol misuse, reduced risk of mental health problems and suicide, improved employment rates and productivity, reduced anti-social behaviour and criminality and higher levels of social interaction and participation. Mental ill health represents up to 23% of the total burden of ill health in the UK-the largest single cause of disability. Nearly 11% of England s annual secondary care budget is spent on mental health. Estimates have suggested that the cost of treating mental health problems could double over the next twenty years. More than 2 billion is spent annually on social care for people with mental health problems. Mental health problems such as depression are also much more common in people with physical illness and having both physical and mental health problems delays recovery from both. Children with a long term physical illness are twice as likely to suffer from emotional or conduct disorder problems. People with one long-term condition are two to three times more likely to develop depression than the rest of the population. People with three or more conditions are seven more times more likely to have depression. Adults with both physical and mental health problems are less likely to be in employment What are the implications for Bromley? In Bromley there is a high prevalence of Common Mental Health Problems such as depression and anxiety. In Bromley there are 157 people per 1000 of the adult population with any neurotic disorder with the most common problem being mixed anxiety and depression. Major depressive disorder is increasingly seen as chronic and relapsing, resulting in high levels of personal disability, lost quality of life for patients, their families and carers, multiple morbidity, suicide, high levels of service use and many associated economic costs. The Community Mental Health Profile for Bromley 2012 has highlighted that Bromley is significantly higher than the England Average for the percentage of people with depression. There is also a higher directly standardised rate for emergency admissions for depressive disorder. What are we currently doing? The Bromley Working for Wellbeing Service provides a range of evidence based psychological interventions for the treatment of mild to moderate anxiety and depression as set out in the NICE guidelines. The service operates a stepped care model of intervention, with a single point of access; the 22
23 more severe the illness, the higher the intensity of service which will be offered. The Bromley Working for Wellbeing Service is provided by a partnership between Bromley Healthcare and Bromley Mind. There is also a range of other counselling services provided through primary care and access to secondary care services for those with more severe illness. What do we intend to do? Over the next three years we will be investing more funding in the Bromley Working for Well Being Service so that we can move towards the national standard of Improving Access to Psychological Therapies (IAPT) services. The present Bromley working for wellbeing service only covers 5% of the population and a good standard service would cover 15% of the population. The baseline funding for the existing IAPT service is 1,433,214 annually and an additional annual 1,612,402 investment will be made over the next three years to meet local requirements There is a need to do more Mental Health Prevention work with children and young people to help build up emotional resilience. We also intend to continue mental health promotion developments which help in developing emotional health as a preventive measure of mental illness. What are the gaps that need to be addressed? The present Bromley working for wellbeing service only covers 5% of the population and a good standard service would cover 15% of the population. There is a need to develop further models of psychological interventions for Mild and Moderate Mental Health Problems such as Depression and Anxiety. What are the expected outcomes? Increased access to NICE approved psychological therapies to 15% of the population with depression and mild mental health problems by 2015 Increased number of patients entering treatment with reduced waiting times An improvement of the mental and emotional well being of the population in Bromley Evidence of clients remaining in or returning to employment Improved client satisfaction with the Bromley Working For Wellbeing Service. Positive impact on the numbers of clients diagnosed, in primary care, with Medically Unexplained Symptoms. It is anticipated that this will create savings in the longer term in the acute sector Measuring numbers of people recovering after treatment i.e. no longer judged as requiring further treatment How will we monitor and measure success? A number of Key Performance Indicators have been designed to measure and monitor success in Improving Access to Psychological Therapies. These include the number of people who have completed treatment and who then retain employment and the number of people who are moving to recovery. Also measured are the 23
24 number of people who have completed treatment not at clinical caseness and lastly the number of people moving off sick pay and benefits. (Caseness is defined by a score of 8 or more on GAD-7 or 10 or more on PHQ-9). Regular reports on the Bromley Working for Wellbeing Services will be presented to the Mental Health Executive Group and the Mental Health Partnership Group for scrutiny. What policy linkages are there? 1. No Health without Mental Health-A cross Government mental health outcomes strategy for all ages. (2011) 2. No Health without Public Mental Health-The case for Action. Royal College of Psychiatrists position statement PS4/ Public Mental Health and Wellbeing-the local perspective. National Mental Health Development Unit.(2010) 4. Foresight mental capital and wellbeing project. Psychological wellbeing: regarding its causes and its consequences. (2008) 5. The Role of Local Government in Promoting Wellbeing- Healthy Communities Programme. New Economics Foundation. (2010) 6. New Economics Foundation. Five Ways to Wellbeing. (2010) 7. NICE Guidelines on Anxiety and Depression. 8. The Marmot Review. Fair Society. Healthy Lives. (2010) 9. Healthy Lives, Healthy People: Strategy for Public Health In England. (2011) 10. North East Public Health Observatory (2012) Community Mental Health Profile. 24
25 9.5 Health & Wellbeing Priority - Increasing Volumes and Complexity of Need Children with Complex Needs and Disabilities What is the issue? The context of need in which planning and provision within Bromley must take place has changed dramatically in recent years: During the last 10 years, the number of very pre-term babies surviving long enough to enter school has increased from approximately 5% to an estimated 85/90%, and of these, 64% have additional needs or are disabled. Nationally the total number of children with profound and multiple learning difficulties (PMLD) in special schools has increased by 29.7% since 2004, and the population of pupils with complex learning difficulties and disabilities in Bromley schools and settings is also increasing. Bromley s multi agency Specialist Support and Disability Panel (SSDP), which receives referrals for children and young people with the most complex special educational needs and disabilities, received 388 referrals of children and young people in the first two school years following its inception in September This increased by 42% in There are currently (February 2012) 3 fully ventilated, technology dependent young children in the borough requiring extremely high, jointly funded care packages both within the home and within Phoenix Pre-School Specialist Support and Disability Service. The year on year increases in the numbers of children with more complex needs and disabilities is making considerable demands on services. Referrals to: 1. the Pre-school Specialist Support and Disability Service saw an increase in the number of children with the most severe, profound or very complex needs of 24% over three years from 2009 [270], 2010 [312] to 2011 [335] 2. the Complex Communications Clinic (Health led) have risen by 15% from 2009 [155] to 2010 [179] 3. the Bromley Children and Adolescent Mental Health Services (CAMHS) for children and young people with moderate to severe mental health problems have risen by 27% from 2009 [1,496] to 2010 [1,901] 4. the Community Paediatricians Service have risen by 13% from April 2010 to September the Community Physiotherapists have risen by 8% from April 2010 to July the Children s Speech and Language Service have risen by 23% from April 2008 [1,958] to June 2011 [2,545] - despite the criteria for service entry and intervention becoming much higher What are the implications for Bromley? The Council has a duty to: provide high quality full time education for these children many of whom have very significant medical as well as educational and care needs. If the Council does not have enough suitable placements for these children in our own schools then it is required to fund costly out of borough placements which are usually in independent schools and often residential settings. 25
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