## Case Study Derby City Council: Integrated Behaviour Change

"The success of b-You under this Labour administration is down to the person-centred approach, and basing targets on individuals' 
priorities and aspirations for improving their own health. The service assesses patients and works with those who really want to change, and lets them focus on their area of concern first and tailors support to their needs. By also working with friends and family, an individual can really be helped on their journey to a positive, healthy lifestyle. Sessions are carried out all over the city, and will soon include the council's new multisports arena for access to a wide range of activities to support the service."

## Councillor Mark Tittley Cabinet Member For Adults And Health

"We have been involved with, and supported, b-You throughout its development and are confident of the health gains for Derby people as a result of the service."

## Andy Layzell, Chief Operating Officer Nhs Southern Derbyshire Ccg

"The work being done in the b-You service is great, and I'm fully on board with what they are trying to achieve, as are my fellow councillors. We are supporting by ensuring we understand how to intervene and make a referral for a resident in our ward area to ensure they receive support from b-You if appropriate. The improvements in health to Derby residents thanks to b-You is yet another great reason to be proud of Derby."

## Councillor Paul Bayliss, Council Leader

"The growth of the b-You service is particularly exciting and innovative, with the introduction of a children and young person's element. The service is targeting children who are overweight and obese, but as a family approach so all members of a family can improve their health and their lives."

## Adam Wilkinson, Chief Executive Key Messages

- Local piloting with independent evaluation 
has supplemented national evidence to demonstrate the benefits of a major shift in 
health and wellbeing services.
- A person-centred approach to behaviour 
change is demonstrating improvements in terms of individual satisfaction, health outcomes and cost effectiveness.

## Context

Derby City is a primarily urban area with around 250,000 residents. The city includes a mix of affluent and deprived areas with a 12-year life expectancy gap and a significant deprivationlevel gap between central and outer areas of the city
. Derby is a young city with around half of the population aged 35 or less. A public health team of around 30 people transferred to the local authority, and is located in the Adults, Health and Housing Directorate. The PCT and council worked closely together on health improvement in the build-up to the transfer and this enabled a major reform to health and wellbeing services - the b-You programme - to commence in April 2013.

## B-You Integrated Lifestyle Behaviour Change

Background Health improvement services in Derby were performing well on an individual basis, but they were also fragmented and did not facilitate a holistic approach to improving individuals' health. Therefore £1.5 million funding from different health and wellbeing programmes was pulled together into a single commissioning pot to provide an integrated health and wellbeing programme covering alcohol reduction, stop smoking, physical activity, and weight management. The evidence for the programme was based on a range of sources including a range of NICE public health guidance and behaviour change theory as developed in the UK through MINDSPACE behavioural economics  at the Institute for Government. 

It was also underpinned by the evaluation of a pilot set up by Derby PCT and carried out by Derby Council leisure services between 2011 and 2012. The pilot focused on long-term behaviour change for people at medium to high risk of serious ill-health. It offered a 12-month personalised programme providing motivational support for patients with a high BMI to help reduce calorie intake, develop sustainable physical activity, reduce alcohol consumption, and manage longterm health conditions. People  who wanted to quit smoking in addition to losing weight were supported to do so by their advisor but smoking alone was not a referral criteria for the pilot. The evaluation demonstrated significant positive outcomes, all of which were far above performance from individual health and wellbeing services:

- 91per cent retention rate - 6 per cent average weight loss (against an 
NHS target of 5 per cent)
- 97 per cent attended sports centres - 100 per cent increase in activity levels
- 93 per cent improved health and wellbeing - 100 per cent satisfaction with the 
programme.
Commissioning In light of the above, the PCT
, working with the council, agreed to mainstream and extend the integrated behaviour change approach across the city. Due to the size of the contract, the PCT went to external tender under Official Journal of the European Union (OJEU) rules. The contract was won by the council's leisure services and commenced in April 2013 for three years with an option for a further two years.

Key points of the programme b-You is person-centred and based around individuals' priorities and aspirations for improving their own health. For example, smoking may be the major health risk for an individual, but if he or she is more concerned/ motivated to reduce their weight  this would be where the programme would initially focus. A large part of the success of the programme is a result of the service assessing patients at referral and working with those who show a true readiness to change. A b-You advisor will work with an individual (and their family/friends) to provide tailored support around that individuals need. The advisor will initially  provide intensive support to develop and implement an individual action plan to help them on their journey. The support will gradually reduce when suited to the individual to allow them to make positive lifestyle choices independently. The programme is carried out in a range of community venues such as children's centres, community centres, libraries  and leisure centres with a specific focus on venues in deprived areas of the city.  In the future this will also include the council's new multi-sports arena incorporating a velodrome, with access to a new swimming pool and a wide range of leisure activities. 97 percent of people in the pilot started to use sport centres for the first time - a significant achievement. The programme is continuing to grow, with a newly developed children and young people's component.  This targets children between the ages of seven and seventeen who are overweight or obese, through a whole family approach. This will enable positive behaviour change for the family as a unit. The programme has changed since the pilot; referrals have been widened beyond GPs to include self referral, midwives, school nurses, clinicians from the acute sector and mental health services to target people who may have high levels of need, for instance as a potential alternative to weight-loss surgery.  The CCG does not provide funding, but has been involved in and supported its development; a paper will be submitted to the CCG board providing evidence about the health gains to the people of Derby.  In future it is hoped to develop a hub and spoke model around GP practice clusters with b-You advisors supporting local practices. Due to its success, there have been suggestions to widen the interventions to include, for instance debt advice or keeping warm. However, while b-You advisors will refer people on to appropriate support, it is felt that at the current time it needs to focus on its core elements rather than expanding its remit until it is fully established.

Initial results So far, 2000 people have participated in the programme, largely people from the most deprived areas. The programme is evaluated quarterly using a standard evaluation framework. Information in the first six months indicates that b-You will reach 1500 four-week smoking quitters over the year. The latest data shows 84 per cent of participants successfully stopped smoking at four weeks, higher than the previous stop smoking service.  However, the main health gains are in 12 month quitters, which the programme will be able to support and identify. That alongside a yearly figure for BMI 
reduction and improved healthy lifestyles will allow the cost benefit of the programme to be calculated. The six month figures suggest that the programme will be very effective both in terms of cost and health outcomes.

## Other Developments Following Public Health Transfer

Some examples of opportunities provided by the transfer include the following. Use of intelligence, analysis and evidence base - public health has had input into the following areas:

- analysis of pathways around nursing 
provision, acute beds and discharge 
(unfortunately this has not been fully 
achieved due to national constraints on sharing patient-level data across health and social care, an issue Derby seeks to see resolved)
- analysis of heating needs of vulnerable 
groups for the council's housing hub
- development of consistent messages for 
all front line staff (NHS, social care, fire service, housing etc) to give out to tackle excess winter deaths.
Rolling out making every contact count (MECC)

- all councillors have received MECC 
training increasing their understanding of public health and equipping them to 
make brief interventions and referrals (where appropriate) in their contacts with communities.

## Future Plans

Derby is a member of the local area coordination network and since 2012 has run a local area coordination programme, in which people who are vulnerable due to age, disability or mental health needs are supported by local area coordinators to develop personal, family and community networks. There are many cost-effective opportunities for improving health through tying together neighbourhood approaches to develop support, including for people with lower level needs who would not be referred to b-You or the local area coordination programme, and these will be pursued; for example, b-You is seeking to identify community health champions.

Measures to improve children's health are being developed across the NHS and the council by a joint appointment in education and a public health consultant as head of commissioning. Derby is currently looking to a broader integrated offer for children and young people 0-19 taking in school nursing the forthcoming health visitor responsibilities.

## Contact

Derek Ward Director of Public Health, Derby City Council Email: derek.ward@derby.gov
.uk