The Active Norfolk strategy makes a commitment to improve the health and wellbeing of county residents through reducing inactivity and tackling inequality. This priority aligns with many of the commitments within the local health system, including those outlined in the Joint Health and Wellbeing Strategy, Norfolk Mental Health Strategy, Promoting Independence Strategy, and many strategic priorities of the Sustainability and Transformation Partnership.
Physical activity also has the potential to play a significant in achieving many of the priorities outlined the NHS Long Term Plan, including:
- Supporting the increased focus on population health management and integration of services through the new ICS and development of Primary Care Networks
- Providing support to older people and their carers and people living in care homes to reduce hospital admissions, promote independence, reduce social isolation and improve wellbeing
- Promoting self-care and a shared responsibility for health to allow people to manage their own health better, particularly those with long term conditions
- Supporting the commitment to develop social prescribing models linked to Primary Care Networks
- Reducing air pollution and support health and wellbeing through the promotion of active travel and creation of environments that support physical activity
- Reducing health inequalities through targeting to those that are most vulnerable, through the developed locality approach
- Improving the health and wellbeing of people with long term conditions, including poor mental health, cancer, cardiovascular disease, dementia, diabetes and respiratory disease
Active Norfolk have a well-established relationship with Public Health and have had a health lead role which has worked across both organisations for numerous years. This has historically focused on the delivery and commissioning of projects and programmes, but has shifted to an investment into organisational capacity and a partnership agreement which is linked to the achievement of strategic outcomes.
Active Norfolk recognised the need to further understand the opportunities to embed physical activity into the broader system, beyond the role and remit of Public Health. To do this, it was felt that we needed to strengthen relationships within the CCGs to get a clearer perspective of their areas of focus and priority.
Active Norfolk had previously worked closely with Norwich CCG on several initiatives, and, although this relationship was quite transactional, there was a foundation of trust that could be built upon, to move it to something that was more collaborative.
In Aug 2018 a paper was submitted to the Norwich CCG Exec Committee outlining a proposal that included Active Norfolk providing strategic capacity to conduct a review into where there might be opportunities to embed physical activity and the wider prevention agenda, across the CCG system. There was a commitment to seek to explore and align existing resources, identify recommendations for future ways of working and determine the terms of a partnership agreement in the form of an MOU moving forwards.
The CCG was asked to endorse the approach from the most senior level and communicate its commitment to staff and partners, commit in-kind support in terms of staff time across the organisation, provide a designated person to provide matrix-style management and provide physical space to allow the appropriate Active Norfolk staff to hot-desk within their offices.
See process model
Aug 2018– Norwich CCG Exec Committee asked to consider and endorse programme of work and organisational commitment to support process – agreed
Aug 2018– Initial scoping with key personnel to systematically review areas of work and create review framework and terms of reference
Oct 2018– Presentation to Senior Team
Oct 2018– Presentation to Your Norfolk Provider & Service Delivery Board
Nov 2018– Feb 2019 – Review process, meetings with key personnel
Feb 2019– Update to NCCG Exec Committee
March 2019– Co-development of prioritisation structure
March 2019– Presentation to STP Primary & Community Care Board (endorsement for roll out across whole system)
April 2019– Presentation of findings to Directorate
May 2019– Prioritisation workshop with identified NCCG/Active Norfolk working group – involving Active Partnership colleagues from Dorset and Devon to share learning
May 2019– Recommendations report to NCCG Exec Committee – see attached.
System Map & Narrative
Norfolk is evolving into an Integrated Care Model, but the current governance structure is modelled around a Sustainability and Transformation Partnership which formed in 2016. This move to STP governance represented a shift from organisationalto system leadership and demands a significant change in the ways of working within the current system, to ensure a more integrated and collaborative approach.
Active Norfolk’s work around health has involved developing an understanding of this system, its influencers and enablers, and strategic priorities, so that we are able to present the case for embedding physical activity in the most appropriate and effective way.
Whilst there are existing strong relationships with the Local Authorities, including Public Health, the decision was made to focus on one of the five CCGs to strengthen our relationships within their organisation, as well as their spheres of influence. What started as a concentrated effort on one part of the system has led to a role for Active Norfolk being identified, and physical activity having an emerging role, in each of the strategic workstreams of the STP. The STP Exec have now requested that the CCG review methodology be rolled out across the whole system, with this process commencing in June 2019.
The process to date has made use of significant amounts of insight being collated to support Active Norfolk’s locality planning process. Active Norfolk have aligned this work with the locality planning methodology in each CCG, which has resulted in the creation of dataset resources (see attachment), that support the recommendations put forward to the CCG – the recommendations can be linked to local outcomes that can be impacted upon by physical activity and are aligned with the 5 government outcomes for sport and physical activity. Furthermore, there has been some exploration of how NHS datasets might be used to risk stratify and target key population groups as a way to engage them in physical activity – a potentially exciting development that could be applied at scale.
There is now greater alignment with the County Council business intelligence function with Active Norfolk’s Insight Officer spending time within that team and ensuring that we are developing resources alongside the wider system, particularly those that are influencing what the Primary Care Networks being established will focus on in the future.
Active Norfolk now have greater levels of insight into the role the organisation might play in the supporting emerging strategies coming from the STP, including a Norfolk Mental Health Strategy, Diabetes Strategy, Prevention Strategy and Frailty Strategy, as well as the Joint Health and Wellbeing Strategy. This insight and understanding has allowed us to position ourselves well within the governance and operational models that have responsibility for implementation.
Identifying senior advocates within the system and developing good relationships built on the principles of collaborative leadership have been an important part of the work to date. Trust, openness and an aspiration for working differently and innovatively have underpinned the process and ensured that the recommendations put forward are co-developed and co-owned.
Whilst they might not recognise themselves as such, we now have a significant network of advocates within the health system that understand the importance and benefits of physical activity and the role it has to play, and ensure Active Norfolk are brought to the table when appropriate. There is still much to do though.
Policy and Investment
Norwich CCG have made an investment into Active Norfolk’s strategic capacity for 2019/20 as a result of this work, to support the implementation of the recommendations taken forward, as well as test a new approach/model for delivery that builds on the Primary Care Networks now being established and is much more collaborative in its approach. This approach will seek align the priorities of the primary care and physical activity sectors, through the co-production of a programme of activity with the community and third sector that fits around the primary care system, and utilises data systems to identify and engage key audiences.
NCCG and Active Norfolk will also be looking at the commissioning policy and processes of the CCG, including Quality Assurance checklists, to ensure that physical activity is embedded and a consideration at the point of service design/service specification and included, where appropriate, in performance management frameworks.
The work with Norfolk CCG and localities has instigated a Training Needs Audit that will be undertaken in 2019 to help to develop our understanding of the current skills, motivations and expertise within the physical activity and non-traditional workforce, particularly in relation to long term conditions. This will be co-developed with the health sector to ensure it is reflective of their strategic priorities and needs.
The health system locally has launched a ‘Norfolk & Waveney health and social care whole workforce conversation’, called #WeCareTogether, that will help shape the vision for the future workforce, behaviours, how organisations work together and develop an understand what’s important to people that work in the system. Active Norfolk will be supporting the system to respond to the outcomes of this consultation and embed physical activity where appropriate.
The CCG have invested into several physical activity initiatives as a result of the review, including a Primary Care Network physical activity pilot, a mental health programme, cycling activity linked to the Great British Cycling Festival and a programme of exercise referral. Through their Healthy Norwich programme they are also investing in additional programmes that include physical activity and are consulting Active Norfolk in the inclusion of PA into contracts.
Active Norfolk are actively involved in the development of a new MSK pilot to embed physical activity into the primary care contract at the point of service design and commissioning. We will also be working across the system to amplify the Long Term Condition campaign being delivered by Sport England and Richmond group, with much of the work with the CCG building a solid foundation for this.
Engagement with NCCG colleagues has been exceptionally positive, building on collaborative leadership values of trust, openness, honesty and respect. Active Norfolk will be undertaking an evaluation of the process ( https://www.smartsurvey.co.uk/s/ELGH5/) with all staff involved, including Exec Leadership, to understand the impact on the following:
- Understanding of Active Norfolk as an organisation and the role that they play in the county
- Understanding of the role that physical activity plays in achieving CCG outcomes
- Understanding of how physical activity can contribute to their area of work
- Confidence in how to embed physical activity into work
- Importance of collaborative leadership principles in undertaking review
- Further support required
Early results show a significant increase in understanding of the role and function of Active Norfolk, the role of physical activity and confidence to embed physical activity.
When scaling up the review across the health and social care system we will embed this survey at baseline and follow up to get a more accurate measure of impact.
Key Learning Points
The following have been identified as the key learning points from the work with the health system to date:
- Senior commitment and endorsement is essential –this has helped to ensure we have the right conversations with the right people and that we have the required buy-in to ensure we can be efficient with time and resources
- Physical activity can’t be presented as the solution – we need to have an understanding of the strategic priorities of the system and them be able to articulate how physical activity can contribute
- It takes time – the collaborative leadership principals are really important and trust, openness, willingness to change etc don’t happen overnight. Active Norfolk initially allowed 6 months to undertake the review and it has so far taken 10 months, and could have taken longer
- Linked to the above, we need to be realistic about how we are measuring outcomes/impact and how soon we expect to be able to articulate it
- There are many of the existing resources we need already in the system, they just need to be better aligned and we need more co-ownership of delivery/outcomes to ensure they are used effectively
- The importance of matrix working and physically spending time within partner organisations environments, where that can be facilitated, shouldn’t be under-estimated. It has had significant impact on the work around health in Norfolk in terms of relationship development
- The emphasis around prevention is increasing within the health sector and there is a greater appetite to engage, and an increasing value being placed on the role of physical activity – this presents Active Partnerships with a significant opportunity to engage with the health system to achieve shared outcomes.
Inactivity & Health Development Manager, Active Norfolk