commentary 2: victoria intensive programme...

Commentary 2: Victoria Intensive Programme (VIP) Updated: 29th November 2019 Version 2

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Please note new additions/changes from version 1 of the commentary are highlighted in red font

COMMENTARY 2: VICTORIA INTENSIVE PROGRAMME (VIP)

Title of piece of work Victoria Intensive Project (VIP) Developing and implementing a neighbourhood project designed to address a growing number of people with alcohol/drug issues and other complex needs in the Victoria area of Stockport, who are creating significant demand in the system but not engaging with services.

Timescale of project Jan 2017 – Feb 2019 (then extended to Sept 2020)

Summary of standards claimed in this commentary

1.2 Use ethical frameworks in your area of work, identifying ethical dilemmas or issues arising and how you address them. 2.5 Interpret and present information using appropriate analytical methods for quantitative data. 2.6 Interpret and present information using appropriate analytical methods for qualitative data. 4.2 Demonstrate how individual and population health and wellbeing differ, and the possible tensions between promoting the health and wellbeing of individuals and of communities. 6.1 Show how organisations, teams and individuals work in partnership to deliver the public health function. 6.2 Demonstrate how you work in partnership in multi-agency collaborative public health work. 6.3 Reflect on your personal impact on relationships with people from other teams or agencies when working collaboratively. 7.1 Describe how you have planned a public health intervention to improve health and wellbeing, demonstrating terms and concepts used to promote health and wellbeing. 7.2 Demonstrate how the culture and experience of the target population may impact on their perceptions and expectations of health and wellbeing. 7.4 Evaluate a public health intervention, reporting on effectiveness and making suggestions for improvement. 7.5 Demonstrate project management skills in planning or implementing a public health intervention.


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Overall Context My current role is Behaviour Change Lead within the Public Health team at Stockport Metropolitan Borough Council. I have been in this specific role since October 2016, although have worked in aspects of Public Health since 2003, and began work around Healthy Lifestyles in October 2015. I am part of the senior management team in Public Health and lead on commissioning a range of services including substance misuse, smoking, physical activity, weight-management and sexual health. My work directly relates to the Public Health commissioning duties as defined by the Health and Social Care Act 2012, and the NHS Long Term Plan, published 7th January 2019. The NHS Long Term Plan shows a strong focus on prevention, including the need to address the top five risk factors identified by the Global burden of disease study1: smoking, poor diet, high blood pressure, obesity, and alcohol and drug use. In terms of local policy context, my work contributes to improving health and wellbeing for Stockport residents and reducing health inequalities. The work I do around prevention and lifestyles supports the work set out in Stockport’s Health and Wellbeing Strategy2, and links to the needs identified in the local Joint Strategic Needs Assessment3. The work I lead on around behaviour change programmes is included in our local Public Health business plan.

This particular piece of work is linked to the substance misuse area. In January 2017, an issue was raised by a GP in the Victoria area of Stockport around a growing number of people with alcohol and/or drug issues and other needs who were creating demand in the system but who were not engaging in community or primary care services. This was taken forward by Public Health, with myself as lead, and I brought together a range of stakeholders to consider the issue more fully and implement a new way of working.

Working with one of our commissioned substance misuse providers, I helped to secure initial funding for the pilot from the then Dept. of Communities and Local Government (DCLG). The bid focussed on a targeted piece of system redesign in order to gain an understanding of the barriers faced by this cohort in terms of accessing mainstream services, and with a view to supporting them into appropriate support. This was in addition to addressing the needs and issues faced in order to reduce demand on crisis services. The ambition was to lead to better outcomes and improved quality of life for this cohort of people as well as reducing health inequalities and costs to front line services. The funding allocation of £65,000 from the DCLG enabled the recruitment of a Complex Needs Link Worker (CNLW).

My Own Role My role in the project was as the project lead. I worked with a range of stakeholders to define the need more fully, develop a new model of working, implement the project, evaluate outcomes and then write business cases to secure ongoing funding. My role included co-ordinating activity and working in partnership with other stakeholders to achieve common agreed aims.

1 Changes in health in the countries of the UK and 150 English Local Authority areas 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Citation Data: Lancet (London, England), ISSN: 1474-547X, Vol: 392, Issue: 10158, Page: 1647-1661, publication year 2018 2 Stockport Joint Health and Wellbeing Strategy 2017 – 2020. https://www.stockport.gov.uk/health-and-wellbeing-board/joint-health-and-wellbeing-strategy 3 Stockport Joint Strategic Needs Assessment 2015/16 https://www.stockport.gov.uk/health-and-wellbeing-board/joint-strategic-needs-assessment


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In terms of governance, a steering group provided project oversight. The Deputy Director of Public Health chaired the steering group meetings. Key partners in this project included: Stockport Public Health, Stockport CCG, Stockport NHS Foundation Trust, Greater Manchester Police, Primary Care (GP representative), Drug and Alcohol Services, Providers of Housing and Temporary Accommodation, Homelessness Support, Adult Social Care, Young People’s Services, The Prevention Alliance and Mental Health Services.

The project promotes joint working and supports a multi-agency approach to meeting complex needs. As complex needs span many agencies, it was imperative that all relevant organisations were committed to working together, and staff were equipped with the skills to support people who had proved difficult to engage in the past.

Aims & objectives of this piece of work The project is targeted at dependent alcohol and/or substance misusers in Victoria whose behaviour challenges services. The aim is to use a person centred approach to:

• Get the right outcome for the individual concerned

• Reduce demand at the hospital and blue light services

• Increase engagement with community and other appropriate services The project was designed to:

• Identify the cohort using key data from local organisations

• Engage clients via a community based outreach worker

• Identify client needs and consider potential support options

• Make community / voluntary services more accessible

• Co-ordinate multi-agency operational meetings to review cases and pathways

• Maintain records of client engagement, interventions, and outcomes. The outcomes being measured for the individual include:

• Improvements in positive functioning (measured by questions derived from Chaos index headings – this includes engagement with frontline services; self-harm (intentional or unintentional); risk to others; risk from others; stress and anxiety; social effectiveness; substance use; impulse control; and housing.)

• Improvements in health and wellbeing (measured by Wemwbs4)

• Increased planned engagement with primary care and community based services

• Positive case studies indicating improved understanding of how to support clients whose behaviour is challenging to local services

• Collateral benefits (including for those considered but not taken on the cohort) The outcomes being measured for the system include:

• Reduction in hospital admissions per person and compared to other areas

• Reduction in emergency department (ED) attendances per person

• Reduction in conveyances to hospital by ambulance

• Reduction in demand/time on adult social care services

• Reduction in adult social care placements or support

4 The Warwick-Edinburgh Mental Well-being Scale https://warwick.ac.uk/fac/sci/med/research/platform/wemwbs


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Main Commentary

Standards being

claimed

Evidence

K = linked to Knowledge

A = linked to Application

Standard 1.2: Use ethical frameworks in your area of work, identifying ethical dilemmas or issues arising and how you address them. Knowledge As a member of the Public Health team, I have been involved in discussions around ethical issues when developing new projects or considering new initiatives. My knowledge has grown through on the job experience and exploring ethical considerations with public health colleagues. I also reviewed the ethical framework produced by Baum et al (2007) 5 in 2016 (notes attached) and revisited this during early considerations of the VIP project (details around this is included in the understanding and application section below).

At the Faculty Of Public Health - Introduction to Public Health: The Context and Climate of Practice Masterclass, I expanded my knowledge of the existing and emerging legal and ethical issues public health practice. This included balancing the rights and responsibilities of the individual with those of the community and the state and highlighting potential ethical issues. This covered areas such as resource allocation, negotiating the political context, data use and management including privacy and confidentiality protection, control of infectious diseases, and balancing individual choice and freedoms while protecting the public good.

I have also attended the Faculty of Public Health - Public Health Ethics and Values and How They Inform a Public Health Approach masterclass. This included: - A knowledge and understanding of public health ethics, and the role of values in deliberations on public health policy and practice - An awareness of the meaning and significance of professional codes of conduct/professional guidance - An appreciation of ethical concepts including justice - Autonomy in relation to health inequalities and health promotion

Understanding and application When considering whether to progress with the VIP project, I used the Baum et al. framework to provide assurance that the project satisfied ethical considerations.

1.2 1.2 1.2

EV VIP 1 (K) EV VIP 2 (K) EV VIP 3 (K)

5 Looking Ahead: Addressing Ethical Challenges in Public Health Practice Nancy M. Baum, Sarah E. Gollust, Susan D. Goold, and Peter D. Jacobson; Published in Global health law, ethics, and policy; Winter 2007


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From the outset, I was conscious that this was a highly targeted project, designed for those with high levels of complexity and vulnerability who chose not to engage with core services, and who lived in a very specific geographical area. This meant that the intensive support provided by the project was not available to people living outside of that area. It was also not available to others with complex needs but who were engaging at some degree with services. To explore this further in a more methodical way, I considered the following six key areas (see attached notes). 1. Population-level utility of the proposed action 2. Evidence of need and effectiveness of the action 3. Fairness of goals and proposed implementation strategies 4. Accountability 5. Expected efficiencies and costs associated with the project 6. Political feasibility and community acceptance Here I also considered medical ethics around - Autonomy (individual); if it limits individual liberties - Non-Maleficence; if it does harm to any individuals or groups - Beneficence; if it improves the well-being of the affected individuals Based this I was able to identify the ethical considerations and issues arising from the project and outline how we were addressing them. This was used provide assurance that the project was the ‘right’ thing to do in terms of an ethical public health intervention. One issue considered was balancing individual choice whilst protecting the public good. The people we are trying to engage had declined support on many occasions, as they did not wish to change their lifestyle. However, this was not only having a negative impact on the individuals themselves, but also on emergency services and the communities in which they were living. We decided to progress with trying to motivate them to engage by addressing what mattered to them (noting that this may very well not be addressing their substance misuse or behaviour at the outset). The concept was that by developing a relationship with them and helping to support them in other areas of their lives, they were more likely to address their substance misuse and other health and wellbeing needs. This would subsequently benefit them, emergency services and the community.

1.2

EV VIP 4 (A)

Standard 2.5: Interpret and present information using appropriate analytical methods for quantitative data. Knowledge


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Working as a commissioning lead with the Public Health team, I have been involved in reviewing data across on a wide range of issues including substance misuse data and sexual health. My knowledge has grown through on the job experience and exploring data with the Public Health Intelligence Lead and other public health colleagues. When I formally joined the Public Health Team in October 2016, a colleague and Public Health consultant recommended using Mastering Public Health (second edition) 6 as reference manual. Since that time I have regularly referred to it and specifically have reviewed section 1A Epidemiology to aid my understanding of statistical terms, including those used commonly in Public Health such as incidence, prevalence and standardisation, years of life lost, differences in population groups and confidence intervals. At a 2019 Faculty Of Public Health - Epidemiology, identifying needs and health intelligence Masterclass, I consolidated my knowledge around quantitative data. This included learning around - causes and patterns of ill-health, including the impact of socio-economic factors on health status of individuals and communities - the importance of accurate and reliable data and factors to consider to ensure that information and data are meaningful and appropriately used - communicating data to different audiences - how health inequalities are monitored and measured - knowledge of the main terms and concepts used in promoting health and wellbeing

Understanding and application When considering the introduction of a new model for supporting complex individuals with substance misuse issues, I reviewed, compiled, analysed and presented quantitative data. Quantitative data can be defined as numerical data which is often used for comparisons and involves counting of people, behaviours, conditions etc.

I analysed quantitative data to understand the current position in more detail, to evidence the level of need in the Victoria area of Stockport, and to consider whether it was appropriate for this area to be selected as the pilot area.

I used information from the most recent lifestyle survey to show patterns of drinking, split by the day that people drank the most that week, and weekly drinking. I reviewed the alcohol related harm hospital based admissions data and used this to show admissions of Victoria residents over a 3 year basis, split by age and gender.

Another key information source which I reviewed was the number of Victoria residents presenting at Accident and Emergency,

2.5

EV VIP 5 (K)

6 Mastering Public Health (second edition) Geraint Lewis, Jessica Sheringham, Jamie Lopex Bernal,

and Tim Crayford, (2015)


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compared with other areas, and the number of people with multiple attendances.

Following analysis of the information, which I considered supported the roll out of the pilot in this area, I presented it to a newly developed project steering group. This was used to provide the background and rationale for this work. The presentation is included for information – relevant slides are 1-6.

2.5

EV VIP 6 (A)

Standard 2.6: Interpret and present information using appropriate analytical methods for qualitative data. Knowledge Working as a commissioning lead with the Public Health team, I have been involved in reviewing service user data across on a wide range of issues including substance misuse. Much of my knowledge has been obtained through on the job experience, working with substance misuse treatment provider agencies and Public Health colleagues, and reviewing qualitative research studies on areas linked to my work areas. As referred to in Standard 2.5, when I formally joined the Public Health Team in October 2016, a colleague and Public Health consultant recommended Mastering Public Health (second edition) as a reference manual. Since that time I have regularly referred to it and specifically have reviewed Section 1 Research methods, part 1D principles of qualitative methods, to aid my understanding of the nature, purpose, benefits and limitations of qualitative data. This included an overview of data collection methods, how to apply these to public health research and policy, analysis and presentation of data, ethical issues, common errors and their avoidance, and strengths and weaknesses. Prior to commencing this work I reviewed a number of publications linked to complex substance misusers who were not engaging with core services. This includes the October 2014, Alcohol Concern Blue Light Project – the Project Manual (attached) which included case studies of individuals who would be targeted under such a project. I also reviewed the Alcohol Research UK research “Frequent attenders to accident and emergency departments: a qualitative study of individuals who repeatedly present with alcohol-related health conditions” published in May 2016 (attached). This detailed the methods used to conduct the qualitative research, such as semi structured interviews with individuals who were frequent attendees at A&E which took place in non-hospital settings, and focus groups with range of hospital staff.

Understanding and application

2.6 2.6

EV VIP 7 (K) EV VIP 8 (K)


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Qualitative data is a broad category of non-numerical data, which can include using words and text in data collection. It can help to describe, explain and gain an insight into behaviours. Examples of qualitative data include interviews, focus groups and observations. The Alcohol Research UK research mentioned above (EV VIP 8 (K)), was undertaken to provide detailed insights in to the views, experiences and characteristics of frequent attenders to accident and emergency departments. Whilst the project I was commencing was not just restricted to individuals who were frequent attenders, this was a client group that would be included in the eligibility criteria and it was reasonable to suggest that others on the VIP cohort would also have similar characteristics and experiences.

One of the key findings of the research was that frequent attenders experience multiple and complex needs, different patterns of substance misuse and varied health and social problems. The group of 30 interviewees reported high levels of mental and physical ill health, unemployment, reliance on benefits, housing issues and social isolation. The main reasons given for drinking were dependence and self-medication to avoid physical and mental health problems.

The research highlighted that A&E was not the optimal place to have detailed discussions about drinking and substance misuse and that staff here needed good working relationships with other agencies including substance misuse services to ensure appropriate pathways and care co-ordination. It also outlined the need to have a flexible person centred system to support this client group and an assertive community outreach model.

I reviewed this qualitative research to help inform the VIP model, and used this to inform my contributions to discussions around defining the model at the Alcohol Project Workshop in March 2017 (item 3.4 - what works well). The key foundation of the VIP model is to have a person centred approach to get the right outcome for the individual concerned and to use a community outreach worker. VIP clients typically have highly complex lifestyles and are frequently socially marginalised or disenfranchised. For these people it can be overwhelming to keep appointments, maintain a diary and fulfil other requirements that are key to effective engagement with traditional provision. This has led to this cohort becoming alienated from agencies and, where support is sought, prone to seeking this from A&E, the hospital and primary care on an unscheduled basis, placing demand on resources. A briefing note on the VIP model which is based on the learning from this is also included for information.

The VIP approach is one which is rapid, targeted and able to respond to need across multiple domains in a flexible manner. VIP works by offering an opportunity for the client to simply become accustomed to engaging with support. This is before involving agencies with a more specialised remit depending on where the greatest need lies, or involving multiple relevant agencies whilst

2.6 2.6

EV VIP 14 (A) EV VIP 9 (A)


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continuing to co-ordinate support and being a point of access for the service user. As part of the ongoing review of the pilot, I highlighted the need for qualitative data to be gathered to provide a greater insight into the particular behaviours and outcomes of clients on the cohort. I wanted the focus of the case studies to be on demonstrating the key points and milestones in the client journey in order to show the impact VIP was having on real people’s lives. I liaised with the VIP outreach worker (who had developed relationships with clients) to determine how best to obtain information and what information we wanted to obtain. We agreed that compiling such information would be best done via one to one conversations with the client (in the format of unstructured one to one interviews). The VIP worker arranged to talk to the clients about this as part of his ongoing work with them. We decided to approach it in this way as clients were reluctant to talk to others about their experiences and we did not want to risk them disengaging. Previous experience of working with these clients also indicated they were unlikely to engage in a structured conversation where there were a number of set questions. The conversations were held at a location convenient for the person, and at a time when they felt comfortable and were willing/able to talk. The basic ask of the individual was to talk through their journey, and let them lead the conversation, but we agreed that the VIP worker could prompt if he felt they had missed something out, if needed to aid clarification or in order to help move the conversation along. It was designed to be an informal discussion which was then summarised back to the client to ensure accuracy. Of note, participants were made aware that we wanted to use their experiences to help review and inform the project, and agreed to how and where this information would be used. A copy of two case studies obtained in October 2018 are included for information. These outline their individual experience and also the role of VIP in being there and supporting them at the time when they really needed it, and listening to what they wanted. These two case studies were shared with the Council Leadership Team as part of the wider evaluation of the VIP programme. I completed this report at the request of the Director of Public Health. They were used to show the project’s diverse approach when meeting the needs of this complex cohort. In the first case, significant effort went into ensuring a safe discharge from hospital and subsequent re-engagement when he became street homeless and at risk of dropping off the radar altogether. In the second case, VIP was able to undertake intensive work to get him to the stage where he was motivated to access alcohol support. The importance of hearing from current service users and their experience of VIP was needed to get a more detailed view of people’s journeys before progressing with the project.

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The remit of this qualitative work was clearly defined at the outset as a factual reflection of a client’s journey - it was not intended to gather detailed information about VIP processes or what could have been done differently to improve the service. However, it is clear that this information would also have been useful to collect and consider. An additional limitation of this qualitative work was that we were unable to have meaningful discussions with those that had chosen not to engage.

Standard 4.2: Demonstrate how individual and population health and wellbeing differ, and the possible tensions between promoting the health and wellbeing of individuals and of communities. Knowledge Much of my knowledge around this area has been gathered through on the job experience, talking to colleagues and reading articles and publications related to such issues. An example, which is still relevant seven years on, is the Home Office consultation on policies to cut alcohol fuelled crime and anti-social behaviour. (Attached for information). This was launched in November 2012 and included consideration of Alcohol Minimum Unit Pricing (MUP). This was pertinent to my area of work around alcohol and community safety. It stimulated significant local discussion and provided me with an opportunity to reflect on a population health approach, in an area that was often targeted at specific individuals or targeted populations. Our local discussions mirrored national ones, noting the clear tension linked to MUP around the rights of individuals versus the population benefit. Supplementary arguments were also put forward around certain groups (e.g. those in lower socio economic groups being disproportionately affected by the increased prices). The introduction of a MUP would have impacted on the whole population, not just those who were drinking more than the recommended limits. This provided significant discussion at the time as we considered whether the introduction of MUP would be acceptable (noting that everyone who drank alcohol would be affected), or whether a targeted approach at those drinking over recommended limits and/or at harmful levels would be fairer to those drinking responsibly and more effective overall.

At the Faculty Of Public Health - Developing and Evaluating Interventions collaboratively Masterclass, I was able to learn more about the population health v individual health considerations. This included discussion about universal (population) approaches, targeted approaches where the focus is on high risk individuals, and proportionate universalism (where actions are universal but with a scale and intensity proportionate to the level of disadvantage) in order to reduce health inequalities.

The ‘Prevention Paradox’ was also referred to, where population level interventions require many people to change for a few to

4.2 4.2



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benefit. The risk here is that it can lead to few changes overall as low-risk people will see little individual benefit for themselves. However, importantly even few changes made by everyone can achieve an observable population level health improvement.

The tension between population and individual health was also explored, including how population level changes can be cheap, effective, automatic and effective, but that there are issues over individual choice and autonomy. This related well to the area of MUP, indeed such issues are still being explored, particularly in light of the recent positive findings from the introduction of MUP in Scotland.

The work I undertook in September 2016 around behaviour change workshops to develop a local vision and set of values and behaviours (see attached) also helped to consolidate my knowledge of how best to address the needs of substance misusers. Here, the vision did not support a population level approach. Its focus was on having a person centred approach and recognising individual’s beliefs and preferences. This included working holistically with people as individuals to enable and empower them to take more control over their own health and wellbeing. Whilst this work occurred before I attended the masterclass noted above, it was interesting to revisit this again as part of the population v individual health discussion.

Understanding and application

There were elements of balancing the needs of the community and the needs of individuals when developing and rolling out VIP. One of the key areas we were trying to address was to provide support to very complex substance misusers who were not engaging in core provision and causing demand on local services. In addition, these individuals were frequently having a negative impact on the communities they were living in. For example causing anti-social behaviour, being under the influence of drugs/alcohol on the street, members of the public ringing police and ambulance service due to concerns about safety etc. The project aimed to improve the situation for the wider population in the area, and reduce demand on public sector and other services. However, this was balanced with the need to provide individual and person centred support in order to improve the situation for the person themselves and ultimately improve the quality of their life and their health and wellbeing. This is reflected in the aim of the project outlined in an early planning meeting. It is important to note that whilst the initial role of the VIP worker is to work flexibly to encourage the individual to engage with him, it is the individual’s decision and if s/he does not want the intensive support on offer, they have the right not to accept it. In this case, the VIP worker would either not commence working with the individual or withdraw from contact and the individual would continue as previously (subject to them having capacity to make

4.2 4.2

EV VIP 13 (K) EV VIP 14 (A)


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their own decisions). In order to access VIP in the first place the person must be referred from another agency and they must consent to being contacted by the VIP worker (please see referral form).

4.2

EV VIP 15 (A)

Standard 6.1: Show how organisations, teams and individuals work in partnership to deliver the public health function. Knowledge My early career as an officer at Stockport Council was within the Community Safety Unit. Part of this role including providing support to the Safer Stockport Partnership Board (our local statutory Community Safety Partnership). This Board comprises of a range of organisations that have a shared goal to reduce crime, anti-social behaviour, re-offending and substance misuse. This includes senior representatives from Stockport Council, Greater Manchester Police – Stockport Division, National Probation Service, Greater Manchester Community Rehabilitation Company, Greater Manchester Fire and Rescue Service, Stockport NHS Clinical Commissioning Group, Stockport NHS Foundation Trust, Stockport Homes and voluntary sector providers. The Board work together to develop and address a number of key priority themes, including Public safety and protection, Protecting vulnerable people, Serious and organised crime, and Transforming justice. By supporting this work, I was able to see at first hand, how agencies came together to determine the priority issues in the community and work collectively to address these. This was especially difficult when public finances began to reduce and there were increasing demands on services. This highlighted that working together was the best means of tackling community safety issues, and put the emphasis on early intervention and prevention. The nature of substance misuse is that it is “everybody’s business”. Drugs and alcohol impact on the health and wellbeing of residents, the safety of communities, and the vibrancy and economic future of town centres and night time economies. There is also the specific impact on children and the need to break the cycle of substance misuse. Substance misuse is a key contributor to driving demand and costs for council and other services. Therefore it cannot be addressed in isolation by one organisation. There has always been a tradition of partners working together in Stockport to achieve such aims and I have been part of this work and learnt about what makes an effective partnership over a number of years. Through experience I have identified and seen at first hand some of the benefits. The people we are working with often have a range of complex issues so it is not possible to effectively address things in

http://www.gmp.police.uk/live/nhoodv3.nsf/division.html?ReadForm&Division=Stockport

http://www.gmp.police.uk/live/nhoodv3.nsf/division.html?ReadForm&Division=Stockport

https://www.gov.uk/government/organisations/national-probation-service/about

https://www.manchesterfire.gov.uk/

https://www.manchesterfire.gov.uk/

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http://www.stockportccg.nhs.uk/

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isolation. By working in partnership we can share expertise, reduce duplication for organisations and provide a better customer experience. It can help us see the full picture, find cross system solutions and make best use of scarce resources. I have also witnessed challenges around conflicting priorities and resources arising from having no direct control over the actions of other agencies. I have also seen ways of overcoming such challenges and recognise the importance of communication; being open minded and getting a robust understanding of the issues different parties face; acknowledging each other’s expertise; working to build successful relationships; and evidencing the benefits that all parties can achieve by working on a particular project / area. At the Faculty Of Public Health - Introduction to Public Health: The Context and Climate of Practice masterclass (May 2019), I consolidated my knowledge of the different roles of organisations and agencies contributing to public health outcomes, and how they work together.

Understanding and application Through the VIP project I can demonstrate the importance of partnership working both at a strategic and practitioner level, and at an organisational, team and individual level. The issues in Victoria were initially raised as being particularly problematic by a Stockport GP who discussed his observations on this cohort of hard to engage individuals with the Deputy Director of Public Health. I was then asked to take things forward to determine the exact nature of need and consider how best to address this. I worked with a range of stakeholders to define the need more fully, develop a new model of working, implement the project and evaluate outcomes. My role included co-ordinating activity and working in partnership with other stakeholders to achieve common agreed aims. The identified cohort have a range of complex health and social care needs and, as such needs span many agencies, it was imperative that all relevant organisations committed to working together, and that staff were equipped with the skills to support people for whom engagement had proved difficult in the past. I drew up a list of potential partners and invited them to an initial discussion meeting in January 2017 (minutes attached). This was followed up by an extended meeting in February 2017 and then a workshop on 9th March 2017. Key partners included Stockport Public Health, Stockport CCG, Stockport NHS Foundation Trust, Greater Manchester Police, Primary Care (GP representative), Drug and Alcohol Services, Providers of Housing and Temporary Accommodation, Homelessness Support, Adult Social Care, Young People’s Services, The Prevention Alliance and Mental Health

6.1 6.1

EV VIP 2 (K) EV VIP 16 (A)


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Services. A former service user also attended to provide a user’s voice. The initial meetings and workshop were used to draw out each agency’s experiences, develop an understanding of the issues from each agency’s perspective, and agree a shared understanding and vision (workshop minutes attached). I led a session which agreed the project remit as: For dependent alcohol and/or substance misusers whose behaviour challenges services, (VIP) Victoria Intensive Programme is a person-centred approach in Victoria which gets the right outcome for the individual. By having a shared vision and understanding we were able to secure buy in from key partners at a strategic and operational level, and I used this to keep us on message / track as the project developed. Following support and ownership from the strategic / project group at an organisational level, it was agreed to have a link worker employed to directly work with and support the person. This link worker is supported by a virtual team as part of a coordinated approach. The virtual team comprises of a ‘core’ and a ‘pull’ element. These involve both whole teams (e.g. adult social care neighbourhood team) and individual workers. I chaired the first core team meeting (agenda attached) in March 17, which brought together a range of individual practitioners to work directly with the client in a multi-agency and co-ordinated way. The core team comprised of named representatives from Public Health, substance misuse services, Adult social care, Stockport NHS Foundation Trust and H3 Homelessness service. At this initial meeting, I made sure everyone had a common understanding of the aims, felt supported by their organisations to take forward this work, and felt able work creatively and jointly with other people in the team to achieve the best outcome for the client. It was agreed that the ‘core’ team would meet every 2 weeks to discuss cases and progress and support needs (with due regard to information sharing), and also consider how VIP was working on a practical operational basis. In addition, there were links to other key agencies as part of the ‘pull’ team, including primary care, housing providers, Wellspring (homelessness service), GM Police and probation / CRC. All individuals who are part of this virtual team understand that we are stretching and enhancing traditional roles, and they are empowered by their agencies to work in a collaborative and multi-agency way. Through working in a multi-agency way, the benefits and also the risks associated with the care and support provided to the individual, are shared across all workers / agencies. This led to a collective and also supportive approach between practitioners. An example of the minutes of the meeting are attached for information.

6.1 6.1 6.1

EV VIP 14 (A) EV VIP 17 (A) EV VIP 18 (A)


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Standard 6.2: Demonstrate how you work in partnership in multi-agency collaborative public health work. Knowledge Much of the knowledge indicated in standard 6.1 (Show how organisations, teams and individuals work in partnership to deliver the public health function) also applies to this standard. This includes my early career working in the Community Safety Unit and providing business support to the Safer Stockport Partnership Board (our local statutory Community Safety Partnership). This Board comprises of a range of organisations that have a shared goal to reduce crime, anti-social behaviour, re-offending and substance misuse. By supporting this work, I was able to see at first hand, how different organisations and individuals came together to determine priority issues and work collaboratively. My experience also includes working on the substance misuse agenda, where a multi-agency approach is required, given the impact on the health and wellbeing of residents, the safety of communities, and the vibrancy and economic future of town centre and night time economies. There has been a history of partners working together in Stockport to work together to reduce the harms caused by substance misuse and I have been part of this work and learnt thorough observing different approaches of organisations and individuals over the years. This learning from others helped me to develop my own approach. This includes tailoring my approach depending on the organisation / individual concerned. I have also witnessed some challenges around conflicting priorities and resources. For example, a police colleague at the time was only interested in reducing offending and not concerned with the health benefits of the individual engaging in substance misuse services. The current substance misuse commissioner was able to highlight the role of our work in reducing crime, and use this as a lever to increase police engagement in making referrals to substance misuse services. At the Faculty Of Public Health - Developing and Evaluating Interventions Collaboratively masterclass, I consolidated my knowledge of the importance of engaging with partners through collaboration to meet needs effectively

Understanding and application My role in the VIP project was as the project lead. I worked with a range of stakeholders to comprehensively define the need, develop a new model of working, and implement the project. My role included co-ordinating activity and working in partnership with other stakeholders to agree and achieve common aims.

6.2

EV VIP 12 (K)


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At the outset I approached a number of organisations to bring them together to be part of the project. Following discussion with a local GP I brought together an initial group to discuss this as an issue (please see minutes of January 2017 meeting). The initial agencies involved were: - Primary care - GP Partner and Lead - Public Health - Stockport NHS Foundation Trust (Alcohol Liaison Nurse) - Targeted Prevention Alliance - Adult social care - Lifeline Project (drugs and alcohol) - Clinical Commissioning Group - START (Lifestyle services including drugs and alcohol) - Stockport Homes (Registered Social Landlord) - Pennine Care NHS Foundation Trust - H3 Homeless service - Pathfinder, Pennine Care (drugs and alcohol) Following this other agencies were also invited: - Greater Manchester Police - NW Ambulance Service - GM Fire and Rescue Service - Probation - Community Rehabilitation Company - Wellspring (Homeless charity) At the subsequent workshop in March 2017, my aims were: - to give all agencies sufficient information so they could see how the issues and proposed project related to their areas, - to provide a safe space to fully consider the issues - to allow them to contribute with their experiences - to be part of defining the approach. At each stage of the early work, I kept all agencies informed of what was happening, what the current thinking was and made sure they were all in agreement with the proposed course of action. By being open and transparent and asking them for their views, I was able to shape the project in a way in which all agencies saw value and bought into. The outcomes we collectively agreed reflected the priority areas for the organisations involved. This made it easier to demonstrate the need for multi-agency working to achieve outcomes which benefited every agency in some way. For example some focused on emergency services, others on social care involvement, others on health and wellbeing. These included - Reduction in hospital admissions - Reduction in ED attendances - Reduction in conveyances to hospital by ambulance - Reduction in demand/time on adult social care services - Reduction in adult social care placements or support - Improved client confidence and self-esteem - Reduced client social isolation

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- Improved positive functioning (autonomy, control, aspirations) - Improved emotional wellbeing The logic model showing these is attached. My approach to collaborative working is to be open and honest in all relationships, invest time to build these relationships, be supportive and take forward and complete agreed actions in a timely way. I seek to find out the priorities of other people and agencies, understand the perspective of others, including any constraints and pressures, and work to find out where our priorities align. Through doing this, we have been able to get to a mutually agreeable vision, consider the wider impact of the work and determine how best to achieve this.

6.2

EV VIP 19 (A)

Standard 6.3: Reflect on your personal impact on relationships with people from other teams or agencies when working collaboratively. Knowledge Reflective practice is a key part of working in a public health role and something I have been undertaking for a number of years. This has been done informally, thinking things through myself and talking about experiences with colleagues, and also more formally through monthly 1-1 supervision sessions and annual Personal Development Reviews with my line manager (Director of Public Health). Testimonial attached for information. As part of reflective practice I have considered how I have approached things with other people from different agencies and what my personal impact has been. This impact is in terms of relationship building and the overall outcome of a given project or task.

At the Faculty Of Public Health - Developing and Evaluating Interventions Collaboratively masterclass, I consolidated my understanding of the importance of engaging with partners through collaboration to meet needs effectively. This included an input about considering how effective I was in a given situation, what worked well and not so well, and whether goals were achieved.

Understanding and application Generally, I feel that the implementation and development of VIP and the multi-agency working element went well. I built good working relationships with representatives from key agencies which contributed to positive outcomes overall for people on the cohort and for the agencies around the table. From the outset I understood the importance of working together in a collaborative way and looked at finding common ground and aligning the priorities of all organisations involved. I also adopted a pragmatic approach after listening to the GM Police colleagues.

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They understood the importance of this work and supported the project but due to other constraints and pressures were unable to commit to becoming part of the core group. Instead of withdrawing completely from the project, we worked together to see how they would form part of the virtual group instead. This involved conversations outside of the usual meeting structures, and was conducted on a one to one basis to fully understand the issues and work together to come to a compromise where police input was still available but in a less resource intensive way. This was subsequently recorded in the minutes of the meeting of 20th April 2017. One of the key things I learnt through VIP was the balance of being flexible to address the needs of partners whilst also keeping the project true to its original aims. This has involved reflecting on the criteria for a person to be part of the cohort and having discussions with key staff to ensure that everyone had the same understanding. For example, the criteria was for those who resisted engagement with core services. As social care colleagues who had originally been involved in the project moved to different positions and new social care staff got involved, there were a number of times when inappropriate referrals were made (see example of minutes of core meeting in October 2017). For example, people who were already engaging in drug or alcohol services but who needed a bit of extra support to get to appointments. In these cases VIP was not the most appropriate service and so the referral was not accepted. This was subsequently discussed and accepted with the new staff but on reflection, I do think that this could have been avoided had I developed a relationship with the new members of staff at the outset, rather than simply relying on former social care staff to do a detailed handover. Following this I have ensured that any new staff who are working with VIP are given a full briefing of the current provision and also the opportunity to raise any issues from their perspective or ideas for improving the service.

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Standard 7.1: Describe how you have planned a public health intervention to improve health and wellbeing, demonstrating terms and concepts used to promote health and wellbeing. Knowledge My current role in the Public Health team is as Behaviour Change Lead and my key work areas are around drugs and alcohol, smoking, physical activity, weight management and sexual health. As part of this work I have kept myself informed of guidance around health promotion linked to behaviour change, for example the Local Health and Care Planning: Menu of preventative interventions by Public Health England published initially in November 2016, which outlined preventative interventions in some of the key areas I am working on.

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EV VIP 22 (K)


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As part of the wider public health team, I have also been briefed and contributed to system wide changes around prevention and empowerment and person centred approaches. Copy of presentation I attended in February 2015 attached for information. This and other similar briefings have enabled me to extend my knowledge around other public health interventions outside of my specialist area. I have also worked with experienced colleagues in the Public Health team to understand their work areas and how they have planned Public Health interventions. For example, the roll out of community blood pressure testing and work around pre-diabetes prevention (formerly we used DESMOND - Diabetes Education and

Self-Management for Ongoing and Newly Diagnosed, then more recently the national diabetes prevention programme). At the Faculty Of Public Health - Developing and Evaluating Interventions Collaboratively masterclass, I consolidated my knowledge of health promotion models. This included health belief models (used to explain and predict individual changes in health behaviours); trans-theoretical models, for example the stages of change (pre-contemplation, contemplation, preparation, action, maintenance, plus relapse) and ecological models (which recognise the multiple levels of influence on health behaviours, such as individual factors which influence behaviour like knowledge, attitudes, beliefs, and personality). There was also the opportunity at this masterclass to refresh my learning on the broad type of public health interventions such as - Social/biologic and environmental interventions (e.g. immunisation) - Behaviour interventions (e.g. health education campaigns) - Political interventions (e.g. Banning of smoking in public places). Each of these are very relevant to my work areas, noting for some I have more direct control and involvement in than others. Here I also built on previous on the job learning and learnt about the steps to developing a public health intervention: Step 1: Start with the problem; Step 2: Seek evidence (determinants and risk factors, what has been done before, what works and for whom, who should you target); Step 3: List possible interventions; Step 4: Conduct an options appraisal; Step 5: Draft the theory of change Step 6: Pilot test, refine; Step 7: Implement; Step 8: Evaluate, refine (or stop). Understanding and application In terms of a health promotion model, VIP is based on the trans-theoretical model, which focuses on the stages of change which individuals go through when making a behaviour change. This is as follows: Precontemplation – not ready to make a change

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Contemplation – maybe ready to make a change Preparation – prepare / plan to make a change Action – do it – make the change Maintenance – keep going, sustained change There is always the possibility of relapse, when the stages of change may start again. This is a model that is often used when working with substance misusers as it effectively characterises the stages most go through. The VIP client group is very complex and the aim is to support them from pre- contemplation through the various stages to maintenance. From the clients we have worked with it was clear that many had been through the stages of change multiple times with varying degrees of success but with relapse as a common factor. The criteria for the project requires referral from other agencies. Some of the people referred were at pre-contemplation stage and were not ready to try to change their behaviour. Here we agreed that the VIP worker would provide an overview of the support available and try to encourage a move to a contemplation stage. However, if the client was resistant to this, the worker would withdraw whilst making it clear the client could return at any time if/ when they wanted some support. Most of the clients identified by other agencies were at contemplation stage; they were considering making some changes to improve their lives but were not sure what or how, or even if they could make any changes given the range of issues they had. Here the VIP worker helped them to prepare and plan for the changes they wanted to make, and then helped to put these plans into action. The referral form/support plan is attached for information. Once they had taken these initial steps the aim was maintenance and to sustain the changes made. As clients engaged and began to make identified changes, VIP started a planned withdrawal from supporting the client (as intensive support was no longer needed as they were engaging and getting help from other core services). For many substance misusers, and especially those with very complex needs on the VIP caseload, relapse is a very real issue. People can go around the cycle of change several times before long term sustained maintenance is achieved. This is acknowledged by all workers and our systems are set up to encourage sustained recovery (ongoing support groups) and to ensure people who may have relapsed can quickly re-access the level of support at whatever point they it. Part of the work undertaken with VIP clients is to consider what personal and social capital they have and encourage the client to build on this. My role in this was defining the ways of working with substance misuse clients and specifically VIP clients and ensuring the project and also the wider substance misuse treatment system was designed to support this. Through working with clients in a person centred way, and following a trans-theoretic model, identifying

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EV VIP 15 (A)


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where they are in the stages of change and tailoring the support based on this, we were able to work with clients to achieve good outcomes. The original aims are provided in the attached logic model and further information, including case studies is provided in the evaluation document (supplementary briefing to the Council Leadership Team).

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Standard 7.2: Demonstrate how the culture and experience of the target population may impact on their perceptions and expectations of health and wellbeing. Knowledge Due to working in a Public Health role and commissioning behaviour change services, I am aware of the characteristics of the people we are trying to support, and the impact this has on how they respond to services. This has been supplemented by national guidance, local strategies and working with colleagues and the population groups themselves to understand this area further. I have learnt that beliefs about health and wellbeing (and illness) can vary by population and sub groups. This can impact on how they respond to illness, when / if they will seek support around health and wellbeing, how they will view the role of health professionals and how they will respond to diagnosis / treatment. People’s perspectives can be influenced by a range of factors, including ethnicity, education, religion, values, gender, age, family, social status, where they originally came from and where they are living now. In 2009 I was involved in the commissioning a new substance misuse treatment system in Stockport and as part of this reviewed NICE QS23. This highlighted that people with drug use disorders often have a range of health and social care problems and that drug misuse is more prevalent in areas of social deprivation, which in turn is associated with poorer health. It also noted that many people with drug use disorders have lifestyles that are not conducive to good health, with examples given that around injecting drug users being particularly vulnerable to contracting blood-borne viruses and other infections. It also explained that a long-term study of people with an addiction to heroin showed they had a mortality risk 12 times greater than the general population. Within the standards it is noted that a number of specific groups of injecting drug users may require special consideration. For example, homeless people, who are more likely to share needle and syringe equipment on a regular basis than others who inject drugs; women, whose drug use may be linked to specific behaviours and lifestyles that put them at an increased risk of HIV and hepatitis infections; users of anabolic steroids and other performance- and image-enhancing drugs; and the prison population, which contains a higher than average number of

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EV VIP 25 (K)


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injecting drug users. Each of these are likely to have different perceptions of health and wellbeing, and people should receive support to access services tailored to their individual needs. I also reviewed and contributed to Stockport’s local drug and alcohol strategy 2014-17, where is it was highlighted that “harmful and dependent use of drugs or alcohol is often associated with a range of other psychological and social issues including poor mental health and wellbeing, domestic abuse, crime and anti-social behaviour”. Drug and alcohol misuse are often intertwined with a range of mental health and social problems, including: depression and anxiety; domestic abuse; child abuse; loss; trauma; housing needs; offending; and severe mental disorders such as schizophrenia. All these factors also have a direct impact on how people view their own lives, their aspirations and their health and wellbeing. Stockport is one of the most polarised boroughs in England in terms of deprivation, and this is reflected in high levels of health inequality. There remains a gap between the most and least affluent parts of the borough of more than nine years for men and seven years for women. Drug and alcohol misuse and related problems play a significant part in maintaining this differential. Given the health inequalities in relation to drugs and alcohol, the strategy notes the need to prioritise services engaging those who are most vulnerable to alcohol and drug-related harm, including people involved in offending or experiencing social exclusion, mental health issues, domestic abuse, or poverty. I have also reviewed Stockport’s Joint Strategic Needs Assessment (JSNA)7, which indicates that the direct causes of these inequalities are mostly cancer, circulatory disease and digestive diseases. All three of these are linked to lifestyle choices including smoking, alcohol, diet and activity. The complex drivers of health inequalities have been documented in the Marmot report, noting that health behaviours play an important part in maintaining such inequalities, but they are also driven by deeper issues of status and stress. Social and health inequalities are both drivers of problematic substance misuse, and exacerbated by the impacts of such misuse. During the Faculty Of Public Health - Understanding Risk and Effectively Communicating Health Risks to Different Stakeholders masterclass, there was an opportunity to explore different types of risks, including inherited, physical environment, social environment and behavioural. Here we considered if we should target groups known to be at high risk or extend prevention efforts to the general population as a whole.

It was noted that everyone at risk should be able to make informed decisions to mitigate the effects of the threat and take protective and preventive action. Traditional approaches were around providing information and telling people what to do. This has moved on considerably as it did not take into account how people process information, communicate and make behavioural

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7 Stockport Joint Strategic Needs Assessment 2015/16 https://www.stockport.gov.uk/health-and-wellbeing-board/joint-strategic-needs-assessment


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decisions. Contemporary approaches include listening and understanding, getting insights into what motivates the population you are trying to engage, building a relationship over time and creating supportive environments where people can make their own informed decisions.

In the training it was highlighted that risks are generally more worrying (and less acceptable) if they are perceived to be involuntary (e.g. exposure to pollution) rather than voluntary (e.g. dangerous sports or smoking); or subject to contradictory statements from responsible sources.

Understanding and application The VIP project is focussed on a particular cohort of substance misusing individuals with very complex needs who are resistant to accessing support and to changing their behaviour. They typically have highly complex lifestyles and are frequently socially marginalised or disenfranchised. For these people it can be overwhelming to keep appointments, maintain a diary and fulfil other requirements that are key to effective engagement with traditional provision. They are a cohort who, in addition to taking drugs and heavy drinking, generally smoke, have a poor diet, do little physical activity, have limited social and family networks, are unemployed, have housing needs and have poor mental health. These are some of the most powerful risk factors in terms of health and wellbeing, despite many being regarded as ‘voluntary’ risks, which can be perceived as less worrying and more acceptable overall. This cohort are very likely to take ‘voluntary’ risks, regarding it as their right to make such choices, even when that choice is not a ‘good’ one or something a health professional would recommend. This choice is something they have feel they have control over, when often they feel they have little control in other areas of their life. At the VIP Workshop on 9th March 2017 we developed personas based on real case studies and looked at what would make a difference in terms of engaging such a cohort to seek support and improving outcomes. It was determined that we needed workers who: - have the resources and time to really focus on the needs of the individual; - who can physically go to client to provide support or meet wherever is best for client; - can help to sort out issues such as benefits, managing money; - can enable people to get to appointments/support at the right place at the right time; - have a good knowledge of services and can explain other services/provision; - can manage expectations and deliver what they promise; can make ‘comfort’ telephone calls – (e.g. how are you feeling today? –

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EV VIP 14 (A)


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not just visits); - have time and the ability to build relationships; - have a person led or at least person-centred approach; - don’t give up on the individual

In order to try and engage with the VIP population group, it is imperative that the worker finds out what matters to the client. This can be done through developing a relationship, asking open questions, spending time with the person and listening. Much of the initial engagement work is around getting to know the person and finding out how the person views their own situation and what is important to them regarding health and wellbeing, as well as other factors in their lives before establishing what they want to achieve and agreeing a way forward.

The nature of the client group means that they have invariably had previous contact and negative experiences with a range of services. This makes it especially difficult for them to engage again with core services as they see them as interfering with their lives. There is a perception that they have no understanding of what the client is dealing with. VIP seeks to present an alternative type of service to encourage people to re-engage with services and take steps to improve their health and wellbeing.

Standard 7.4: Evaluate a public health intervention, reporting on effectiveness and making suggestions for improvement. Knowledge Since working in a Public Health role, I have been able to benefit from ongoing on-the-job learning and development around project evaluation. I have been involved in developing work areas and determining effectiveness of projects in order to make recommendations about future provision and funding.

An example of this was in early 2014 when I was involved in an evaluation review of LOTO (Life On The Outside). This was a joint Community Safety and Public Health project which aimed to provide support to non-statutory offenders (many of whom had substance misuse issues), improve outcomes for them and lead to a reduction in offending. The actions from an initial meeting and subsequent final evaluation are attached for information. This work was led by another colleague, and by working with her on this evaluation, I was able to get an understanding of the type of information required, how to present this and how to use the evaluation to support a business case for continued funding. This evaluation was submitted to and accepted by the Substance Misuse Joint Commissioning Group, an independent group of stakeholders with a remit around drug and alcohol provision, which had provided the initial funding.

I used learning from this and other public health related projects to develop practical experience of evaluating projects. Through

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reflection and working with others on different projects I have been able to refine such skills over the past few years.

At the Faculty Of Public Health masterclass, Evidence Based Public Health: Accessing, Appraising and Applying the Evidence Base, I formalised my learning around how to apply evidence to programme planning, implementation and evaluation. This included refreshed learning around the 5 step approach to Evidence Based Medicine8 1 Assess: Ask focused questions 2 Access: Find the most robust evidence to answer it 3 Appraise: Use skills of critical appraisal to review evidence 4 Act / Apply: Apply the findings to the realities of practice & needs of the population 5 Audit / Assess: Review the first 4 steps and consider changes for the next time I also attended the Faculty of Public Health masterclass, Developing and Evaluating Interventions Collaboratively, which gave me a solid basis on which to reflect on my previous learning and develop further. This included the CDC Framework for Evaluation: Step 1: Engage stakeholders Step 2: Describe the program Step 3: Focus the evaluation design Step 4: Gather credible evidence Step 5: Justify conclusions Step 6: Ensure use and share lessons learned

Understanding and application One of the first stages of was VIP was developing a very clear vision of what the project was trying to achieve (please see attached Logic model). This facilitated work around preparing an effective evaluation as I was able to look at the overall aims and then use the evaluation to show to what extent the aims had been achieved. From the very beginning of project development, I was aware that a Cost Benefits Analysis was required. Funding was received from the DCLG and one of the conditions for this was undertaking a cost benefit analysis (CBA). This was to consider the balance of costs and benefits and demonstrate whether an intervention provides sufficient financial benefit. As part of this I gathered information on the individuals on the cohort from a range of agencies and input this into cost benefits analysis tool which had been developed by New Economy and supported by the Cabinet Office. The completed CBA tool is attached for information. I was also keen to consider the potential benefits and challenges associated with VIP that did not fit neatly within the remit of the

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EV VIP 30 (K) EV VIP 12 (K) EV VIP 19 (A) EV VIP 31 (A)

8 Sackett David L, Rosenberg William M C, Gray J A Muir, Haynes R Brian, Richardson W Scott. Evidence based medicine: what it is and what it isn't BMJ 1996; 312 :71


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CBA but were also important to reflect a wider perspective of the success of the project. Therefore in addition to the CBA an evaluation report was prepared and submitted to the Council Leadership Team. This included detail on the cohort, outcomes and cost benefits, learning from the pilot, levels of need across Stockport, future provision and options to extend, and appendices which contained case studies. In January 2019, I also liaised with SQW (an independent provider of research, analysis and advice in economic and social development), who had been commissioned by the Ministry of Housing, Communities & Local Government around projects funded under the Communities Fund) to prepare an evaluation report. This contained key learning and proposals for the future using CBA methodology. In summary the evaluation documents highlight that key elements of the identified success criteria have been achieved. This includes: - A reduction in number of unscheduled contacts with emergency services including ED attendances at Stepping Hill Hospital, ambulance conveyances, unscheduled hospital admissions - Reductions in residential care placements and social worker time - Improvements in individual wellbeing and functioning. - Reductions in levels of drug and alcohol use There was an increase in police incidents after cohort start but the actual numbers were very small so not regarded by the Project Group as a particular issue. By completing the CBA tool using actual data from the project and assumed sustained delivery at this level over a 3-year period, we were able to demonstrate both fiscal and economic benefits and the return on investment. When this was combined with qualitative data and learning from the pilot, this re-confirmed the original thinking behind the project. There was and is an unmet need in cases of the highest level of complexity and for these individuals initial engagement opportunities need to be highly flexible. The evaluation also contained recommendations for the future roll out of the project and an indication of funding required for each option. Following the evaluation, some additional funding was secured to extend the pilot to another locality in Stockport. There are also development plans currently in place with Adult Social care to include VIP in its new ‘Front Door’ operating model.

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Standard 7.5: Demonstrate project management skills in planning or implementing a public health intervention. Knowledge


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As part of the Stockport Council’s training programme for managers I have undertaken a variety of training courses since I commenced employment here in June 2003. This included a 5 day project management course in 2006 (example certificate attached). In addition, in 2016 an updated handbook for SMBC managers was introduced (copy attached) which all managers must adhere to. Section 8 Managing Projects gives an introduction to project management and the framework used to run projects (based on the PRINCE2 methodology).

In July 2019, at the Faculty Of Public Health - Developing and Evaluating Interventions Collaboratively Masterclass, I consolidated my knowledge of the principles and stages of programme planning, implementation and evaluation

Understanding and application The VIP project was initially a time limited pilot project to respond to an identified need in the borough which was not being met (notably that people with complex needs were not engaging in core services). When developing VIP project I completed a Project Initiation Document (PID attached). This covers a number of key project management areas which need to be considered when proposing the introduction of a new service pilot / project. As part of this I considered and outlined the background, objectives, scope, deliverables, organisation / roles and responsibilities and management structure, communications, milestones/timescales, resources and risk management linked to the VIP project. This was also used as a basis for the Logic Model which I subsequently completed as one of the grant funding requirements of the DCLG in April 2017. In order to maximise the likelihood of this being a successful project, I self-assessed the proposed project against some basic criteria and was able to demonstrate: - there was a clear remit for the project which all stakeholders understood and supported - the provision was needed by the target client group and delivered in an appropriate way for that group - the provision was needed by other services in an effort to reduce demand on crisis interventions - it was achievable within the timeframes required - it was achievable within the budget available - it was able to be monitored to help inform future provision. Throughout the project, regular updates were taken to inform the Project Board on progress and any issues which could affect the successful delivery of the project. (An example of this is attached for information),

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EV VIP 33 (K) EV VIP 34 (K) EV VIP 12 (K) EV VIP 35 (A) EV VIP 19 (A) EV VIP 36 (A)


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The multi-agency way of working, combined with a desire to do things differently on the ground and the strong strategic oversight around VIP, led to a request for a funding bid to be submitted to extend the initial pilot. When the original project funded by the DCLG stopped in August 2018, I was able to secure funding from Stockport Together (a local Partnership comprising of NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Care (a federation representing all Stockport GPs). Following this additional funding to Sept 2020 was subsequently secured from the Safer Stockport Partnership (our local Community Safety Partnership) to enable its further continuation (email confirmation included).

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EV VIP 37 (A)

Key outcomes / results

The specific outcomes for the key work areas are included in the commentary section above, and particularly in Standard 7.4: Evaluate a public health intervention, reporting on effectiveness and making suggestions for improvement. In summary, the project has been regarded as a success by the Project Team and other key stakeholders. It has achieved many of the key elements of the identified success criteria. This includes reductions across the majority of key outcomes including hospital attendance, ambulance conveyances, hospital admissions and social work placements / social worker involvement, and significant improvements in health and wellbeing outcomes. More specific details are provided below.

Unit Pre-cohort

12 months

Post-cohort 12

months

(extrapolated)

Difference %

difference

Emergency Department

attendances

Incidents 242 176 -66 -27%

Ambulance conveyance

to ED

Incidents 212 162 -50 -24%

Hospital admissions Incidents 109 88 -21 -19%

Police attending

incident

Incidents 10 14 4 40%(1)

Residential care Weeks 14 0 -14 -100%(2)

Social Care worker time Hours 2,500 624 -1,876 -75%


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Illicit drug dependency (3)

Persons 2 0 -2 -100%

Alcohol dependency (4) Persons 22 4 -18 -82%

Increased

confidence/self esteem

Persons 16 3 -13 -81%

Reduced isolation Persons 16 5 -11 -69%

Positive functioning

(autonomy, self-control,

aspirations)

Persons

16 11 -5 -31%

Emotional wellbeing Persons 16 8 -8 -50%

In addition, the cost benefits analysis (based on extrapolated figures and costs/benefits accrued over a 3-year period), indicated fiscal benefits of £364,238 (a 2.83 financial return on investment) and economic benefits of £896,776 (a 5.50 economic return on investment). The outcomes evidenced and general learning from the pilot have been instrumental in raising awareness of the work and enabling us to secure additional funding from Stockport Together and the Safer Stockport Partnership to enable the continuation/expansion of VIP until Sept 2020.

Overall Reflections

I am continuously working on improving my reflective practice, recognising that this is key skill within public health, and that by reflecting on situations and considering what worked well and what didn’t, I can consider how effective my practice is and where I would do things differently in the future. Generally, I feel that the implementation and development of VIP has gone well in terms of project management, partnership working and on delivering effective outcomes for both the individuals accessing it, and also health and social care and wider services in terms of reduced demand and associated costs. I have included specific reflections linked to some key elements referred to in this commentary throughout and also some summarised reflections below. I feel that VIP did raise some ethical considerations. This was particularly in terms of balancing individual choice whilst protecting the public good, and also limiting to the geographical area where the project was available. I found it useful to consider an ethical framework to provide assurance that the project was the ‘right’ thing to do, and I would complete a similar exercise for future public health projects to reassure myself from a Public Health practitioner basis even if this was not a requirement from the Project Team. Working within Public Health there is often a significant amount of quantitative data available, more so than in any other areas I have worked. This brings many benefits as there is often something relevant from acknowledged reputable sources. However, sometimes the data is not exactly what


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you want or in a format you can readily interrogate and interpret. For any new projects I would always spend some initial time scoping what is available and sifting out the most relevant information to support the work. I have found it harder to source qualitative data. Again this is something I would always seek at the outset of a project as this provides an invaluable perspective. It is also something that I would include in any project evaluation as this not only provides a richer picture, it could also be used to support any new project or initiatives where relevant.

When developing VIP, there were elements around balancing the needs of the community and the needs of individuals, and some discussion and consideration around what was the right approach and what was the key aim of the project. Whilst the question needed to be fully considered, I think for this project, the two aims were not mutually exclusive. It supported the needs of the individual and put them at the fore-front, whilst still ensuring benefits for the community for those who decided to engage. In terms of partnership working and collaborative working, there is a wealth of theory and practice available to help develop learning around this area and get an understanding of the key considerations you should be looking at. This provides an excellent basis on which to build, but is no replacement for on the job experience as much depends on inter-personal relationships and understanding and developing a relationship with the individuals concerned. At a masterclass session there was a comment to ‘never underestimate the right cup of coffee with the right person’ and this is something that I will always remember, particularly in the early days of project development and if/when challenges arise. I also think it important as project manager to invest time with new people joining the project part way through the design or implementation phase. This is to ensure that they understand the aims and objectives and have the same understanding as others involved. VIP is based on the trans-theoretical health promotion model, which focuses on the stages of change which individuals go through when making a behaviour change. This was chosen as it is the model adopted by our current substance misuse services. Most people access our services when they are at the contemplation stage and once engaged are ready to prepare and plan to make a change. We have done work over the past few years to try and ensure that people who relapse are able to quickly re-access support. I still think that this model is most appropriate for substance misusers but do intend on looking at other models to see if they are appropriate for my other work areas. I am particularly interested in how the beliefs about health and wellbeing (and illness) vary by population and sub groups. My work is around behaviour change and often working with people with complex needs who come from disadvantaged backgrounds. I think it is essential that I understand their individual characteristics and make sure services are in place which can support them to best engage with initial support / treatment as appropriate. Going forward, I want to ensure in all the services I commission, a person-centred approach delivered flexibly and responsively to needs. With the VIP project, there needed to be a very clear vision and also an effective evaluation approach planned at the outset in order to secure funding from the DCLG. This really helped to focus people’s minds on the things we were trying to achieve and also have a clear idea on what an effective outcome would look like. Such clarity helped secure stakeholder engagement and commitment to the project and also enabled the project to stay on track. Without a comprehensive Cost Benefits Analysis and evaluation document, evidencing the effectiveness of the project and preparing bids for future funding would have been considerably more difficult. This is something that I have learnt from and intend to spend sufficient time on when developing future projects. In terms of project management, we are operating at a time of reducing resources and often faced with the need to do things differently and do them within a short timeframe. With this comes the risk of not investing sufficient time at the outset to agree a project plan. I have seen first-hand the


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benefits of spending time to think about the plan, ensure it is feasible and can be delivered and that it is regularly updated to ensure key milestones are achieved.

List of evidence EV VIP : Indicates evidence linked to the VIP commentary Number: Indicates the order in which it is referred to in the commentary K: Indicates evidence linked to knowledge A: Indicates evidence linked to application Dates are colour coded to provide an indication of currency of evidence at original submission date (November 2019). Green: Within 3 years: Nov 2016 – 2019 Amber: Between 3 and 4 years ago: Nov 2015 – Oct 2016 Red: Over 4 years ago: pre Nov 2015

No Description of piece of evidence Indicators Date

EV VIP 1 (K) Notes on ethical framework produced by Baum et al 1.2 2016

EV VIP 2 (K) Certificate - Faculty Of Public Health - Introduction to Public Health: The Context and Climate of Practice Masterclass,

1.2 6.1

01/05/19

EV VIP 3 (K) Certificate - Faculty of Public Health - Public Health Ethics and Values and How They Inform a Public Health Approach

1.2 27/09/19

EV VIP 4 (A) Notes – ethical considerations VIP 1.2 05/06/17

EV VIP 5 (K) Certificate - Faculty Of Public Health - Epidemiology, identifying needs and health intelligence Masterclass, I

2.5 01/05/19

EV VIP 6 (A) Presentation to VIP steering group 09/03/17 2.5 09/03/17

EV VIP 7 (K) Blue Light Project Manual (Alcohol Concern) 2.6 2016

EV VIP 8 (K) Frequent Attender research (Alcohol Research UK) 2.6 May 2016

EV VIP 9 (A) VIP model briefing note 2.6 12/06/17

EV VIP 10 (A) VIP case studies 2.6 Oct 2018

EV VIP 11 (K) Home office consultation 4.2 Nov 2012

EV VIP 12 (K) Certificate - Faculty Of Public Health - Developing and Evaluating Interventions collaboratively Masterclass

4.2 6.2 6.3 7.1 7.4 7.5

01/07/19

EV VIP 13 (K) Behaviour change vision and values document 4.2 Sept 16

EV VIP 14 (A) VIP planning workshop minutes 2.6 4.2 6.1 6.2 7.2

09/03/17

EV VIP 15 (A) VIP referral form 4.2 7.1

June 2017

EV VIP 16 (A) Minutes of VIP project meeting 6.1 6.2

19/01/17

EV VIP 17 (A) Agenda of first VIP core team meeting 6.1 20/03/17

EV VIP 18 (A) Minutes of VIP core team meeting 17/05/17 6.1 17/05/17


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EV VIP 19 (A) VIP logic model 6.2 7.1 7.4 7.5

April 2017

EV VIP 20 (K) Testimonial regarding 1-1 supervision 6.3 14/06/19

EV VIP 20 (A) Minutes of Core VIP group 6.3 20/04/17

EV VIP 21 (A) Minutes of Core VIP group 6.3 11/10/17

EV VIP 22 (K) PHE Local Health and care planning document 7.1 Nov 2016

EV VIP 23 (K) Presentation - prevention and empowerment and person centred approaches

7.1 05/02/15

EV VIP 24 (A) Evaluation document (supplementary briefing to the Council Leadership Team).

2.6 7.1 7.4

16/11/18

EV VIP 25 (K) NICE QS 23 7.2 2009

EV VIP 26 (K) Stockport drug and alcohol strategy 2014-17 7.2 2014

EV VIP 27 (K) Certificate - Faculty Of Public Health - Understanding Risk and Effectively Communicating Health Risks to Different Stakeholders masterclass,

7.2 27/09/19

EV VIP 28 (K) LOTO actions from initial evaluation meeting 7.4 05/03/14

EV VIP 29 (K) LOTO evaluation 7.4 27/05/14

EV VIP 30 (K) Certificate - Faculty Of Public Health masterclass, Evidence Based Public Health: Accessing, Appraising and Applying the Evidence Base,

7.4 01/07/19

EV VIP 31 (A) VIP completed CBA tool 7.4 Nov 2018

EV VIP 32 (A) Communities Fund evaluation report 7.4 24/01/19

EV VIP 33 (K) Certificate – project management 7.5 03/03/06

EV VIP 34 (K) Handbook for SMBC managers 7.5 July 2016

EV VIP 35 (A) VIP Project Initiation Document 7.5 10/01/17

EV VIP 36 (A) Report to VIP Project Board 7.5 10/07/17

EV VIP 37 (A) Email confirmation re SSP funding 7.5 18/12/18

commentary 2: victoria intensive programme...

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