This is the text of a presentation on a public health view of the biggest wins for the health and social care system, given to the Local Government Association's awayday for health and wellbeing portfolio lead elected members in October 2015.

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The Big Wins for the Health and Social Care
System
A presentation to the health and social care system leadership round table
Community Wellbeing Portfolio Away Day
Local Government Association, 2 October 2015
Jim.mcmanus@hertfordshire.gov.uk
Jim McManus
We can no longer afford our current health and social care system, because of the
burden of disease and disability presenting. We must do better at preventing
avoidable loss of health and function (including avoidable disability) which results
from poor prevention of ill-health becoming worse, and which results in avoidable
demand for health and social care. Just a few examples are:
 diabetic foot amputations and sight loss from poorly controlled diabetes
 avoidable sight loss needing social care packages
 avoidable muscle and mobility deterioration in people who become sedentary
after stroke, heart disease or other diagnosis
 Avoidable musculoskeletal disease and associated disability in people with
weight problems and other health problems
 The ongoing disability and disease from smoking in people with long term
conditions
We do not get prevention right. Primary prevention (stopping a disease happening in
the first place, for example keeping a healthy weight and not smoking) is hugely
important for all but will not stop the current burden of exacerbating ill-health. We
need a logic model for prevention across the whole health and social care system

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which includes secondary prevention (reversing ill-health or preventing exacerbation)
and tertiary prevention (keeping best function and limiting disability.) Lifestyle
interventions for everyone are essential to this and evidence1
shows physical
activity, healthy weight and quitting smoking are essential to secondary and tertiary
prevention as well as primary.
There are some high impact actions we can take to reduce cost, make the system
sustainable and deliver change. Cultural and systems barriers stop this happening.
But NHS and local authority planning, commissioning and priority systems need to
be brought together to enable this. Local control by Health and Wellbeing Boards
who can work on these priorities and remove structural and cultural barriers is crucial
to achieving this.
Below are four principles and some high impact actions under each
Principle: Prevention first and always
1. Consistent high quality management of the biggest risk factors for
exacerbation of long term conditions in primary care. This requires four
consistent components
a. Clinical management especially good quality drug regimens, focus on
adherence with regimens and regular drug use reviews
i. Develop approaches for multimorbid patients and for
polypharmacy which is focused on stabilisation, functioning and
secondary and tertiary prevention as goals
b. Significantly increase lifestyle interventions as an essential component,
with physical activity FOR EVERYONE and robust motivational referral
systems between primary care and LAs
c. Social contact and purposeful activity to maintain mental resilience
2. A whole system prevention logic model which incorporates priorities for
primary, secondary and tertiary prevention across all agencies
3. Preventive actions and pathways in secondary care are crucial to preventing
worsening and disability
Principle: Think and act system wide
4. A focus on reducing and realigning systems and costs
1
The Academy of Medical Royal Colleges (2014) Exercise: the miracle cure. London: AMRC

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a. Reducing and preventing avoidable disability (i.e. people with existing
conditions become so avoidably ill they need social care) is the low-
hanging fruit in the system
b. Reducing and preventing avoidable disability in people with severe
mental illness is also low hanging fruit
c. Focus more on what people with autism and learning disabilities can
do to stay in employment and training for maximum independence
d. Keep people with long term conditions in work or economically active
as long as possible. Others in Europe do much better than we do
5. Pathways need to be system wide not just clinical, working in social care and
public health and preventive services
6. Focus on people outcomes, adjustment to long term conditions, self
management and resilience
7. More embedded behavioural and psychological skills across the system for all
staff
a. Skills for patient professional interaction and motivation to understand
and maintain health
b. Skills for helping and motivating on behaviour change
i. Hertfordshire recently started this with pharmacists and others. It
is already showing benefit
Principle: Think and act Lifecourse
8. Develop and apply a whole lifecourse offer, with healthy start in life being
crucial.
9. Focus on ensuring healthy childhood through healthy school and child
settings
10.Focus on reducing avoidable disability (physical and mental) in working age
adults by ensuring healthy workplaces
11.Focus on healthy ageing by ensuring older people can access lifestyle
interventions easily and consistently
Principle: make systems work across layers and levels

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12.Our current systems are too disjointed. Interventions may focus on individual
levels (eg prescribing) when social levels (ensuring access to lifestyle
services; policy etc are all needed.) This needs to be factored into systems
thinking. Take tobacco control, you need all these layers to make it work.
Think layers, think system!
Individual  Smoking cessation treatments and
counselling/support
Social  Cultural norms on smoking as
undesirable
Environmental,
Legislative etc
 Smoking bans in public places
 Smoking in workplace policies
 Restrictions on sales and
advertising
Service level  NHS and other services must STILL
do better at getting users off
tobacco. Especially in mental health
settings. 64% of tobacco use is by
people with mental health
problems