Jim McManus, OCDS, CPsychol, CSci, AFBPsS,FFPH, FRSPH Director of Public Health, Hertfordshire County Council 10 th September 2014 Hertfordshire Sports and Physical Activity Conference Challenges and opportunities for Sport and Physical Activity

Some starting points Physical activity as routine is important to the future of our county –Health –Economics –Healthy, resilient, rounded people Sport is equally important

Important to Hertfordshire: Some common goals Sport perspective Punching our weight in sports at all levels Economic, environmental, cultural outcomes –Employment in sport Health perspective A strategic shift to prevention The resilience agenda The sustainability agenda Healthy population, thriving economy Employment and skills perspective Employment in the sector Skills of participation in sport benefit people and employers

Hertfordshire’s strategic commitment to physical activity 1. A priority for the Lifestyle and Legacy Partnership (formerly the Olympic legacy partnership) bringing 40 agencies together 2. priority in each district council strategy and there are multiple services 3. A priority for the University in Sports Science 4. A large and thriving Sports Partnership 5. A large network of community sports clubs 6. A priority in the health and wellbeing, Public Health and Sustainable Transport Strategies 7. A priority in the Better Care Fund Plan for health and social care integration 8. A priority in each NHS Commissioning strategy

Whats going on now – a selection 1 Significant district council investment in leisure services and offers, every district offering a form of exercise on referral but this will be further developed over the next year Every district has a leisure offer encompassing indoor and outdoor leisure activities Chief Leisure Officers Association and Sport England are working on a joint District-County-Sports Partnership project to develop a commissioning framework for physical activity for Herts Community grants fund for physical activity funded by public health to be developed by Sports Partnership Every leisure service employee in Hertfordshire can access free public health training £1m per annum public health investment in district councils

Whats going on now – a selection is year of cycling, year of walking next…. Public Health and CCGs and Districts are working with an at scale physical activity programme Workplace health challenge funded by Public Health Workplace health work funded by public health Pool bikes and bike to work scheme in the County Council District councils working on targeted and universal physical activity and leisure offer Public Health and NHS about to employ physical activity promotion manager in primary care to develop physical activity pathways 32,000 people go on Health Walks a year funded by Public Health and District Councils, led by Countryside Management Service Cycling development small grant fund for community agencies as part of Year of Cycling Key third sector agencies commissioned like Groundwork and others 2,500 bikeability courses in schools

Nothing less than a cultural shift to physical activity as mother nature’s way of keeping us healthy will resolve the challenges we face And nothing less than firm resolve to share the same strategy and vision, and work to deliver that, from every partner, will get us there (get behind the Sports and Physical Activity Framework consultation])

Why: We are facing an epidemiological crisis with avoidable disability creating huge burdens Avoidable early deaths Chronic disease – poor self management, poor management of sub-clinical risk, must do better on prevention and early intervention Disability and costs to social care and NHS Some sections of our population at very high risk of avoidable misery and death Mental health – intervening too late Resilience and Happiness – likewise

Avoidable disability

Avoidable Disability 2 74 year old sedentary male

Avoidable Disability 3 70 year old tri-athlete

Primary Prevention Secondary Prevention Tertiary Prevention in and Out of hospital

Ok, so if that’s why, then how? We cant just turn off the tap We can just shift huge quantities of money, the need is still there A culture shift to everybody active has got to be part of our plan

Primary Prevention Secondary Prevention Tertiary Prevention The shift to prevention

16 Prediction forecast / target services Secondary Prevention Primary Prevention Universal & Well-being LOW MODERATE SUBSTANTIALCRITICAL Reduce numbers of people coming into high-cost services and moving along threshold banding Intensive Home Support Residential Care Motivation, Support Skills, Services Tertiary Prevention

So how do we get there? 1. Produce a clear single framework for physical activity and sport we all sign up to 2. Build a system wide approach to deal with it 1.Be clear on roles, responsibilities and outcomes 3. A more nuanced understanding of lifecourse and behavioural change 1. Cogntiive and Planned 2. Habitual and automatic

Produce a clear single framework for physical activity and sport we all sign up to Shared framework across the county we all agree to Understand the contribution of each agency to that and work it through commissioning –Eg Exercise on referral

Build a system wide approach to deal with it 1. Identify what we want 2. Identify whose job it is to do what 3. Build the system together

Lifecourse and behavioural change Make health and Sports Psychology more available Identify skills and competencies across the whole system

Quick wins and delivery tools Five big wins 1. Shift up clinical complexity in primary care 2. Step up secondary prevention of complex cases 3. Step up self care and self management in chronic disease 4. Commission secondary prevention pathway 5. Commission primary prevention for key risk groups Policy and Delivery Tools Pathways and structured care approached Health and social care integration Behavioural sciences Health Checks and public health services Brief interventions

What it means for NHS Services Preventive services in every patient pathway and lifestyle for every patient Routine referrals to physical activity A “can do” approach to disability and rehabilitation Exercise on referral at scale Sports and Exercise medicine Levels and competencies from brief intervention onwards Preventive services in clinical services link up to community services (referral for leisure and behavioural interventions) Commissioning for self-management in chronic disease

What it means for public health Commission lifestyle services Commission them in a way which enables people to work together and build systems Commission to support a strategic and cultural shift to prevention Support the leadership of the Lifestyle and Legacy partnership and the Sports Partnership Lead Exercise on Referral and Sports Medicine developments

What it means for District Councils Be the local glue for exercise on referral schemes Provide menu of activity choices at all levels Use district offer monies and sport england monies to build culture change The lead agencies in their areas

What it means for providers A menu of opportunities from walking to elite sport and back again A register of trainers who can work with people Close links with commissioners and with NHS referral mechanisms

What it means for Sports Continue to be part of punching our weight in elite sports Continue to drive up participation Be a major part of cultural shift

Strategic Shift Implications for the Sports Partnership Implications for the Lifestyle and Legacy Partnership Where is the LEP in all this?

15 Actions being taken so far (more will be done) 1. New weight management service already commissioned and reached 1 st 1,000 referrals in three months, more will be commissioned 2. Obesity pathway in place for tiers 1 -3 obesity care. Revision late New lifestyle partnership launched with lifestyle offer for Herts residents to be ready by Easter for phased roll out 4. New online lifestyle service launched in February 5. Workplace physical activity challenge funded and running (Herts Sports Partnership) 6. Workplace Health improvement programme running (Business in the Community) 7. 93% of GPs in Herts now doing NHS HealthChecks 1. Obesity Plan approval by Cabinet due March New child weight management service to be commissioned in Broxbourne whole area obesity pilot underway with Borough and County Council, schools and NHS 4. Fast food takeaway restrictions 5. Countryside walks scheme 6. Year of Cycling launching May Funding for District Councils to work on health improvement agreed and each District working out its plans 8. Continue child weight measurement programme

Behaviour Change Pathway Approaches 2nd Line – Behaviour Change 3rd Line - Activity 4th Line – Specialist 1 st Line – Brief Intervention Opportunistic brief advice by GP, pharmacist or practice nurse 1Identify health issue of concern (and follow appropriate pathway for that, e.g. obesity) 2Assess motivation to change 3If motivated, refer on 4If not motivated,  Raise awareness of risks.  Offer written information on healthy eating and physical activity.  Raise again in 3 months.  Offer information prescription Smoking is primary, main or only goal If fall into 1 st or subsequent line category of advice within Obesity Care Pathway refer to Lifestyle Programme, provided there are no contraindications and if co-morbidities or person has BMI over 30, GP has assessed and supports referral. Check this …. Discuss primary or main goal then refer appropriately For patients with co- morbidites Patients who are diabetic or have coronary heart disease or a history of heart problems must have referral from appropriate primary care team or secondary care to participate in programme. Behaviour change programme to be developed in partnership with specialist services The evidence base for changing health behaviour is developing quickly. Brief interventions in primary care (by practice nurses and GPs) can motivate people to change, providing referral onwards is speedy. This pathway Refer to smoking cessation service Weight loss, healthy living or CVD risk is main or primary goal Refer to ifestyle Service Patients with highly complex psychological or emotional issues (e.g. depression or eating disorder.) If not already in contact with such services, refer to IAPT programme psychology or primary care mental health team

Example: cycling as part of a County of Opportunity Physical activity becomes second nature Health benefits from self propelled transport (walking, cycling) Sustainability benefits from self propelled transport Cycling on referral

Our ambitions for cycling More people cycling more often Cycling as sustainable transport Cycling as pleasure and keeping healthy Cycling on referral from health professionals Cycle safety and learning for kids and adults Mental health and physical health benefits A new way of doing the Cycling Forum

Year of Cycling We will put cycling on the map in Hertfordshire as a leisure, health and transport activity Complete revision of some work we’ve been doing including website and apps Start of a 3 year plus cultural push on physical activity County Council, Cycle Clubs, Districts, NHS, Police, working together

Year of Cycling 1 year plus legacy period Year of walking follows Then year of swimming Culture change Already having an impact £2m investment in District Councils by Public Health Chief constable and county council agree to new policy on cycling events/races

The Policy Context (England) does give us scope to address this Local Authorities – duty to promote and protect health of population NHS CCGs – duty to reduce inequalities in health Behaviour change is a tool but we need to use it properly and use the right methods A balanced strategy using a range of tools and strategies

Thank you! Public Health page Free learning resources for public health