Soft Market Testing Questionnaire
SCHPH00181 Staffordshire Healthy Communities Service
THIS IS NOT A CALL FOR COMPETITION
1. Introduction
Staffordshire County Council (SCC) wishes to transform its health
improvement and lifestyle commissioning model to reduce demand and the
flow of Staffordshire citizens into Health and Social Care provision. This will
require a focus on maintaining an active and healthy population whilst
providing appropriate support to individuals who are over 50 years old, in
communities which have the poorest health and are at greatest risk of
requiring Health and Social Care.
2. Target Population
We are currently scoping the potential to utilise risk stratification tools to
identify at risk people. In the absence of such tools we have attempted to
model the potential target population to provide an estimate of the ‘at risk’
population.
2.1 Target Population Modelling
Based on data availability at a Lower Super Output Area (LSOA) level, a
number of indicators have been tested for their relationship with rates of
funded long-term Health and Social Care users aged 65 and over (excluding
those living in care homes). Eight indicators showed a relatively good
statistical relationship with long-term state funded Health and Social Care
users (Appendix 1). These indicators were used to develop a Health and
Social Care needs index for Staffordshire.
Using this index, 52 LSOA areas have been identified within which 27,600
adults aged 50 years and over are considered to be at increased risk of entry
into Health and Social Care (Appendix 2).
It should be noted that the target population may change in response to any
risk stratification tools that can be utilised locally which will ensure more
effective targeting of the service.
3. NHS Health Checks
The Healthy Communities Service will be expected to deliver the NHS Health
Check programme on behalf of SCC. The NHS Health Check programme
aims to prevent heart disease, stroke, type 2 diabetes and kidney disease,
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and raise awareness of dementia both across the population and within high
risk and vulnerable groups.
The NHS Health Check is made up of three key components: risk
assessment, risk awareness and risk management. During the risk
assessment standardised tests are used to measure key risk factors and
establish the individual’s risk of developing cardiovascular disease. The
outcome of the assessment is then used to raise awareness of cardiovascular
risk factors, as well as inform a discussion on, and agreement of, the lifestyle
and medical approaches best suited to managing the individual’s health risk.
The programme has also been designed so that the majority of the NHS
Health Check, including the tests and measurements required for the risk
assessment, can be delivered in different settings. The NHS Health Check
can be carried out locally in any suitable location and by a suitably qualified
Professional. Links would need to be made with local GPs to ensure patient
information is transferred securely.
One of the programme’s objectives is to reduce health inequalities. Local
Authorities may tailor the delivery of the programme to achieve this. Although
Local Authorities have a duty to offer the NHS Health Check to all eligible
people Public Health England supports approaches that prioritise invitations to
those with the greatest health risk. A recent review of NHS Health Checks in
Staffordshire highlighted:
 Residents in their sixties are more likely take up their offer of an NHS
Health Check for confirmation they are healthy and well. This
compares to younger ages who do not attend their NHS Health Check
as they may perceive themselves to not be at risk due to their current
health status and age.
 Those in high areas of deprivation are not engaging with the
programme.
 Analysis showed both mortality and hospital admissions were higher
where NHS Health Check uptake rates were low.
Based on this learning we envisage that the Healthy Communities Service will
deliver a targeted NHS Health Check programme to the target population
(Section 2.1). This programme will be required to increase uptake of NHS
Health Checks particularly among the 50 – 60 age group and in the 60 plus
age group who may be in ill-health but not known to GPs. The programme
will also ensure all NHS Health Checks are good quality.
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3.1 NHS Health Check Current Uptake
Table 1.0 shows the number of NHS Health Checks being offered and uptake
levels during 2015/16 in Staffordshire and within identified target areas (see
section 2) for those aged 50—74 years.
Table 1.0
Staffordshire
Targeted
Areas
Total 50-74
population
275,516
21,403
Estimated
eligible 50-74
population
192,861
14,982
Number
offered a
NHS Health
Check
16,856
1,593
Number who
received a
NHS Health
Check
9,586
631
4. Referrals
The NHS Health Check will be a referral route into the Healthy Communities
Service. It is envisaged that the service will also provide relevant assessment
and referral training to a range of front line workers, linking in where possible
to existing training. For example, Lets Work Together and Making Every
Contact Count (http://makingeverycontactcount.co.uk/ ). The development of
a risk assessment checklist and referral forms and pathways will be required.
5. Intervention
A review of the evidence in relation to what approaches can help to reduce
the demand on or delay entry into Health and Social Care has moved the
thinking from purely behavioural delivery to one which is bespoke and can flex
between behavioural and practical support according to individual need.
The Healthy Communities Service will need to build on local assets and skills
within the community to help citizens help themselves and one another and
connect individuals to wider community networks and programmes. There will
be three levels of support requiring different degrees of input as follows:
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
Universal Offer (Available to most) Not in Service scope
This will include a wider digital offer that is capable of risk assessing
(including the provision of digital NHS Health Checks), together with
enabling access to a wider range of information and acting as a
community navigator, which signposts citizens to a range of support /
services and; community capacity building.

Targeted Support (Available to targeted populations -Some)
Providing behavioural interventions to individuals from identified
geographical hotspot areas to reduce preventable risk factors that result in
poor health e.g. stopping smoking, improving poor diets, increasing
physical activity levels and social prescribing aimed at reducing loneliness
and social isolation.

Bespoke Targeted Support (Available to individuals in targeted
population with high needs - few)
Identifying individuals, who are showing signs of struggling to cope,
agreeing support required using an asset-based approach and providing
personalised coaching and practical skills to promote independence and
resilience e.g. malnutrition and dehydration prevention, home-based
activity to increase mobility and ability to maintain activities of daily living,
social prescribing and befriending.
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6. Healthy Communities Aims and Predicted Outcomes
The aim of the Healthy Communities Service will be to prevent or delay
citizens entering state funded Adult Social Care. This will be achieved by:





Reducing lifestyle risk of falls in citizens at greater risk of falling / with a
history of falls.
Improving social connectedness and reducing loneliness.
Preventing strokes through tailored lifestyle interventions (targeted at
individuals at greater risk of or following stroke / Transient Ischaemic
Attacks).
Reducing lifestyle (mobility / fluid intake) risk factors associated with
individuals at greater risk of Urinary Tract Infections (UTI) / with a
history of UTIs.
Supporting better health and wellbeing in the early stages of dementia
through providing lifestyle support.
6.1 Individual level outcomes






Individuals who move from at risk of fall to no risk
Individuals who reduce their loneliness or social-isolated score
following intervention
Individuals who successfully stop smoking at 12 weeks, self-report
Individuals malnourished or at risk of malnutrition who demonstrate
stable weight (for those whose pre to initial assessment measure
shows weight loss) or have gained weight (for those whose pre to initial
assessment weight was stable) at 12 weeks.
Obese Individuals who achieve 5% reduction in body weight at 12
weeks
Individuals who increase their physical activity score following
intervention
7. Current Prevalence
Table 2.0 shows the current prevalence of indicators relevant to the Healthy
Communities Service in Staffordshire and within identified targeted areas.
Table 2.0
Indicator
Prevalence
Staffordshire
Targeted areas
Smoking 50+
Obesity 50+
Malnourished* 65+
Physically Inactive
50+
Falls * 65+
Lone Pensioner
Households
8.4%
27%
10%
34%
16%
32%
10%
40%
Number of
individuals from
targeted areas
4400
9188
1400
11,468
35%
12.6%
35%
15.1%
4800
5443
5
*Based on estimates and applied to population figures.
8. Potential Delivery Model
The potential delivery model for the Healthy Communities Service is by a hub
and spoke (see 8.1 below). It is envisaged that this approach will allow the
prime provider to build on existing assets within the identified community and
enter into formal agreements (for example a partner agreement, sub-contract
or grant) with a diverse range of providers to meet the outcomes of the
service.
8.1 Healthy Communities Potential Delivery Model
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9. Proposed payment structure
The estimated annual budget identified to deliver the Healthy Communities
Service is between £1.4 million - £1.6 million per annum.
It is anticipated that approximately 50% (£700,000 - 800,000) of the Contract
value will be fixed and approximately 50% (£700,000 - £800,000) will be
Payment By Results (PBR).
The proposed payment system will involve a combination of fixed and PBR
payments. The ‘fixed’ component of the Contract will be paid as long as the
Service is delivered in accordance with the Contract and Specification.
Whereas, the PBR components will be linked to the number of successful
outcomes delivered. A minimum target for individual successful outcomes (as
detailed in section 6.1) is likely to be detailed in the Specification based on
local need. In order to maximise the efficient use of the public resource
providers will be asked to detail the number of individual outcomes they can
deliver within this financial limit.
10. Timescales and estimated budget
It is proposed that the Healthy Communities Service commences on 1st April
2018.
11. Purpose of Document
The responses submitted as part of this soft market testing questionnaire is to
seek the market’s views on the development of a local model, the capacity of
the market to deliver these services, and the level of interest in this proposed
procurement activity.
12. Process
This Soft Market Testing (SMT) document contains a series of questions that
we would like you to answer, submitting your written responses by 12 noon
Tuesday 13th June 2017. Please send your response to the email address
shown at the end of this page. If you have any queries with regards this
exercise these should also be addressed to the contact name shown below.
Your responses will not be scored in any way. This is an information gathering
exercise and is not a pre-qualification process. This SMT exercise does not
form part of any subsequent formal procurement process.
Your responses will be used by the Council’s project team, in commercial
confidence, to inform the service specification, relevant schedules and
Contract.
Please try to limit the size of your response to each question to ensure that it
is brief and to the point. Please ensure that you clearly state any assumptions
made when responding.
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You must carefully consider the use of phrases such as “in confidence” or
“commercially sensitive” when responding since they will not necessarily
protect your organisation’s information from disclosure under the Freedom of
Information Act 2000. In respect of any information submitted by your
organisation which is considered to be commercially sensitive, you should
clearly identify such information as “commercially sensitive”.
Completion of the following questions will not infer any advantage upon
individual organisations, as stated above this is an information gathering
exercise only.
Completed questionnaires should be returned via email to;
Sarah Lynn (Category Manager)
Telephone: 01785 854645
Email: [email protected]
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Targeted Population
Approach/model
1. How do you see this service fitting alongside and complementing (not
duplicating) existing care pathways, programmes and services that are
currently delivered in Staffordshire?
If you are currently unaware of existing pathways, programmes and
services delivered in Staffordshire, please provide a response based
on your experience of other areas.
2. Do you agree with the proposed delivery model detailed in section 8?
Yes / No
If yes, please state why you agree.
If no, please suggest how it could be done differently and what benefits the
alternative approach would bring for service users, providers and/or SCC.
3. Based on the proposed hub and spoke model and identified LSOA
areas. How many spokes do you think would be required to support
delivery across targeted areas? Alternatively, if you feel the service
could be delivered via a different approach please provide details of the
approach
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Risk Stratification/identification of target population
4. Based on the proposed model, how would you utilise new or existing
risk stratification/identification tools to ensure effective targeting of
services?
5. Who would administer assessment tools and refer into the service?
What are the potential links to existing front line training sessions in
Staffordshire? For example, Let’s Work Together, Making Every
Contact Count.
Delivery
6. Current NHS Health Check research highlights that people in areas of
deprivation are less likely to take up an offer of an NHS Health Check.
How do you think this element of the service could be delivered to
ensure these populations engage?
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7. We envisage utilising an asset-based, rather than deficit-based,
approach to the Healthy Communities Offer. How do you see this being
achieved?
8. Based on the proposed model, how do you see the bespoke offer
being delivered and what level/skill mix of staff would be required?
9. How would you ensure a seamless client journey for clients with
multiple needs accessing community interventions?
Costs
10. Do you agree with the proposals detailed within the proposed payment
structure?
Yes / No
If no, please suggest how it could be done differently and what benefits the
alternative approach would bring for service users, providers and/or SCC.
11
11. How can the service demonstrate increased efficiencies through the
lifetime of the Contract?
Outcomes
12. Based on the existing prevalence levels detailed in section 7. Please
indicate the number of outcomes against each individual outcome
indicator that you think could be delivered against the contract value?
Individuals who move from at risk of fall to
no risk following 12 week intervention
Individuals who reduce their loneliness or
social-isolated score following intervention
Individuals who successfully stop smoking
at 12 weeks, self-report
Individuals malnourished or at risk of
malnutrition who demonstrate stable
weight (for those whose pre to initial
assessment measure shows weight loss)
or have gained weight (for those whose
pre to initial assessment weight was
stable) at 12 weeks.
Obese Individuals who achieve 5%
reduction in body weight at 12 weeks
Individuals who increase their physical
activity score following intervention
13. Do you feel the individual outcomes are suitable based on the aims
detailed in section 6?
Yes / No
If no please provide alternative outcomes and potential ways to measure
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14. Do you foresee any difficulty in providing evidence to support delivery
of individual outcomes detailed in section 6.1.
Yes/ No
If yes please provide alternative measures.
General Information
15. We are looking for informal expressions of interest in these services at
this stage in order to establish the level of market interest. Would your
organisation be interested in bidding for these services?
Yes / No – delete as appropriate
If yes how would you bid for the work? Please select one of the following;
As a sole provider
Prime contractor with sub-contractors
Prime provider with sub-contractors
As a consortium
Sub-contractor to a main
provider/contractor
Other please explain
If NO - We would be interested to know why organisations may not be
interested in bidding for these services. Please provide more detail below if
you are able to share this information.
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16. Please use this opportunity to provide any other feedback or outline
any other requirements that need to be considered/included.
Your organisation
Name of organisation:
Point of Contact:
Email address:
SCC may contact the organisation to seek clarity on responses received or to
further discuss responses submitted as part of this questionnaire.
Which services does your organisation currently deliver?
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Appendix 1
Indicators which showed a relatively good statistical
relationship with long-term state funded Health and Social Care users






Income Deprivation Affecting Older People Index (IDAOPI), 2015
People aged 50 and over with no cars or vans in household, 2011
Emergency (unplanned) admissions, 2015/16
Risk of loneliness index (Office for National Statistics modelled data)
People aged 65 and over with a limiting long-term illness, 2011
People who feel a bit unsafe or very unsafe walking alone after dark
(Mosaic modelled data)
 People who visit their GP more than once a month (Mosaic modelled
data)
 People who do not exercise (Mosaic modelled data)
Note: The indicators do not demonstrate a causal relationship.
NB: some indicators which were identified as being triggers for entry into
social care form the evidence base or stakeholders have not been included
due to lack of (robust) data availability at LSOA level, for example,
bereavement, stroke prevalence, people with urinary tract infections and
incidence of falls.
15
Appendix 2: Map showing Risk of Adult Social Care Needs Index
Data compiled and analysed by Insight, Planning and Performance
16
Risk of Health and Social Care Needs Index: areas at very high risk
LSOA
E01029346
E01029349
E01029350
E01029354
E01029355
E01029356
E01029359
E01029360
E01029388
E01029404
E01029407
E01029409
E01029410
E01029427
E01029437
E01029447
E01029448
E01029453
E01029468
E01032898
E01029492
E01029496
E01029499
E01029527
E01029535
E01029538
E01029547
E01029548
E01029553
E01029554
E01029555
E01029560
E01029566
E01029588
E01029599
E01029604
E01029666
E01029691
E01029692
E01029715
E01029725
E01029727
E01029734
E01029763
E01029766
E01029809
E01029827
E01029834
E01029835
E01029845
E01029849
E01029859
Ward name
Brereton and Ravenhill
Cannock East
Cannock East
Cannock North
Cannock North
Cannock North
Cannock South
Cannock South
Hednesford North
Western Springs
Anglesey
Anglesey
Anglesey
Eton Park
Horninglow
Shobnall
Shobnall
Stapenhill
Winshill
Burton
Chadsmead
Chasetown
Curborough
Summerfield and All Saints
Audley and Bignall End
Bradwell
Chesterton
Chesterton
Cross Heath
Cross Heath
Cross Heath
Holditch
Knutton and Silverdale
Ravenscliffe
Thistleberry
Town
Perton Lakeside
Common
Coton
Highfields and Western Downs
Coton
Manor
Penkside
Biddulph East
Biddulph East
Leek North
Belgrave
Bolehall
Castle
GlHSCote
Mercian
Stonydelph
Data compiled and analysed by Insight, Planning and Performance
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Local authority
Cannock Chase
Cannock Chase
Cannock Chase
Cannock Chase
Cannock Chase
Cannock Chase
Cannock Chase
Cannock Chase
Cannock Chase
Cannock Chase
East Staffordshire
East Staffordshire
East Staffordshire
East Staffordshire
East Staffordshire
East Staffordshire
East Staffordshire
East Staffordshire
East Staffordshire
East Staffordshire
Lichfield
Lichfield
Lichfield
Lichfield
Newcastle-under-Lyme
Newcastle-under-Lyme
Newcastle-under-Lyme
Newcastle-under-Lyme
Newcastle-under-Lyme
Newcastle-under-Lyme
Newcastle-under-Lyme
Newcastle-under-Lyme
Newcastle-under-Lyme
Newcastle-under-Lyme
Newcastle-under-Lyme
Newcastle-under-Lyme
South Staffordshire
Stafford
Stafford
Stafford
Stafford
Stafford
Stafford
Staffordshire Moorlands
Staffordshire Moorlands
Staffordshire Moorlands
Tamworth
Tamworth
Tamworth
Tamworth
Tamworth
Tamworth