Agenda item

To receive a Population Health Management update from David Cummings and Alan Bell, NENC ICB Northumberland Place.

Members received a Population Health Management update from David Cummins and Alan Bell, NENC ICB Northumberland Place.

The following key issues were raised:-

•        The seven Primary Care Networks in Northumberland had each identified a project(s) which they would be focus on.  These included child poverty, obesity, smoking and cancer.

•        In areas of the South East of Northumberland, there were significant levels of inequalities, deprivation and low income.  For example, average household income after tax in Morpeth was £44,000 compared to £26,000 in Ashington.  There were big gaps in life expectancy for both men and women between different parts of the county.

•        PCN population health management projects were detailed as follows and each was assigned a Public Health Consultant

•        Cramlington/Seaton Valley – Chronic disease/depression.  100-150 patients aged 35-65 living within the most deprived decile and suffering with depression and CVD/COPD would be invited to be part of the project.

•        Valens – Frequent Flyers (High Intensity Users) – 433 patients with 10+ GP appointments in the last 12 months.  Provide with bespoke intervention such as links with local pharmacies and practice nurse etc.

•        Wansbeck – Child Poverty – Hotspots in Hirst and Ashington Central and focus on 15 patients aged 11-12).  Child poverty in Wansbeck 26% compared to the national average of 17%.  Multiple stakeholders including Cygnus Support, local regeneration groups, safeguarding team and CAB.

•        Well Up North – Obesity – Targeting parents of children in top 20% of weight.  Workshops with stakeholders had been held.  Referrals from Health Visitors, school nurses, early years settings, GPs etc.

•        Northumbria – Smoking/Cancer – Focus on deprived areas of Cramlington and variable uptake of cancer screening.  Hope to identify a vulnerable cohort for the project.

•        West – Alcohol Identification and Brief Advice – Focus on 30-60 patients with BMI of 30+ and anxiety.  Cohorts less likely to be asked about alcohol to be identified.  Include Mental Health practitioners and include the Northumberland Recovery Project.

•        Blyth – A&E attendances (0-4 years).  There had been a significant increase in the number of A&E and Urgent Care attendances.  Focus on Cowpen and Kitty Brewster which had the highest rates.  Engaging with families to find why they are using A&E and using Healthwatch to survey families.  Secondary focus on childhood obesity

•        Common themes running throughout the projects were data sharing/access to data/analysis of data/complexity and engagement.  It was hoped to get data sharing agreements in place.

•        Next steps and conclusions

•        Wide range of projects which support the inequalities agenda

•        PCN workshop planned for October with an opportunity to share initial learning

•        Importance of long-term data sharing agreements/MOUs between all health and care providers.

The following comments were made:-

•        Patient Participation Groups could have an important role in engagement within each PCN.  Their involvement would be raised with the leader of each project.  Within the Valens PCN, there was a move towards the PPG changing its focus to health inequalities

•        It was important that this work along with the Health Inequalities Plan dovetailed and that neither went off at a tangent.

•        Many of the projects aligned closely with thematic leads within the restructuring and remodelling of the 0-19 service.  Key posts would be appointed to including a community anchor post which would develop partnerships and ensure strong links with all partners.  There needed to be a single point of contact within the 0-19 service.

•        Monitoring progress was important, and the Health & Wellbeing Board was the ideal body to do this.  Remaining focused on the issues in hand was vital.

•        Work was already ongoing regarding the low level of uptake of benefits and helping individuals to make claims.  It was hoped that benefit advisers would have a presence in GP surgeries.

•        Childhood obesity was a very complex area.

•        Data sharing issues were currently hindering the projects and it was a tricky problem to resolve.  A solution would be found with support from all involved.

The Chairman thanked Alan Bell and David Cummins for their presentation.

RESOLVED that

(1)       the presentation be received

(2)       regular updates be received every three months.