As part of the whole system health and care transformation programmes East Sussex Better Together and Connecting For You, East Sussex County Council has developed a system wide asset-based approach to prevention and early intervention with a view to making sustainable change at scale and pace.
This has involved extensive community engagement and partner organisations from the health, care, voluntary and other sectors. Multi-agency delivery groups, locality networks and Locality Link Workers are all part of the infrastructure underpinning the programme of work developed from this approach.
A system of grant making has been established to encourage a ‘whole settings’ approach to prevention and health improvement in a range of settings. This has proved successful in both education and health settings. It provides an opportunity to receive a grant to support identification
and implementation of individual settings’ own evidence-based plans and priorities, encouraging ownership and ‘buy-in’ from participants. Evaluation currently under way includes assessment of community benefit and return on investment for health and care as well as the impact on the local economy.
The county of East Sussex has a population of just over half a million people, with an older age profile than England and the South East, more than a quarter of whom are aged over 65, significantly more than in England (18 per cent) and the South East (19 per cent). Four per cent of the total population is aged over 85; the second highest of all county and unitary authorities in the country, behind Dorset.
Black and minority ethnic (BME) groups account for 8 per cent of the county’s population making it less ethnically diverse than nationally (20 per cent) and the South East (15 per cent).
Deprivation is a mixed picture with significant levels of deprivation in the urban areas of Hastings and Eastbourne, but with many rural areas hiding pockets of deprivation. About 19 per cent of children live in low income families, but this rises to 40 per cent in some parts of East Sussex.
The health of people in East Sussex is varied compared with the England average. Life expectancy for both men and women is higher than the England average. Nonetheless, life expectancy is 7.7 years lower for men and 6.0 years lower for women in the most deprived areas of East Sussex than in the least deprived areas.
The percentage of people who smoke in East Sussex (17.1 per cent) is higher but not significantly different to England as a whole (15.5 per cent). Hastings has the highest percentage of the adult population smoking in England.
There were significantly more hospital admissions for alcohol-specific conditions among under-18s in East Sussex than in the average local authority in England.
Many more people were killed and seriously injured on roads in East Sussex between 2013 and 2015 (66.7 per 100,000 people) as compared with 38.5 for England.
Health priorities in East Sussex include reducing circulatory diseases, cancers and respiratory diseases to reduce health inequalities.
Organisation
Building community resilience
Improving health and embedding prevention across the system is a core part of placebased whole systems transformation programmes in East Sussex (East Sussex Better Together (ESBT)) and as part of Connecting 4 You (C4Y) in the west of the county. Underpinning the approach was a recognition of the need to do things differently, follow the evidence wherever it led and develop and test new levers for change at a population level. The programme is predicated on designing systems across health, social care, voluntary sector and wider partners to improve health outcomes.
Following a comprehensive engagement programme, Building Strong Communities, findings were used to identify local priorities, and a community resilience steering group established, chaired by the director of public health with senior level representation from children’s and adults’ services, the
clinical commissioning group (CCG) and the voluntary sector. The intention was to utilise the strengths that individuals and communities contribute to improving health outcomes, by embedding asset based approaches across the system. This set in motion a multi-component work programme.
Three new multi-agency delivery groups were established and eight Locality Link Workers recruited to help new joined-up health and social care teams to work more closely with communities. Locality Networks have been established across the county, supported by local voluntary sector infrastructure
organisations and the Locality Link Workers.
A process was designed to coordinate funding bids for external funding and a workforce development plan created to support the workforce in embedding asset-based approaches in their roles. Commissioners also agreed the development of a shared approach to social prescribing. Voluntary and community sector (VCS) organisations have collaborated to identify a lead provider to bid for Department of Health funds to support development of a co-produced approach to social prescribing.
Work has been carried out to enable social value secured through procurement to be aligned to programme priorities.
Health and wellbeing initiatives
Empowering a whole settings approach To support growing personal resilience and embedding primary and secondary prevention across the whole system, a programme of transformational work in
various settings has been undertaken.
There had previously been varied engagement with training offers and policy guidance on public health and prevention issues from a number of different settings across the county. Following conversations with a range of partners about how to do things differently at scale and pace, a system of offering grants for evidence-based work was devised with the objective of giving control and ownership of the work to grant recipients.
This form of empowerment drew an enthusiastic response. It engaged prospective grantees early in thinking about how they might contribute to health improvement and reducing health inequalities,
as they had the responsibility of developing a plan which had to be agreed before they could start spending their grant. Grants have proven an effective mechanism for engaging settings in taking leadership and ownership of change in their sphere of influence, rather than change being led externally.
Prevention in healthcare settings
An initial joint-funded Making Every Contact Count (MECC) programme was created with Hastings and Rother CCG and the acute and community health care trust. Over 2,000 people have been trained to date and MECC is now part of mandated training for East Sussex Healthcare NHS Trust. Further work is being undertaken to review activity across the trust as part of a comprehensive health promoting trust programme, for example, embedding government buying standards in catering
and food shops, developing a staff health and wellbeing and active travel programme, including providing NHS Health Checks for all eligible staff, and reviewing trust activity against National Institute for Care and Health Excellence (NICE) public health guidance.
The work is led by an assistant director and overseen by a steering group which brings together all prevention activity across the trust, including work through the Commissioning for Quality and Innovation (QOF) system. In addition an NHS Health Check programme for staff has commenced in the Sussex Partnership Foundation Trust and is in development for Sussex Community Foundation Trust as the first phase of development of new health improvement programmes in those trusts.
A new programme of one-off small grants to GP practices has begun to enable practices to develop their own plans for embedding prevention in practice. initial applications include testing of systematic identification of high risk groups such as people whose body mass index (BMI) is over 30 and smokers. This is followed by proactive phone invitation by practice staff to lifestyle services; and
work with the patient participation group to identify older people who have been recently bereaved to ensure they are getting out, eating properly, not becoming isolated and to link people into services and activities including help with food shopping.
Prevention in schools and nurseries
A grant-making approach to schools to support their development and delivery of a whole school health improvement plan resulted in very strong widespread engagement of schools who welcomed the opportunity to put forward their own ideas about what initiatives are likely to work. One hundred and eighty three primary and secondary schools are participating in changing their approach to health improvement and doing things differently in a sustainable way. Schools and colleges have created inspiring action plans and started embedding primary prevention and whole-school health improvement activities including:
- school food menu redesign
- participatory activities in food and cooking
- daily physical activity interventions such as the Daily Mile
- initiatives to promote active play and playground development
- investment in their staff skills to deliver high quality health and wellbeing
- engagement with parents and the wider community.
A condition of the grant included securing pupil voice in school plans, and, as a result of priorities identified by children and young people in round 1 of the grant, a second round of grants is being rolled out prioritising mental health and wellbeing. The East Sussex School Health Service received additional funding to support schools to implement their plans and have now added a new Youth Health Ambassador Apprentice role to their structure to support pupil voice in school health.
In addition to the funding provided by public health, schools have chosen to align school funding, and/or secure external funding (for example, grants from funding bodies) to further support delivery of their whole school health improvement plans. To date around £196,000 extra funding has been aligned to support whole school plans.
Over 90 per cent of nurseries in Eastbourne, Hailsham and Seaford CCG and Hastings and Rother CCG areas of the county signed up to the nursery transformation programme and completed a baseline Healthy Eating and Physical Activity (HALO) Check which provides an evidence-informed framework in which to assess and enhance dietary and physical activities. Following implementation
nurseries are re-audited to assess their increased score.
There has been a higher participation rate by nurseries in more deprived areas. Activity as part of this programme is starting to feature positively in Ofsted reports.
For example, “After recent training, staff have improved their support of children’s healthy lifestyles. They support children well as they use new balance bicycles and trampolines to help develop balance, coordination and physical skills. Children are very active and show strong physical development.” (A nursery in Langney, Eastbourne (OFSTED, 2017).
Nurseries have used creative ways to engage with parents about the importance of healthy lifestyles, and the changes they are making.
A logic model and evaluation plan has been developed to identify the learning from the programme and identify what works in embedding asset-based approaches. Community members and community and voluntary organisations are involved in the evaluation and a mixture of quantitative and qualitative evidence will be included. Questions to be considered include:
- What does the asset approach achieve?
- Does it achieve health-related goals?
- How does it work: what is the ‘theory of change’ that explains how the inputs produce the outputs that impact on the defined goals and outcomes?
- In what contexts has it worked?
In addition, work has been undertaken to identify the economic impact of primary and secondary prevention interventions. Information on Return on Investment (ROI) for interventions has been taken from a variety of models, tools and information. These include the NICE ROI models for alcohol,
tobacco and physical activity, the PHE weight management economic assessment tool; the PHE Cardiovascular Disease Prevention. Opportunities tool and ‘menu of prevention interventions’ and NHS England’s Aide Memoires for Prevention.
Some interventions potentially have considerable impact outside of health and care services, for example on local productivity and other aspects of the local economy along with benefits to the
community. These have been included in estimates of ROI.
Future plans and challenges
Building on the success of the 2016/17 settings based transformation programmes, work is continuing to extend activity and embed approaches as part of everyday activity of settings to support sustainability. This includes:
- A second round of school grants provided to schools which include an extended focus on action to address obesity, and a new focus on mental health. The vast majority of schools are participating in the second round of grants which will support embedding activity and sustainability of interventions as part of routine activity in schools.
- A continued focus on improving health outcomes through early years settings with a second round of nursery grants in development.
- The development of a health improvement grants programme for community pharmacy to support a rapid role out of the Healthy Living Pharmacy programme.
Councillor Keith Glazier, Leader, East Sussex County Council
We welcomed the move of public health to local government. Closer working with the public health team has given us a different perspective on what public health is about: we have learned that it is important to look at the health of the whole of the population, not just people who are unwell.
Early intervention and prevention are absolutely vital in doing this.The reason that public health sits with me at a corporate level in the council is because we recognise that health is a whole council issue. For example, as the largest employer in the county, we have taken a ‘One Council’ approach in training our staff with the public health message. Our goal is that every time somebody contacts a council employee the opportunity is taken to offer advice, support or signposting in relation to health.
This fits well with our general objective of ‘helping people to help themselves’. Having public health in the council has given us the opportunity to influence more directly how health and care work together with an emphasis on prevention. But we councillors have also learned more about the importance of evidence-based work.
The director of public health’s annual public health report and the joint strategic needs and asset assessment have helped councillors to understand that relevant statistics are available to them even at ward level and can shed light on the lives of their constituents and on the health and care needs of their communities.
Key messages
- A comprehensive community and partner engagement programme is essential in developing a public health approach to prevention that will be genuinely transformative and sustainable at scale.
- Financial constraints but also a recognition of the existing strengths and potential of individuals and communities are drivers for a population-wide asset-based approach.
- The right infrastructure (in this case multi-agency delivery groups, a trained workforce, Locality Networks and Locality Link Workers) is needed to support public health and prevention work with
- communities to improve health and wellbeing outcomes.
- Support for community and personal resilience are helping to embed primary prevention across the whole system.
- A grants programme for health improvement initiatives has been successful in engaging and empowering a wide range of settings, including those in deprived areas, in developing creative strategies that suit their specific context and population groups.
- Evaluation of the prevention programmes should include return on investment outside the health and care services, for example in community benefit and improvements in the local economy.
Contact
Anita Counsell, Head of Specialist Health Improvement
Email: [email protected]