The document discusses shifting to a prevention-focused approach to public health. It outlines 5 premises: (1) there is an epidemiological crisis with avoidable deaths and chronic disease; (2) policy context supports prevention; (3) clear roles and a nuanced understanding of behavior change are needed; (4) "big wins" include shifting clinical complexity and increasing prevention; (5) prevention efforts should be phased and layered across the lifecourse. Actions taken so far include new weight management and lifestyle services, and increasing health checks. A behavior change pathway is outlined moving from brief interventions to specialist support.

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Jim McManus, OCDS, CPsychol, CSci, AFBPsS ,FFPH, FCIEH, FRSPH
Director of Public Health, Hertfordshire County Council
Health and Wellbeing Board Development Day
29th July 2014
A Strategic Shift to Prevention

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Premise 1: We are facing an epidemiological
crisis
• Avoidable early deaths
• Chronic disease – poor self management, poor
management of sub-clinical risk, must do better
on prevention and early intervention
• Some sections of our population at very high
risk of avoidable misery and death
• Mental health – intervening too late
• Resilience and Happiness – likewise

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3
Prediction
forecast / target services
Secondary Prevention
PrimaryPrevention
Universal&Well-being
LOW
MODERATE
SUBSTANTIAL CRITICAL
Reduce numbers of people coming into high-cost services and
moving along threshold banding
Intensive Home Support
Residential Care
Motivation, Support
Skills, Services
Tertiary Prevention

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Primary
Prevention
Secondary
Prevention
Tertiary
Prevention
in and
Out of hospital

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Premise 2: The Policy Context (England) does
give us scope to address this
• Local Authorities – duty to promote and protect
health of population
• NHS CCGs – duty to reduce inequalities in
health
• Behaviour change is a tool but we need to use it
properly and use the right methods
• A balanced strategy using a range of tools and
strategies

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Premise 3: There are four big tasks
1. Analyse the system and identify problems
2. Build a system wide approach to deal with it
3. Be clear on roles, responsibilities and
outcomes
4. A more nuanced understanding of lifecourse
and behavioural change
1.Cogntiive and Planned
2.Habitual and automatic

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Premise 4: Winds and delivery tools
Five big wins
1. Shift up clinical complexity in
primary care
2. Step up secondary prevention
of complex cases and
3. Step up self care and self
management in chronic
disease
4. Commission secondary
prevention pathway
5. Commission primary
prevention for key risk groups
Policy and Delivery Tools
• Pathways and structured
care approached
• Health and social care
integration
• Behavioural sciences
• Health Checks and public
health services
• Brief interventions

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Primary
Prevention
Secondary
Prevention
Tertiary
Prevention
The shift to prevention

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Premise 5: Phasing and Layering across
lifecourse
•Think through what we can do short term
•Start work on the medium term
•Set the policy framework for the long term
•Build this understanding among partners
•Get started and realise
•County, District, Parish, NHS, Business and
Community Sector working together

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Premise 5: Phasing and Layering
• Phasing across the lifecourse and time
Working age
Accumulation
Of risk in
Late working
age
Good early
Years
outcomes
For lifetime
Mental
health

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Premise 5: Phasing and Layering across
Lifecourse
• Layering levels of action
• Population – smoking ban
• Sub-Population – NHS health checks
• Individual – motivational interviewing, asserting
clinical management of risk factors, pathways

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What it means for NHS Services
• Preventive services in every patient pathway
• Levels and competencies from brief intervention
onwards
• Preventive services in clinical services link up to
community services (referral for leisure and
behavioural interventions)
• Commissioning for self-management in chronic
disease

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15 Actions being taken so far (more will be done)
1. New weight management service already
commissioned and reached 1st 1,000
referrals in three months, more will be
commissioned
2. Obesity pathway in place for tiers 1 -3
obesity care. Revision late 2014
3. New lifestyle partnership launched with
lifestyle offer for Herts residents to be ready
by Easter for phased roll out
4. New online lifestyle service launched in
February
5. Workplace physical activity challenge
funded and running (Herts Sports
Partnership)
6. Workplace Health improvement programme
running (Business in the Community)
7. 93% of GPs in Herts now doing NHS
HealthChecks
1. Obesity Plan approval by Cabinet due
March 2014
2. New child weight management service to
be commissioned in 2014
3. Broxbourne whole area obesity pilot
underway with Borough and County
Council, schools and NHS
4. Fast food takeaway restrictions
5. Countryside walks scheme
6. Year of Cycling launching May 2014
7. Funding for District Councils to work on
health improvement agreed and each
District working out its plans
8. Continue child weight measurement
programme

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Behaviour Change Pathway Approaches
2nd Line – Behaviour Change 3rd Line - Activity 4th Line – Specialist1st Line – Brief Intervention
Opportunistic brief advice by
GP, pharmacist or practice
nurse
1Identify health issue of
concern (and follow
appropriate pathway for
that, e.g. obesity)
2Assess motivation to
change
3If motivated, refer on
4If not motivated,
Raise awareness
of risks.
Offer written
information on
healthy eating and
physical activity.
Raise again in 3
months.
Offer information
prescription
Smoking
is primary,
main or
only goal
If fall into 1st or
subsequent line category
of advice within Obesity
Care Pathway refer to
Lifestyle Programme,
provided there are no
contraindications and if
co-morbidities or person
has BMI over 30, GP has
assessed and supports
referral. Check this ….
Discuss primary or main goal
then refer appropriately For patients with co-
morbidites
Patients who are diabetic or
have coronary heart
disease or a history of heart
problems must have referral
from appropriate primary
care team or secondary
care to participate in
programme.
Behaviour change
programme to be developed
in partnership with specialist
services
The evidence base for changing health behaviour is developing quickly. Brief interventions in primary care (by practice nurses and
GPs) can motivate people to change, providing referral onwards is speedy. This pathway
Refer to
smoking
cessation
service
Weight
loss,
healthy
living or
CVD risk
is main or
primary
goal
Refer to
ifestyle
Service
Patients with highly complex psychological or emotional
issues (e.g. depression or eating disorder.)
If not already in contact with such services, refer to IAPT
programme psychology or primary care mental health team