Jim McManusJoint Director of Public Health

Birmingham City Council

Prevent, Enable, Personalise, Realise some tentative experience from Birmingham

COSLA Annual Conference 2012

Jim McManus

Joint Director of Public Health

Birmingham City Council16th February 2012

Delivering Success:

Public Service Reform – Big Tasks

1. Localism Act

2. Elected Mayors??? Errr...

3. NHS Reforms – public health, clinical commissioning groups, NHS Commissioning Board, Health and Wellbeing Boards

4. Police and Crime Commissioners

5. Open Public Services White Paper

6. Spending Review

7. Social Care Funding

Big Asks

• Do better with a lot less• And by the way your population is still getting older, needier and

growing• And you will have a 25% increase in dementia• And immigration will bring costly TB and CVD• Oh, and you’ll have more folk with learning disabilities• And they all have to have personal budgets

The basic message – complex relationships, big tasks

Life circumstances

Good outcome

Bad outcome

Behaviours

The arrows include public services and access

The basic message – interventions = big asks

Life circumstances

Good Health

Ill Health

Behaviours

Birmingham ChangePrevent, Enable, Personalise, Realise

• Major Change – reducing buildings, reducing costs, outsourcing, mutuals

• New single contract (50,000 people)

• New operating model for children – universal, targeted, special and complex

• New Operating Model for adult social care – prevent, enable, personalise

• Benefits realisation• Radical new ways of doing

things

New Ways of Working

• Not just rely upon commissioning• Working with wide range of civil society partners• Shared leadership of Health and Well-Being Board• Support from HealthWatch• Using new powers and new resources to create healthier communities

The Big Ask: What success looks like...

£37million

Range of targeted/ Flexible Services

Support to service user /Citizens

Number of those receiving

preventive services

Prediction and Prevention

Self management

Supported to stay in their Home

Customer Satisfaction

Increased Improved flexibility

Increased

Increased through joint interventions

Increased through community resources

People supported to manage LTC

Why does service change matter?

Life Expectancy against Core Cities

Male Female

England 78.3 82.3

Sheffield 77.8 81.5

Leeds 77.7 82.0

Bristol 77.2 81.9

Birmingham 76.4 81.3

Newcastle 76.2 81.0

Nottingham 75.2 80.3

Liverpool 74.5 79.2

Manchester 74.0 79.1

4th out of 8 Male5th out of 8 female

Life Expectancy by Ward

Gaps in school readiness at 3 and 5 years by family income: UK

Ave

rage

per

cent

ile s

core

Waldfogel & Washbrook 2008

National Audit Office 2010not on course!

And what has got us there? Barriers to reform

• Focus, or lack of it• Starting with a promising intervention, then making sure it is doomed to

fail by tinkering about• Scientific Grounding and Understanding of Need (or lack thereof)• Partnerships – obsessed with structure and governance• Poor integration of joint commissioning• Cultures...Aaarrrghhh!!!!!• Deficit – We know more than you

Not getting value of

Intelligence in achieving Better Outcomes...

Does anyone actuallyReally do all this?

What did we achieve?

Keeping on Track

Prioritisation

Best Buys/Best Dos

Need

Writ across all Programmes

1. Telecare £14 million

2. Intelligence and Information Programme

3. Predicting need in social care

4. Data sharing with GPs

5. Diverting people from social care and hospital

6. Targeting young people to reduce risk

7. Worklessness

8. Decent Housing

9. Preventing Extremism

10. Enablement

11. Public Health Transition

Critical Success Criteria – Fire Service

• Falls Assessment• Telecare Assessment• JSNA and data sharing• Population density of fire and need• Sharing populations• Well constructed outcomes based agreements

Health and Care: Our Burdens of Disease mean Prevention is wrong way round

Primary Secondary Tertiary

The Big Ask: What success looks like...

£37million

Range of targeted/ Flexible Services

Support to service user /Citizens

Number of those receiving

preventive services

Prediction and Prevention

Self management

Supported to stay in their Home

Customer Satisfaction

Increased Improved flexibility

Increased

Increased through joint interventions

Increased through community resources

People supported to manage LTC

Whole System plus focused action

The example of health inequalities

The Conceptual FrameworkReduce health inequalities and improve health and well-being for all.

Create an enabling society that maximises individual and community

potential.

Ensure social justice, health and sustainability are at heart of policies.

A. Give every child the

best start in life.

C. Create fair employment and good work for all.

B. Enable all children, young people and

adults to maximise their capabilities and have

control over their lives.

D. Ensure healthy

standard of living for all.

E. Create and develop

healthy and sustainable places and

communities.

F. Strengthen the role and

impact of ill health prevention.

Equality and health equity in all policies.

Effective evidence-based delivery systems.

Policy objectives

Policy mechanisms

The Golden Thread

Need, Outcomes Priorities, Interventions

Health Inequalities : What we know

• Edinburgh World Congress of Epidemiology 2011• Non Communicable Diseases• Impoverished understanding of behavioural sciences in some public

health programmes• Multiple Tracks. Public policy action in all of them

Policy History...Zzzzz

• Black Report 1982 (UK)• Ottawa Charter 1986 (World)• Health of the Nation 1984 (England & Wales)• Our Healthier Nation 1998 (England & Wales)• Healthier Wales 2000 (Wales)• Choosing Health 2005 (England)• WHO Commission on Social Determinants 2009• Marmot Review of Health Inequalities 2010

2008

2007

The upshot of all this is that whatever framework you use.....

It’s the same problem!

The Big Tasks

• Short term challenge of tertiary prevention• Medium term problem of keeping the ill well• Short term problem of stopping avoidable events• Long term problem of changing determinants of health, health

expectations, behaviour and culture

The Big Tasks

The Ask

• Short term challenge of tertiary prevention

• Medium term problem of keeping the ill well

• Short term problem of stopping avoidable events

• Long term problem of changing determinants of health, health expectations, behaviour and culture

Who

• Social Care, NHS, Housing

• NHS, Social Care, Housing, Leisure

• NHS, Leisure

• Local government par excellence

Birmingham’s use of Marmot

Activities Framework

• 1. Adopt the Outcomes

• Starting well

• Developing well

• Living well

• Working well

• Ageing well

• 2. Add an outcome “dying well”

• 3.Cut our JSNA and Strategy across the Lifespan

• 4. Use as “golden thread”

• For Health Inequalities Action

• For JSNA

• For Health and Wellbeing Strategy

• For Integration

• As a lifecourse approach to human ecology

Examples of Marmot in practice

LGBT MENTAL HEALTH PREVENTION

• Lifecourse approach using Marmot

• Early development• Mental health problems onset• Tasks for each lifestage• Community and Public Sector

tasks• Interdependencies

• Use of Marmot Framework across lifecourse

• Tasks for adult social care and older adult social care elucidated

• Incorporation into third sector contracts with third sector

• Preventive workstream

ExamplesStart Well Develop Well Age Well

Adults & Communities

High priority parents in touch with A & C

Transition Older Peoples’ offer from prevention to very high need

Homes & Neighbourhoods

Overcrowding and infant mortality

Decent Homes Standard Access, Trips, Falls, Extreme Weather, Adaptability,

Development Back to work packagesDigital inclusion

Back to work packages for parentsDigital Inclusion

Volunteering and work packagesDigital Inclusion

NHS Infant MortalityConception

Frail Elderly

Demonstrated

• The role of public health sciences in public service can be significant

• The role of behavioural sciences in public service reform can be significant

• Public health disciplines can be applied across public service reform

Thank You!Jim.mcmanus@birmingham.gov.uk