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Wayne Farah
Carer
Patient
HSJ Patient Leader
Vice Chair Newham CCG
30/11/2015
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INFORM
CONSULT
INVOLVE
DELEGATE
EMPOWER
Beyond Engagement
Community Ownership
It’s only when we give ownership of health and health services back to the community that they can create them in their own image and give them back to us transformed
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Bob’s StoryMy GP told me I was pre‐diabetic and gave me advice on changing my life style ‐exercise all that stuff. Its not easy changing your life so I ignored it. Six months later I
was diabetic. Being told what to do doesn’t mean you can do it. I wish I had practical help to change my life style earlier.
Dr William Bird
Intelligent Health
Newham Community Prescription
A Clinical Perspective
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People
Healthy Communities
People Place PurposeEngaged Connected Reason
© 2014 Intelligent Health
© 2014 Intelligent Health
Fear and Chronic Stress
PeopleLoneliness
PlaceHostile
PurposeRejection
The disconnection can be summarised in
three areas
• © 2015 Intelligent Health
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Chronic Inflammation: “The Cause of Causes”
Chronic Inflammation
Starts in children as young as 6yrs
oldArthritis
Cancers
Cardiovascular disease
DiabetesAnxiety and Depression
Obesity
Dementia
© 2012 Intelligent Health/NHS London
Causes of Chronic Inflammation
• Eating red or processed meat, sugar and fat
– The immune system is switched on after a meal creating inflammation.
• Visceral Fat
– This fat is toxic and creates a continuous supply of inflammatory markers.
• Oxidative damage
– Free radicals from mitochondria cause damage to cells creating inflammation.
© 2012 Intelligent Health/NHS London
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© 2015 Intelligent Health
Physical ActivityIf we are physically active either two hours before
or two hours after a meal we release Lactoferrinthat switches off the
immune response
Some diets of refined
carbohydrate, fat and
processed meat creates
inflammation
Poor DietOur gut
bacteria are critical in reducing
inflammation
Chronic Stress increases risk to Visceral Fat Visceral fat is related to inactivity, stress
and obesity.The fat cells are
faulty and release continuous amounts
of inflammatory markers
Visceral Fat Aschbacher, Kirstin, et al. "Chronic stress increases vulnerability to diet‐related abdominal fat, oxidative stress, and metabolic risk." Psychoneuroendocrinology46 (2014): 14‐22.
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Reducing Inflammation - Fat
© 2014 Intelligent Health
© 2015 Intelligent Health
Visceral fat increases all cause mortality
OR 1.83 (1.23 to 2.73)Kuk, Jennifer L et al. Obesity;2006;14: 336‐341.
Physical activity reduces visceral fat before subcutaneous fat particularly in obese and diabetic patients
Visceral Fat
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Visceral fat reduction with exercise
‐25
‐20
‐15
‐10
‐5
0
Lean Obese Type 2 Diabetes
% Loss of Fat
Axis Title
Fat loss after 13 weeks of walking 60 mins a day and no weight loss
S/C Fat Visceral Fat
© 2014 Intelligent Health
Lee S et al. J Appl Physiol 2005;99:1220‐1225
Oxidative Damage
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Sedentary High fat diet and Stress
Mitochondrial DNA
Reactive Oxidative Species
Anti‐Oxidants
Mitochondria
Oxidative PhosphorylationInner membrane
Physically Active, low fat and not stressed
© 2014 Intelligent Health
Mitochondrial DNA
Oxidative Phosphorylation
Anti‐oxidants
Mitochondria
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© 2012 Intelligent Health/NHS London
Telomeres get shorter
• © 2015 Intelligent Health
Epel, Elissa, et al. "Can meditation slow rate of cellular aging? Cognitive stress, mindfulness, and telomeres." Annals of the New York Academy of Sciences 1172.1 (2009): 34‐53.
Hezel, Aram F., Nabeel Bardeesy, and Richard S. Maser. "Telomere induced senescence: end game signaling." Current molecular medicine 5.2 (2005): 145‐152.
Senescence: The end of the cell releases huge amount of inflammation.
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Finally physical activity creates its own antiinflammatory
© 2012 Intelligent Health/NHS London
Contracting MusclesRelease powerful Anti‐inflammatories called Myokines
Muscles also• Reduce insulin
resistance and mediate 75% of glucose uptake
• Burn more calories at rest than fat
• Protect joints
Community Prescription
• Addresses first-order desires • meaning to life • personal
development • contributing to the
community
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Chronic Stress
Health Model linking determinants to disease
© 2014 Intelligent Health
1) People
Social connections
2) Purpose
Sense of Purpose
3) Place
Connection to place
Poor Health BehaviourSmoking Drinking Inactivity Diet
Stress Hormones
Chronic Inflammation caused by shortened telomeres and mitochondrial damage
Diabetes, CV disease, cancer, arthritis, COPD, mental health, dementia
Determinants
Effectors
Mechanisms
Outcomes
Resilience
Wellbeing
Inputs
Clinical Medicine
Community Prescription
Wayne Farah
Community Prescription
Vice Chair Newham CCG
30/11/2015
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Theory
Social Prescribing A framework and process for linking patients with non‐medical sources of support within the community? Horne et al. (2013)
Mechanism for externalising NHS resourceconstraints to VCS?
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Combat ill health by givingGP’s prescribing solutionsthat address the socialdeterminants of health, andby building a communityinfrastructure that connectspatients to the resourcesthey need to engage inactivities that promotehealth, wellbeing, and socialinclusion
Newham Community Prescription
Bob why don’t you
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Choice Community Partner
Clinician Navigator
NCP Pathway
Support from next door
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David Idiabana & Taskin Saleem
Co‐Chairs Staywell Partnership
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Activities in Community Prescription
10 21 23 25 25 28 5269
136 140 145
193216 225
368 375
0
50
100
150
200
250
300
350
400
Particpants
Subco Trust
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Dr William Bird
Intelligent Health
Newham Community Prescription
An Evaluation
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Diabetes in Newham
Physical Activity Before and After NCP
0
100
200
300
400
500
600
700
800
900
Physical Activity
Before After
© 2014 Intelligent Health
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Wellbeing Score
© 2014 Intelligent Health
49
50
51
52
53
54
55
56
57
58
Change in Wellbeing before and after NCP
Before After
ROI for QALYs all patients participating in NCP for 2 years
• 2347 participants 1.2% of population
• Cost of community prescription £247,862
• 856 patients reaching 150 mins a week of moderate physical activity
• 32 QALY’s gained (Using NICE tool)
• Benefit cost ratio 2:52
• Net present value of QALYs £381,628
• (Net present value of reduced productivity £281,607)
© 2012 Intelligent Health/NHS London
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Preventing Diabetes
• 1079 patients that attend the NCP
• 224 would develop diabetes within 2 years (10.4/100 patient years)
• Physical activity reduces risk by 58%
• So now 129 patients will not develop diabetes
• Cost per person with diabetes per year is £777 (complications) and £517 (treatment). Total £1293
• Total Savings = £333,594
© 2012 Intelligent Health/NHS London
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Admissions Cost
Breakdown of costs from the admission of diabetic patients
Diabetes Related Complications of Diabetes Other Conditions
A whole person approach to LTC management is critical. For the 7,686 diabetics at the end of Year 1, only 17% of costs in Year 2 were directly or indirectly related to diabetes.
Chronic inflammation in diabetic patients is causing additional healthcare costs.Steve Hajioff, MD MRCGP MFPH Medical Director Health Dialog Analytic Solutions World Healthcare Congress 2010.
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Total potential savings of getting 1079 patients with prediabetes more active
through NCP • Net present value of QALYs £381,628 (NICE)
• Net present value of increased productivity £281,607 (NICE)
• Net savings on healthcare costs for diabetes £333,594
• Additional savings of urgent hospital admissions through other causes ?
Wayne Farah
Conclusions
Vice Chair Newham CCG
30/11/2015
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Vision
NCP Model
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Procurement
Localised Provision 50% activity delivered by local community partners
Lead Provider
Hub and Spoke Model
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Accreditation
Quality Assurance & Community Development