It Gives Me Great Pleasure to Introduce This Report on Transforming Health Improvement

• Health Improvement Advisory Group
• Public Health Wales Board
• Public Health Wales website for the public domain

1 Foreword

By Professor Gareth Williams, Chair of the Health Improvement Advisory Group of the National Health Improvement Review.

It gives me great pleasure to introduce this report on Transforming Health Improvement in Wales.

Like all post-industrial societies Wales faces major challenges to the health of its population and, as a consequence, to its health policies – both for the delivery of health care and for the prevention of ill-health. Figures from the 2011 Census reveal that of the 10 local authority areas in England and Wales with the worst health, five are in Wales. Informing the work of this review, therefore, is the firm conviction that in order to improve the health of the population we in Wales must move from an ‘illness service’ to a ‘wellness service’, a service which places much more emphasis upon the prevention and promotion of better health. This is by no means a new idea - it has a long history in Wales31. Almost exactly 10 years ago the late Sir Derek Wanless warned that unless we find ways of attaining ‘full engagement’ of the public and the professions in disease prevention and health promotion we will see the build up of ‘unsustainable pressure’ on the health and social care sectors in Wales32. And that was during a period of increasing investment in the NHS.

Today we are in a very different situation: post-recessional, buffeted by a continuing economic downturn and subject to the UK Coalition Government’s austerity policies. Whatever one may think of those policies, they clearly concentrate the minds and the budgets of policy-makers working across all sectors in Welsh Government, not least in health.

While there have been significant examples of innovative health improvement initiatives, they have tended to lack integration across the health sector and between health and other sectors. This review has looked at the current status of health improvement activity in Wales, at what works well and what works less well, and points the way beyond the current landscape of stand-alone initiatives, duplication of effort and inadequate evidence to a more integrated approach based on a clear set of principles. While this review has focussed upon the health sector, it has done so with a clear understanding of the importance of building better partnerships with local government and the third sector.

Many people have been involved in this review, working to tight timescales and collecting and synthesising a variety of different points of view and forms of evidence. I am enormously impressed by the amount that has been achieved, and I firmly believe that this report can be used to put into action a more confident, forward-looking and sustainable approach to health improvement in Wales.

Contents

1Foreword

2Executive Summary

3Background

4Approach

5Introduction

5.1The challenges

5.2The future of health improvement

5.3Delivering the vision

6Health in Wales: The context

7Current Position: Mapping activity and establishing the baseline

8Sub-group findings

8.1Evidence review sub-group findings

8.2Health Economics and Programme Budgeting and Marginal Analysis (PBMA) sub-group findings

8.3Other services and initiatives

8.3.1Initiatives which represent core public health service activity but have previously been funded through a grant or other funding mechanisms

8.3.2Small Grant Schemes to support health improvement action

8.3.3Public health advocacy

8.3.4Public health action plans for specific groups

8.4Communication and engagement sub-group findings

8.4.1Local Public Health Teams

8.4.2Local Government

8.4.3Third sector and wider stakeholders

8.4.4Public views

8.5NHS sub-group findings

8.5.1Maximising the role of the NHS in supporting health improvement

8.6Health inequality

9Key Emerging Themes

9.1Communications

9.2Research and evidence

9.3Multifaceted and integrated approaches

9.4Impact and outcomes

9.5Efficiency and value for money

9.6Building on what we have

9.7Citizen centred approach and reducing inequality

9.8Health Improvement: Maximising its potential

10Health Improvement: Fit for the future

10.1Our vision

10.2Our guiding principles

10.3Our approach: Starting with people

10.4Life course approach

10.5Proportionate to need

Delivering services proportionate to need:

10.6Our wider community: Social and environmental impact

Fitting all this together

11Conclusions

12Recommendations and actions

12.1Delivering transformational change

12.2Maximising health improvement potential

12.3Transforming Health Improvement across Wales

12.4Sustaining Health Improvement

12.5Re -focus National Health Improvement Priorities

12.6Building Evidence for Change

13References

14Acknowledgments

14.1Health Improvement Advisory Group Members

14.2Executive Delivery Team Members

14.3Sub-groups

14.3.1Evidence Review sub-group

14.3.2NHS Health Improvement sub-group

14.3.3Communication and Engagement sub-group

14.3.4Economic sub-group

14.3.5Inequalities sub-group

14.3.6PBMA Expert Reference Panel

14.4Health Improvement Review Programme Office

2 Executive Summary

Purpose and summary of report

This document provides a report on the findings of the Health Improvement Review to inform subsequent strategic direction and final recommendations. It provides an outline of the review process and sets out the case for transformational change. It articulates the:

1. current status of health improvement activity in Wales;
2. challenges and opportunities that exist in a fast-moving and constantly changing operating environment; and
3. case for, and the means by which, urgent transformational change should be expedited.

Health improvement in Wales

Health Improvement is crucial to the future sustainability of health and social care. Wales, as a nation, has to address a range of complex health challenges during what will continue to be a highly dynamic period of change. It is vital that through targeted investment in health improvement, prevention and early intervention across the NHS, local government and wider afield, we create a healthier Wales. We need to make sure we are getting the most from the resources we have, moving from an “illness dominated service” to a “wellness service” and to one where people and their needs are the focus1. With this in mind, the review has sought to understand and evaluate current health improvement activity across Wales and consider how we should reshape services, environments and the way we work to improve health and wellbeing.

Changing the way we work

There is a wide variety of work taking place across Wales to support health improvement, both nationally and locally. Despite many examples of best practice and excellence, our efforts to improve health and wellbeing remains static and needs to continually adapt to changing circumstances. The current fragmented model often based upon single approach solutions, silo teams, segregated budgets, inadequate evidence, outcomes and/or inappropriate targeting of need, is no longer viable. We need to change the way we work to more integrated and collaborative approaches engaging with local people, communities and professionals.

The Programme Budgeting and Marginal Analysis2 (PBMA) undertaken as part of the review provided a useful, systematic approach to draw together a wide range of evidence to inform the investment and disinvestment decision-making. The analysis created a context for discussion, dialogue and joint learning, through an independent panel to inform decisions on current programmes. It identified those which should be maintained and improved (Stop Smoking Wales, National Exercise Referral Scheme, Welsh Network of Healthy School Schemes), those that should continue to be monitored (Designed to Smile, Fresh Start, Champions for Health, HIV Prevention and Empower to Chose, ASSIST and Baby Friendly Initiative), those which needed further on-going consideration (Mental Health First Aid, No Smoking Day and aspects of the breastfeeding programme), and those which had the potential for disinvestment (The Cooking Bus, Smoke Bugs, and Smokers Helpline Wales). It also identified the need to strengthen outcomes, value for money, reach and sustainability in core public health activity, health improvement grant schemes, public health advocacy support and programmes for specific vulnerable groups.

The way forward

As funding pressures across the NHS intensify the need to target resources to achieve the best possible outcomes based upon evidence and value for money will increase. Equally pressing, is the need to explore and exploit opportunities for integration, collaboration, cross-sector working and greater use of digital technology.

The review concluded that the current model as it stands lacks critical mass, and is unsustainable. To ensure we achieve the best possible outcomes from the resources we have available we need to focus on a smaller number of High Impact Level Health Improvement areas with greater depth and integration. We also need to build upon existing best practice, pool resources, leverage our collective knowledge and skills and integrate and unite services.

Furthermore, the review concluded that Wales should adopt a more integrated approach based upon a guiding set of principles and addressing needs at different stages of life. The new approach should include a comprehensive portfolio of evidenced interventions, with complementary and reinforcing actions across a range of variables with clear outcomes.

The Health Improvement Review has identified key recommendations and actions to respond to the challenges transforming health improvement in Wales, summarised below:

• Transform health improvement in Wales through a people focused Life Course Framework and adopting a guiding set of principles.

• Adopt a combination of approaches for future activity including fiscal, legislative, social marketing and community engagement.

• Increase strategic collaboration and partnership working with key stakeholders, particularly local Government and the third sector, to support integrated local delivery.

• Reshape the portfolio of health improvement programmes making them more holistic and integrated.

• Re-direct resources into areas most likely to achieve greater reach and better outcomes.

• Explore innovative ways to work more closely and have more dialogue with local people and communities, building on their networks, support and assets.

• Tackle obesity as a priority through an integrated approach.

• Improve the monitoring, evaluation and reporting of health improvement programmes.

• Unify the public health workforce to create critical mass, share learning, and improve efficiency.

• Adopt a ‘proportionate to need’ approach to address inequality.

• Support local delivery through improved collaboration, innovation and integrated flexible services embedded into local systems.

• Ensure there is capacity and flexibility to explore new opportunities that arise from developments such as the proposed Public Health Bill.

• Actively pursue opportunities to strengthen health improvement across the NHS, particularly primary care.

• Improve efficiency and impact through the use of digital technology and social media.

• Ensure existing evidence to support health improvement interventions (particularly NICE guidance) is implemented consistently across Wales and adapted to local circumstances.

• Address evidence gaps through innovation and R&D in collaboration with academia.

Making it a reality

The review concluded that to achieve the strategic objective of moving from an illness service to a wellbeing service, a dedicated change programme of Health Improvement Transformation should be established as a matter of urgency. It should be supported by a steering group that should oversee the execution of the detailed recommendations set out in this report and also the requirements in the Programme for Government.

This transformation programme will ensure that the approach in Wales is re-focused, at pace, to:

 improve health outcomes

 reduce inequalities

 meet the changing and accumulating needs across the life course model

 work in partnership with key stakeholders

 maximise use of all resources.

3 Background

At the request of the former Minister for Health, Social Services and Children, Professor Sir Mansel Aylward CB completed a brief review of a number of key national health improvement programmes in 20113. From this, it was recognised that further consideration should be given to the future direction for health improvement and constituent programmes across the board. The current Minister has tasked Public Health Wales to undertake this, steered by a Health Improvement Advisory Group (HIAG) which will make recommendations.

The HIAG has been tasked with considering the future direction for health improvement and health improvement programmes in Wales. It must ensure sustainability, value for money and the delivery of priority outcomes consistent with national policy specifically ‘Programme For Government’, ‘Together for Health’, ‘Our Healthy Future’ and ‘Fairer Health Outcomes for All’. It will also need to take account of wider relevant policies which may be linked to health improvement. The work has also been guided by the following agreed objectives:

• The assessment of the most effective means of delivery in the future, taking account of wider evidence and innovative practice, cross cutting national policy, value for money and integration.

• A review of the future direction for health improvement and health improvement programmes in Wales with funding from Welsh Government’s Health and Social Care Directorate or Public Health Wales (taking account of other wider contributors and programmes).

• The identification of opportunities to strengthen the holistic delivery of health improvement including the realignment, restructuring, and transformation of current programmes that would help ensure sustainable and cost-effective outcomes are achieved.

• The consideration of the role Public Health Wales and other key contributors play in supporting health improvement, as an integral part of the wider context of health improvement in Wales.

4 Approach

The Health Improvement Advisory Group has steered the review process to establish the current position and baseline against which alternative models could be evaluated. Four separate sub-groups were established to undertake specific assessments on significant aspects of the review. They were:

• Evidence review
• Health economics
• Communication and engagement
• NHS

The outputs of these groups were used to inform the report. There has also been extensive consultation with professionals and wider stakeholders.

5 Introduction

5.1 The challenges

This review is taking place at a time of broad economic and social change, alongside specific transformation in health and social care services. Levels of smoking, obesity and alcohol consumption, along with technological and demographic change, are putting pressure on health and social care services, which are struggling to meet demand. The alarming increases in obesity, both in childhood and adults, suggest that by 2025, 40% of the population will be obese4. By, 2050 we are likely to be an ‘obese society’. In addition, the health of the poorest people in our communities is increasingly lagging behind the best5 for a complex combination of economic, social and cultural reasons.

Despite considerable effort across a range of interventions and programmes, inequalities in health have widened and progress with some health related behaviours have flat-lined at too high a level4,5. The need to make the best use of limited resources in the NHS has always been a priority, but the imperative is now greater than ever. Prioritising health improvement to reduce demand and lessen inequalities will be essential across all public services.

This overall situation, together with added concerns that some changes to the determinants of health (particularly cuts to welfare benefits) will further undermine the potential for progress, reinforces the need for this review.

The review provides us with a real opportunity to take stock and reflect on developments to date. It allows us to consider what we have achieved and think about where we need to go next. It will enable us to refresh our approach in the light of recent evidence and feedback, and to improve future health outcomes. It will also help us to see if there is scope for further investment and ensure that existing investment is being best used to improve health and wellbeing effectively, equitably and at pace.

Given the immense challenges ahead it is crucial we make Wales a world leader in health improvement. To do this we need to build on the good work achieved in many sectors, work collaboratively and systematically plan action to reduce the health inequality gap.

5.2 The future of health improvement

Health improvement aims to sustain and improve health and wellbeing, reduce inequalities and redress the unnecessary burden of illness and the associated costs. To achieve sustainable health improvement, we need to get this right and re-balance the context of care, based upon prevention, early intervention and health promotion across the board. The time has come to make a decisive shift away from managing sickness to creating a healthy Wales for everyone1,6. Ensuring health improvement becomes everybody’s business will be crucial to making this a reality.

5.3 Delivering the vision

To achieve sustainable health improvement is complex. Its determinants are rooted in a wide range of socio-economic, cultural and behavioural process requiring innovative and evidence-based services and policies inside and outside the health sector.

Fortunately, Wales has a strong policy framework provided through Together for Health and Our Healthy Future1,6 alongside a range of other related plans addressing more specific issues such as the Tobacco Control Action Plan and Fairer Health Outcomes for All. This framework is underpinned by a number of programmes which have promoted the health of Wales and shown progress through the dedication and hard work of many people. Some of these initiatives (Welsh Network of Healthy School Schemes, Corporate Health Standard and ASSIST) have achieved UK and international recognition.