Agenda item

Population Health Management - Progress and Next Steps


The Director of Public Health advised that the focus had been on Public Health Management (PHM) being used as an enabling framework to tackle health inequalities.  The work commissioned in North West London (NWL) had focussed on place based projects in relation to frailty and falls in Hillingdon.  There had also been some initial focussed work on obesity and health checks. 


The Board noted that Ms Caroline Morison, former Managing Director of Hillingdon Health and Care Partners (HHCP), had presented the PHM information to the Borough HPB.  Consideration needed to be given to the approach that would be taken and prioritising the use of the PHM framework going forward in the Borough. 


Ms O’Neill stated that the PHM work being undertaken by Optum had progressed well.  However, the process had been paused to enable Healthwatch Hillingdon to support the process by engaging with residents as this intelligence had been missing.  Action Learning Sets had been held and key interventions had started to be developed and implemented.  It was agreed than an update on the progress of the Optum project be provided to the Board at its next meeting on 29 November 2022. 


At a NWL level, £7.2m of health inequalities funding had been made available from NHS England.  A three week consultation had been undertaken across NWL to identify how this funding could be used to build capacity but the outcome of the consultation had yet to be confirmed. 


Health Checks

Ms Becky Manvell, the Council’s Public Health Manager, advised that the NHS Health Check programme in Hillingdon aimed to prevent heart disease, stroke, type 2 diabetes, kidney disease and some types of dementia.  Eligible residents should receive an NHS Health Check every five years.  These appointments were undertaken in all 45 general practices in Hillingdon, lasted approximately 15-20 minutes and measured height, weight, waist circumference, pulse rhythm and blood pressure.  Information was also gathered in relation to alcohol consumption, physical activity and smoking status and their CVD risk was calculated and communicated and healthy life advice given or a GP referral made where necessary. 


Covid had negatively impacted on the Borough’s ability to meet its target for the number of Health Checks undertaken (65% / 2,700 per quarter) and there appeared to be a significant variation in achieving this at a Primary Care Network (PCN) and local practice level. 


Currently, Hillingdon had worse levels of cardiovascular disease (CVD) than the London average as well as the national average.  It was anticipated that an increase in the Health Checks undertaken across eligible groups would enable the identification and treatment of more people with undiagnosed CVD.  Those with a higher risk of developing CVD could be supported and those with a lower-level risk could be signposted and advised.  The more Health Checks that were carried out in Hillingdon, the greater their impact would be. 


The Board was advised that there was some overlap between the areas with the fewest Health Checks undertaken and the areas of greatest deprivation.  Consideration would need to be given to breaking down the data and providing further analysis to increase the uptake of Health Checks. 


Work was being undertaken to reduce the variation in the Health Checks amongst individual general practices and on improving access via a range of community settings with appointments available at different times of the day and week, exploring the possibility of an outreach service to complement the current general practice model. 


The work that was being undertaken would improve outcomes for Hillingdon residents by increasing the uptake of preventative interventions as well as enabling higher risk groups to be targeted.  A gap analysis would be undertaken to identify under served groups to then engage to understand how this disparity could be addressed.  This engagement could include initiatives such as the blood pressure (BP) checks which was recently undertaken at Botwell Library.  The Board welcomed this type of proactive outreach as a large number of residents would only seek out medical attention when it was an emergency. 


Awareness of and the profile of NHS Health Checks would need to be raised through better communication as it was thought that patients would not actively reject the opportunity to have a Health Check.  It was important that, when patients were having a Health Check, they were aware that that was what it was as it was not always being made obvious as these checks were sometimes done as part of a visit to the GP for another issue.  It was suggested that the Covid Champions be used to help educate residents and promote NHS Health Checks.  


In the medium to long term, a digital NHS Health Check offer was under development by NHS Digital and expected to be ready in about two years.  Once this facility was available, it was expected that the age range for the programme would be expanded to include those aged 30-39 (currently around 48k residents).  It was suggested that a lot more needed to be done, particularly in relation to places like Botwell and Hayes, and that waiting another two years for the digital offer to come online was unacceptable. 


It was queried whether there had been a direct correlation identified between the NHS Health Checks being undertaken and positive health outcomes.  Ms Manvell advised that an NHS Health Check dashboard was being developed which would hopefully address this.


Professor Ian Goodman noted that it was going to be difficult to get those who most needed help, support and advice to have an NHS Health Check.  Fifty two years ago, Dr Julian Tudor Hart had recognised and referenced an Inverse Care Law whereby those who most needed medical care were least likely to receive it and those who needed it least would use health services more (and more effectively).  However, these residents would be more likely to engage if the information and education about healthy lives was taken out to them in their own environment.  Professor Goodman advised that he had engaged with a colleague who had spent a number of years implementing a scheme in Brazil and was now doing a similar thing in London. 


35% of those in Hillingdon that were eligible had not yet had a Health Check.  It would be important to target those residents that had not yet had one and to have that conversation about why it was important to identify health issues early.  The uptake in the more deprived communities needed to be increased as these were the residents that were more likely to have long term conditions.  Effort then needed to be made to ensure that support is available to those who needed it to reduce the risk of any conditions that were diagnosed. 


It was agreed that an update on the progress of this project be brought to the Board at its meeting on 7 March 2023.



Ms Shikha Sharma, Public Health Consultant at the London Borough of Hillingdon, advised that the obesity rates had increased in recent years, and so had the gap in rates between the most and the least deprived people.  Obesity was strongly linked to deprivation. In Hillingdon, the small areas of deprivation also had the highest obesity rates; which was of significance due to its negative impacts on health of the most vulnerable people. Nationally, hospital admissions due to obesity were shown to be 2.4 times higher in deprived areas. 


Consideration was now being given to understanding the current achievements in terms of preventing obesity and to determine the impact of actions that had been undertaken and the associated learning on a local and national level.  Local partners understood that obesity was a significant issue and, although there had been discussions and initiatives introduced to tackle obesity, there were still gaps.  A whole system approach that involved bringing everyone together across the system to identify areas for targeting (and working together to action those), was proposed.  In order for this to work, certain mindsets and behaviours would need to be promoted and adopted across the system. This would involve acting on wider environmental factors as tackling obesity was not just about diet and physical activity.


To tackle obesity, the population health management (PHM) methodology would be utilised where partners studied local data together to identify the individuals and then look at the risk factors and remove barriers.  Staff working in areas such as leisure services, healthcare and social care all needed to be confident in raising the issue of weight and should have knowledge of the interventions that were available to help.  It was suggested that tackling obesity was everyone’s responsibility. 


Ms Sharma advised that sufficient data was not currently collected in relation to who attended what activities in the Borough.  As such, it would be more difficult to motivate people to use services or to identify who the non-users were, which areas people lived in and whether or not they had the skills needed to be able to lose weight. The National Institute of Health and Care Research (NIHR) had identified interventions which had been successful and, if applied locally, would need to be monitored to identify their impact and effectiveness as well as identify what didn’t work. 


Nationally, there had been an increase in rates of people who were overweight and obese.  Although obesity rates for adults and children had appeared to have increased in Hillingdon too, due to interruption caused by COVID-19, there were gaps in the collection of local data (as in other boroughs nationally). As a result of the pandemic lockdowns and exclusion of ‘bubbles’, it had not been possible to measure children’s heights and weights and complete data to usual levels in schools. There was further evidence in the data of lifestyles related to diet and physical activity not improving in Hillingdon. As well as physical activity levels for children and adults in the Borough being significantly low, children’s dental health was poor and the uptake of 5-a-day was low.  The Population Health Management model would shift the focus to treating obesity as a chronic disease involving action on upstream measures across the identified population.


Data collection needed to be improved and residents’ engagement needed to be increased.  To this end, workshops would be scheduled to target areas where inequalities and obesity levels were comparatively high such as Hayes and Harlington, West Drayton and Yiewsley. 


The Health and Wellbeing Board was asked to provide leadership at place to implement a whole system approach for healthy weight through PHM.  Partners were supportive of stakeholder professionals to be involved in the PHM process and agreed that progress insight and recommendations for achieving whole system approach ambitions be reported back to the Health and Wellbeing Board at its meeting on 29 November 2022.


It was queried whether the action being undertaken now differed greatly to that taken five or ten years previously.  Ms O’Neill advised that reducing obesity was not just about looking to reduce how much someone ate / calorie intake but was also about the infrastructure that sat behind that.  The Council was deemed to be an enabler in relation to services such as planning, housing development, etc, and the NHS looked to promote health literacy, etc.  This all needed to be put together to produce better outcomes, whilst also understanding the drivers of obesity and barriers to losing weight (which included the increasing cost of healthy food versus something like a relatively cheap bucket of fried chicken). 


Activity that was already being undertaken to address obesity had been mapped out and gaps identified and filled.  However, more strategic oversight was needed.  The Council’s fortnightly senior manager meetings could be used to help position Public Health better within the local authority.  For example, it was recognised that housing maintenance covered a huge range of public health issues which could be included in the medium to long term transformation programme.  There were some policy decisions that would need to be made to enable work to be undertaken effectively and all partners needed to work together as a beacon. 


Although there appeared to be a lot of enthusiasm for the proposed way forward, concern was expressed that enthusiasm had not previously been enough to produce results.  Consideration would need to be given to what had worked before and prioritise what would give the biggest return and prove the most robust when evaluated.  Professor Goodman advised that colleagues at Brunel University were able to evaluate health interventions and would likely be happy to be involved. 


Councillor Sue O’Brien noted that the schools had a range of resources that could be used to tackle obesity such as Multi Use Games Areas (MUGAs).  She also queried what action Hounslow had taken that had resulted in significant improvements to obesity levels there.  Ms O’Neill advised that Hounslow had made a significant investment in tackling obesity.  Dedicated leads had put together ambitious plans that were then promoted to the LGA and London Councils to secure funding, which then attracted additional funding.  


It was agreed that an update on the progress of this project be brought to the Board at its meeting on 7 March 2023.


RESOLVED:  That the following be noted:

1)    the current status of the place-based PHM programme on falls and frailty commissioned by NWL in the Borough;

2)    discussions at the Health Protection Board that proposed:

a)    how we embed population health management in wider projects;

b)   how this approach can more efficiently become a systematic tool for improving outcomes in defined communities; and

c)    how we can best use the opportunities presented as part of the NWL ICB consultation on investing in PHM to tackle health inequalities at Borough level;

3)    two examples of public health focused work that were starting to use PHM as an approach to achieving improved outcomes and offer a different approach to two long-standing health needs to achieve more impact;

4)    an update on the progress of the Optum project be provided to the Board at its next meeting on 29 November 2022; and

5)    updates on the progress of the obesity and Health Check projects be considered by the Board at its meeting on 7 March 2023.

Supporting documents: