Using Data to Drive Activity in East Suffolk

Nicole Rickard, Head of Communities and Leisure, East Suffolk Council and Jep Ronoh, Consultant in Public Health Medicine, Suffolk County Council

Context

• Two Integrated Care Systems – Norfolk and Waveney / Suffolk and North East Essex (SNEE)
• Eight Community Partnerships to maintain our connection to our communities
• Data (and insight) led priority setting and problem solving
• Three Integrated Neighbourhood Teams (south of the District - the five CPs in this area ‘nest’ into these)

• CP map

• Ageing Population – more than one in four are aged 65 and over
• Limited ethnic diversity – 96.2% of the population is White, compared to 93.1% in Suffolk and 81% in England
• More than 30,000 people live in ‘Core 20’ areas
• More people in East Suffolk are affected by income deprivation than in Suffolk overall – 11.5% (10.1%)
• Life expectancy gaps within the district of 9.3 years for Men and 10.1 years for Women
• 20%+ say that their lives are limited a lot or a little by a long-term health condition or disability (higher than Suffolk and England)
• Fewer with qualifications at Level 3/4 than national average, almost 20% of the 16-64 population have no qualifications
• Activity levels in children lower than average and obesity higher
• Gross weekly pay for full time workers in 2023 was £633.80 compared to £705.70 in England
• Homelessness is rising and the social housing waiting list shows the gap between housing supply and demand
• Many homes need upgrades to remain suitable due to poor energy performance, cold and damp

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Ease the Squeeze and Community Help Hub – responding to the Cost-of-Living crisis

DATA: Impact of cost of living - rising numbers on Universal Credit (in and out of work) and increased use of food banks

Well Minds East Suffolk

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DATA: QOF Framework shows higher than average levels of depression at eight GP practices

• 150 half-day The Essentials training places delivered by Suffolk Mind for voluntary organisations and community groups
• Mental Health First Aid three-day courses
• Well Minds East Suffolk Booklet – hard copies and online version

Keep Warm and Well (Warm Homes) pilot with N&W ICB/Great Yarmouth BC

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DATA: PHM data about residents Over 65 and under 14 with respiratory conditions and admission in last 6 months

• Pilot across GY and Waveney ‘Place’
• ICB data about respiratory conditions and recent hospital admissions
• Mapped against Suffolk Warm Homes data about residents living in homes with an E, F and G rating
• 409 calls made by the ICB Protect Now Team
• 98 referrals to ESC Community Help Hub for pro-active contact

Case Study:�Woodbridge INT WHAT Project

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Using PHM data, the Woodbridge INT identified that the older people of Woodbridge have above average falls. They introduced Woodbridge Holistic Assessment Team (WHAT) assessment days where target patients could meet with a range of professionals to develop a preventative ‘care plan’. 

Services offered: Medication review, Assessments of bone health and strength, gait, and balance, Measurement of weight and height, and blood pressure lying/standing.

Teams involved: Access to professionals on rotation, including nurse, physiotherapist, occupational therapist, podiatrist, pharmacist, social prescriber. 

Immediate benefit to patients:  

•   “As a result of attending today I will use a walker”.
• “I will get bars put in the bathroom and be more tidy”.
• “Confidence…I will walk more rather than move more”.

Outcome: All interventions had a positive impact (i.e. cost savings outweigh the cost of implementation)

DATA: PHM data pack produced for the INT

Feel Good Suffolk

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• Suffolk District & Borough Councils in partnership with SCC Public Health and health sector delivering healthy lifestyle services - Smoking Cessation, Physical Activity, and Healthy Weight.
• Funding based on population health management data and prevalence of smokers, physical inactivity, and obesity.
• Referral rates reflect prevalence and populations – highest rates are within East Suffolk (32%), with Lowestoft (36%) and Felixstowe (26%) the largest numbers of referrals.

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• Public Health Management data and population estimates have guided which groups to target – such as Routine and Manual workers (high smoking prevalence) and those with disabilities or long-term health conditions (high prevalence of physical inactivity)
• Since launching on 1^st Oct 2023, we’ve used referral/outcome data to guide resource levels required to deliver and ensure the effectiveness of our interventions

DATA: PHM data pack produced by ICB partners combining health and population data

Holiday Activities and Food (HAF) Programme

• Target cohort is families on Free School Meals – additional focus on 23 LSOAs with most FSM children
• Provision in the Easter, Summer and Christmas holidays – minimum 4 hours a day plus food (ideally a hot meal)
• Easter 2024 – 35 programmes, 3136 places
• Range of providers from very local to national organisations
• Wraparound support e.g. breakfast, meal kits, cooking sessions, connections into additional support as needed

DATA: Free School Meals data

Public Mental Health programme

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DATA: PHM Report for Suffolk and Public Health Report 2022. Suffolk Mind Emotional Needs Audit

• Four pilot areas in East Suffolk – Lowestoft, Beccles, Felixstowe (Core 20 populations), plus a rural CP area
• Emotional Needs Audit – Suffolk-wide but boosted in pilot areas
• Report for each area produced by Suffolk Mind/SCC
• SCC COMF funding to create £50k pot for projects per area:
• Felixstowe Wellbeing Hub
• Beccles Hub coordinator
• Early intervention ambassadors
• Mental Health First Aid and Suicide bereavement training
• CTEA Befriending programme
• Community Chinwags
• CAP financial support/life skills

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*Sarah* attended a Well Child Support group due to challenges with wellbeing and early stages of self-harm: “Each week she comes out with something she has made - she loves it. I think the support that she got was through being able to talk to the facilitators…but also just being in a friendly happy place where she could be herself”

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Suffolk Positive Futures delivered a weekly boxing session for young people, initially at Ormiston Denes High School and then Ultimate Boxing Gym: “I have really enjoyed the boxing sessions, they give me a chance to be active and try a new activity I had not thought about trying before. The boxing coaches take an interest in each of us and make us feel welcome”

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Alan attended an ActiveLives seated exercise class in Felixstowe: “I look forward to the class with enthusiasm each week. It is helping me to cope better with my arthritis which is very painful. The exercises not only make me physically stronger, but have improved my emotional and mental wellbeing enormously, due to family issues beyond my control”

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�Lowestoft Healthy Hearts ��DATA sources used to inform project: �Census, OHID –Fingertips, Place Based Needs Assessment (QOF), NHS RightCare (Future NHS), 2022 Annual Public Health Report (APHR), CVD Prevent, PHM data, Community Voices

• Project aims to address health inequalities in Lowestoft
• Focus on cardiovascular disease (CVD) risk factors – hypertension
• Anticipated outcomes
• Reduce morbidity and mortality from cardiovascular disease in our most deprived communities.
• Increase the diagnosis of hypertension
• Optimise hypertension management.
• Reduce barriers to accessing healthcare
• Empower Lowestoft residents to make healthy behaviour choices which have an impact on heart health
• Phased approach
• Community Voices (engagement)
• Lowestoft Healthy Hearts (interventions)

�Why Lowestoft?

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DATA: 2021 APHR, PBNA, OHID (Fingertips)

CVD Prevent: Lowestoft PCN is an outlier for hypertension diagnosis and management, obesity prevalence, and smoking prevalence

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Why Lowestoft?����

Lowestoft

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Rest of Waveney

DATA: OHID – Local Health

Lowestoft performs worse than the rest of the Waveney area on many health indicators

Why hypertension?

DATA: OHID – Segment Tool

Cardiovascular disease is one of the biggest drivers of life expectancy gap between the most deprived and the least deprived quintiles in Suffolk by cause of death.

�Why hypertension?

• Hypertension is the largest single known risk factor for cardiovascular disease and related disability.
• There is evidence that action to lower blood pressure does reduce the risk to health. For example, a major systematic review in the Lancet found that in the populations studied, every 10mmHg reduction in blood pressure resulted in a:
• 17% reduction for coronary heart disease
• 27% reduction for stroke
• 28% reduction for heart failure
• 13% reduction in all-cause mortality
• 4 in 10 adults with hypertension are aware of their condition and are managing it optimally
• In line with CORE20PLUS5 targets, it vital to target the 20% most deprived and PLUS populations (e.g., minority ethnic communities) - otherwise we risk increasing inequalities..

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Finding and treating people with high blood pressure is arguably the most effective way to prevent heart attacks, strokes, cognitive decline and premature death and disability.

SOURCE: Health matters: combating high blood pressure - GOV.UK (www.gov.uk), Tackling high blood pressure, PHE 2014, NHS England » Core20PLUS5 infographic – Adult

Why hypertension?������

Hypertension is also a “doorway” …

An opportunity to: 

• Address underlying risk factors and wider determinants of health, further reducing CVD risk
• Stress
• Overweight
• Smoking 
• Deprivation
• Diet 
• Personalise and co-ordinate and manage care of those with comorbidity.
• Prevent other major conditions developing

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DATA: PHM

Many people with hypertension also have underlying comorbidities (e.g. diabetes, CKD, obesity) and other CVD risk factors

��Community Voices�������

• Face to face engagement with residents in a range of community hubs across the town.
• Working with 5 VCFSE organisations hosting trained community champions.
• Understand what is important to Lowestoft residents
• Gauge understanding of CVD and its risk factors
• Understand “health(y) behaviours”
• Gain insight to inform the design of a LHH programme
• 55 conversations recorded as at 7 May 2024 – 75% with individuals, 25% with groups, 136 people in total engaged, majority 45-54yrs.

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DATA: Anonymized community conversations captured and fed into Norfolk & Waveney ICB Community Voices Insight Bank (Power BI database)

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��Community Voices�������

DATA ANALYSIS: Nvivo analysis to give insight for service development.

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Free text categorised using COM-B components and barriers / enablers

��Community Voices�������

DATA ANALYSIS: Nvivo analysis to give insight for service development.

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Free text categorised using COM-B components and barriers / enablers

��Community Voices�������

DATA ANALYSIS: Nvivo analysis to give insight for service development.

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Free text categorised using COM-B components and barriers / enablers

��Lowestoft Healthy Hearts (Interventions)��DATA: �Community Voices�PHM�Eclipse�UCL Framework�QoF�CVD Prevent�