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Delivering triple prevention: a health system responsibility
Comment
Delivering triple prevention: a health system responsibility The aphorism that prevention is better than cure continues to grow in relevance. As populations become progressively plagued by multimorbidity and avoidable long-term disorders, the need to prevent illness is increasing. In England alone, almost one in five adults smoke,1,2 a third of men and half of women do not meet recommended levels of physical activity,2 and almost two-thirds of adults are overweight or obese.2 This is compounded by health inequality, with obesity prevalence in the most deprived decile of the population twice that in the least deprived decile.1 The pressures on health systems are clear; for example, obesity costs the National Health Service (NHS) in England almost £5 billion, and diabetes costs the NHS almost £10 billion, annually.2 As policy makers and administrators attempt to achieve fiscal sustainability for health systems, drastic upgrades in prevention to improve population health and moderate service demand are essential. A crosssectoral approach is needed, as outlined in the upcoming Government Childhood Obesity Strategy, from improved education, to active support from industry, and robust lifestyle modification. The NHS is launching a triple prevention strategy, which includes initiatives for patients, staff, and the public. This strategy aims to set an example for other sectors in England, as well as for other health systems worldwide.3 The first focus of triple prevention is patients. Although broad lifestyle recommendations such as sensible diet, ideal bodyweight, frequent exercise, and not smoking are helpful, targeted approaches in at-risk patients with specific long-term disorders can yield the greatest results. For example, targeted efforts to prevent type 2 diabetes have been widely supported.4 In 2002, a randomised controlled trial by the US-based Diabetes Prevention Program Research Group5 showed that lifestyle modification could reduce the incidence of type 2 diabetes by 58%, compared with a 31% reduction with metformin, over a mean follow-up of 2·8 years. The intervention was shown to be both safe and cost effective,5 and randomised controlled trials of similar interventions in several other countries have showed similar results. The challenge of implementing such programmes has been politico-economic. Prevention requires health systems able to capture the benefits of reduced disease
prevalence and service demand, with robust primary care services able to deliver it—unfortunately a rare combination worldwide. However, the single-payer nature of the NHS, coupled with policy alignment generated by the NHS Five Year Forward View—our roadmap for the health system—has enabled a national Diabetes Prevention Programme to be established, set to enrol 10 000 people in 2016 and then be scaled up.1,6 Other health systems, especially those offering universal coverage, could deliver similar programmes. Indeed, Finland, which has a largely public-funded universal health system, has established its own diabetes prevention programme. The second focus of triple prevention is health-care staff. As efforts to improve system productivity and performance increase, so should the emphasis on staff health and wellness. When health-care organisations prioritise staff health, performance is enhanced, patient care improves, staff retention increases, and absence due to sickness is reduced.7 However, more than 700 000 NHS staff are overweight or obese, the rate of sickness-related absence in the NHS (4·1%) is 27% higher than the UK public sector average, and threequarters of hospitals do not offer healthy food to staff who work night shifts.8 The financial implications are substantial, with the annual cost of sickness-related absences in the NHS alone exceeding £2·4 billion. Health systems should lead by example to improve workplace wellness. Advocating prevention while hosting an unhealthy food environment on hospital premises is unacceptable. To address this problem in the NHS, we have launched a national £600 million incentive to drive delivery of workplace wellness. This incentive will be included in NHS commissioning contracts to encourage NHS hospitals and providers to prioritise the health of staff. We have also established a staff wellness programme, starting with 12 hospital trusts and covering more than 70 000 employees.9 Board-level leads at each organisation champion this agenda, visibly building engagement across their organisations. Training is offered to line managers to equip them to deliver health and wellbeing changes for staff. To support individual staff, the NHS Health Check has been made available to staff aged 40 years or older, and staff have been given access to services such as
www.thelancet.com/diabetes-endocrinology Published online March 8, 2016 http://dx.doi.org/10.1016/S2213-8587(16)00073-5
Lancet Diabetes Endocrinol 2016 Published Online March 8, 2016 http://dx.doi.org/10.1016/ S2213-8587(16)00073-5
1
Justine Davies
Comment
physiotherapy, smoking cessation, and evidence-based weight management services. The third focus of triple prevention is visitors and the public. Health systems have a responsibility to create healthy environments for visitors and the public, encouraging evidence-based lifestyle modification while setting an example to other sectors. In the UK, sugarsweetened beverages are the largest source of added sugar (roughly 30% of all added sugar) for children, and the second largest in adults.10 Consumption of sugarsweetened beverages is an important contributor to obesity in children and adults, and has also been linked to an increased risk of type 2 diabetes.11 However, sugarsweetened beverages are widely sold on NHS premises, together with foods high in fat, sugar, and salt. To address this issue, the NHS is taking drastic measures to create a model environment for visitors and the public. The NHS is the first health system to consult on the introduction of a sugar tax, possibly in the form of a fee to be paid by vendors for each sugarsweetened beverage sold. We are also introducing a rolling programme of contract renegotiation with food and drink providers on NHS premises. As contracts and franchises approach renewal, efforts will be made to restrict or remove the unhealthiest foods from vending machines and shops, to offer healthier, affordable alternatives, and to eliminate promotions of unhealthy products. Finally, we are consulting on the content of new, enhanced mandatory hospital food standards for 2
patients, staff and visitors, enforced through the NHS standard contract, including phased food reformulation to systematically reduce added sugar. These interventions have been established in the past year. Effective delivery and robust assessment of costeffectiveness and outcomes will be essential to ensure success. Theoretically, the tax-funded, single-payer NHS enables preventive initiatives to be rolled out across the system; however, implementation has been limited by fragmented pools of funding. Five strategies will therefore be key to delivering triple prevention. First, dedicated funding is essential to rapidly introduce momentum to an otherwise neglected objective: prevention. NHS England has invested in its Diabetes Prevention Programme and Workplace Wellness initiative nationally, enabling prioritisation. Second, because effective prevention needs to involve multiple stakeholders and be built into local communities, relevant delivery partners and advocates of prevention should work in alignment. The Diabetes Prevention Programme is being implemented collaboratively by NHS England, Public Health England, and the patient charity Diabetes UK, with expressions of interest from local NHS clinical commissioning groups, local government, and primary care practices, building alignment between local, regional, and national partners.6 Downstream rewards of prevention such as alleviation of operational demand and conservation of fiscal supply, are only realised in an integrated system. The third strategy is therefore to dissolve boundaries between primary and specialist services, and between health and social care. A parallel shift from individual organisation accountability to accountability spanning all service providers in a locality is needed, with mutual, fixed responsibility over their population cohort and capitated, pooled budgeting. Such architecture, similar to an accountable care organisation, disincentivises unnecessary use of health services and rewards payers and providers for preventive efforts.2 Fourth, infrastructure and culture should be improved in tandem. Without effective clinical engagement, enrolment into employer wellness programmes and referral of patients to relevant preventive initiatives will be poor. Changes in professional education, accreditation, training, and guidelines should be introduced to ensure clinicians are incentivised and enabled to drive prevention efforts.
www.thelancet.com/diabetes-endocrinology Published online March 8, 2016 http://dx.doi.org/10.1016/S2213-8587(16)00073-5
Comment
Finally, efforts are needed to scale-up triple prevention initiatives. Although our Diabetes Prevention Programme is due to enrol 10 000 people in its first year and our Workplace Wellness initiative covers more than 70 000 employees, almost 5 million people have prediabetes in England, and there are 1·3 million NHS employees in the country.1 Robust approaches to roll-out should be in place at the start of design and delivery to ensure appropriate scale-up. Delivery of triple prevention is essential. Health systems are facing unprecedented demand due to growing, ageing populations burdened by increasing long-term disorders. Health systems have a responsibility to improve the health of patients, staff, and the public, to lead by example, and to achieve sustainability. Prevention is the primary means by which these ambitions can be simultaneously achieved, enabling populations to enjoy the improvements in health and longevity that they have rightly come to expect.
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Mahiben Maruthappu
NHS England, Health Education England, Trust Development Authority, Public Health England, Monitor, Care Quality Commission. Five Year Forward View. London: NHS England, 2014. https://www.england.nhs.uk/ wp-content/uploads/2014/10/5yfv-web.pdf (accessed Feb 18, 2016). Public Health England. Annual report and accounts 2014/15. https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/449365/Annual_report_29july-WEB-final.pdf (accessed Feb 2, 2016). Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff 2008; 27: 759–69. Knowler WC, Barrett-Connor E, Fowler SE, et al. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346: 393–403. Diabetes Prevention Program Research Group. The 10-year cost-effectiveness of lifestyle intervention or metformin for diabetes prevention: an intent-to-treat analysis of the DPP/DPPOS. Diabetes Care 2012; 35: 723–30. Maruthappu M, Sood H, Keogh B. Radically upgrading diabetes prevention in England. Lancet Diabetes Endocrinol 2015; 3: 312–13. Boorman S. NHS and wellbeing: final report. London: The Stationery Office, 2009. Cross-Government Obesity Unit. Healthy weight, healthy lives: one year on. London: HM Government, 2009. Maruthappu M, Sood H, Black C. Prioritising prevention and the health of NHS staff. Lancet 2015; 386: 1322–23. NatCen Social Research, MRC Human Nutrition Research, University College London. Medical school, national diet and nutrition survey years 1–4, 2008/09–2011/12. 7th edn. Colchester: UK Data Archive, 2015. Pan A, Malik VS, Hao T, Willett WC, Mozaffarian D, Hu FB. Changes in water and beverage intake and long-term weight changes: results from three prospective cohort studies. Int J Obes 2013; 37: 1378–85.
Chief Executive’s Office, NHS England, London SW1 6LH, UK [email protected] I serve as Senior Fellow to the Chief Executive of NHS England, advising on prevention. I co-founded the NHS Diabetes Prevention Programme and the NHS Workplace Wellness Programme, designed the NHS Sugar Tax and led the NHS contribution to the Government’s Childhood Obesity Strategy.
www.thelancet.com/diabetes-endocrinology Published online March 8, 2016 http://dx.doi.org/10.1016/S2213-8587(16)00073-5
3
Delivering triple prevention: a health system responsibility The aphorism that prevention is better than cure continues to grow in relevance. As populations become progressively plagued by multimorbidity and avoidable long-term disorders, the need to prevent illness is increasing. In England alone, almost one in five adults smoke,1,2 a third of men and half of women do not meet recommended levels of physical activity,2 and almost two-thirds of adults are overweight or obese.2 This is compounded by health inequality, with obesity prevalence in the most deprived decile of the population twice that in the least deprived decile.1 The pressures on health systems are clear; for example, obesity costs the National Health Service (NHS) in England almost £5 billion, and diabetes costs the NHS almost £10 billion, annually.2 As policy makers and administrators attempt to achieve fiscal sustainability for health systems, drastic upgrades in prevention to improve population health and moderate service demand are essential. A crosssectoral approach is needed, as outlined in the upcoming Government Childhood Obesity Strategy, from improved education, to active support from industry, and robust lifestyle modification. The NHS is launching a triple prevention strategy, which includes initiatives for patients, staff, and the public. This strategy aims to set an example for other sectors in England, as well as for other health systems worldwide.3 The first focus of triple prevention is patients. Although broad lifestyle recommendations such as sensible diet, ideal bodyweight, frequent exercise, and not smoking are helpful, targeted approaches in at-risk patients with specific long-term disorders can yield the greatest results. For example, targeted efforts to prevent type 2 diabetes have been widely supported.4 In 2002, a randomised controlled trial by the US-based Diabetes Prevention Program Research Group5 showed that lifestyle modification could reduce the incidence of type 2 diabetes by 58%, compared with a 31% reduction with metformin, over a mean follow-up of 2·8 years. The intervention was shown to be both safe and cost effective,5 and randomised controlled trials of similar interventions in several other countries have showed similar results. The challenge of implementing such programmes has been politico-economic. Prevention requires health systems able to capture the benefits of reduced disease
prevalence and service demand, with robust primary care services able to deliver it—unfortunately a rare combination worldwide. However, the single-payer nature of the NHS, coupled with policy alignment generated by the NHS Five Year Forward View—our roadmap for the health system—has enabled a national Diabetes Prevention Programme to be established, set to enrol 10 000 people in 2016 and then be scaled up.1,6 Other health systems, especially those offering universal coverage, could deliver similar programmes. Indeed, Finland, which has a largely public-funded universal health system, has established its own diabetes prevention programme. The second focus of triple prevention is health-care staff. As efforts to improve system productivity and performance increase, so should the emphasis on staff health and wellness. When health-care organisations prioritise staff health, performance is enhanced, patient care improves, staff retention increases, and absence due to sickness is reduced.7 However, more than 700 000 NHS staff are overweight or obese, the rate of sickness-related absence in the NHS (4·1%) is 27% higher than the UK public sector average, and threequarters of hospitals do not offer healthy food to staff who work night shifts.8 The financial implications are substantial, with the annual cost of sickness-related absences in the NHS alone exceeding £2·4 billion. Health systems should lead by example to improve workplace wellness. Advocating prevention while hosting an unhealthy food environment on hospital premises is unacceptable. To address this problem in the NHS, we have launched a national £600 million incentive to drive delivery of workplace wellness. This incentive will be included in NHS commissioning contracts to encourage NHS hospitals and providers to prioritise the health of staff. We have also established a staff wellness programme, starting with 12 hospital trusts and covering more than 70 000 employees.9 Board-level leads at each organisation champion this agenda, visibly building engagement across their organisations. Training is offered to line managers to equip them to deliver health and wellbeing changes for staff. To support individual staff, the NHS Health Check has been made available to staff aged 40 years or older, and staff have been given access to services such as
www.thelancet.com/diabetes-endocrinology Published online March 8, 2016 http://dx.doi.org/10.1016/S2213-8587(16)00073-5
Lancet Diabetes Endocrinol 2016 Published Online March 8, 2016 http://dx.doi.org/10.1016/ S2213-8587(16)00073-5
1
Justine Davies
Comment
physiotherapy, smoking cessation, and evidence-based weight management services. The third focus of triple prevention is visitors and the public. Health systems have a responsibility to create healthy environments for visitors and the public, encouraging evidence-based lifestyle modification while setting an example to other sectors. In the UK, sugarsweetened beverages are the largest source of added sugar (roughly 30% of all added sugar) for children, and the second largest in adults.10 Consumption of sugarsweetened beverages is an important contributor to obesity in children and adults, and has also been linked to an increased risk of type 2 diabetes.11 However, sugarsweetened beverages are widely sold on NHS premises, together with foods high in fat, sugar, and salt. To address this issue, the NHS is taking drastic measures to create a model environment for visitors and the public. The NHS is the first health system to consult on the introduction of a sugar tax, possibly in the form of a fee to be paid by vendors for each sugarsweetened beverage sold. We are also introducing a rolling programme of contract renegotiation with food and drink providers on NHS premises. As contracts and franchises approach renewal, efforts will be made to restrict or remove the unhealthiest foods from vending machines and shops, to offer healthier, affordable alternatives, and to eliminate promotions of unhealthy products. Finally, we are consulting on the content of new, enhanced mandatory hospital food standards for 2
patients, staff and visitors, enforced through the NHS standard contract, including phased food reformulation to systematically reduce added sugar. These interventions have been established in the past year. Effective delivery and robust assessment of costeffectiveness and outcomes will be essential to ensure success. Theoretically, the tax-funded, single-payer NHS enables preventive initiatives to be rolled out across the system; however, implementation has been limited by fragmented pools of funding. Five strategies will therefore be key to delivering triple prevention. First, dedicated funding is essential to rapidly introduce momentum to an otherwise neglected objective: prevention. NHS England has invested in its Diabetes Prevention Programme and Workplace Wellness initiative nationally, enabling prioritisation. Second, because effective prevention needs to involve multiple stakeholders and be built into local communities, relevant delivery partners and advocates of prevention should work in alignment. The Diabetes Prevention Programme is being implemented collaboratively by NHS England, Public Health England, and the patient charity Diabetes UK, with expressions of interest from local NHS clinical commissioning groups, local government, and primary care practices, building alignment between local, regional, and national partners.6 Downstream rewards of prevention such as alleviation of operational demand and conservation of fiscal supply, are only realised in an integrated system. The third strategy is therefore to dissolve boundaries between primary and specialist services, and between health and social care. A parallel shift from individual organisation accountability to accountability spanning all service providers in a locality is needed, with mutual, fixed responsibility over their population cohort and capitated, pooled budgeting. Such architecture, similar to an accountable care organisation, disincentivises unnecessary use of health services and rewards payers and providers for preventive efforts.2 Fourth, infrastructure and culture should be improved in tandem. Without effective clinical engagement, enrolment into employer wellness programmes and referral of patients to relevant preventive initiatives will be poor. Changes in professional education, accreditation, training, and guidelines should be introduced to ensure clinicians are incentivised and enabled to drive prevention efforts.
www.thelancet.com/diabetes-endocrinology Published online March 8, 2016 http://dx.doi.org/10.1016/S2213-8587(16)00073-5
Comment
Finally, efforts are needed to scale-up triple prevention initiatives. Although our Diabetes Prevention Programme is due to enrol 10 000 people in its first year and our Workplace Wellness initiative covers more than 70 000 employees, almost 5 million people have prediabetes in England, and there are 1·3 million NHS employees in the country.1 Robust approaches to roll-out should be in place at the start of design and delivery to ensure appropriate scale-up. Delivery of triple prevention is essential. Health systems are facing unprecedented demand due to growing, ageing populations burdened by increasing long-term disorders. Health systems have a responsibility to improve the health of patients, staff, and the public, to lead by example, and to achieve sustainability. Prevention is the primary means by which these ambitions can be simultaneously achieved, enabling populations to enjoy the improvements in health and longevity that they have rightly come to expect.
1
2
3 4
5
6 7 8 9 10
11
Mahiben Maruthappu
NHS England, Health Education England, Trust Development Authority, Public Health England, Monitor, Care Quality Commission. Five Year Forward View. London: NHS England, 2014. https://www.england.nhs.uk/ wp-content/uploads/2014/10/5yfv-web.pdf (accessed Feb 18, 2016). Public Health England. Annual report and accounts 2014/15. https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/449365/Annual_report_29july-WEB-final.pdf (accessed Feb 2, 2016). Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff 2008; 27: 759–69. Knowler WC, Barrett-Connor E, Fowler SE, et al. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346: 393–403. Diabetes Prevention Program Research Group. The 10-year cost-effectiveness of lifestyle intervention or metformin for diabetes prevention: an intent-to-treat analysis of the DPP/DPPOS. Diabetes Care 2012; 35: 723–30. Maruthappu M, Sood H, Keogh B. Radically upgrading diabetes prevention in England. Lancet Diabetes Endocrinol 2015; 3: 312–13. Boorman S. NHS and wellbeing: final report. London: The Stationery Office, 2009. Cross-Government Obesity Unit. Healthy weight, healthy lives: one year on. London: HM Government, 2009. Maruthappu M, Sood H, Black C. Prioritising prevention and the health of NHS staff. Lancet 2015; 386: 1322–23. NatCen Social Research, MRC Human Nutrition Research, University College London. Medical school, national diet and nutrition survey years 1–4, 2008/09–2011/12. 7th edn. Colchester: UK Data Archive, 2015. Pan A, Malik VS, Hao T, Willett WC, Mozaffarian D, Hu FB. Changes in water and beverage intake and long-term weight changes: results from three prospective cohort studies. Int J Obes 2013; 37: 1378–85.
Chief Executive’s Office, NHS England, London SW1 6LH, UK [email protected] I serve as Senior Fellow to the Chief Executive of NHS England, advising on prevention. I co-founded the NHS Diabetes Prevention Programme and the NHS Workplace Wellness Programme, designed the NHS Sugar Tax and led the NHS contribution to the Government’s Childhood Obesity Strategy.
www.thelancet.com/diabetes-endocrinology Published online March 8, 2016 http://dx.doi.org/10.1016/S2213-8587(16)00073-5
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