Dorset County Council: using technology to deliver behaviour change at scale

A high priority for public health on transferring to local government in Dorset and even more so since the advent of STPs has been to make health improvement provision more consistent and equitable across the county and to join up support for different lifestyle risks. It was also a priority to draw on proven theories of behaviour change and to monitor outcomes. LiveWell Dorset is an integrated single service delivered by one contractor to support change across a range of risks and behaviours. 

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“Public health now has far more visibility across all partners, including the NHS, the police and the voluntary sector. We have learned how the wonderful natural asset of our countryside< can be a resource to help people change their behaviour.”

Councillor Rebecca Knox, Leader Dorset County Council and Chair of Health and Wellbeing Board “As part of our sustainability

and transformation plan I have challenged our whole system in Dorset to take prevention seriously by implementing a range of measures at scale and pace. Central to this has been putting science into our behaviour change service, and this seems to be delivering results.”

Dr David Phillips, Director of Public Health 

A Payment by Results (PbR) contract is used to incentivise the engagement of people from the most deprived communities. The service is supported by coaches working to a defined behaviour change framework built into a customer relations system. The introduction of the system has attracted significantly more users with beneficial outcomes in terms of behaviour.

Background

Dorset has a diverse population of 750,000 covering rural and urban areas, including three top tier authorities, Bournemouth Borough Council, Dorset County Council and the Borough of Poole. 

There are considerably more people in the over 60 age group than in younger age groups and this proportion is rising significantly. There are only 1.8 per cent of people from an ethnic minority group as compared with the England average of 13.2 per cent.

The health of people in Dorset is generally better than the England average. Dorset is one of the 20 per cent least deprived counties

in England. However, about 14 per cent of children live in low income families and there are areas in Bournemouth which are classed

as among the most deprived in England. 

Life expectancy for both men and women is higher than the England average but is 5.4 years lower for men and 5.0 years lower for

women in the most deprived areas of the county than in the least deprived areas.

Rates of childhood obesity are better than the England average. Levels of teenage pregnancy and breastfeeding initiation are also better than the England average although levels of smoking at time of delivery are worse than the England average. However differences in these are significant within Dorset.

Public health transformation five years on 15 Among adults, rates of hospital stays for self-harm and people killed and seriously injured

on roads are worse than average. Most other public heath outcome indicators are better than the England average.

The key health priorities for Dorset are reducing inequalities, promoting healthy lifestyles, preventing ill health; working better together to deliver prevention and early intervention at scale and pace; and improving value for money.

Organisation

The public health team in Dorset provides cross-council support to Bournemouth Borough Council, the Borough of Poole and Dorset

County Council. A Joint Public Health Board, which is made up of councillors from each of the three partner councils, with a rotating chair, governs Public Health Dorset’s work.

Dorset is developing a first wave Accountable Care System in the development of which public health has played a significant role,

enabling prevention to be put ‘at the top table’, in the view of the Director of Public Health (DPH). Before public health transferred to local authorities, health improvement service provision was inconsistent and inequitable. 

Separate providers offered services to tackle unhealthy behaviours in different ways, and with different access criteria depending on

where people lived. Services focused on addressing single behaviours, rather than addressing the wider needs of the individual.

Health improvement services rarely used proven theories of behaviour change in a systematic way. Similarly, the quality of the data collected to monitor outcomes varied with limited information on the extent and duration of any changes in their behaviour.

Health and wellbeing initiatives

Public Health Dorset realised there was an opportunity to transform health improvement services by de-commissioning the separate services and designing an entirely new integrated service model. Objectives for the new model were:

  • a single integrated service, with a clear offer to public and professionals
  • better recognition and a clearer brand 
  •  excellence and expertise in behaviour change, based on an evidence-based model (NICE guidance PH49)
  • an ability to support more people, and capture better information over the longer-term about how successful their support had been
  • ability to work at scale, including using technology, social media and modern marketing approaches
  • meeting the strategic goals of effectiveness, efficiency and equity, recognising the need for better value in resource-constrained times.

LiveWell Dorset

LiveWell Dorset went live in April 2015, provided by Optum, part of the United Health Group, which won the tender. It offers a single service for people who need to access support for one or more of the four common behaviours (smoking, drinking, diet and exercise). The final contract value was in two parts – a core funding element of £645,000, with an additional Payment by Results (PbR) contract with the chance to earn up to an additional £275,000. This PbR was used to incentivise the service to engage people preferentially from the most deprived parts of the county. Previous services had been used predominantly by people living in less deprived communities.

The greatest impact in raising awareness came from using simple business cards to connect people to the service via GP surgeries, pharmacies and other venue, including hospitals, libraries, community venues and local authority frontline staff. By signing up to LiveWell Dorset, individuals can try and change multiple behaviours together, one after the other or when they feel ready. The service is made up of advisers and coaches. Advisers receive telephone referrals into the service, and start by assessing a client’s requirements and level of need. The advisers also introduce the concept of 1:1 behaviour change support with coaches. Coaches provide behavioural advice and support, based upon the COM-B model of change developed by University College London Centre for Behaviour Change, to make long-term lifestyle change. The model was built into a customer relations system used to guide the coaches, so that interventions are automatically suggested to coaches based on the barriers that they have identified on assessment.

LiveWell Dorset has a team of Wellness Coaches, each covering a designated locality. A team of telephone-based wellness advisers

helps support people when they first come into the service, assess behaviour barriers, and deliver brief interventions. In addition to the 1:1 behavioural support, coaches are responsible for following up LiveWell Dorset clients living in their locality at three, six and 12 months. People can access the service by self-referring or they can be referred by health professionals in many different locations.

In terms of outcomes, the average contract spend for the service is £750,000 – a saving of £0.25 million per annum compared with the previous separate health improvement contracts. The service is supporting many more people compared with the previous separate services. In the first 18 months, there were 10,321 referrals into the service. Of the four lifestyle pathways available through LiveWell Dorset, the healthy weight pathway is the most popular, with 8,184 users in the first 18 months. The next most commonly used pathway was the smoking pathway (1,979 users), followed by the physical activity (1,562 users), and alcohol (339 users). There are consistently more referrals into LiveWell Dorset from people living in the 20 per cent most deprived communities than from more affluent communities. More women than men are currently accessing LiveWell Dorset, and more older adults than younger adults.

LiveWell Dorset has embedded communications support to drive involvement and engagement via social media. This includes using targeted social media campaigns to increase interest in the service, either by joining national campaigns like Stoptober, or running bespoke campaigns around particular issues. The #MyHappyHour campaign for Bournemouth asked people to tell the service how they were swapping happy hour drinks on Fridays for healthier experiences. Evaluation showed that the campaign was successful in directing people from Bournemouth to visit the LiveWell Dorset website.

In the first 18 months, of those who provided data (approximately 20 per cent):

  • 59 per cent of people reduced their weight
  • 48 per cent stopped smoking
  • 69 per cent increased their activity
  • 75 per cent reduced their alcohol consumption.

Future plans and challenges

The service is undergoing continued development in line with the public health team’s leadership of the Prevention at Scale

programme of the Dorset Sustainability and Transformation Plan. The team recognises that almost doubling the number of people

actively engaged in health improvement (from 270 per month to nearly 500 per month) is a start, but believes that the service could offer

more support digitally. To that end a bespoke digital platform that allows people to self-serve is being developed to supplement the service, planned for launch in April 2018. It is currently being tested with professionals and the public.

The final challenge is how to achieve ‘prevention at scale’ in the emerging Dorset Accountable Care System. LiveWell Dorset acts as a focal point in our local system to prompt organisations to consider how they are embedding prevention in their business. We know that many professionals don’t deliver low level behaviour change interventions because they don’t consider it core business, lack confidence in its impact, and lack knowledge, skill and time to deliver. Our message to professionals is don’t do this alone, but work with the LiveWell Dorset service. The digital platform will allow us to share evidence of impact at individual and locality level, while our work with organisational development and HR leads across the system is developing the sector with better skills and awareness of behaviour change and how to work in a prevention-oriented way.

A councillor’s perspective

Councillor Rebecca Knox, Leader Dorset County Council


The transfer of public health to local government has been a positive move for the county. There was a lack of knowledge and confusion among the public – and, indeed, some councillors – about the difference between public health and NHS treatment services. On moving into local government, the public health team has drawn out a council and system-wide theme of prevention and made us aware that investment at one end before people become ill or lose their independence can bring about savings at the acute end. I had been a chair of a fire authority so I understood how work on prevention can stop people ending up in hospital or A&E. I think there is now a much

deeper understanding of this issue in the community, including in the voluntary sector and in parish councils. My own parish council is now aware of how its actions, such as encouraging walking on rights of way, can have a health impact.

I have also noticed that clinical commissioning group (CCG) attitudes have changed towards local government and also to prevention. They can see that implementing public health prevention initiatives at scale, such as through the LiveWell service, can help them to meet their own objectives. They also understand how our governance model works and could help them, for example by enabling

communities to be engaged at a local level in health initiatives.

Key messages

  • Central to the LiveWell approach is a shift beyond commissioning of separate vertical programmes to one platform with a strong
  • emphasis on evidence-based design of services and systematically evaluating impact.
  • This integrated approach and the use of coaches drawing on a model of change built into a customer relations system appears to be having a sustained impact.
  • With the aim of reducing health inequalities, a differential payment by results commissioning strategy rewards has significantly improved access to the system by people from deprived backgrounds.
  • Having an effective behaviour change model is central to a consistent and coherent offer around prevention as part of the STPs and
  • evolution to accountable care systems.

Contact

Dr David Phillips, Director of Public Health

Email: [email protected]

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