The Staying Healthy Pathway
Condition: Life – Prognosis: Good
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Everyone living in Y&H deserves the same thing - the best possible chance of staying in good physical and mental health for as long as possible. As most people recognise, responsibility for staying healthy begins at home; but it is affected by a wide range of factors and services.
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This chapter sets out why we want and need to do more to support people to make healthy choices; and how the NHS and other partners in Y&H could achieve this. In particular, it offers a framework for action, which should enable individuals, the NHS and partners to understand how together we can make the right choices and interventions to stay healthy. Our hope is that we will add life to years and years to life. And – by persistently targeting our efforts – reduce the gap between those who experience the best of health and the worst.
The Case for Change
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There have been a number of national reports over the past decade, setting out the reasons why the long-term health of the population is so critical to the NHS. The most important of these, the Wanless review of 2004 indicated that it would be possible to save £30 billion pounds of public expenditure by 2022/2023, if individuals were fully engaged in their own health care; responsible for knowing what to do to stay healthy and aware of where to get help and then take action.
Alcohol consumption in Yorkshire and the Humber. Over a third of adults drink more than the recommended daily allowance. The third highest prevalence of "binge drinking" – 22% compared to England average of 18.6%. Deaths from chronic liver disease have almost doubled in the region in the past decade. The highest percentage (5%) of people dependent on alcohol compared to the national average (3.6%).
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The Staying Healthy CPG report (available at www.yorksandhumber.nhs.uk) was written in the context of growing concern about the impact of 'lifestyle diseases' stemming from the choices people are making about how they live. Many recent national reports have detailed the rapidly increasing problems caused by smoking, inactivity, poor diet and drinking too much alcohol. These choices lead to poor health outcomes and cause increased disease, disability and death. They also place additional costs on the economy – through sickness and inactivity and of course further demands on NHS services with increases in the need for treatment and support.
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The Staying Healthy CPG looked at the demographics for Y&H against the backdrop of these reports, and the long-term consequences they identified of failing to improve health. They identified the three biggest threats to the overall health of the population in Y&H for the next decade: the abuse of alcohol; rising obesity and the continued prevalence of smoking. There are many other areas that could have been considered, but the CPG concluded that a spotlight on these three areas was most likely to focus attention and effort on issues of greatest impact.
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The evidence for reaching this conclusion is set out in the more detailed report of the CPG.
Alcohol
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When it comes to alcohol, people in Y&H have some of the highest levels of alcohol consumption in the country. Alcohol contributes significantly to morbidity and mortality including gastrointestinal, cardiovascular, neuropsychiatric, cancer and maternal and perinatal disorders. Acute conditions also include alcohol poisoning, accidents, assaults and self–harm.
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Our focus groups demonstrated that these risks are not well understood – people saw alcohol as much less of a concern than being overweight.
Obesity
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Extrapolations in the Foresight report indicate that on current national trends, by 2015, 36% of males and 28% of females will be obese. By 2025, 47% and 36% respectively are estimated to be obese, if no action is taken. The picture in Y&H is predicted to be worse than these national trends and further graphs can be seen in the technical appenix available at www.yorksandhumber.nhs.uk. Some of the problems in the region are already becoming apparent – for example by 2010 we are likely to have the highest number of obese or overweight girls aged 11-15 in England.
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These are not just issues for the NHS; these are issues for individuals, for society and for other key bodies. In our polling over 50% saw themselves and their families as responsible for ensuring that we tackle these issues.
Tobacco
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Smoking has been an issue of concern in the past and overall in Y&H prevalence rates have dropped over the past decade. However, with just under 1 in 5 deaths in Y&H attributable to smoking, there are still high levels of smoking compared with the national average, and high levels of smoking amongst manual workers compared with professional groups – with a consequent impact on the likelihood of premature death and disability.
What can the NHS in Yorkshire and the Humber do?
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Improving health and wellbeing is not just the role of the NHS; nor is the NHS the most significant influence on people's lifestyle choices that affect their health. For example local authorities can have a significant impact – this is recognised in joint working between local authorities and the NHS – such as joint Director of Public Health appointments and Local Area Agreements. But the CPG decided that if the NHS could improve its contribution, both in what it can do, and in how it influences others, we could together begin to improve health and tackle inequalities in the region.
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In light of the evidence about what works, and the scale of the problems in Y&H, the CPG has made a number of proposals which it believes can reduce the risks attendant on smoking, alcohol misuse and rising obesity. These are summarised below. There is further detail available in the detailed report from the CPG.
Key Recommendations
Alcohol
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The NHS in Y&H should improve screening and identification of people with alcohol use problems.
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PCTs should commission the systematic use of brief interventions to "industrialise" their use across NHS services.
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PCTs should commission a range of 'tiered' services to cope with people who present with different levels of dependency and ensure simple referral routes are accessible from screening points.
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PCTs should commission services separately from drugs misuse services as the evidence suggests that people with alcohol problems are more likely to use separate rather than shared services.
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The NHS should work with other organisations to reduce the accessibility of alcohol, including an increase in its price.
Obesity
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Every PCT should develop and commission localised weight management services for their local population. These services are available from a range of providers who offer support and information for dieters. To meet life expectancy targets these should focus on adults at mid-life.
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Services could be commissioned based on the smoking cessation service model, using similar referral protocols to enable quicker implementation.
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NICE guidance on brief interventions should be implemented consistently by a wide range of NHS settings and staff. Ideally, this would include primary care, secondary care, community services, family centres, local authority and voluntary settings.
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NICE guidance indicates that for adults who are morbidly obese, surgery may be the best intervention. PCTs should proactively collaborate on setting the specification and agreeing when these services should be commissioned so that there is a common standard across the region.
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There should be a systematic programme of local work to reduce the levels of obesity through the development of:
- Food policy and better food skills for adults.
- Transport and the built environment – making activity easier/safer.
- More opportunities for active leisure.
- Local employment.
- Quality of school food, drink and activity programmes.
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The recommendations of the Staying Healthy CPG – which are focused on adults – should be also linked to the Government initiative on child weight management which is aimed at tackling rising obesity levels amongst children.
Tobacco
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Every PCT should commission the systematic and "industrialised" use of brief interventions and referrals into effective smoking cessation support services. In addition there should be training for as many other front line social care/community workers/volunteers as possible in carrying out brief interventions and referrals to services.
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PCTs should commission free Nicotine Replacement Therapy for the smoking population and make it widely and freely available to all.
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The CPG recommend changing the headline measure from number of quitters to smoking prevalence in order to align incentives better to what will make the biggest impact on health.
What will make a difference?
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The key insight the CPG set out in their report is that if we continue to deal with risk factors in a piecemeal fashion we will achieve only minor health improvement across the population. We need to take on a systematic and 'industrial' scale to our approach and in order to do this we need to provide a framework for action from which all agencies can see their respective roles. If we do not, then the NHS will face an increasing workload in the next 10-20 years; and people will continue to suffer premature death and/or avoidable poor quality of life. This has consequences both for our society as a whole and our economic prospects as a region.
The Staying Healthy Rainbow Model
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The framework for action developed by the CPG is based on an understanding that:
- first, many different factors impact on your health; and
- second, there are key moments in your life when you are motivated to become healthier.
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This insight means that the NHS, and other partners, need to identify the best opportunities for intervention; and then use the evidence available both regionally and nationally to make the most effective intervention. The Staying Healthy Rainbow Model therefore is a visual representation that aims to illustrate what different interventions could be made, mapped against a person's life.
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The upper coloured bands represent the various influences and environments that affect any individual. These range from personal behaviours outwards to wider life in communities and society.
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The lower coloured bands represent the choices, support and interventions a person may take advantage of to stay healthy. Again these range outwards from personal choice and motivation, through healthcare and other public services to the overarching public policy.
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All individual lifelines are unique. However, as recent NICE guidance has confirmed, there are certain common episodes in most people's lives that provide opportunities for significant positive behaviour and lifestyle change. Examples include the onset of pregnancy, schooling, major illnesses and operations, and retirement.
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The model uses one person's timeline. Whilst it is not intended to represent the definitive timeline of all people, it reveals the multidimensional and unique nature of a person's life course and how through that life course there are numerous opportunities for the NHS and its partners to help a person stay healthy.
The Model Explained – Alcohol
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The CPG recommended that the objective around alcohol should be to promote and sustain a drinking culture which is safe and responsible – whilst recognising that alcohol intake is almost always seen as a 'rite of passage' into adult life.
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The CPG used the rainbow model to identify the key 'flashpoints' in people’s lives where interventions could have the greatest impact on their use of alcohol. These are:
- Adolescence.
- Pregnancy.
- Mid life – from late 30s onwards the pattern is that regularity of drinking increases (but with fewer binges).
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The CPG looked at what works in developing a sensible approach to alcohol, recognising that evidence suggests that alcohol consumption patterns of individuals are strongly influenced by parents and peers. There is clearly more work to be done with partners to understand and identify how we can shape social attitudes to alcohol to support a sensible drinking culture. Accepting that this is a long term task which needs to be done, the CPG focused on where it believed that the most impact could be made by the NHS.
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In terms of what works, the CPG identified three key areas:
- Screening, identification and brief advice in primary care and other settings.
- Treatment and rehabilitation programmes for problematic drinkers.
- Enforcement of under-age sales restrictions.
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There was no evidence that raising awareness of units as a measure of alcohol intake (the Know Your Limits campaign) was having an impact on patterns of consumption.
Good practice
In Rotherham – a Local Enhanced Service to include screening / brief interventions and a range of medical interventions to support community detox and relapse prevention. Extended brief interventions within the primary care setting. Local training strategy that includes primary care training needs surrounding alcohol.
The Model Explained – Obesity
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Rising trends of obesity offer one of the biggest threats to the future health of the population in Y&H, and consequently the future wealth of the population in Y&H. Taking action to halt the rise will reduce premature death, disability and disease. This is perhaps one of the hardest areas to tackle, as few, if any western countries have yet halted a year by year rise in levels of obesity.
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The CPG identified that the key 'flashpoints' on the Y&H life course model, where interventions are likely to be most effective are:
- During pregnancy.
- Post-pregnancy (breast feeding).
- Pre-school.
- Mid life.
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There are a number of obesity pathways (prevention and cure) which have already been developed at national level for both children and adults – with NICE guidelines for implementation. These set out clearly the action that is required, by who and when.
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These pathways have not been repeated in this document but successful activities include:
- Brief interventions in primary care and other settings.
- Weight management programmes.
- Exercise referral schemes.
- Surgical interventions (in line with NICE guidance).
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Obesity is a priority issue for the region across all age ranges and obesity in children is clearly an issue which we must address. This will be a focus of weight management and food policy recommendations.
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However, the Staying Healthy CPG and this report profiles adult obesity specifically. This is because – if we do nothing – it is much more likely to result in higher rates of disease, disability, and ultimately death within the ten year timescale of this review.
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This work has provided the opportunity to develop short term measures with potential for quick wins – and recommendations for the next ten years. It is the mid-life adults of today who – if we do nothing – will give most cause for concern and who will require increased levels of resources and service inputs from the NHS. And to put it bluntly, supporting and prioritising mid-life adults with weight issues will most directly impact on the realisation of our aspiration to raise life expectancy and narrow the gap.
The Model Explained – Tobacco
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Smoking harms health. There are no levels where smoking does not have an impact on overall health. The CPG set out the goal of reducing disease, disability, death and preventable healthcare costs due to tobacco use.
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Using the rainbow model, the key 'flashpoints' where there is most chance of preventing people from starting smoking, or supporting them stopping smoking are:
- During adolescence: encouraging the young not to start smoking.
- Pregnancy: supporting pregnant women to stop smoking.
- Major operations and illnesses: making recovery faster and easier.
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We know that the well developed national approach encourages delivery of comprehensive (6 strands) integrated and sustainable tobacco control strategies at local level. The success of the tobacco control work to date – and the falling rates of smoking prevalence – illustrate how important a 'wholestream' approach is.
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Successful activities include:
- Screening and brief interventions for pregnant women.
- Promotion of smoke-free homes/environments.
- Brief interventions in primary care and other settings.
- Pre-operative smoking cessation protocols (NICE recommendation).
- Nicotine Replacement Therapy (NRT).
- Availability and accessibility of good quality smoking cessation services.
- Restricting access to tobacco products and eliminating tobacco promotion.
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In Y&H, we have developed the top 10 High Impact Interventions which will help people stop smoking, and stop them from starting to smoke.
Barriers to Change
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The CPG considered what was holding back greater improvements in health. It identified six key areas:
- The failure to systematically apply brief interventions by the whole of the NHS workforce. Instead, in some areas, interventions remain the domain of the specialist service or the public health team.
- There is not currently enough capacity to deal with the levels of need (as opposed to demand) for both brief interventions and advice.
- Weight management services are not yet systematically developed or tailored to the needs of different groups and are not widely commissioned by the NHS. They also tend to focus on diet rather than a combination of food and activity advice.
- Dealing with the wider 'obesogenic' environment (as identified in the Foresight Report) requires concerted collaborative action of all partners and political will. NHS action will only be able to treat the symptoms.
- Systematic application of screening and brief interventions – for example one study in Y&H suggests GPs are 3-4 times less likely to identify alcohol misuse than in other regions.
- There is not always the opportunity for individuals to refer themselves into specialist services; and as a consequence, opportunities to improve health are missed.
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In light of these views about where the barriers are, the CPG made its recommendations about what works, to understand better what needs to be done to tackle the three key threats it identified: alcohol, obesity and tobacco.
Conclusion
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Changing individual behaviours, and changing social attitudes, is no easy task. What the Staying Healthy CPG have done is to make a strong case for why we cannot stand still in the face of these problems; and to develop a framework for action which should help the NHS in Y&H and other partners identify what they need to do.
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In their report, the CPG calls for a 10% shift in investment into prevention and support for lifestyle changes. The SHA supports the ambition to turn the spotlight onto prevention, with a significant shift in investment, but it is clear further work would be needed to understand exactly how such a shift might be measured and what it would buy. In the first instance, the SHA would like to measure progress on output indicators – life expectancy and health inequalities.
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It is clear that if we share an ambition for people to lead longer and healthier lives then individuals and their families will need to take more responsibility for their own health. In return the NHS needs to make staying healthy core business so that it is easier for people to make healthy choices. The NHS cannot do this alone, strong and focussed partnerships will be key to delivering better physical and mental well being for people in Y&H.
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Our pledge in taking forward this pathway will be to promote healthy lifestyles – with a halt in the rise of obesity.
Sources:
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This chapter is based on the work of the Yorkshire and the Humber Staying Healthy Clinical Pathway Group. Report available at www. yorksandhumber.nhs.uk. Membership of the group is shown at Appendix 1.
2
Securing Good Health for the Whole Population, Derek Wanless, 2004
3
Foresight Report, Tackling Obesities: Future Choices, October 2007
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NHS Deliberative Event, September 2007
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National Alcohol Needs Assessment Research Project (ANARP), Department of Health 2005
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Our Future Health Secured, A Review of NHS Funding and Performance, Derek Wanless, Anthony Harrison, John Appleby, Darshan Patel, Kings Fund 2007
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Choosing Health, Making Healthy Choices Easier, Department of Health 2004