30/11/2015. Wayne Farah. Vice Chair Newham CCG. Carer Patient HSJ Patient Leader

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1 Wayne Farah Vice Chair Newham CCG Carer Patient HSJ Patient Leader 1

2 Beyond Engagement INFORM CONSULT INVOLVE DELEGATE EMPOWER Community Ownership It s only when we give ownership of health and health services back to the community that they can create them in their own image and give them back to us transformed 2

3 Bob s Story My GP told me I was pre diabetic and gave me advice on changing my life style exercise all that stuff. Its not easy changing your life so I ignored it. Six months later I was diabetic. Being told what to do doesn t mean you can do it. I wish I had practical help to change my life style earlier. Dr William Bird Intelligent Health Newham Community Prescription A Clinical Perspective 3

4 2014 Intelligent Health People People Healthy Communities Place Purpose Engaged Connected Reason 2014 Intelligent Health Fear and Chronic Stress The disconnection can be summarised in three areas People Loneliness Place Hostile Purpose Rejection 2015 Intelligent Health 4

5 Chronic Inflammation: The Cause of Causes Cardiovascular disease Diabetes Anxiety and Depression Cancers Arthritis Chronic Inflammation Starts in children as young as 6yrs old Obesity Dementia 2012 Intelligent Health/NHS London Causes of Chronic Inflammation Eating red or processed meat, sugar and fat The immune system is switched on after a meal creating inflammation. Visceral Fat This fat is toxic and creates a continuous supply of inflammatory markers. Oxidative damage Free radicals from mitochondria cause damage to cells creating inflammation Intelligent Health/NHS London 5

6 Poor Diet Some diets of refined carbohydrate, fat and processed meat creates inflammation Our gut bacteria are critical in reducing inflammation Physical Activity If we are physically active either two hours before or two hours after a meal we release Lactoferrin that switches off the immune response 2015 Intelligent Health Visceral Fat Chronic Stress increases risk to Visceral Fat Visceral fat is related to inactivity, stress and obesity. The fat cells are faulty and release continuous amounts of inflammatory markers Aschbacher, Kirstin, et al. "Chronic stress increases vulnerability to diet related abdominal fat, oxidative stress, and metabolic risk." Psychoneuroendocrinology 46 (2014):

7 Reducing Inflammation - Fat 2014 Intelligent Health Visceral Fat Physical activity reduces visceral fat before subcutaneous fat particularly in obese and diabetic patients Visceral fat increases all cause mortality OR 1.83 (1.23 to 2.73) Kuk, Jennifer L et al. Obesity;2006;14: Intelligent Health 7

8 Visceral fat reduction with exercise 0 Fat loss after 13 weeks of walking 60 mins a day and no weight loss Lean Obese Type 2 Diabetes 5 % Loss of Fat Axis Title S/C Fat Visceral Fat Lee S et al. J Appl Physiol 2005;99: Intelligent Health Oxidative Damage 8

9 Sedentary High fat diet and Stress Oxidative Phosphorylation Reactive Oxidative Inner membrane Species Anti Oxidants Mitochondrial DNA Mitochondria Physically Active, low fat and not stressed Oxidative Phosphorylation Anti oxidants Mitochondrial DNA Mitochondria 2014 Intelligent Health 9

10 Telomeres get shorter Epel, Elissa, et al. "Can meditation slow rate of cellular aging? Cognitive stress, mindfulness, and telomeres." Annals of the New York Academy of Sciences (2009): Intelligent Health/NHS London 2015 Intelligent Health Senescence: The end of the cell releases huge amount of inflammation. Hezel, Aram F., Nabeel Bardeesy, and Richard S. Maser. "Telomere induced senescence: end game signaling." Current molecular medicine 5.2 (2005):

11 Finally physical activity creates its own antiinflammatory Contracting Muscles Release powerful Anti inflammatories called Myokines Muscles also Reduce insulin resistance and mediate 75% of glucose uptake Burn more calories at rest than fat Protect joints 2012 Intelligent Health/NHS London Community Prescription Addresses first-order desires meaning to life personal development contributing to the community 11

12 Health Model linking determinants to disease 1) People Social connections 2) Purpose Sense of Purpose 3) Place Connection to place Determinants Stress Hormones Community Prescription Chronic Stress Poor Health Behaviour Smoking Drinking Inactivity Diet Chronic Inflammation caused by shortened telomeres and mitochondrial damage Diabetes, CV disease, cancer, arthritis, COPD, mental Clinical health, dementia Medicine 2014 Intelligent Health Resilience Inputs Wellbeing Effectors Mechanisms Outcomes Wayne Farah Vice Chair Newham CCG Community Prescription 12

13 Theory Social Prescribing Aframework and process for linking patients with non medical sources of support within the community? Horne et al. (2013) Mechanism for externalising NHS resource constraints to VCS? 13

14 Newham Community Prescription Combat ill health by giving GP s prescribing solutions that address the social determinants of health, and by building a community infrastructure that connects patients to the resources they need to engage in activities that promote health, wellbeing, and social inclusion Bob why don t you 14

15 NCP Pathway Clinician Navigator Choice Community Partner Support from next door 15

16 David Idiabana & Taskin Saleem Co Chairs Staywell Partnership 16

17 Activities in Community Prescription Particpants Subco Trust 17

18 Dr William Bird Intelligent Health Newham Community Prescription An Evaluation 18

19 Diabetes in Newham Physical Activity Before and After NCP Physical Activity Before After 2014 Intelligent Health 19

20 Wellbeing Score 58 Change in Wellbeing before and after NCP Before After 2014 Intelligent Health ROI for QALYs all patients participating in NCP for 2 years 2347 participants 1.2% of population Cost of community prescription 247, patients reaching 150 mins a week of moderate physical activity 32 QALY s gained (Using NICE tool) Benefit cost ratio 2:52 Net present value of QALYs 381,628 (Net present value of reduced productivity 281,607) 2012 Intelligent Health/NHS London 20

21 Preventing Diabetes 1079 patients that attend the NCP 224 would develop diabetes within 2 years (10.4/100 patient years) Physical activity reduces risk by 58% So now 129 patients will not develop diabetes Cost per person with diabetes per year is 777 (complications) and 517 (treatment). Total 1293 Total Savings = 333, Intelligent Health/NHS London Chronic inflammation in diabetic patients is causing additional healthcare costs. Steve Hajioff, MD MRCGP MFPH Medical Director Health Dialog Analytic Solutions World Healthcare Congress A whole person approach to LTC management is critical. For the 7,686 diabetics at the end of Year 1, only 17% of costs in Year 2 were directly or indirectly related to diabetes. Breakdown of costs from the admission of diabetic patients Diabetes Related Complications of Diabetes Other Conditions 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Admissions Cost 21

22 Total potential savings of getting 1079 patients with prediabetes more active through NCP Net present value of QALYs 381,628 (NICE) Net present value of increased productivity 281,607 (NICE) Net savings on healthcare costs for diabetes 333,594 Additional savings of urgent hospital admissions through other causes? Wayne Farah Vice Chair Newham CCG Conclusions 22

23 Vision NCP Model 23

24 Procurement Lead Provider Hub and Spoke Model Localised Provision 50% activity delivered by local community partners 24

25 Accreditation Quality Assurance & Community Development 25