Welcome and Introduction to Public Health England

Welcome and Introduction
Jeremy Porteus, Director,
Housing Learning and
Improvement Network

Public Health England
Prevention and Sustainability
Stephen Morton,
Programme Director,
Sustainability for Public health Benefits
24 November 2015

Public Health England exists to protect and improve
the nation’s health and wellbeing, and reduce health
inequalities. It does this through world-class science,
knowledge and intelligence, advocacy, partnerships
and the delivery of specialist public health services.
PHE is an operationally autonomous executive
agency of the Department of Health.

Section 7A
Agreement
The national public health system
Public Health
England
The Department of Health
will set the legal and policy framework,
secure resources and make sure public health is
central to the Government’s priorities.
The PHE-NHSE
Partnership Agreement
Executive Agency
Chief
Medical
Officer

Public health advice
People and communities
Health and wellbeing boards
Local government CCGs
& their
support
PHE
centre
NHSE
NHS & IS
Providers
3rd sector
providers
Commissioner of public health services
Sources of public health advice in the ‘Place-based’
approach to local public health

PHE - Four Core Functions
• protect the public’s health from infectious diseases and
other public health hazards
• improve the public’s health and wellbeing
• improve population health through sustainable health and
care services
• build the capacity and capability of the public health
system

Achievements in 2014-15
Preventing disease
Collaborative TB strategy
Diabetes prevention programme
Childhood flu vaccination
Ebola response
Tackling specific health risks
Stop smoking programme
Preparing the sugar report (Sugar Reduction: the evidence for action)
Mortality and particulate air pollution report
Addressing broader health determinants
Health inequalities (‘Healthy People, Healthy Places’, Due North report)
Spending and outcomes tool

PHE – Selected Priorities
• tackling childhood obesity
• reducing dementia risk
• ensuring every child has the best start in life
• support individual and societal behavioural change
• tackle antimicrobial resistance
• contribute to improved global health security
• ensure the public health system is able to tackle today’s challenges and is
prepared for those emerging in future
Source: PHE Annual Plan 2015/16

Our future population
The population of the UK is growing and
is projected to increase to 73.3 million
people by 2037, an increase of over 9
million people from 2012 levels (ONS 2013).
The population over 75 is projected to
nearly double in the next 30 years, to
around 13% of the UK population in 2037
(ONS 2013).

Public health outcomes framework
To improve and protect the nation’s health and wellbeing and improve the health of the poorest, fastest
Outcome 1)
Increased healthy life expectancy – taking
into account health quality as well as length of life
Outcome 2)
Reduced differences in life expectancy between
communities (through greater improvements in more
disadvantaged communities)
Improving the wider
determinants of health
1
19 indicators, including:
• Children in poverty
• People with mental
illness or disability in
settled accommodation
• Sickness absence rate
• Statutory
homelessness
• Fuel poverty
Health improvement2
• Excess weight
• Smoking prevalence
• Alcohol-related
admissions to hospital
• Cancer screening
coverage
• Recorded diabetes
• Self-reported wellbeing
Health protection3
• Air pollution
• Population vaccination
coverage
• People presenting with
HIV at a late stage of
infection
• Treatment completion
for tuberculosis
Healthcare and public
health preventing
premature mortality
4
• Infant mortality
• Mortality from causes
considered preventable
• Mortality from cancer
• Suicide
• Preventable sight loss
• Excess winter deaths

PHE
provides
expert
advice
to local
government
DsPH have
influence
across all
local
government
spend
PHE provides expertise
in local area teams
Embedding ‘making
every contact count’
Leverage from the public health
ringfence
Influence on wider
spending
in commercial and
voluntary sectors
Clinical
Commissioning
Groups
and

Your health is determined by:
what you do
who you are
where you live
where you don’t
live

Our future climate
IPCC Climate Change 2013 The Physical Science Basis.

Direct and indirect health effects,
including
• Impact on health services –
demand, business continuity,
supply chains
• Impact on infrastructure
(utilities)
• Economic impacts
• Community
resilience/cohesion

Heat and cold-related mortality
Hajat S, et al. J Epidemiol Community Health 2013;0:1–8.
doi:10.1136/jech-2013-202449

‘EXTREME’ WEATHER IN THE UK
2000 – flooding
2001- flooding
2003 – heatwave
2005 - flooding
2006 – drought
2006 - heatwave
2007 – flooding
2008 – flooding
2008 – snow and ice
2009 – flooding
2010 – flooding
2011 – warm spring
2011 – warm autumn
2012 - drought
2012 – wet summer
2013 – heatwave
2014 – flooding
Alex Nickson, GLA

Source: 2nd Lancet Commission on Climate
Change and Health (Watts et al., 2015)
Mitigation
co-benefits

Best Buys for Sustainability
and Public Health Benefits
Active Travel
Air quality, greenhouse gases, childhood obesity, type 2 diabetes, social
networks…
Urban Green Space
Heat islands, mental health, children and nature, aging well…
Energy Efficient Homes
Excess winter morbidity, greenhouse gases, fuel poverty, heat-wave
resilience….
Sustainable food
Greenhouse gases, diabetes, obesity, social networks…

PHE Briefing and Evidence Resources

Physical activity: Our greatest defence
A
Physical Activity contribution to reduction in risk of mortality and long term conditions
Disease Risk reduction Strength of evidence
Death 20-35% Strong
CHD and Stroke 20-35% Strong
Type 2 Diabetes 35-40% Strong
Colon Cancer 30-50% Strong
Breast Cancer 20% Strong
Hip Fracture 36-68% Moderate
Depression 20-30% Moderate
Hypertension 33% Strong
Alzheimer’s Disease 20-30% Moderate
Functional limitation, elderly 30% Strong
Prevention of falls 30% Strong
Osteoarthritis disability 22-80% Moderate

Climate change
Environmental
pollution
Physical
inactivity
Overweight/
obesity
Road injuries
Chronic
disease
Mental well-
being
Noise/Quality
of life
Vehicle
transport
Promotion of
active transport
Credit: PURGE
Health co-benefits – Transport

Green Space and Health
.
1.There is significant and growing evidence on the health benefits of
access togood quality green spaces. The benefits include better self-rated
health; lower body mass index, overweight and obesity levels; improved
mental health and wellbeing; increased longevity.
2.There is unequal access togreen space across England. People living
in the most deprived areas are less likely to live near green spaces and will
therefore have fewer opportunities to experience the health benefits of
green space compared with people living in less deprived areas.
3. Increasing the use of good quality green space for all social groups is
likely to improve health outcomes and reduce health inequalities. It can
also bring other benefits such as greater community cohesion and
reduced social isolation
Reuben Balfour and Jessica Allen. Improving Access to Green Spaces: Briefing. IHE. Sept. 2014.

Multiple benefits of energy efficiency
Capturing the Multiple Benefits of Energy
Efficiency, International Energy Agency
• 6 billion to repair
excess cold hazard
in UK homes
• Payback 7 years

The first argument we make in this
Forward View is that the future
health of millions of children, the
sustainability of the NHS, and the
economic prosperity of Britain all
now depend on a radical upgrade
in prevention and public health.

NHSE/PHE Healthy New Towns Programme
•NHS England with support from PHE
are inviting local authorities, housing
associations and the construction
sector to identify development projects
where they would like NHS support in
creating health-promoting new towns
and neighbourhoods in England
•EOIs by 30th September 2015

Working across the NHS, Public Health and Social Care system www.sduhealth.org.uk
16%
19%
65%
Travel
Building energy use
Procurement
Breakdown of NHS England 2010
CO2 emissions (15 million tons)

Procurement Breakdown
4.38
1.78
1.61
0.74 0.72 0.68 0.66 0.62
0.29 0.28 0.27 0.21
0.46
-
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
5.00
Pharmaceuticals
Businessservices
MedicalInstruments/equipment
Paperproducts
NHSFreighttransport
Foodandcatering
Othermanufacturedproducts
Manufacturedfuels,chemicalsandgases
Construction
Waterandsanitation
Wasteproductsandrecycling
Informationandcommunication
technologies
Otherprocurement

Improves public health,
reduces inequalities
Less road trauma, less air
pollution, less fuel poverty,
fewer winter deaths, more
physical activity, fewer
overweight/obese people
Lower levels of long term,
multiple preventable conditions
More investment
in health
promoting
systems + public
infrastructure
Adds more life to years,
not just years to life
Less dependence
of formal health
and social care
system
Based on: “Claiming the Health Dividend”,
Coote, A. King’s Fund. May 2002
e.g. more sustainable
housing, transport, and
food systems
Virtuous circle for health

Improves patient experience convenience
and safety, saves money...
Care closer to home,
better use of
pharmaceuticals
Less dependence and need for
top down, secondary/tertiary
formal health care >>> fewer
unnecessary and avoidable
admissions
More
prevention
More empowered, supported, and
informed self care
More investment
in sustainable
models of care
Based on: “Claiming the Health Dividend”,
Coote, A. King’s Fund. May 2002
Less wasteful, unsafe,
unaffordable, inconvenient,
unnecessary, and
unsustainable institutional
healthcare
Virtuous circle for care

Source: Sustainable Development Unit (2014)
Sustainable development
• Reduce the harmful impacts of
how we live
• Enable a transformation in the
environment, society, health
and wellbeing

The Triple Bottom Line
Environment
Social
Wellbeing
Economy

The Triple Bottom Line
Environment,
Economy and
Wellbeing

UN Sustainable Development Goals
No poverty
Zero hunger
Good health and well-being
Quality education
Gender equality
Clean water and sanitation
Affordable and clean energy
Peace, justice and strong institutions
Partnerships for the goals
Decent work and economic growth
Industry, innovation and infrastructure
Reduced inequalities
Sustainable cities and communities
Responsible consumption and
production
Climate action
Life below water
Life on land

Acknowledgements
Contributions of slides or content:
• Angie Bona, Head of Extreme Events and Health Protection
• Sotiris Vardoulakis and PHE Air Pollution and Climate Change Group
• David Pencheon (Sustainable Development Unit)
• Carl Petrokovsky and the PHE Healthy People Healthy Places Group

Building the World of Tomorrow
- The importance of system wide approaches
David Maher davidmaher@nhs.net
NHS England / Public Health England
Sustainable Development Unit

“We should meet the needs of the
present…
www.sduhealth.org.uk
…without compromising the ability of
others, in future or elsewhere now, to
meet their own needs”
- from the Brundtland Commission

Acute
Specialist
Mental Health
Ambulance
Primary Care
SHA
2.00m
1.50m
1.00m
0.50m
0.00m
2.50m
3.00m
3.50m
tCO2e
Acute
Specialist
Mental Health
Ambulance
Primary Care
SHA
Acute – medical
instruments and
equipment
Acute - building
energy use (gas
andelectricity)
Primary care and
acute – business
services
Primary care – pharmaceuticals
including GPprescriptions
Goods and Services carbon footprint – carbon hotspots

Health care buildings
in a
sustainable health
and care system

This Himalayan hospital is powered by solar energy. Patients in
rural Nepalese hospitals like this one often have their treatment
interrupted by power cuts. A new funding model lets hospitals
pay for their rig over eight years, bringing solar power within
their reach for the first time.

“Unplanned hospital admissions
are a sign of system failure”

1. For the health of the public
– More physical activity, better diet, improved mental health, less
road trauma, improved air quality, less obesity/ heart
disease/cancer, more social inclusion/cohesion...
2. For the sustainability of the healthcare system
– More prevention, care closer to home, more empowered / self
care, better use of drugs, better use of information and IT,
fewer unnecessary admissions, better models of care…
A convenient truth: what is good for addressing
climate change and creating a sustainable
world......is ALSO good for health and care NOW

Summary
• Sustainability has 3 mutually reinforcing dimensions:
– Financial
– Environmental
– Social / ethical
• Healthcare infrastructure (buildings) = one important
part of a SYSTEM with 5 important opportunities:
– Flexibility - that increases value and health (not just activity)
– Prevention through partnerships and incentives
– New models of care: with default place of care being home
– Empowered staff /patients with IT and near patient small tech
– Health systems (and professionals) being visible exemplars of
a safe, secure and sustainable future

What causes health?
Environmental
sustainability:
Living within
planetary limits
Social
sustainability:
Healthy and
resilient people
and communities
Economic
sustainability:
Fair and
sustainable
economic
system
Health,
wellbeing

60% rise in 10 years
James Jarrett, James Woodcock, Ulla K. Griffiths, Zaid Chalabi, Phil Edwards , Ian Roberts , Andy Haines Lancet 2012

200 years of health professionals protecting and
improving health
2. Cholera: Broad
Street Pump,
1854
3. Smoking
and
tobacco,
1962
8. Sustainable
development,
climate change
1. Slavery
Abolition
Bill, 1833
4. Nuclear
proliferation
5. Alcohol 6. Obesity 7. HIV/AIDS

A 60% rise in diabetes in the UK in the last 10 years

“The potential benefits of physical activity to health are huge. If a
medication existed which had a similar effect, it would be regarded as a
‘wonder drug’ or ‘miracle cure’.”
Liam Donaldson, Annual report of the Chief Medical Officer, 2009

Dr. Margaret Chan,DG of WHO:
“For public health, climate change is the defining
issue for the 21st century… The evidence is there,
and it is compelling. Here is my strong view: climate
change, and all of its dire consequences for health,
should be at centre-stage, right now, whenever talk
turns to the future of human civilizations. After all,
that's what's at stake.”
15th September 2014

1. We are very busy - focussed on the day job
2. We are trained to react to demand, problems
and crises, more than to prevention.
3. We are doing a lot for health already (“moral
offset”)
4. We work in systems that are rewarded more for
activity than for outcome
Why don’t we do more?

NHS guidance for CCG Authorisation

What can we do now?
1. Embed prevention principles into contracts
2. Use CQUIN to drive innovation
3. New models of care and joined up services
4. Consider social value and the Marmot principles
in tenders and service delivery

SC18 Sustainable Development is the NHS Standard Contract clause which
commissioners and providers use to agree the parameters of their commitment to
social and environmental sustainability. It has the following requirements:
1.In performing its obligations under this Contract the Provider must take all reasonable
steps to minimise its adverse impact on the environment.
2.The Provider must maintain a sustainable development plan in line with NHS Sustainable
Development Guidance. The Provider must demonstrate its progress on climate change
adaptation, mitigation and sustainable development, including performance against carbon
reduction management plans, and must provide a summary of that progress in its
annual report.
3.The Provider must, in performing its obligations under this Contract, give due regard to the
impact of its expenditure on the community, over and above the direct purchase of goods
and services, as envisaged by the Public Services (Social Value) Act 2012.

For more details:
David Maher
M: 07740 362092
E: davidmaher@nhs.net
W: www.sduhealth.org.uk
t: @sduhealth
Victoria House, Capital Park, Fulbourn,
Cambridge, CB21 5XB

COMMUNITY DEVELOPMENT
and HEALTH
DR BRIAN FISHER MBE
GP
NHS ALLIANCE
HEALTH EMPOWERMENT LEVERAGE PROJECT

COMMISSION
COMMUNITY
DEVELOPMENT
HEALTH PROTECTION
RESPONSIVE SERVICES
EMPLOY COMMUNITY
DEVELOPMENT WORKERS
SAVE MONEY
TACKLE HEALTH
INEQUALITIES

Increasing
inequality
Austerity
KILLS PEOPLE
Threat to
community
life
Shrinking
the state
+
________________________________________________________________

UNDER PRESSURE
•Hollowed out
communities
•Threat to mental health
•Attenuation of social
networks
•Weakening of
associational life
•Deterioration in health

COMMUNITY BUILDING/DEVELOPMENT
• Local people identify their own needs
and aspirations
• Influence the decisions that affect their lives
• Improve the quality of their lives, communities and society
in general.
Co-production where individuals,
communities and public service organisations
pool skills, knowledge and abilities to create
opportunities and solve problems

Community-centred approaches
for health & wellbeing
Strengthening
communities
Community
development
Asset based
approaches
Social network
approaches
Volunteer and peer
roles
Bridging
Peer interventions
Peer support
Peer education
Peer mentoring
Volunteer health
roles
Collaborations &
partnerships
Community-Based
Participatory
Research
Area–based
Initiatives
Community
engagement in
planning
Co-production
projects
Access to
community
resources
Pathways to
participation
Community hubs
Community-based
commissioning
The family of community-centred approaches
(South2014)

DISRUPTIVE COMMISSIONING
•Using community development workers
•Create resident led neighbourhood partnership
• Agencies and residents together
•Build community activity from the partnership’s
agenda

A RESIDENT-LED
PARTNERSHIP
LED BY RESIDENTS
THEIR EXPERIENCE DRIVES CHANGE
FORMAL STRUCTURES MAY BE NEEDED
A CORE REACHES OUT

ASSET-BASED
COMMUNITY DEVELOPMENT
•Statutory services become more responsive
•Promotes health protection and community
resilience
•Helps tackle health inequalities
•Has an impact on behaviour change
•Saves money

CD
Stronger and
deeper Social
Networks
RESILIENCE
Health protection
Resilience to economic
adversity
Better mental health
ENHANCED CONTROL
Can negotiate with services
More strength for self-care
Health inequalities reduce

6-Month Survival after Heart Attack,
by Level of Emotional Support
0
10
20
30
40
50
60
70
Men Women
Percentdied
0
1
2 or more
Sources of support
OUTCOMES – HEALTH

SOCIAL NETWORKS
REDUCE MORTALITY RISK
• 50 % increased likelihood of survival for people with stronger social
relationships .
• Comparable with risks such as smoking, alcohol, BMI and physical
activity.
• Consistent across age,
sex, cause of death.
• 2010 meta-analysis of data [1] across 308,849 individuals,
followed for an average of 7.5 years
1] Social relationships and mortality risk: a meta-analytic review. Holt-Lunstadt, Smith, Bradley Layton.Plos Medicine July
2010, Vol 7, Issue 7. www.plosmedicine.org doi:10.1371/journal.pmed.1000316

LEWISHAM CD PROGRAMME IN 2 DEPRIVED
WARDS
• By public health to improve health, using a CD approach
• Working with GP practices
• Within a strategic framework – and including participatory budgeting
A return on investment of between 2:1 and 3 :1
suggests good value for money.
http://www.lewishamjsna.org.uk/Reports/North_Lewisham_Health_
Improvement_Programme_Sep13.pdf

COMMUNITY OUTCOMES IN LEWISHAM
• High level of community capital and capacity generated – lay
& professional synergy
• Many volunteering & training opportunities
• Many community groups received practical & financial
support
• 9% increase :‘Definitely agree that
can influence local decisions’
• 11% increase ‘Definitely enjoy living
in neighbourhood’

PHYSICAL HEALTH OUTCOMES IN LEWISHAM
• HEALTH BEHAVIOUR
• Quitting smoking - 62% increase, 7% increase rest of Lewisham
• Increased consumption of fruit & veg - 22% inc
• Increased levels of physical activity - 33% inc
• Weight loss
• WORKING WITH PRIMARY CARE
• Increased uptake of & improvements in services
• Big increase in recording of BP for people with high blood pressure
• 4x increase in people expressing concern or referred with suspected cancer
symptoms
• 3x number of cancer referrals per month
• Improved management of chronic problems like diabetes & back pain

MENTAL HEALTH OUTCOMES IN LEWISHAM
•Improved physical and mental health outcomes
•13% increase in those ‘Feel very/quite happy
with life in general’
•Increased confidence, self-esteem
•24% increase in ‘those not feeling
anxious or depressed’
•Many social, work and
financial outcomes

SOCIAL RETURN ON INVESTMENT
• A saving of £559,000 over three years in a
neighbourhood of 5,000 people, for an investment of
£145,000: a return of 1:3.8
• For £233,655 invested across four authorities the
social return was £3.5 million.
• For every £1 a local authority invests, £15 of value is
created.

SAVINGS TO THE NHS
• Peer support in mental health in Leeds saved bed days and reduced hospital re-
admissions by 50%
• Partnerships for Older People’s Project http://www.pssru.ac.uk/pdf/rs053.pdf
• overnight hospital stays reduced by 47%
• use of A & E Departments by 29%;
• phone calls to GPs fell by 28% and appointments by 10%.
• Every £1 spent on POPP services generated £1.20 in savings on emergency beds
• People Powered Health
• savings of 7 % for CCGs : £21m per CCG
• reductions in A&E attendance, planned and unplanned hospital admissions, and
outpatient attendance
http://www.nesta.org.uk/sites/default/files/the_business_case_for_people_powere
d_health.pdf

PRINCIPLES FOR SOCIAL ACTION ON
HEALTH
• Enable people to organise and collaborate to:
• identify their own needs
• take action to exert influence on the decisions which affect their lives
• improve the quality of their own lives, the communities in which they live, and
societies of which they are a part.
• Address imbalances in power and bring about change
founded on social justice, equality and inclusion.
• Active communities make a marked difference to their own health
and life expectancy.
• Co-production between communities and service providers
thrives if communities are enabled to become leading players in their own interests.
• Look for the strong, not the wrong:
a needs-and-assets based approach

POLICIES FOR SOCIAL ACTION ON HEALTH
• A community development strategy in every Health and Well-Being
Board and CCG.
• Joint Strategic Needs Assessments to become Joint Strategic Needs
and Assets Assessments
• Support investment in community development and social value.
• All CCGs to collect evidence of local
community development.

POLICIES FOR SOCIAL ACTION ON HEALTH 2
• Workforce capacity and capability in community development
ensured by Health Education England and LETBs.
• A community development work programme developed by Public
Health England.
• Commissioning and delivering evidence based community
development should be part of CCG Assurance.
• A Transformation Fund

WE CALL ON HEALTH
AND OTHER AGENCIES TO:
• Inspire residents to become key players in developing their own
health and well-being.
• Be prepared to listen, respond and work in new ways.
• Harness the interventions that have the best evidence and are most
reproducible. These include community development or community
building or community transformation
• Develop, through community building, community led
neighbourhood partnerships of residents
and service providers.

92
Healthy Eating
“The Route to Health and
Wellbeing”
Or how our dietary choices are
cooking up a storm and costing
the earth…..

Who is Tim Finnigan???
• Married, two children (grown up)

Who is Tim Finnigan???
• Married, two children (grown up)
• Likes running up hills and likes a pint
• 30 years R&D in Food and Drink
• PhD Canola protein, Government food research, APV,
General Foods and...

I’M HERE IN PART TO TELL
“THE QUORN STORY” BUT
ONLY IN THE CONTEXT OF…..
 AS AN ILLUSTRATION OF WHY WE NEED HEALTHY NEW PROTEINS WITH A
LOW ENVIRONMENTAL IMPACT
 AND THE GOOD NEWS THAT ‘IT CAN BE DONE’
 AND TO INTRODUCE THE IDEA OF “THE TRILEMMA”

The Trilemma of dietary choice
Tilman, M and Clark, D. Nature 515,518–522(27 November 2014)doi:10.1038/nature13959
The implementation of dietary solutions to the tightly
linked diet–environment–health trilemma is a global
challenge, and opportunity, of great environmental
and public health importance.
We argue that it is no longer possible to separate the impact of
our dietary choices on the health and wellbeing of both our
bodies and of the environment

The 1960s was a time of
huge achievements...
The context

....And growing concerns
The Green Revolution

Period Organism Technical Developments
1946 - 54 Candida utilis Continuous process yeast from sulfite liquor (US)
1948 – 53 Chlorella sp Production of algae in open systems (Japan)
1959 Saccharomyces cereviciae Continuous production bakers yeast (UK)
1954 - 63 Morchella sp Submerged culture of mushroom mycelia
1959 – 72 C. lypolitica Food yeast from hydrocarbon
1963 – 74 Fungi Pekilo process (Finland)
1964 – Fungi Mycoprotein and QuornTM
1970 – 74 C utilis Food yeast from ethanol (US)
1971 – 75 K Fragilis Continuous production of yeast from ethanol or
whey
1979 – 80 Methylophylys
methylophylus
Bacterial SSP Pruteen from methanol (UK)
1983 -85 C utilis, K fragilis, S
cereviciae
SSP from ethanol and carbohydrate (US)
Developments in single cell proteins for food or
feed
1964 Fungi Mycoprotein and Quorn

A man with a big idea
Inter-generational equity

101
From 1964 to 1985 – time flies……….

“Quorn ….began by
taking the original
fungi found in soil and
domesticating it in the
same way that our
ancestors did with
many plants.”
Spector, T (2015) The Diet Myth. Weidenfield
and Nicholson pp 137
Quorn has many influential advocates
102

+ a large number of ducks, rabbits, horses, turkeys…
..3 camels and one unfortunate mule
Chickens 110,000
Pigs 2,630
Sheep 922
Goats 781
Cows 557
The scale of livestock production is driven by our desire
for cheaper and more plentiful meat, but there are damaging
consequences, which at the moment are forecast only to intensify
The current context…

http://www.fao.org/fileadmin/templates/wsfs/docs/expert_paper/How_to_Feed_the_World_in_2050.pdf
http://www.tristramstuart.co.uk/FoodWasteFacts.html
http://ecowatch.com/2014/04/11/agricultures-greenhouse-gas-emissions-2050/
Challenge Consequence
To feed 9bn in 2050 FAO say we need a 60% increase in food production
some of the true costs of cheap and plentiful animal protein
Our demand for ever cheaper and more plentiful meat has
a number of potentially devastating consequences…
104

106

http://www.fao.org/fileadmin/templates/wsfs/docs/expert_paper/How_to_Feed_the_World_in_2050.pdf
http://www.tristramstuart.co.uk/FoodWasteFacts.html
http://ecowatch.com/2014/04/11/agricultures-greenhouse-gas-emissions-2050/
107

109
 THERAPEUTIC (disease
treatment)
 PROPHYLACTIC (disease
prevention)
 GROWTH PROMOTION
http://www.soilassociation.org/LinkClick.aspx?fileticket=H7srxwglZ-s%3d&tabid=313

Italy, 2013
EFSA: “Overcrowding is a risk factor for disease
expression and other causes of poor welfare
and should be avoided”
Regular antimicrobial use facilitates high animal densities:
The Lancet Infectious Diseases Commission, 2013
AS OUR DEMAND FOR CHEAPER AND PLENTIFUL MEAT
RISES SO WILL THE USE OF ANTIBIOTICS IN INDUSTRIAL
ANIMAL PRODUCTION

• “Urgent action is needed to ... reduce antibiotic usage in animal
husbandry”, WHO, 2014
• “Use of antibiotics as growth promoters should be banned worldwide as
has happened in the EU”: The Lancet Infectious Diseases Commission, 2013
• “Routine preventative use of antibiotics is unacceptable” UK AMR Strategy:
Annual progress report and implementation plan, December 2014
“failure to address antibiotic
overuse in agriculture and
its role in drug resistance is
like trying to stop lung
cancer without factoring in
smoking…..”

113

THE No 1 CONTRIBUTER
 1/3rd water use
 18% -30% of global GHG emissions
 45% of all land
 91% of rainforest destruction to date (1 acre per second)
 Species loss
 Ocean deadzones
 Habitat destruction
 The rise of the superbug
 Micronutrient depletion
 Unaccounted costs of poor health and environmental impact
 Animal welfare and cruelty on an unprecedented scale
Our biggest lever is to eat less meat

“The need for new
business models that help
address the 9bn challenge
- including a healthy new
protein with a lower
environmental impact….”
Prof. Alan Knight Single Planet Living
Big steps toward small footprints

“For all Mankind’s supposed
accomplishments, his continued
existence is completely dependent
on six inches of topsoil and the
fact that it rains…..”

Why pharmacy?
DEBORAH EVANS FRPHARMS
PHARMACY CONSULTANT
ENGLISH PHARMACY BOARD MEMBER OF ROYAL PHARMACEUTICAL
SOCIETY

Community Pharmacy
Over 11,000 community pharmacies in England
99% of the population can get to a pharmacy within
20min by car
96% by walking or using public transport
Estimated 1.6 million visits a day
Average 14 visits per year

Public Health England
“There are powerful new models
emerging … Public Health England
are supporting the scaling up of
Healthy Living Pharmacy
programme”
“There is potential for big wins for
the health of the public”
“We will promote pharmacy teams
as part of the wider public health
workforce”
Prof Kevin Fenton
Director of Health &
Wellbeing, PHE

Where are we now?
Public Health England support acceleration of the concept
Over half of all LPC areas are engaged
1850 pharmacies are HLP or on journey
2000+ through leadership development
3000+ Health Champions

Enablers
Quality
Criteria
Environment
Engagement
Workforce
Health Champion
Health Promotion
ZoneLeadership
Development
Community OutreachProactive support

deb@deborahevans.co.uk
@HLPharmacist

Tackling Fuel Poverty
Jenny Holland, Head of the
Parliamentary Team, UK ACE

PREVENTING ILLNESS 2015
BLOOD GLUCOSE MONITORING OPTIMIZATION

Delivering Sustainable Blood Glucose
Monitoring
• Who are Nipro Diagnostics
• What are the challenges presented by diabetes: NHS Alliance Film
• Why is blood glucose monitoring important
• How have Nipro proved so successful in facilitating cost effective
blood glucose monitoring
• What does this success look like?

• July 2014: Recognition of Nipro’s success in providing cost effective BGM
and support to CCGs in Derbyshire
• West Berkshire CCG cluster identified as best practice in partnership
working, having delivering significant cost savings and reinvested them into
innovative local diabetes service redesign
• Dec 2014: ITN film tells the story from the perspective of the key
stakeholders across the West Berks CCGs, highlighting the huge challenge
diabetes presents and they have successfully tackled it

Working in Partnership Nipro & West
Berkshire

Costs & Challenges Presented by
Diabetes
• Currently consumes 10% of
the UK health service budget
• Predicted to rise to 20% by
2020
• 2012: cost of diabetes
treatment in the UK: £14
billion*
• Annual cost of blood glucose
monitoring in the UK over £210
million
Complications of Diabetes
Include:
• Heart disease
• Stroke
• Kidney disease
• Nerve damage leading to
amputation
• Retinopathy

Why is Blood Glucose Monitoring
Important?

Important?
• Self-monitoring of blood glucose is a beneficial part of diabetes
management, and included as part of a daily routine it can help with
necessary lifestyle and treatment choices
• Monitoring can also help a patient and their HCP tailor treatment to
help prevent any long-term complications from developing
• Blood glucose monitoring only has a value if the results are
understood and acted upon, and because of the cost implications it
is vital that testing is clinically appropriate to each individual patient

Important?
Understanding blood glucose levels is a key part of diabetes self-
management
For people with diabetes, blood glucose targets* are as follows:
• Before meals: 4 to 7 mmol/L for people with type 1 or type 2
diabetes
• After meals: under 9 mmol/L for people with type 1 diabetes and
under 8.5mmol/L for people with type 2 diabetes
• Recommended blood glucose levels have a degree of
interpretation for every individual and should be agreed in
conjunction with HCP guidance

DVLA Guidelines On Blood Glucose Monitoring
for Insulin Users & those on Sulphonylureas
• Group 1 testing: No more than 2 hours before journey, and then
every 2 hours of driving
• Group 2 (lorries and buses) testing: Twice daily and at time
relevant to driving. No more than 2 hours before each journey, and
every 2 hours of driving. 3 months of blood glucose results must be
provided upon request and in the event of an accident.
Therefore:
• Drivers must test with a meter with a large (500 test+) memory:
• Drivers should test using a meter that auto detects control solution*

BGM is Essential but Expensive
• Calendar year to July 2015 – Cost of BGM in the UK = £211.5*M
• £174*M of these tests are carried using price premium test strips
• West Berkshire CCGs have demonstrated that it is possible to
switch 65% to the cost effective Nipro TRUE brand test strips and
have thereby saved £800,000** over four years

Nipro Diagnostics – Critical Success
Factors
• High quality, accurate and ISO 2013 compliant* meters & strips
• Cost effective, easy to use & easy to teach meters
• Partnership approach to facilitating appropriate switching
• Support from designated Business Development Manager at
CCG/Health Board level
• Dedicated field sales support at a practice level
• Office support from dedicated sales support Account Managers
• UK based, freephone, patient helpline
• Bespoke educational materials designed to allow patients to better
manage & understand their blood glucose (under HCP guidance)

What Does Our Success Look Like?
2014-2015
£2.3M in savings realised for the NHS across the UK
• 4 Derbyshire CCGs - £389,000
• Luton & Beds CCGs - £235,000
• Scottish Borders Health Board - £89,000
• North Somerset CCG - £81,000
• Lambeth CCG - £21,000 (yr 1) Southwark to follow

Summary
• Diabetes presents a huge challenge to
UK healthcare budget
• Blood glucose monitoring is essential
in managing diabetes, can be
expensive, yet presents the
opportunity for significant cost savings
• Nipro can help PCOs realise these
savings with no compromise to patient
care
• A partnership approach between
PCOs & industry can best deliver
these savings
• Focus need not be cost cutting but the
reallocation of resource to fund
improved diabetes services at a local
level

Angie Prysor - Jones,
Commisioning Manager,
HENRY

Training
Consultancy
Clinical Management
Dr Julia Lewis
Consultant Addiction Psychiatrist

Bob
pulseaddictionstraining.com
Introducing….

Bob

35 units per week 28 units per week

Heavy Drinking
Low Thiamine
Stores
Alcohol Toxicity
on Brain
Uncontrolled
Withdrawal
B1

B1
Increased
Glutamate
Brain Cell
Death
Reduced
Brain Cell
Repair
ARBD

Acute
Medical
Acute
Global
Confusion
Non-permanent
Cognitive
Dysfunction
Permanent
Cognitive
Dysfunction
ongoingup to 3 years2-3 monthsdays - weeks

25
%
25
%
25
%
25
%
No
Recovery
Minor
Recovery
Significant
Recovery
Moderate
Recovery

Diagnosed
@ 65
Die
@
75
If….

0
6
12
18
24
Without Specialist InterventionWith Specialist Intervention
£inBillions
£22.8bn
£11.8bn

He is isolated in a single
moment of being, with a
moat or lacuna of
forgetting all around him

Training
Consultancy
Clinical Management

Visit our stand today and find out how we can support you
Thank You

Delivering warm and healthy homes
Case Study: Warm Homes Oldham
Nigel Banks
Sustainability Director
Keepmoat

Contents
1. Why Warm Homes Oldham was set up
2. NHS Business Case for investment
3. What the service offers
4. Measured impacts so far…
5. The Moral Case for investment
Q&A

1. Why Warm Homes Oldham was set up

Fuel Poverty in Oldham
• In 2012, 15% of Oldham’s residents were in fuel poverty,
approximately 13,500 households
• Rises in fuel bills, recession and welfare reform mean the
problem is likely to get worse
• Oldham has a lot of older homes (harder to insulate) and a
high number of residents on low incomes/benefits
• Fuel poverty is caused by:
– Poor housing: low energy efficiency standards, hard to treat housing,
high heating costs
– Energy prices: unfair payment methods, rising energy prices
– Low income: fuel costs represent a higher proportion of income

MONTHLY HEATING
BILL TO HEAT A
HOME ADEQUATELY
Gas heated Electrically heated
Insulated (filled)
cavity
Un-insulated
solid wall
Insulated
(filled) cavity
Un-insulated
solid wall
1 bed flat £ 16.26 £ 27.55 £ 52.20 £ 88.46
2 bed flat £ 19.59 £ 33.20 £ 62.91 £ 106.60
2 bed mid terrace £ 20.73 £ 35.12 £ 66.57 £ 112.78
3 bed mid terrace £ 23.21 £ 39.33 £ 74.55 £ 126.28
2 bed end terrace £ 36.39 £ 61.65 £ 116.85 £ 197.97
3 bed end terrace £ 40.75 £ 69.04 £ 130.84 £ 221.68
2 bed semi-detached £ 39.70 £ 67.26 £ 127.47 £ 215.97
3 bed semi-detached £ 42.68 £ 72.31 £ 137.05 £ 232.19
2 bed semi bungalow £ 27.82 £ 47.14 £ 89.34 £ 151.36
3 bed semi bungalow £ 30.04 £ 50.89 £ 96.45 £ 163.40
Plus DHW & Elec: £63/month £100/ month
Energy Bills are unaffordable

Excess winter deaths and illnesses
• There are around 100 excess winter deaths in Oldham each
year, 75% of which are due to cold related illnesses.
Mean number of daily deaths each month and mean monthly temperatures – July 2011 to July 2012 – England and Wales – ONS Statistical bulletin 2012

Indoor temperature & your health
• 18-24o
C, no risk to sedentary, healthy
people
• Below 16o
C, diminished resistance to
respiratory infections
• Below 12o
C, increased blood pressure
and viscosity
• Below 9o
C, after 2 or more hours, deep
body temperature falls

© NEA 2012© NEA 2012
Cold weather impact on heart &
respiratory illness

• There are around 100 excess winter deaths on average in
Oldham each year, 75% of which are due to cold related
illnesses. Mainly in those aged 65 +
Mean number of daily deaths each month and mean monthly temperatures – July 2011 to July 2012 – England and Wales – ONS Statistical bulletin 2012
Excess Winter Deaths & Illnesses

The service aims to help households out
of fuel poverty by offering them a wide
range of support.
Aim of Warm Homes Oldham

‘Community Budget’ pilot: 1,000 people out of Fuel Poverty
— First of its kind nationally
— Involves local partners coming together to fund a preventative
service, they will then share the savings (through reduced
health and social care demand)
— Detailed analysis of health and social care demands impacts
— Results of the project will be reported back to Government
who are looking at this as a flagship scheme.
Ambitions

How is it funded?
— Payment by results mechanism
— NHS Oldham CCG and Oldham Council provide funding
for every house that will be lifted out of fuel poverty
— Energy Company Obligation (ECO) funding
— Initially focused on HHCRO (Affordable Warmth) and
target areas most at risk of fuel poverty (from data
mapping)
— Promoted to all homes across Oldham in second phase

2. NHS Business Case for investment

Oldham: Cost Benefit Analysis
• There is a positive benefit cost ratio of 1.5:1 due to the savings
anticipated through reducing demand on the health and social
care sectors
• Total costs in 2013/14 were estimated at £200k and total
benefits at £300k
• From a healthcare perspective, the following measures could
be considered:
– Hospital admissions attributed to cold and damp homes
– Mental health cases attributed to cold and damp homes
– Cases of falls and injuries attributed to cold and damp homes

Measure Numbers Source
Avg. EWD per annum 100 Local data – NHS Oldham
Avg. hospital admissions pre-death 8 DOH Winter warmth fact sheet
Avg. admissions per annum 800 Calculated from above
10% attribution to cold homes 80 21.5% referenced in The Marmot review.
Reduced for pessimism based on Hill’s
report
Hospital Admissions
Avg. falls admissions per annum 333 Local data – NHS Oldham
10% attribution to cold homes 33 Assumed similar as EWD. 21.5% referenced
in The Marmot review. Reduced for
pessimism based on Hill’s report
Falls & Injuries

No. of residents suffering from MH
depression/anxiety
15692 Local data – NHS Oldham
No. of cases linked to fuel poverty 6322 MH symptoms 4 times more likely in
fuel poverty homes - DOH Winter
Warmth fact sheet
Mental Health
Total number of Oldham homes in
fuel poverty
13597 Local housing data
Average family size (adults) 1.84 National statistics
No. of fuel poor residents 25018 Calculated from the above
Residents in fuel poverty

Measure Nos.
Intervention
cost
Cost per
person
£
Calculation
Hospital admissions EWD 80 £1630 £5.21
(Number of cases / fuel
poverty population) X
(intervention cost)
Hospital admissions - Falls 33 £1630 £2.15
Mental health service contact 6322 £942 £238
Health cost saving per person out of fuel poverty £245.36
*Please note the unit intervention costs are extracted from the cost database developed by New Economy Manchester
(supporting the Troubled Families programme).
Thus, if each vulnerable resident of Oldham is lifted out of fuel poverty, the total estimated healthcare cost
saving would be of the tune of £245 X 25018 = ~£6.1 million per annum which may be unrealistic in the
near term.
If instead a modest 2000 Oldham residents (10% of the fuel poor) are lifted out of fuel poverty, it still
presents the opportunity of saving £245 X 2000 = £490K of healthcare costs. Given our target of 1000
residents a year, we are looking at an estimated £245K healthcare savings a year.

225
What Warm Homes Oldham offers
• Insulation
• Heating Improvements
• Smart Meters
Property
Improvements
• Behavioural Advice
• Tariff Switching
• Meter Advice: Pre-pay & incorrect meter readings
Energy
Advice
• Warm Homes Discount eligibility
• Benefits Checks
• Emergency Credit, Debt Issues, Trust Fund Applications
Income
Maximisation
• Temporary Heating, Age UK winter warmth pack
• Priority Services Register
• Referrals to Other Preventative Services
Other
Support

4. Measured impacts of the service

• 2,321 people brought out of fuel poverty (Vs target of 2,200)
• Over £2.1m of utility grant funding brought to scheme
• 671 boilers, 151 external wall insulation, 152 cavity/loft installs
• £953 average household savings from all interventions
• £133,857 extra benefits secured through CAB benefits checks
• £72,327 worth of trust fund grants secured for homes who are
not on benefits with poor heating systems
Results from first 2 years

Local Pilot Analysis
Pilot Count
Total Households included in pilot analysis 381
Total Individuals included in pilot analysis 795
Hospital Activity

GP Appointments and Drugs Prescribed
• From a sample of 5 individuals involved in the scheme, total GP
appointments went down by -8% while the cost of drugs prescribed
increased by 14%.
Measure
GP Appointments
before Warm Homes
GP Appointments
after Warms Homes
Variance
Medications issued
before Warm
Homes
Medications issued
after Warms Homes
Variance
Person 1
9 6 -33% £1,024.7 £689.8 -33%
Person 2
12 12 0% £526.0 £906.2 72%
Person 3 10 3 -70% £420.6 £541.5 29%
Person 4
6 8 33% £9.9 £36.9 272%
Person 5
0 5 0% £173.0 £279.7 62%
Total
37 34 -8% £2,154.3 £2,454.0 14%

High Risk
before and
High Risk
after: 0.7 %
Low risk before and low risk
after: 79.9 %
Low to high risk: 0.4%
High to low risk: 19.1%
• General Health Questionnaire 12 (GHQ-12)
Wellbeing

Life Satisfaction
• Mean up from 6.3 to 6.9 (out of 10)

5. The Moral Case for investment

PREVENTING ILLNESS 2015: WORKSHOP
DIAGNOSTICS IN ACTION

All is not what it seems…
This is Not a ‘Presentation’
…Please feel free to ask
questions and contribute to a
discussion around any of the
points raised in the next 20
minutes

Diabetes; The Scale of The Problem
UK Diabetes Prevalence
Currently, the number of people diagnosed with diabetes in the UK is estimated
to be 3.2 million. This represents 6% of the UK population
It is widely predicted that up to 630,000 people in the UK have diabetes but
remain undiagnosed
Adults: 10% have type 1 diabetes
Adults: 90% have type 2 diabetes
Children: 98% have type 1 diabetes
Children: 2% have type 2 diabetes

Blood Glucose Testing
Recommendations
2015 NICE guidelines recommend that people with type 1 diabetes &
those with type 2 on insulin, should test their blood glucose at least 4
times per day, including before each meal and before bed
Guidelines for type 2s vary; consensus is that structured Self-
Monitoring of Blood Glucose (SMBG) has positive effects on people
with non-insulin dependent type 2 diabetes; helping them to understand
their condition, reduce their HbA1c, and improve their diabetes control
where they are supported with guidance on how to test, when to test
and what to do with their results

Immediate Consequences of Poor
Glycaemic Control
Glycaemic control best achieved through appropriate diet and exercise
regime and monitored via BG testing
Hypoglycemia (< 4mmol/L)
Dizziness, fatigue, nausea, potentially loss of consciousness
Hyperglycemia (>11mmol/L*)
Thirst, excess urination, tiredness, potentially Diabetic Ketoacidosis

Test Strip Frequency Model for UK Market 2014
Type 1 & 2 Split Type 2 Type 1
People with Diabetes 3,000,000 2,700,000 300,000
90.0% 10.0%
Treatment Split Diet Only Tablets T2's Insulin Injected Pumped Inj. Paeds Pump Paeds Gestational
28.0% 55.0% 17.0% 87.0% 3.0% 7.0% 3.0% -
756,000 1,485,000 459,000 261,000 9,000 21,000 9,000 9,000
% testers 10% 35% 70% 70% 70% 70% 70% 100%
No. of testers 1,135,650 75,600 519,750 321,300 182,700 6,300 14,700 6,300 9,000
Test Freq. per week 4 4 14 28 42 28 42 42
Packs 50's per year 4.2 4.2 14.6 29.1 43.7 29.1 43.7 43.7
Segment total pks (000's) 13,846,560 314,496.0 2,162,160.0 4,678,128.0 5,320,224.0 275,184.0 428,064.0 275,184.0 393,120.0
Drug Tarriff Price 14.70
NTS £000's £203,544,432 £4,623,091 £31,783,752 £68,768,482 £78,207,293 £4,045,205 £6,292,541 £4,045,205 £5,778,864
Segment Share 100% 2.3% 15.6% 33.8% 38.4% 2.0% 3.1% 2.0% 2.8%
Strips of Total Market % 17.9% 82.1%

The Medicines Management Dilemma
• Approx 82% of test strip usage is type 1 and type 2s on insulin
• This is a huge challenge for medicines management at a primary
care level, where the traditional approach is to target type 2 patients
for blood glucose testing switch in order to save money
• Why? It’s simple, not contentious amongst HCPs, perceived as low
risk
• As we have demonstrated in the likes of West Berks, if the product
(& practice level support) selected to help implement switch is high
quality, then almost all well controlled diabetes patients can be
appropriately switched. This then can release significant savings for
reinvestment in diabetes services

Targeted Switch at a Practice Level
Where would you start?

“There is no point in testing blood
glucose…”
“… Unless you do something with the result”
Sue Craddock diabetes nurse consultant

QuickTick
• An Educational portfolio
focused on diabetes,
structured blood glucose
monitoring and it’s benefits
• Designed for patients but
under straightforward guidance
from a HCP
• Simple to understand and
simple to use

Too High, Too Low, Don’t Know?…

What Else Can We Do?
• Diasend compatibility – Telehealth
Forth Valley, Ayrshire & Arran, Portsmouth
• Practice level switch assistance and supporting data
Cwm Taf, Lincolnshire,
• Bespoke patient communications and mailings
North Somerset, Scottish Borders
• Long term partnership to meet new challenges & changing priorities
Berkshire, Derbyshire, Tameside & Glossop
• Secondary and specialist care engagement and endorsement
Portsmouth, Lambeth, Wandsworth, Leicester

What Else Can We Do?
• Publicity for diabetes
services at a local
level
• Fundraising (JDRF)
• Endorse the quality of
orthopaedic service in
Gloucestershire…

Part of the BRE Trust
BRE: Linking Housing and Health
Chris Johnes
Housing & Health
johnesc@bre.co.uk

About BRE
All profits from the BRE Group are
used by the BRE Trust to fund new
research and education programmes
that will help to meet its goal of
‘building a better world together’
In 2014 BRE Trust expenditure on
research was £2.8 million,
compared with £3.4 million the
previous year. These funds support
the three key elements of the
Trust's activities: research,
publications and five university
centres of excellence

Excess winter deaths (England and Wales)
An estimated 31,100 excess winter deaths
occurred in England and Wales in 2012/13
ONS

Housing Health and Safety Rating System (HHSRS)
Category 1 hazard = ‘Poor Housing’
Physiological Requirements Protection Against Infection
Damp and mould growth etc. Domestic hygiene, pests and refuse
Excessive cold Food safety
Excessive heat Personal hygiene, sanitation and drainage
Asbestos etc. Water supply
Biocides
CO and fuel combustion productions
Protection Against Accidents
Lead
Radiation Falls associated with baths etc.
Un-combusted fuel gas Falling on level surfaces
Volatile organic compounds Falling on stairs etc.
Falling between levels
Psychological Requirements
Electrical hazards
Fire
Crowding and Space Flames, hot surfaces etc.
Entry by intruders Collision and entrapment
Lighting Explosions
Noise Position and operability of amenities etc.
Structural collapse and falling elements

HHSRS Category 1 hazards (EHS 2011)
3.4 million (15%) of English homes have a Category 1 HHSRS hazard
1,369
4,894
5,453
6,161
7,545
8,201
9,204
15,336
15,394
23,871
28,355
32,283
35,222
47,284
53,349
74,054
78,132
107,168
107,603
112,051
128,590
239,930
543,848
1,325,088
1,352,837
0 200,000 400,000 600,000 800,000 1,000,000 1,200,000 1,400,000
explosions
excess heat
water supply
lighting
noise
uncombusted fuel gas
ergonomics
electrical problems
carbon monoxide
structural collapse
overcrowding
domestic hygiene
food safety
sanitation
entry by intruders
damp and mould
collision and entrapment
falls associated with baths
hot surfaces
radon
lead
fire
falls between levels
falls on the level
cold homes
falls on stairs

Typical HHSRS outcomes and 1st year treatment
HHSRS Outcome
Hazard Class 1 Class 2 Class 3 Class 4
Damp and mould
growth
Not applicable
-
Type 1 allergy
(£2,034)
Severe asthma
(£1,027)
Mild asthma
(£242)
Excess cold Heart attack, care, death
(£19,851)
Heart attack
(£22,295)*
Respiratory condition
(£519)
Mild pneumonia
(£84)
Radon (radiation) Lung cancer, then death
(£13,247)
Lung cancer, survival
(£13,247)*
Not applicable
-
Not applicable
-
Falls on the level Quadriplegia
(£92,490)*
Femur fracture
(£39,906)*
Wrist fracture
(£1,545)
Treated cut or bruise
(£115)
Falls on stairs and
steps
Quadriplegia
(£92,490)*
Femur fracture
(£39,906)*
Wrist fracture
(£1,545)
(£115)
Falls between levels Quadriplegia
(£92,490)*
Head injury
(£6,464)*
Serious hand wound
(£2,476)
(£115)
Fire Burn ,smoke, care, death
(£14,662)*
Burn, smoke, Care
(£7,435)*
Serious burn to hand
(£1,879)
Burn to hand
(£123)
Hot surfaces and
materials
Not applicable
-
Serious burns
(£7,378)
Minor burn
(£1,822)
Treated very minor
burn
(£123)
Collision and
entrapment
Not applicable
-
Punctured lung
£5,152
Loss of finger
£1,698
£115
Not applicable = HHSRS class very rare or non existent
* = Costs after 1 year are likely to occur, these are not modelled
Main source: National Schedule of Reference Costs
2010-11 for NHS Trusts

NHS first year treatment costs 2011
Excess
Cold
£848 M
Falls
on
stairs
£207 M
Falls -
baths
£16 M
Fire
£25 M
Falls on
the level
£128 M
Damp
£16 M
Collision
£16 M
Hot
surfaces
£15 M
Falls
between
levels
£84 M

Including all sub-standard housing
– 2010 report: Total cost of poor housing = £600m
– 2014 report: Total cost of poor housing (HHSRS Cat 1) = £1.4bn
– 2014: Add HHSRS Cat 2 housing = + £428m
– 2014: Add all sub-standard housing = + £160m
– The full cost (in terms of NHS first year treatment costs) of
sub-standard housing = £2.0bn

Comparative cost burden to the NHS
Risk Factor Total cost burden to the NHS
Physical inactivity £0.9 billion – £1.0 billion
Overweight and obesity £5.1 billion – £5.2 billion
Smoking £2.3 billion – £3.3 billion
Alcohol intake £3.2 billion – £3.2 billion
Poor housing £1.4 billion – £3.5 billion?

The cost of making poor housing acceptable
– Low cost work includes:
– Re-locate cooker (£157)
– Install 2 wired smoke detectors (£194)
– Install handrail to staircase (£295)
Medium cost work includes:
– Replace lead piping (£1,890)
– Rewire house (£3,657)
– Redesign staircase (£4,325)
High cost work includes:
– Re-fit kitchen (£7,000)
– Damp remedial works (£10,940)
– Solid wall insulation (£20,000)
Total cost of making all HHSRS Cat 1 hazards acceptable = £10bn
Average cost = £2,875
–
£123
£229
£391
£584
£919
£1,195
£1,730
£3,305
£7,898
£59,672
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
£- £10,000 £20,000 £30,000 £40,000 £50,000 £60,000

Payback example: Falls on stairs
– HHSRS Band C (Cat 1 hazard)
– Work = replace balustrades
– Cost of work = £314
– Annual benefit to NHS = £146
– Payback = 2.1 years

Case study: cost-benefit of energy improvements
Before: solid, un-insulated stone walls,
partial double glazing, small amount
of roof insulation, off-peak storage
radiators, electric immersion heater.
– Cost of upgrade = £0
– SAP = 22
– Annual fuel cost = £965
– CO2 emissions = 8,972 kg pa
– HHSRS Band = A (Cat 1 hazard)
– Household in fuel poverty
After: condensing gas boiler and radiators
for space and water heating,
top-up loft insulation,
full double glazing.
– Cost of upgrade = £3,528
– SAP = 59
– Annual fuel cost = £461
– CO2 emissions = 4,666 kg pa
– HHSRS Band F (Low hazard)
– Household not in fuel poverty
– Cost savings to NHS pa = £528
– Payback to NHS = 5.1 years
WHEN YOU MAKE A HOME MORE
SUSTAINABLE YOU ALSO MAKE
IT MORE HEALTHY!

Who is already using the data?
– Public Health England
• to inform their ‘Healthy housing, healthy places’ strategy
– The Department of Health
• to improve their knowledge base on the relationship between housing and health
– DCLG
• to help make the case for the future of the EHS, by demonstrating its value for cost-benefit scenario modelling
– Eurofound
• as the basis of their pan-European ‘cost of inadequate housing’ model
– Chartered Institute of Environmental Health (CIEH)
• to promote their role in reducing the impact of poor housing on health
– Chartered Institute of Housing (CIH)
• to demonstrate the value of the Decent Homes programme
– Care and Repair
• to make the case for investment to support vulnerable people in their own homes
– DECC
• to advertise the added value of energy efficiency improvements

The Housing Health Cost Calculator
– Helps quantify the extent to which improvement to the housing
stock takes pressure off health services
– Demonstrates the value of the work carried out
– Can assist in the targeting of resources towards actions with the
greatest returns
– Can assist in bids for funding
– Website will calculate cost to NHS and to society
– Can add a post work assessment to measure savings
– Costs of doing work can also be added, enabling the calculator
to work out a payback period

How to add a case
– Cases can be added one
by one
– You can identify dwellings
by address, UPRN or both
– HHSRS system uses
representative scale
points
– Average values put in by
default
– NHS costs and costs to
society appear at the
bottom of the screen

Reviewing your data
– Can order data by rank,
hazard, or savings

Hazards in England and Wales
Rank* Hazard Savings to NHS Savings to Society
01 Excess cold £1,746,584 £4,366,460
04 Falling on stairs etc £112,730 £281,825
03 Damp and mould growth £107,578 £268,945
02 Fire £98,951 £247,378
05 Electrical hazards £63,431 £158,578
09 Falling on level surfaces etc £53,915 £134,788
08 Personal hygiene, Sanitation and… £39,995 £99,988
12 Crowding and space £37,595 £93,988
07 Falling between levels £34,207 £85,518
11 Food safety £20,315 £50,788
14 Structural collapse and falling … £17,322 £43,305
15 Collision and entrapment £15,563 £38,908
06 Entry by intruders £12,947 £32,368
21 Explosions £7,605 £19,013
13 Domestic hygiene, Pests and Refu… £7,461 £18,653
17 Falls associated with baths etc £3,679 £9,198
10 Carbon monoxide and fuel combust… £3,002 £7,505
16 Flames, hot surfaces etc £2,925 £7,313
18 Lighting £2,864 £7,160
23 Uncombusted fuel gas £2,004 £5,010
19 Excess heat £1,166 £2,915
22 Noise £814 £2,035
20 Position and operation of amenit… £717 £1,793
25 Water supply £489 £1,223
24 Lead £306 £765
26 Radiation £115 £288
£2,394,280 £5,985,708

Case study - Derby
– Renovation and refurbishments to 32 dwellings
– 117 hazards found
– Three most common hazards
– Excess cold
– Fire
– Entry by intruders
– Total cost of works - £65,709

– Savings to NHS of £23,191 each year
– Savings to society of up to £58,000 each year
– Payback period to NHS of under 3 years
Case study - Derby

Lambeth GP Food Co-op:
Our Story So Far

Lambeth: A Snapshot 2014
• 310,000 residents/335,000 by 2020
• 37,000 with long term conditions and growing
• 16,000 at risk of malnutrition
• 6,000 using foodbanks

Aims and Objectives
• Funded by NHS Lambeth CCG and Lambeth Council 2013/15.
• 3 year development cycle.
• Transform unused space inside GP practices for food growing.
• Engage patients especially with long term health conditions, socially
isolated and lonely.
• Build community-led health co-operative.
• Address diet, nutrition, health and wellbeing.
• Influence NHS sustainable food procurement in acute sector.
• Awarded Best Sustainable Food Initiative by Public Health
England/NHS Sustainability Unit 2013.

Who we are
Patients, doctors, nurses, practice staff,
gardeners and Leaders of Public Health

Co-op team position planters in surgery
garden
Mawbey Health Centre, Vauxhall
March 2014

Ephat and Zarena planting together
Late Spring 2013
Paxton Green Surgery: Gipsy Hill

Patients Planting Fruit Trees, Mawbey Group
Practice, Vauxhall
February 2015

King College Hospital NHS Foundation
Trust/Corner Surgery
NHS Sustainability Day 26th March 2015

Getting ready for Open House at Lambeth
Walk Group Practice
July 2015

A picture of general practice in the future?

A Voice from the Project
“I have now moved away from settling for ready
meals and am back to creating delicious meals
from fresh ingredients, which can only be good
for my general health and wellbeing.”
Lambeth GP Food Co-op member 2015

Lambeth GP Food Co-op
Follow us on Twitter@GPFoodCoop Email: GPFoodCoop@gmail.com
•
Funded by the London Borough of Lambeth and NHS Lambeth Clinical Commissioning Group.
Supported and grown by the people of Lambeth

NHS Birmingham South Central
A New Approach to Risk Reduction in
Type 2 diabetes

• Across our CCG there is a mix of both high Black and Minority Ethnic (BME) populations
and social deprivation.
• The percentage of people 17+ diagnosed with diabetes is higher in each of the Birmingham
CCGs than the England average
• There is a gap in diagnosed prevalence and estimated prevalence in adults that requires
investigation
• By 2025 the projected prevalence of diagnosed and undiagnosed diabetes could increase
to over 90,000 (with an increase in prevalence from 8.5% to 10.3%)
• Obesity is also increasing in Birmingham and there is a strong relationship with diabetes
Birmingham South Central

BSC’s CVD LIS
• BSC CCG established a CVD Local Improvement Scheme (LIS) in 2014 with an
emphasis on identifying and managing patients at risk of developing type II
diabetes mellitus.
• Local Improvement Scheme including:
– Case finding and management of patients with pre-diabetes
– Promote self care through individual management plans, including in-practice care
education and the offer of referral for structured education programmes
– Designed by GPs for GPs
– Uses Practice List as resource for case finding

Central Edgbaston Kings Norton Northfield Pershore BSC TOTAL
DM - High risk
screen - ANY –
HbA1c 42-47
(post 1/04/2014)
4469 1286 1229 1751 1166 9958
DM - High risk
screen –
LATEST
HbA1c <42
328 90 115 139 95 756
Total population 107959 46692 39537 53343 35698 282351
Percentage of
population at risk
4.14% 2.75% 3.11% 3.28% 3.27% 3.53%
CVD LIS – Diabetes First Year Achievement

Learning to Date
• NDH Patients can be identified and risks reduced through GP intervention with or without lifestyle
intervention
• Intervention has worked across different demographics
• Peer support, self selecting Practice Groups, Clinical leadership in design
• Supported by clinical system pop ups and bespoke templates
• Noted a 7% reduction in at risk group (see regression to mean slides)
• User and community engagement essential
• Payment by outcomes works

Regression to the mean
• We identify patients with pre-diabetes using a measure of HbA1c
– 42 to 46.9 = pre-diabetes
• HbA1c varies from day to day within the same person
– Therefore some people will have HbA1c levels in the pre-diabetes range by
chance
• These individuals are likely to be back in the average range the next time we
measure
– They will seem to have improved even without any intervention

Illustration of Regression to the Mean
1. Let’s assume that average HbA1c is 37 in Birmingham’s non-diabetics
– Let’s assume that the distribution of HbA1c values in the population is as
expected
2. Let’s assume that when we measure HbA1c we get day to day biological
variation within each individual.
– This variation is equivalent to a standard deviation of 1.9%

0
10
20
30
40
50
60
70
80
24-24.9
25-25.9
26-26.9
27-27.9
28-28.9
29-29.9
30-30.9
31-31.9
32-32.9
33-33.9
34-34.9
35-35.9
36-36.9
37-37.9
38-38.9
39-39.9
40-40.9
41-41.9
42-42.9
43-43.9
44-44.9
45-45.9
46-46.9
47-47.9
Frequency
HbA1c value
REMEASURED HbA1c
This is what get when we measure HbA1c a
second time in the “MEASURED” pre-
diabetes cases.
- The chances are that the 149 cases will still
be high.
- But most of the remaining 69 which just
had a high measure by chance will be normal
again.

Demonstrator Site Activity
BSC is delivering a blended programme, which includes:
• The enhancement of our existing CVD LIS Diabetes Scheme
– Enhanced CVD Local Improvement Scheme that provides for structured capture (template/read coded) of lifestyle
change preferences and referral route.
– The current LIS only provides for identification and review, the adapted scheme will ensure completion of a standard
template for each person seen and drive a motivational interviewing approach.
and
• Builds on the way current Lifestyle Change Support Services commissioned in Birmingham by the local
authority.

Third Sector Providers
We have worked with two local well established third sector providers of
lifestyle interventions, Gateway Family Services and Health Exchange:

Provider data collection
• Blood Pressure
• Dietary change (assessment tool tba)
• HbA1c (indicating average blood sugar levels over 3 months)
• Other anthropometric measures (e.g., waist circumference)
• Weight
• Perceived importance of and confidence in achieving healthy levels of
activity and a healthy diet
• Quality of life (EQ5D);
• Self-reported physical activity (GPPAQ)

The Service
Components of the scheme include:
1. Community Engagement – three local community engagement events
2. Motivational Interviewing - Training in motivational interviewing for front line clinical staff and
brief intervention techniques for lifestyle change.
3. LIS Development - Enhanced CVD Local Improvement Scheme that provides for structured
capture (template/read coded) of lifestyle change preferences and referral route.
4. Core Intervention - Commissioning a pilot local structured programme for people at risk of
diabetes from existing providers - to include nutrition and exercise (in line with national evidence
base).
5. Feedback – designing enhanced feedback and tracking for those on structured programmes.
6. Local evaluation - to support the wider local authority led lifestyle services re-procurement
process. Including preferences and barriers to accessing services from BME groups.

Summary
• No show stoppers
• Went live late October
• Internal target to recruit 1500 by January
• Moving on to expression of interest for national first wave roll out
• CCG leads committed as are our Networks
• Patient enrolment via primary care
• Building relationship between providers and practice

Preventing illness
Innovations, housing and a sustainable healthcare system
24 November 2015
Merron Simpon
Housing and Health Lead, NHS Alliance

The Graph of Doom + minimum wage

Slow demise of Supporting People …
• 2003: Supporting People (SP) programme launched as £1.8bn
ringfenced budget.
• 2009: Ringfence removed amid concerns councils would spend
funding on other priorities.
• 2011: SP ceases to be separately identified in councils' funding
formula.
• 2011-12: Housing minister urges authorities against cutting SP
budgets.
• 2013: SP allocations influence local authorities' "start-up settlement".
• 2014: SP disappears from settlement figures entirely.

“I’m no financial genius ... But I have no
hesitation in saying I don’t think the state
is going to be able to cover this. This needs
a new bargain and partnership between
the people and the state. The earlier that
partnership begins, the better.”
Alister Burt, Minister for Community and Social Care
… on the challenge of meeting long-term care costs

Innovations in ‘prevention’
Heatherstones Court
• Regaining independence in a community setting
• Calderdale Council, CCG, Foundation Trust,
Connect Housing
• BCF funded
Sheltered Outreach Service
• Pilot, supporting 10 FACS-ineligible older people
living in private housing
• Moat GP surgery and Raven Housing Trust
• Joint funded
Lancaster Warm Homes Service
• Warm homes + injuries reduction in under 5s
• Lancaster HIA delivers the service
• Funded by Public Health, CCG, RoSPA

Innovations in ‘prevention’
Thurrock Well Homes programme – private homes
• make homes safer by reducing the risk of ill health or
accidents
• put residents in touch with health and lifestyle services
that can improve quality of life
Social prescribing
• Frequent GP presenters >10x/6 mths
• South Yorkshire HA and Doncaster CVS
• Health and Social Care Innovation Fund
Over 75s health and wellbeing
• Work from GP surgery with over & under-presenters
• Tameside GP Federation and New Charter Housing
• GP-funded

From treating illness …
… to creating health
Creating
Health
(3Cs)
Preventing illness
(3Ps)
Treating illness
Increasingcontrol

Getting to know your housing organisations
• Use www.housingforhealth.net
• Warning … Health and Housing talk different languages! And NHS
Alliance is bilingual
• We can help you to identify which housing organisations you should
be talking to, about what, and help to structure the discussions

If you want to have a voice in shaping the future of health
and the NHS, then please join the NHS Alliance
http://www.nhsalliance.org/join-us
contact Merron Simpson for more information:
Merron@newrealities.co.uk 07973 498603

Alix Sheppard
Public Health Specialist
Youth Health Movement Consultant

The youth health movement
The yhm is a collective of young people and organisations
who work with young people, empowering and involving
them to actively promote health and wellbeing in
community and educational settings.

Identifying the need
• Only 15% of girls and under a third of boys report meeting the Chief Medical
Officer’s guidelines for physical activity of at least one hour of physical activity each
day
• More than 8 out of 10 adults who have ever smoked regularly, started before age 19
• The UK has one of the highest alcohol abuse rates in Europe
• 50% of life-time mental illness (excluding dementia) starts before age 15
• Around one third of young people aged 11–15 are overweight and around 1 in 5 are
obese and 8 out of 10 obese teenagers go on to be obese adults
• PHE data examples

Policy based
PHE
• The link between pupil health and wellbeing and attainment (Nov
2014)
• Improving young people’s health and wellbeing: A framework for
public health (Jan 2015)
• A guide to community centred approaches for health and wellbeing
(Feb 2015)
• Promoting children and young people’s emotional health and
wellbeing (March 2015)
• Key Data on Adolescence 2013 (AYPH, PHE 2013)
• Children’s view of services; A rapid review (NCB, 2009)

What is a yhc?
YHC
Listening
and
supporting
Role
modelling
healthy
behaviours
Signposting to
health services
Designing and
delivering
campaigns
Feed back on
YP issues
Supporting
health
messages

The yhc role
Able to give accurate information on how to live a healthier life
Using the skills and knowledge to improve own life and that of the
family
Signposting to services and places for help and support
Being an inspiration to others
 Gaining a qualification- first step on career ladder for health
 Myth busting- some of the mis-information about health
 Making it sick [sic] to be healthy

Training
• RSPH Level 2 Certificate for Youth Health Champions
• 13 QCF credits
• Ofqual accredited
• Equivalent to a GCSE Grade A-C
• Communication skills
• Team working
• Presentation skills
• Interactive workshops

For more information on the Youth Health
Movement please visit www.yhm.org.uk
Alix Sheppard
Youth Health Movement Adviser
asheppard@rsph.org.uk

Closing speech
Jeremy Porteus, Director,
Housing Learning and
Improvement Network

Welcome and Introduction to Public Health England

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