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NICON24 Day 1 - Video 2 (Prevention - Planting our Docken Leaves)

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NICON24 Day 1 - Video 2

'Prevention - Planting our docken leaves' (parallel session), with Danny Moore, Strategic Account Director, Novartis (Session Chair); Professor Joanne McClean, Director of Public Health, Public Health Agency; Lord Victor Adebowale, Chair, NHS Confederation; and Heather Reid, Director of Nursing and AHPs, Public Health Agency

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Event summary:

NICON24 'Grasping the Nettle' was the premiere event for HSC leaders and partners in Northern Ireland, bringing more than 700 delegates together to discuss how to secure the best health and care outcomes.

We had an exciting and packed agenda at this year’s conference, which took place on 16 and 17 October 2024. Seeking to address the immense pressures in the system, we used our time together to explore what we can do, working creatively and collaboratively to agree which nettles to grasp to best support progress.

We have now made recordings of the mainstage sessions available across both days of the conference.

Learning objectives

  1. Understand current investment in preventative medicine, as well as the direct and indirect funding structure for health prevention in Northern Ireland and England.
  2. Learn about the Public Health Agency and its strategy for addressing health inequality and its focus in Northern Ireland.
  3. Analyze the inverse care law and how this relates to a population's health needs.
  4. Gain knowledge about the effectiveness and current challenges of integrated care systems, their governance, and their focus on prevention.
  5. Recognize the potential of collaboration with the pharmaceutical industry and its role in a secondary prevention agenda.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

So welcome everybody. This is our session on prevention and planting our dock leaves. It's a thorny and sort of a long established nettle that will be grasping this afternoon when we look at prevention. And I think it's fair to say there's a lot going on in this space. So there's a new program for government, there's the refresh of making lives better. We've got a new integrated care system, we've got the new ministers live better initiative that will be coming up and there's a big and huge drive on population health. So all in all huge topic and one that we want to sort of get her eye in today just to sort of set our focus. We know that prevention. There's a big part of that reflecting health inequality and inequity. We heard from the minister before that around 20% of people's health determinants relate directly to health rather than the sort of broader social determinants. And for this session, we're going to really focus in on that 20%. That's the focus and the aim of the session is to bring us up to speed. We're going to hear from the top. We're going to hear from Public health Agency and Victor and others that I'll introduce in a moment around some of their thoughts on prevention and for leadership and then we really want to stop there and open it up for AQ and, and have hopefully an engaging discussion. So that's a little bit the format. The aims are really to come out with a few tangibles and some ideas on how we address prevention. It's a massive topic, there's a few different areas on it. So is the funding balance, right? That's something for us to think about. If you look at the funding in Northern Ireland, which is 7.27 0.8 billion lbs, the funding goes in. If you look at the direct funding for prevention, we're talking around 2% 150 million indirect funding. There's obviously a broader agenda there. That's similar to England where it's 5% direct funding on prevention. Is that balance, right? How does that affect, how would it be best spent? So that's our focus. We've got a few different key topic areas. So I'm going to just very quickly headline our panel and then we're going to hear from them in turn and then we'll go to questions. So to my right, Aman, it needs very little introduction. We've got Lord a who's joined us here is going to share a little bit about the England experience. Some of the work the icss have done already. Maybe a bit from the report and thoughts. We're looking enough to have Professor Joanne mclean, Director of the Public Health Agency here in Northern Ireland to talk to us about the massive impact that health inequality has and a little bit about what's the strategy, the plan and where we're at and what our sites focused on here in Northern Ireland. And then also we've got Heather Reid, great to have Heather here, Director of Nursing and PA PA. And she's going to talk to us a little bit about collaboration and the roles of different sectors as well as a sort of key focus for her team. Shes and just on the collaboration front, I guess, just to talk a little bit about why no art is here and why is the conference sponsored by the AB and what's the role that we bring? So I think collaboration is probably the number one call out you may have heard from, from an ABPI perspective. You know, the industry are not looking to just sell medicines, they're looking at an overall care pathway. And if you haven't partnered with the pharmaceutical industry before you may be used to partner with other sectors, then there's a call out to explore it. There's a recent publication, a joint publication from the Confed NHS Confed and the ABPI that sets about a route map of how to partner with industry. It's got live examples in there, but it's also got a really handy sort of governance model that you can explore if you want to move partnership forward. There was also a really great report by far or CF in England and the ABPI looking at those areas in the NHS that partnered with the pharmaceutical industry and other tech, life sciences, tech industries had better outcomes for their patients better, doing some nice guidance and standards and actually were delivering more in terms of what they needed to do for their local population. So that's my call out is to think about this prevention agenda. Think about secondary prevention, think about the role the pharmaceutical can play as well. But more to the point, let's hear from our experts and the panel and I'd like to start with Victor and as we thought and prevention, I'm always worried about call an expert on anything. Um My observation, I'm just making my observation. There's nobody, not many people in this room isn't there? Given it's one, the one pillar of the whole left shift. I'm just perhaps we might discuss why that is, it could be me, which is quite possible, but I just think it's a bit odd. Hm. Anyway, I have the following views on prevention. First of all, we're at the foothills of doing it, the incentives that we have across the health system tend to move in the opposite direction partly because it's hard to measure prevention. And the Treasury don are a bit skeptical about whether how you count it and how you account for it. So we've tended to avoid it, but the whole NHS was actually predicated on the notion of prevention, you know, mainly the prevention of death but ill health over a long time. Um, and we've, we've kind of failed to do that, I would say. So the shift that we are all involved in making is quite a big one actually, um, towards prevention and the following things that, that we need to do those practical things, to be honest. And we were talking about one of them Children and young people, you know, um I'm pretty clear and I'm thinking the evidence, you can tell me that I'm wrong, but I'm pretty clear, the evidence is pretty clear that if you make the intervention in the first five years, you reap the benefits of the next five, which is in the lifetime of a parliament if you intervene with Children now and you don't even have to do it everywhere. You need to do progressive universalism. Well, do do it in the places that need it most. You would reap the most benefits. The other is of course the ever present inverse care law which states that those in need of health and social care the most tend to gain the least. And um that's about how you understand your population's health. So I will just say whenever I go to an area that has an integrated care system, an ICB ICS ICP, I only ask three questions to know whether they're actually going to work. The first is how do you understand the needs of your population? And if they show me a huge slide deck created by a consultant or a set of reports that tell me, I know they're going to fail if they show me a map of the area that they are responsible for and the populations and the population flows ie where the most needs are the poor people and all that don't have to be perfect. It just has to be good enough tick. I know they're going to win. The second question is how do you know that this map is agreed upon by all the people in this patch, you need to spend money on health and social care and prevention. And if they send me a load of contracts, um slide decks and other paraphernalia, I know they're gonna fail if everyone has signed the map because they've all studied it and they all agree that this is the mark tick, they're more likely to succeed. And the third question I asked them is how do they know they've made any improvements in preventing people from ending up where they don't wanna be, which is in hospital or dead. And if they tell me that they have a widespread of indicators across everything with no prioritization in accordance with their understanding of the inverse care law as it predicates in their area. I know they're going to fail three questions. It's not rocket science. So our icss aren't that old. Our integrated care systems aren't that old in the UK. They have struggled with resistance to their power. They've struggled with the governance in relation to the other ecologies, ICS, ICP Acute Trusts which operate as they tell me, independent sovereign bodies, NHS England. That is still to be sorted out in governance terms. But I'm very clear about governance, it only has one purpose which is to improve services to people outside the room. And if that isn't clear in the intention, what's the point in having the governance to pay people on governance boards? So there's still a lot of work to do there just to clarify the governance. The final thing I would say is that um we are spending, I don't know the numbers there. People in this room wouldn't know but we are spending. And, and this dozy pointed this out when he talked about bringing services closer to the community, what he was really talking about was negative versus positive value transfer, right? And for those service flow and geeks, you'll know that positive value transfer is the equivalent when you walk into your bank and you want to take out 10 quid. Somebody comes up to you and says you can have the 10 quid, but I'll also deal with all your financial needs right now. That's positive value transfer. It means you don't have to go anywhere else. Saves you money, saves the bank money, negative value transfer is what happens in too many cases. You go to your bank the equivalent and you want to draw a tenner out, but you have to go to 10 different tellers. None of which can give you more than 1 lb, send you to the next one. That's how the health service operates. So when he talks about that in the da review, that's what he's talking about any. So an indicator that you are not preventing anything for anybody and you are wasting money is whether you are delivering positive or negative value transfer in any service. It doesn't matter what it is. Does that make sense? Oh, good, thanks. Thank you. Do you want, do you want me and whatever suits you? Yeah. Fine. Slide Dick Victor. You're gonna love it. So it's lovely to talk to this packed audience and Victor. I would not take the guilt yourself. They know me. They know Heather and I have recently become a Taylor Swift fan. So um my brother in law has a Tshirt and it says it's me. Hi, I'm the problem. It's me. So Victor, I think it's me, not you because they know they know that I love slides. So the slides are not going to go. Ok. So I am Joanne mclean. I'm the Director of Public Health and the ph A and I'm going to present a little bit of work today that we have done very recently to inform the priorities of the I CS and the integrated partnership boards in particular. So we're gonna give you a little bit of an overview of what I'm going to talk about to talk about people. First of all, because quite often we talk about health inequalities and poor health and premature death and even maps victor, it can be a little bit depersonalized and we forget at the middle of this, there are people and there are patients and there are people who need to be looked after and cared for. So I want to talk about a bit, a bit about people. First, I want to talk a little bit about what makes us healthy and really focus on what makes us not healthy. And I then I want to talk about some key findings that we have whenever we really have drilled down and deconstructed. What are the reasons behind the differences that we see in life expectancy in Northern Ireland between those who are the most affluent and the most well off in our society and the most disadvantaged. What, what is it the cause of that? And then what can we do about it? So we'll have the next slide. So bringing it back to people, this is a picture of a patient and this patient probably is in every single one of our hospitals right at this minute. And whenever I worked clinically, I used to see this patient a lot and he could have had COPD, he could have had lung cancer. He could have had heart disease, or he could have had all of those things wrapped up together. And what I used to notice as a very young and inexperienced, um, junior doctor was that a lot of these patients? I worked in Craigavon Hospital and a lot of these patients came from the same road, They all came from the Westland Road and in my kind of inexperience, it was only in my early twenties, I hadn't really looked up from my books much. Um, in my sort of, I used to think, gosh, the Westland Road must be a really long road because all the patients seem to come from it. What I realize now as an old person is that the Westland Road in Porta down is in one of the most disadvantaged wards that we have in, in the southern area. And I suppose even at that stage, whenever I was young and naive, I was recognizing that, like, you know what Michael Marmot says, we treat these patients, they claim with the same things and then we send them home and really the things we're not really tackling the things that make them sick, the things that will keep them sick and the things that will prevent them from getting better. And I'm not going to focus on the inverse car off day. But as healthcare providers and people who are interested in health. That's a really important concept that we need to get to grips with the people who need our services. Most the people from the most disadvantaged areas are the people who are least able to access them. They face so many more barriers than you or I would face if we were sick. So this has been mentioned in passing earlier and quite often as a public health doctor and as director of Public Health, I think to myself, oh gosh, Joanne, really, you should go home and go back and work and help the people from the Westland Road because really health services can only impact about 20% of health because really what makes people sick? Really, what impacts life expectancy? It boils down to a couple of things. It boils down to how much money you have. It boils down to the inequality particularly in income within the society and it boils down to lots of wider policy things. And sometimes we can get a bit overwhelmed and think gosh, we can't influence them or else we can run off and try to tell other people to do things, but we need to stop step back ourselves in health. We need to think what about that? 20% are services set up well enough to make sure that people from the Westland Road and other places like that can get services. If they have a heart attack, can access follow up care. We introduce things like um patient directed. Follow up, what if you don't have a phone? What if you work at mcdonald's? You're not light off your shift to ring your GP. All these things we need to start to think about. So for us, my message today is that if you look at this, OK, 20% is health care, 30% is health behaviors and other things that's massive. So even though we want to collaborate and do other things, the things that are within our gift are pretty substantial. So we, we think about our strategic context here in Northern Ireland, many of you will be familiar with the work of Michael Marmot and a lot of what he talks about, if you think about the Marmot sort of his recommendations and the things that you should do, it's all about um giving every child the best start in life, making sure people get a good education, good jobs, good income, all those things and really bringing different parts of government and different departments together to work. So how do we do that? Well, actually on paper, we have some really good policies here. We have making life better. And if anyone has read, making life better, I'll not ask for show of hands. But if anyone has making life better read, making life better. It's the cross executive public health strategy for Northern Ireland. And actually it's very good if you read it it talks about all the things that Michael Marmot talks about and it tells us what to do. Do we do it? That's a different question. I go to the making life better meetings and I'm the only person who actually reports and report from a health point of view. So while all the other government departments are involved, there's something about what are their incentives, what, what are levers. So I want to talk now briefly and Danny will be getting edgy. But I want to show you some really interesting slides from my slide dick. So Northern Ireland, you all know this population of about 1.9 million aging population, older people, people over 65 have now actually taken over younger people in the nuts in the last couple of years ago. So again, I want to think about male life expectancy and as I say, life expectancy can be a bit of a dry concept you think? Hm. What does that mean? So again, I to try to focus myself and to focus us in this room today, I always think about some newborn babies. So if we think about babies who are born today in the Royal, in the Royal Maternity Hospital, and we think about those wee babies. Now they're boy babies. And then with this slide, I need to change the slides. I have to find out these are boy babies, don't like the pig, she the pig sheep, confusing. They are boys. So if you think about two babies born side by side in Northern Ireland today, one baby lives in Sandy Row. One baby lives in Upper Malone. Look at the difference in their life expectancy. That is not fair. Now, hopefully people can see that but that if you're born in the most disadvantaged areas, you can expect to live until you're about 74. If you're born in the most advantaged area, it's over 81 7 years difference in life expectancy. What's causing that. So we really wanted to get in behind what's causing this life expectancy in the UK had been improving quite rapidly. And then something happened about 2010 and you can see it's starting to flatten off and it's fallen particularly in the more disadvantaged areas. And we've seen a very similar pattern in Northern Ireland here. And you can see this, this is healthy life expectancy for females. And you can see that healthy life expectancy, the difference between the most advantaged and the most disadvantaged is even bigger for healthily life expectancy. So if you look at this and you mightn't be able to see the numbers. So I'm gonna call them out if you look for 2020 2022 which is the most up to date and recent figures we have. If you're a baby born in the Malone Road, born in one of our most affluent areas, you can expect to have a healthy life expectancy that you're about 67. Ok. If you're born in the, one of our most disadvantaged areas, you can only, your healthy life expectancy is closer to 53. That's huge. It's massive. Lots of people in this room or 53 or older. Yeah, just think about that for a minute. So, again, what's, what's causing this? And as, as a public health doctor I'm thinking, ok. Right. What's driving this, what is the reason for these differences? So we've done some work to really drill down and look under it. And if you look at what causes premature deaths in Northern Ireland before the age of 75. And you can see it's heart disease, it's suicide and self inflicted injury, massive massive problem, a massive cause of potential years of life lost. It's cancer and it's the cancers that are caused by smoking, lung cancer, those sort of things. It's chronic liver disease. We have a massive issue with alcohol related harm in northern Ireland and I'll present a little bit more on that. But again, alcohol accidental overdose, which is drugs. So again, this is about um drug related deaths and we'll talk a little bit more about those. It's other respiratory diseases like um CO PD and things like that. Ok. What are all these? And this is just the breakdown of those um inequalities. What do all those things happen? Colin every single one of those drivers of the biggest life expectancy differences have a preventable factor. A huge prevention factor. So that's a really positive thing for us to hold on to it. They can be presented. Some of those things are smoking. Big thing of that is smoking, smoking. Sometimes people think and people actually say to me it's just smoking doesn't really matter anymore. People don't really smoke anymore. Rubbish. Smoking causes about 2000, 200 deaths in northern Ireland every year and it causes those deaths in the most disadvantaged areas. Smoking kills, smoking still kills and smoking will continue to kill. So if you look at this graph, you can see in the sort of most disadvantaged areas in our population, about one in four people smoke. Whereas in the most advantaged areas where people have the benefit of a good education, good income, all those things, it's only about one in 14. So smoking kills causes cancer. So if you look at who have had a look to see, look what are the big drivers of mortality and avoidable mortality and smoking is number one coming in that close. Second is obesity and physical activity. Again, big differences in how much physical activity people take and how the prevalence of obesity between our most advantaged and disadvantaged areas. Alcohol I've mentioned it before. Alcohol harm is huge. Alcohol related admissions are the biggest cause for use of bed days in middle age that it's huge. And you can see again, massive differences in your likelihood of dying as a result of alcohol from the most advanced to disadvantaged areas. And if you look at that, it's 9.1 in the most advantaged areas and almost 40 in the most disadvantaged areas. Four fold difference, huge drugs. This is our biggest difference. So if you think of drug deaths, some of them are illegal drugs, some of them are things like, um, prescription medications, all those things with deaths related to drugs. Again, massive difference. And these are the things that are causing the difference in life expectancy. These are the things that are causing the inequalities and these are all preventable and they're all, we have lots of programs that are tackling these, but we can really step them up. So again, suicide, massive differences between suicide deaths and rates in the most advantaged and disadvantaged areas and mental health. Again, difference in prevalence between rich and poor areas. So I know Victor doesn't like slides, but I think it's really important for us to understand that as a health system, we can make a difference. I think that things are our responsibility. It's not all a lot of it is about how much money you have in government policies and income inequality. A lot of bit about that. But there are things we can do. We have programs that work, we know the programs that work. We have got many of them and we will continue to work on them. But the one thing I would say today. So I don't know whether I am the problem and that's why people saw me in the program and said, oh God, she's not a pain. I'm not going there. But actually we talk an awful lot about prevention in the health service. We have cancer strategies that talk about prevention, front and center. We have all sorts of strategies that talk about how prevention is really important. I think we have to start to put our money where our mouths are. And I think we actually have to focus on prevention and the reason we have done this work in the pa and we've focused on the causes of death, which is a little bit reductionist because of course, it's more complicated than that. Of course, the reasons that people smoke or drink or take drugs or experience difficulties with their mental health and the most disadvantaged areas are complex, their diversity. But all those other things that we do work with partners, but we need to think what can we do, what can we do ourselves? What can we do with our services and what can we do with our partners? So overall, I think this is a really positive time. I think that it is good that at least we're starting to talk about prevention. And I would ask everyone who's here today to really go away and think what can I do in my area to increase prevention? And how can we as a system really get a front and center because every single disease, every single program of care that we have has a, a preventative element of it. And I've already shown you a little tiny bit. But we hope that by actually showing the figures, showing the evidence even though there's slides that you can suddenly, because I certainly had a petty dropping moment when I said, my goodness. Look at the number of deaths that smoking is causing. Look at the number of deaths that alcohol is causing all those things. There are things we can do about the he was getting very fitted, he told to fit. No, not, not at all. And uh thank you, Joanne. Real passion. There some very stark messages which, which we'll, which we'll return to. Let's hear from our final Panelist. A thanks. Anyway, I've got slides and notes. Um It's lovely actually to, to speak to the pack crowd as as well and, and, and, and a lot of these things as well. It sometimes it feels like you're preaching to the converted in, in days like this. Um But I think I'm really mindful as well that sometimes a we do need to be reminded, but, but there is a real strength in coming together to try and, and come up with the solutions as well and, and similar to Joanne, I'd like you to think about as we're, as we're moving through and a promise won't take, it won't take too long to go through the slides if you really think about yourselves and what your responsibilities are as an individual, as a citizen in the, in the communities that you work in, but also as a staff member and the organizations that you work in and as a leader, most of the people sitting in this room have influence and have leadership as well. So it's really about how you bring those things to bear. So, um this is, this is really talking about about live better, so live better is in an initiative that was launched by our minister um Mr Mike Nesbitt earlier on in the year. And uh Mike came to visit us here at the PH A and actually talked very passionately about what makes him tick and what, what difference did he want to bring as a minister? And um you know, it was music to that. I actually the focus was going to be on um social inequalities and trying to make things better around prevention and, and those areas as well. So that's what we're trying to focus on. I'm just thinking I need to move the slides on, don't I, you got that one at the. So, so I'm gonna talk a little bit about what live better is by the focus on inequalities. Joanne has already covered a lot of that. So I'm not gonna focus too much on it where we've got to so far, it's relatively new innovation and what will happen next. So you'll recognize Mr Nesbit there up in the, up in the um the corner. So this is, this is not a new concept. Um Victor talked about the inverse um uh the inverse uh law there. It, it's not a new concept for us but, but it's something that we probably haven't really spent enough time thinking about. What do we need to do around it. Um One of the things with this initiative um is it doesn't come with a pot of money. So in all of those good things, necessity is the mother of invention. So if we don't have money, all of those avenues that we would normally have thought about aren't available to us in this one. So if you think about whenever we have, when in, in a normal way of working, we quite often have spent a lot of our times going down traditional areas we work in, we work with colleagues that are like us that know the same, the same knowledge as the same skills, the same competencies as us and we work in the same organizations together. We're not exposed to different ways of thinking different ways of, of um different cultures, different skills, different knowledges. So live better is aiming to try and bring together people from across the system, from primary care HSE trusts and from the the community and voluntary sector and really engage with the community themselves. Because if we don't have lots of money to try and improve things. It's not something that you can roll out. We actually have to think about doing things slightly differently. So how are we going to do that? Um Deprivation, Joanna has already looked at what we wanted to do was focus on those areas that are most deprived and bring uh bring health care resources to them about. I mean, if you think of being at the top of the league table, there's many things that we would want to be at the top of the league table. One deprivation is not it about one in three people live in deprivation in Northern Ireland as compared to one in five in the rest of the UK. That's not a great statistic as well. We really wanted to focus this in on primary care as well. GPS are at the real heart of our community and are still very much seen as the first point of contact and a very trusted source as well. So those primary care teams were seen to be a really, really important place to start. We have very good relationships obviously between primary and secondary care, but we felt that there's probably room to further strengthen that as well. So um we've been working with our, using our data, using all of the various bits and pieces to turn in our arsenal to come up with a number of GP practices that where there is blanket deprivation. So that we can concentrate on those. Um Why focus on inequalities? I think Joanne has already already um shown that, that you're very, very, um, well, why we wish to do that we're striving for equity here. But, but actually the reality is that the, the deprivation gap, the, the, the difference between the haves and the have nots is actually getting wider year on year rather than actually coming together as well. So this is very much our biggest challenge and it doesn't matter where you live in the world, either you can look at any company or any, any country across the world. It's really, you know, it's, it's not unique. People who have the poorest income have the worst health. So the challenges for them just continue to go even if the individual themselves is doing everything they can to support a healthy lifestyle, just the wider environment, the challenges build up year after year for them. Um Joanne showed the picture of the babies. This is a baby boy or the girl and the boy growing up a little bit as well. Um But there's more than, there's more to living or there's more to life than just living and dying. Um It's, it's actually about how they live more than a decade of poor health is just not um It's, it's just not right. It's just not what we want for any of our Children. Good health matters to individuals and to the society. So the big message there is is um reducing inequality is certainly going to change lives and it's absolutely not. OK. Um Michael Marmot, um Joanne has mentioned him a couple of times. He's our poster boy really for health inequalities as well. He's our guru. Whenever he came to the City Hall, we all trotted along, I think um and got books signed. Um but he is such a wise man whenever it comes to talking about this. Um and he also talks about health inequalities. It, it really and what it, what it reflects on us back as a society as well. Um And, and what we as a society do to try and, and support, support the people in this. And I'm just really conscious that the people in this room actually can make a difference. You have the knowledge, you have the skills, but you're also really well connected, you've got the influence as well. So we have to challenge ourselves in terms of actually what is it? Are we individually going to do about that? So going back to the to the live better, what's happened so far, we did have an initial stakeholder as we would normally do in the health service. We love coming together and, and having meetings, but we did come together and have um from from across the system as well, had a really helpful stakeholder workshop to actually try and see. Well, what could we do by coming together as Well, this is again not new in the world of general practice. Um Doctor T Heart in 1971 talked about the inverse law of of care as well. And we know that actually the availability of good medical care in the primary care setting as well is not as present in those deprived areas as it is in the less deprived areas. GP S in primary care are dealing with increased levels of multi morbidity, increased complexity, a lot more mental health issues as well. Staff are reporting in a lot of, a lot of stress. There's a lot of pressure on GP S as well. But there's also some challenges around the connections between GP practices, their communities and within the, within the service themselves or within the population themselves. We're more and more getting problems with either digital exclusion or literacy problems as well. There is also sometimes a lack of understanding within the staff um working in the working in the community settings about their understanding of the wider determinants of health as well. So that's something that we need to address as well. So um we, we had that workshop and we've asked everybody to come along and actually put essentially their money where their mouth was, but actually come along, not just with ideas, but with actually, I suppose a demonstration of what it is that they could actually do. Um We've worked with our colleagues around the, looking at the data and we've identified sort of the 50 most deprived uh GP populations as well and I've invited them to be involved in this and we've had really, really helpful and positive feedback from our GP support as well in that area. We're probably going to focus now on two areas, one in, in the, up in the west in Derry Stroke, Londonderry and the other one in Belfast. And that those announcements will happen in due course as well. We've continued to have real engagements with our GPS and with our trust colleagues as well and the CNV sector in those areas. And again, this is about trying to come together to see what it is that we could, that we could do how we could actually make a difference. We had um we've asked um all of our health and social care colleagues and our primary care colleagues and those in the C and B sector to start thinking about, well, what could you do across the life course, starting off with the early years? And um and victor you quite rightly say that that the, the impact if we can make it as early on in life and actually even preconception if we can have healthier moms um well supported so that they can actually be really good moms and support them and their families for the first couple of years of life. The difference and the value that we get down the line is immeasurable and not just for the families themselves. But in terms of cost for the health service as well, it's well well worth doing and that that's economically demonstrated in so many different ways. Also looking at the, at how we manage an adulthood as well and then the older people, we talk through some of the potential options. So looking at vaccination programs, screening programs, prevention in terms of diabetes as well, we know that that's a, a, an, an ongoing issue. There's about 100 and 15,000 people living in adults living in northern Ireland with diabetes. Most of them type two, we have another 1500 Children living with diabetes, mostly mostly type one diabetes. But what we want to do is to try and stop that tide, that increased complexity that diabetes brings to anybody's life, get in there at the beginning. So that's doing things like addressing obesity, addressing BP. So what is it that we can in those areas? So we're working at the minute with, with our primary care, colleagues, with our trust colleagues and with the CNV sector to try and identify what are the initiatives that we could work better together on. So, rather than actually us working in silos, so that the GP does, does their um their consultation um that the nurses in the community work separately and in the C and B sector, how can we actually work better together to make a better um a better impact on everybody's lives. So what's what's gonna happen next? Um The, the practices have been confirmed now and we're continuing on with that engagement. Um And once we start to focus on those initiatives, they'll hopefully probably get off the line or um later on this, this autumn in the next couple of months or so. We don't underestimate the challenges. This is a relatively new way of working. We've certainly got pockets where we work really, really well together. But certainly setting primary care as the link and primary care has got a lot of experience in this area across the rest of the UK. So it's really about trying to build on that and develop that here in Northern Ireland, but not just within primary care that we bring in the rest of the health and social care groups together. So we know it's difficult to do, we don't have a budget. So we have to think of other ways of doing it. But we also have to be really mindful about the um the uh populations and the communities that we're working with well with as well and making sure that we're not doing something that we can't continue that we're not raising expectations or, or parachuting in and then, and then leaving. So we have to be very, very careful about how we do that in a sustainable supportive way for our communities as well. Um And we're also conscious as well. It's sometimes difficult to stand back and sometimes like flying an airplane, you know, changing the wheels while you're still flying as well. People do need to take a little bit of time. We're spending so much time firefighting that it's difficult sometimes to look upstream and actually say, well, how do you actually stop putting the fires out from starting in the first place as well? So there's a little bit of that going on, but lots of opportunities there both in terms of aligning and, and making a better bang for our buck and with the existing resources that we have really, really trying to think through what assets that we have in our wider communities, what can we use, what can we build on in there as well? Um And, and really testing as well. Some of the public health initiatives are there other things that we could do to try and engage better with communities to increase our screening rates, increase access? You know, people are quite often saying it's not about not wanting to have your child vaccinated, but if you've got three other Children and have to get two buses to the GP surgery to get your vaccination, that's a big barrier. So some of this is about how do we actually get, take down some of those barriers and figure out how we get to the help to those who need it most. Um And um one of the other things as well that we're hoping to do is is improve, the, improve the, um I suppose the data and the outcomes around this, this slide is, is the last one and it's, it's not the last because it's the least important, but it's the one that I really want to leave you with. It's actually about the community at the end of the day and the engagement and the engagement. I mean, if, if, if communities can't be involved in creating their own destiny and creating those health champions there, it's, it's absolutely not going to help. So going back to the beginning, um I'm hoping that everybody has thought about what it is that they would do. Raise your hand. If you think that there's something else that you could do over and above what you're currently doing that might actually make a difference or do you think you're maxed out already or is there something else that you could all do individually? Two hands up? Yeah, couple up. I think we can all do something a wee bit more than what we're currently doing. If we think carefully about, about how we organize ourselves and are prepared to take those brave steps into the next era. Thanks very much. So, we're going to open it out for some questions. Now, while you gather your thoughts, please, to bring a question, you've come to this because you're I'm sure passionate about the area of prevention. So just to recap, I shared with us how he challenges systems to think about, they understand their population, are they in their population? And what value they transferring Joanne? We heard lots of statistics, which is fantastic to look at what the problem is. I think a lot of people recognize it and I think that generally people can, we put our money where our mouth is. What does action look like? Great thoughts and collaboration. Next steps and a big push to what are we going to individually do? So let's take some questions. We can start you introduce yourself. And then the question, Steve Austin Medical Director of Southern Trust, I've just by Victor's first word, words about the lack of people here, you thought there should have been more. And when I looked at Joanne's first slides about the list of conditions, you look at the list of conditions of that, but they were the list of conditions we have in our emergency departments as the commonest most frequent at tender that are turning up in our emergency departments. So in some ways, it is a really good question to ask, why are not people here because we're facing the acute problem in acute trusts of that. But the answer is not treating the conditions, it's preventing the conditions in the first place. And I think the point is really, really well made. There's a really strong link up between your data and what's turning up causing the acute pressures and trusts. Those are certainly the commonest conditions causing the greatest drain in our resources. So I think it's, it, it is a question about how we try and engage the public. So how do you think we should engage more into this space? So is it the key question to get more people in for Juan for me? Thank you. II think, I think you're right. They're the things that cause presentations. They're the things that cause preventable death. For me thinking from like stepping right back to our priorities as a health system, whenever we produce, for example, a cancer strategy, I'm not saying this to be critical, but to produce a cancer strategy. And we recognize that a lot of cancer is preventable. A lot of it is preventable by something as simple as reducing smoking rates. But whenever the strategy has got recommendations around prevention, but no funding and no program to kind of deliver. Similarly, whenever we invest in services, be it or respiratory services, I think we should be stepping back and saying these are preventable conditions. If we're not going to invest, whether I and I can't be arbitrary of how much it is 10% 5% or whatever. If we're going to invest in respiratory conditions, we need to be thinking about prevention in every single investment we need. Otherwise we're just constantly on this kind of hamster wheel. So I think it's about stepping back in every investment or decision we make that we think about the preventable element of it. Yeah, I guess, um, just, I want to say about slides, I've got nothing against slides as long as they're brief. But II would have, I think what the point I was trying to make that. It's ultimately, it's about relationships. So the means by which you're going to get that shift to prevention are already there. It's just that they're not being run in the court, they're not being run in a way that's likely to produce the outcome that you're talking about. That's, that's what I'm saying. So certainly in, in, in, in England, you know, the ICSS spend the money. If there's no one else that does it, they could decide to spend it differently actually. Um But in order to do that, there are certain things I need to do, one is understand population health, one is under, in the way cos if you do that, that's gonna show up, right? And then it becomes a matter of, well, you're either leading the change, you're either following it or you need to get out of the way. So that's why I was saying what I was saying that the response is kind of obvious that the numbers, um, you know, we all know what the numbers are. The question is. What do you do? And I'm suggesting it's not as complicated as some people would like to make it. It's actually relatively straightforward. As for the funding question, I am always struck by the notion of the need for double funding or even more funding. I do want to push back on the notion of how do we spend the money that we've got? I do question some of the waste which is spent on processes that aren't linked to any credible intention that leads to the kinds of outcomes that we need. I would ask you to read two reports. One has been mentioned, the Carnal Far NHS Confed report, which is very clear about what we could be spending money on that would produce better value and better outcomes. And the other is the IPPR commission on Health and wealth, both of which uh pretty clear route maps to what you could be doing. Kind of now just, just to write Northern Ireland red and wrote a report on health and wealth and well worth a read. And there's a question at the, at the back. Thanks very much. My name is Paul Du and I'm retired now about eight years before that I used to help Heather organize this conference alongside other things. I spent a year in Belfast looking at alcohol misuse, we spend out of the public purse, something like 100 and 20 million lbs a year on alcohol misuse in Belfast. The biggest spender of public money in Belfast is a Belfast health trust, uh well intentioned people. But whenever I asked them to give me a copy of their alcohol misuse plan, they struggled whenever I went to the second largest spender in Belfast of public money. Belfast City Council, they said no, they didn't have an alcohol misuse plan. They had a community safety plan and that is part of the problem. It's really interesting to hear the intersection of public health and primary care with population health and health inequalities. But we know what the health inequalities are and surely if we want to do something about addictions or mental health or obesity or criminal justice or suicide or educational underachievement, because all of those are common denominators, then we need to have move out of the health silo that we currently talk about and that's not the people here's fault. It's because we are funded in silos. Our accountability and governance mechanisms are in silos and we need to move beyond that. So if we want to do something, uh we really need to uh uh decide what our community mission is and health players are a key partner in that. But what is our community mission? And surely it has to be about having a healthy, wealthy and wise community where we create a better life for all and in that context, then we have a better chance of engaging with other government departments at the department of the Economy, our own skills, the department of community around their interventions and economic and activity and around the Department of Education. Because four out of every 10 kids who leave school in Northern Ireland leave with few no qualifications. And we're now at a stage where we see intergenerational inequality. So health can't do this on their own. What we need to do is have that healthy, wealthy and wise approach. It seems to me and I'm much more joined up. I welcome the initiatives that have been taken, but they're not enough and we can't do it alone in health. No, that's all true. But, you know, you can do 20% which makes a big difference. And actually, I think health could do a lot more in relation to convening the right partners around the room and putting the patient and the community in the center because that's why you're all paid regardless of whether you work for the NHS or not. So I do think there's more could be, I think health could play a much, much more effective convening role in a community, not just in the public sector, the private sector as well. I also think that as is the case in England, northern Ireland is moving towards this as well. You need a health in all policies approach and you do know because I'm sure these experts will tell you that the most effective intervention in regarding to alcohol use is alcohol pricing at least. So that's the indication. As far as I know, I used to run the largest addiction provider in the UK pretty much and I know that we could be doing a lot more around alcohol pricing and alcohol education at schools. But it then directly refers to the point of to five and before and which is about things like health. We used to use this term thriving Children. Remember you're probably old enough to, I don't want to say that I'm old enough to remember the notion of thriving Children. We kind of lost that. And in doing that, we've probably wasted several billions of pounds that we didn't need to spend. But if we would have just kept that going, and one of the things that the confed is looking to do, which is why we published the report last week on communities is provide the practical evidence base as well as the techniques necessary to do exactly what you're saying, which is build from the ground up and the top down and meet in the middle. Could we, yeah, could we hear from Joanne and quickly just on, in, in your talk, you said it's in our gift and what we can address this stand show maybe just on pause point and then we'll, we'll stop for questions and have some closing thoughts. So I did reference in my presentation and making life better strategy. I absolutely agree with you. I mean, quite honestly, if I had money to invest, I'd probably invest it in education. Um But the, the making life better strategy is a really good strategy. It talks about, I mean, one of the indicators is the number of Children leaving school with five GG CS ESI think the challenge for us is to get that prioritized across departments. And I have thought a lot about um how do we make the marmot principles real? I actually asked Michael Marmot about this whenever he visited after I got him to sign the book, I said to him. Um ok, so you tell us, tell me how you do that. What should I say to Peter May whenever I see him next, how do we do this? And I can't actually remember what he said, but I have been thinking about this and thinking about this and thinking about this and II agree that it is helpful to have health in all policies. But I actually think we need to step back sometimes in health and understand that we have a, we have a common goal across all government departments of healthy happy people, but we've got different agendas. And if you think about education, I think we shouldn't preach to education that they should invest in schools and that people should have fair education, that we shouldn't have an education system that is stacked up against the most disadvantaged Children with academic selection. That's, that's, that's what I think. But I think we probably shouldn't pick a fight with them and go and say we want you to keep people healthy. I think what we should, we should say is we want to help you Yeah, get Children to achieve their 5 g CSE SA grade C and above. So I think it's about making sure that they're agendas, they're aligned to ours. So it's not about beating them up and saying you need to make everyone healthy. It's about understanding that good education, good public services are good for health, but it's all in making life better. Thanks Joanne. We're actually gonna, um I'm just gonna ask each of the panel members actually for closing thought or action. Just sort of one thing that you don't want to leave people with and maybe start with yourself. Are you going? That's great. I suppose the, the one thing um that, that strikes me as well is, is, is that we have to be, have the public at the, you know, have the, have the Children in particular, but the public at the center of this, we all work in health care and, and I guess we've all been guilty of it as well. Is, is thinking about that whenever we're making decisions, whenever we're developing business cases, whenever we're doing this, particularly in, in acute trusts, if you're doing a service development or if you want to improve that is this the best thing that we can do for our local population and start to have those conversations at trust board level at um and with all of the, all of the various um I suppose mechanisms we have to communicate and influence as well we have to start taking the hit in terms of what we believe is important, whether or not it's the, the right thing to do, whether it's a ambulance waits or things like that. We have to actually start taking the hit and stop pushing the people into the river upstream and start making that and that, that's going to change it. It's going to take a, a culture change, but we have to start doing that now. Thank you. And I think for me it's about not getting depressed and thinking to ourselves, oh, we're only 20%. As victor said, 20% is a lot. Plus with those health behaviors and those sort of other things like smoking and things, it's much bigger than that. So I think we need to look at our own um world first and I think then we need to influence our partners and education and all those different places as well. But don't, don't get depressed and think, oh, there's nothing I can do about this because it's about income or of these other things, there are things that we can all do about it. Gosh, if you're lucky enough to be in this room, you're far too lucky to be pessimistic. I don't know any, but you paid to be optimistic. I think, to be honest, if I had, if I had the cash, I'd spend it on the first five years, that's what I'd do because if I was a politician, I'd see the results in five years within five years. And I would also do it in the, in the poorest areas. First, you would see the results. Politicians are about results. Um I think the following things are necessary. I think we need to focus more on public health. Actually, I think we need to give it a bigger platform in the shift debate. I think that it's necessary to do that. My colleague from Wales has mentioned this in relation to Wales. And I think you're absolutely right. I think we should do this across the piece. Secondly, I think we need to learn from each other. Northern Ireland is learning fast. So is England, we shouldn't reinvent the wheel. So is Wales, we should have a collective view. What works here will probably work there. Why repeat it? And I think we should measure the outcomes of our current services in terms of what they will prevent, not just their activity? Fantastic. And then just to wrap up this one quick thing for myself is to think about collaboration and partnership. We've heard that there's good evidence base that when you reach out your partner with the pharmacy industry, life science industry, you can make a difference on that. 20 per cent, take a small focused area and think about partnership. And I suppose the other conclusion is one of optimism I was here last year, Michael mcbride, just with the other chief Medical Officer has released a report about secondary prevention. The need to really drive that forward. There's been a lot of optimism in the sessions I've been in. So I think that continues. I think the one challenge I think has given us, which I really agree with is there aren't as many people in this room, there isn't as much funding perhaps on prevention as we'd like. So to take that thought and think about in our own roles. What can we do? Thank you very much and a massive thanks to the panel members, Joan He Victor. Thank you. You Yes. So.