Department of primary care health sciences, University of Oxford: winner, service delivery innovation award

Daniel Lasserson, senior clinical researcher, and Maggie Webb, unit manager, in the emergency multidisciplinary unit.

An emergency unit designed exclusively for old and frail patients is keeping them out of acute hospital and helping to prevent bed-blocking.

The emergency multidisciplinary unit (EMU) established at Abingdon community hospital in Oxfordshire is hoped to become the national model for the future of emergency care for older people.

Patients can be referred to the EMU, which is seen as an alternative to an acute hospital A&E, by either their own GP, a community nurse or ambulance paramedic.

The unit, which is open seven days a week from 8am-8pm on weekdays and 10am-4pm on weekends, is not available for patients who have suffered a stroke or a heart attack, who would still be taken to the local acute hospital's A&E. The majority of the 5,500 patients it has seen arrive with chest or bladder infection or heart failure. The average patient age is 89.

Staffed by elderly care physicians, GPs, nurses, healthcare assistants, therapists and social workers, the unit can quickly assess a patient. It has point of care blood testing with rapid results and X-ray facilities so the unit can guarantee speedy diagnosis.

The EMU has five hospital beds available for patients who may need to be kept in for a maximum 72 hours. A "hospital at home" nursing team is also available to provide support to patients who are sent home to recover.

"I would say that the EMU is more than just a casualty for older frail patients – it's more intensive because we aim to provide care for the episode at the time or for a number of days," says Dr Daniel Lasserson, a GP and senior clinical researcher at the department of primary care health sciences, University of Oxford, who helped design this new model of care.

Lasserson adds: "Its aims to deliver an acute care pathway for frail older patients that does not rely on bed-based care, yet can still provide appropriate medical, nursing and therapist treatments within an individually tailored care plan as close to the patient's home as possible.

"It was designed to challenge the existing urgent care pathway of admission to an acute hospital with its associated harms of unfamiliar and physically challenging environment and loss of independence."

The EMU, he says, addresses the dilemmas of how to best care for a growing elderly population with complex needs and multiple chronic conditions and to provide an alternative to "office hours" general practice or acute hospital bed-based care.

According to the EMU audit, 65% of patients who are assessed by the unit are able to stay in their own home – only 17% of patients need acute hospital care.

Lasserson says this new way of working, known as "interface medicine", is challenging the traditional medical training and care. Oxford has created an Interface Medicines Fellowship and is in discussions with Health Education England about how it can be developed nationally.

This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.

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Southern health NHS foundation trust: winner, leadership award

Clinical psychologist Claire Corbridge brainstorming examples of how to deliver integration at a Going Viral session. Photograph: Southern health foundation trust

Southern health NHS foundation trust is one of the largest mental health and learning disability trusts in England. It has a staff of 9,000 working across 150 sites, spanning five counties and was created following the merger of Hampshire partnership NHS foundation trust and Hampshire community healthcare NHS trust in 2011.

A key challenge for the new trust was how to ensure that everybody felt part of the same organisation and shared the same values, behaviours and goals. Part of the solution was its Going Viral leadership development programme which, since its launch in June last year, has coached, developed and supported 550 staff. Another 240 will join the programme this autumn.

Richard House, interim head of leadership and management development, says Going Viral has its roots in the trust's organisational and people development strategies which define the attitudes, values and behaviours expected from its workforce in achieving its core aims. He says: "The NHS Constitution goes some way towards doing that but it isn't specific about behavioural expectations."

The Going Viral programme has three modules that tie in with the trust's core objectives – how to redesign services to improve quality and provide better value for money; how to integrate health and social care with partners and how to provide better outcomes and experiences for patients. The course, which takes place over six months, is delivered in nine-and-a-half day sessions. The learning groups are deliberately made up of staff from different departments so they can develop together.

House says the programme is different from others because it does not select employees according to their NHS banding, but by the amount of influence and responsibility they have. He says: "We have tried to include people, not by their pay band or whether they have management responsibility, but by how influential they are in their multi-disciplinary team. For example, a consultant physician who is only responsible for him or herself."

The programme was introduced before the publication this February of the damning Francis report into the Mid Staffordshire NHS foundation trust.

That report identified how an "insidious negative culture" and "disengagement from managerial and leadership responsibilities" contributed to Mid Staffs' failings. Going Viral, says House, is confronting those leadership challenges identified by Francis.

He says: "I think people feel more listened to and empowered and involved in the processes and realise what is expected of them. It's been transformational for people. One medic said to me 'I wanted to hate the programme and went in with that attitude; but I realise now it was one of the best learning opportunities I have ever had.'"

Health Education England and other trusts from around the country have already taken an interest in Going Viral. The trust, which has its headquarters in Southampton, is organising an open event for later this autumn about the leadership programme and how it fits into its organisational development work. House says: "This is too important not to share with others – to enable them to take on this grand scale change."

This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.

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Housing to be included on health and wellbeing boards, says Jack Dromey

Shadow minister Jack Dromey said the decoupling of housing and health in public policy has been a mistake. Photograph: Bob Fallon/guardian.co.uk

Housing representatives will be given a seat at local health and wellbeing boards under Labour plans to improve the integration between housing, health and social care, according to shadow housing minister Jack Dromey.

Speaking at the Labour conference at a Guardian fringe event sponsored by Moat housing association, Dromey said the decoupling of housing and health in public policy had been a mistake as good quality housing was "arguably the greatest contributor towards public health".

Local health and wellbeing boards were introduced in 2012 to bring together senior council staff, elected members and NHS staff to build partnerships, tackle health inequalities and improve how the sectors work together.

The announcement follows former health minister Paul Burstow's call for the housing minister role to be relocated to the Department of Health.

Dromey also announced a Labour government would scrap the "affordable rent" programme which determines the funding and rent levels of social housing, and would subsidise housing providers with grant funding and investment. But he added that a Labour government would be "very demanding" of how housing providers used the funding.

Moat chief executive Elizabeth Austerberry said reduced funding housing associations receive under the affordable rent programme had constrained the development of new affordable homes.

Opposition leader Ed Miliband said in his conference speech that Labour would introduce a use-it-or-lose-it ultimatum to developers to prevent land banking. Charles Seaford of the New Economics Foundation welcomed this but added: "You also have to be willing to designate land for housing that doesn't currently have planning permission.

"It's not up to people to apply, they just get it. You don't have a free market when it comes to land, essentially."

Photograph: Bob Fallon/guardian.co.uk

Former deputy prime minister John Prescott proposed a land-sharing agreement between local authorities and developers, in which councils retain ownership of the land but permit developers to build on it to reduce house prices by removing the land value from the total cost.

"Why don't [local authorities] keep the land?" said Prescott. "The building costs are say 50%, so let that be the mortgage. That's a £60,000 house. That's the rate of a deposit now in London."

The announcement that a Labour government would double the rate of housebuilding to 200,000 homes a year was warmly received, but Austerberry said less restrictive regulation would be required to increase the number of homes housing associations can build.

Austerberry called for more flexible tenures within the social housing sector: "Not only do we need to be building more units, we need to think of more ways that people can occupy those units depending on their financial circumstances and their lifestyle at any particular time," she said.

Dromey also repeated Labour's pledge to abolish the under-occupancy penalty, or bedroom tax as its known to critics.

"Once every generation there comes a tax so bad that the next generation looks back and asks the question 'why the bloody hell did they do it?'," he added.

Jack Dromey, Charles Seaford and Elizabeth Austerberry were speaking at the Labour party conference Guardian fringe event on 24 September. Read the housing cliff report here.

This content is brought to you by Guardian Professional. Join the housing network for more news, analysis and comment direct to you.

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Public health faces a fresh start

It's year zero for the world of public health. What lies ahead for councils? Photograph: Stocktrek Images, Inc. / Alamy

Since the transfer of responsibility for public health to councils about five months ago, directors of public health in England have worked in upper-tier local authorities.

My job is in Hertfordshire, a county of 1.1m people, with 37 settlements, 10 district councils and a public health system that was really designed for unitary local government.

Some of us are very new to local government, and in a variety of places we are tasked with leading our local authorities and partners to deliver improvements to the health of the population. It can feel both exciting and slightly scary.

For most of the peers I have spoken to (around 45 in the last six months) about how transition has gone, this is essentially year zero for the new public health world.

We are all busy taking over NHS contracts and getting them where we want them to be, while grappling with the fact that for many of us the finances don't stack up without considerable support from partners.

Most of us need some support in adapting and applying our skills and portfolios as leaders. We are learning how to become capable and expert officers working well with strong political leaders. For some of us the journey is smoother than others and we recognise our local authorities have had to work hard too to make this happen.

The challenges facing us are significant. We need to do more to give our children a healthy start in life.

Our working age population is not as healthy as it needs to be to reach old age without considerable cost to the public purse from disease-related disability. The inequalities in life expectancy and disease free life expectancy between richest and poorest and for people with learning disabilities, offenders and people with severe mental health challenges sometimes feel like they're ineradicable.

However, I still think the opportunities are immense, and that they far outweigh the challenges. My peers here and in other councils tell me, as I also hear from partners locally, that there is a real realisation across NHS, county councils, district councils, third sector and criminal justice sector we are all in this together.

In Hertfordshire we are already building a public health partnership with district councils, third sector, Healthwatch, NHS, police and crime commissioner, probation and university as core partners. I know I cannot deliver public health without them.

So where are we going?
Everyone seems to have slightly different starting points but public health teams and partners seem to be getting everything in order. The best partnerships take consideration of the following:

• The opportunity to apply and test thirty years of theory and evidence on health inequalities . Our current public health challenges are a complex manifold of structural, system, behavioural and environmental challenges. Everyone has a bit of the answer. One thing the new – if fiendishly complex – system seems to be doing is spurring people to relationships not structures as a way of building public health strategies and systems.

• Public health must be put at the heart of local leadership. This is a massive opportunity for elected politicians as well as officers. How well we do this is a test of our mettle and a sign of our success in local government.

• We need to get back to people-centred public health, where we build the new system around peoples' lives and experiences, and support people to do things for themselves and with each other. Community agencies come into their own here.

• The potential of the new system needs to be considered. The sheer scale of expertise and influence which Public Health England can lever at national level and the similar scale of local delivery which directors of public health and partners can make happen at local level bode well, if we each remember clearly what we are best at.

• A number of areas are getting to grips with how to layer public health interventions across populations (targeting young smokers as well as manual and routine workers, for example) and across time (short term interventions to get people into public health services, with longer term behavioural solutions to keep people resilient.) This can only be promising.

• Networks are springing up. Counties are talking to each other about making public health work in two-tier areas. Districts are talking about their contribution. Public health teams are benchmarking themselves against each other on topics like school nurses and excess deaths. It might be informal, but it's happening.

All of this requires an enduring vision, and an ability to see beyond two years. But all of it is a sign that public health is alive, broadening its influence and alliances and recruiting new advocates.

You may find this naïve, annoyingly up-beat, hopelessly idealistic or perhaps grimly determined in the face of reality. And perhaps all that is true. But if you find a better way, I'd love to hear it.

Jim McManus is director of public health at NHS Hertfordshire and Hertfordshire county council.

• Want your say? Email sarah.marsh@theguardian.com to suggest contributions to the network.

Not already a member? Join us now for more comment, analysis and the latest job opportunities in local government.

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Undervalued Stocks In The Health Care Select SPDR: Best Of The Best

A few days ago in this article (here) I presented a table showing the risk-adjusted relative performance of the nine SPDR sector ETFs. The clear winner in this contest was the SPDR Health Care Portfolio (XLV). Despite having a beta of .61, one of the lowest of all the sector SPDRs, XLV has chalked up a 10.3% gain since late June, when the latest solid rally in this ongoing bull market got started. This is 4.9 percentage points more than we would expect from XLV given the portfolio's lower risk profile.

I thought it would be nice to look at the top holdings in XLV to see if this outstanding ETF has any companies which are still undervalued. How? By comparing recent valuation parameters like PE and Price/cash flow to their historical averages for those companies.

This isn't finding diamonds in the rough: holding XLV hasn't been rough. This is looking for diamonds in the diamond mine.

A glance at the State Street website (here) shows some basic characteristics about XLV:

45% of the fund is in pharmaceuticals.Biotech, healthcare equipment and care providers share the remaining 55% almost equally.Recent yield and P/E ratio were 1.51% and 16.6x, respectively.

Like many ETFs the top ten holdings are a vast majority of the weight of the fund, so we will look at these companies first. I used the following subjective criteria to scan these companies for value:

Steady growth in earnings over the last decade. The primary attraction of stocks in this sector is combination of solid growth and lack of cyclicality.A trailing PE ratio nearer to the lows of the last decade. Companies selling at high or record high PEs are already fully valued.A cash flow multiple also below traditional levels of the last ten years.

Admittedly, these criteria are subjective, not mechanical like a lot of stock screens. However, this allows the judgment of the analyst or the investor, which is essential if you are going to be comfortable with your stock holdings and risk profile. For example, XLV holding Abbvie (ABBV) was eliminated from consideration since it is a recent spinoff from Abbott Labs (ABT) and has less than a year of trading history.

Two companies passed muster: Amgen (AMGN) and United Health Group (UNH).

Amgen first. What isn't there to like about a biotechnology company which has a record of profitability going back to the early 1990s? It even pays a decent, well covered dividend. Imagine being able to pick up these shares at just over ten times trailing earnings, as you were able to for the two years after the crash, even though earnings growth barely blinked. Missed your chance? Well, trailing P/E is still modest.

(click to enlarge)

Sure 20x is the not the extremes available a few years back, but it is still attractive given a stock whose profits have gotten back on track after a punk stretch earlier in this decade. While 35x-40x eps is probably not realistic, the 22x we saw prior to the crash appears doable. Applying this to projected 2013 earnings of $7.35 from Value Line or $7.25 from Yahoo Finance gives us a target price of $160 a share or so.

Even using the XLV average multiple of 16x (which has been a clear "buy" level over the last two years) gives us a price of $116, not far from current levels. So risk is quite limited.

Using cash flow multiples from Value Line the guidelines are less precise. Unlike PE compression, which stopped for the broad market and growth stocks a few years ago, "cash flow compression" is still evident for many shares. Using Value Line data, AMGNs cash flow multiple has been as high as 18x and as low as 6x since 2004. Right now it is selling for 12x, smack in the middle. That seems conservative, since 15x cash flow is the average for shares in this ETF. Let us just apply this 15x average to the 2013 cash flow estimate of $9.05 from Value Line (Etrade estimates $8.46). We get a range of $136 to $126. Say $130 as a midpoint. Blending this with the $160 target above and perhaps being a bit more conservative on PE multiples, we can still be comfortable with a target price for AMGN of $140 a share.

That is a 21% gain from current prices for one of the highest quality and lowest risk stocks in the biotech sector.

United Health Group is quite similar to Amgen. Hit hard in the crash though earnings quickly recovered, there is still room for some PE expansion without getting to the outrageous levels which prevailed over a decade ago.

(click to enlarge)

I wish to apply XLV's average PE of 17x to the solid consensus estimate of $5.50 a share for UNH, giving us a target price of about $94 a share.

Like AMGN, UNH has also seen its cash flow multiple shrivel. Right now the multiple is 11x, though in the past it has been more than twice that and in the despair of the crash, as low as 5x. I do not feel comfortable using 15s like I did with AMGN, as insurance company UNH is a lot less sexy than AMGN will ever be. And believe it or not but the dividend yield is less. Thus I will just retain the current 11x cash flow estimates of $6.85 and $6.79 from Value Line and Etrade, respectively. This gives us price of about $75 a share.

Leaning toward the lower end of the two prices because of the lower dividend, we can come up with a blended target price of $83 a share. This is 15% higher than the current price. While not an eye popping return compared with the typical stock or Index, it has some appeal for shares that are less risky than average as these shares are.

Nonetheless AMGN appears to be the better positioned of the two.

So for investors who are a bit nervous given the great strength shown by XLV, especially in the last few months, you can improve your risk-return profile by choosing its most attractive actively traded component, AMGN.

Disclosure: I am long AMGN. I wrote this article myself, and it expresses my own opinions. I am not receiving compensation for it (other than from Seeking Alpha). I have no business relationship with any company whose stock is mentioned in this article. (More...)

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Health and fitness events and meetings in the coming week

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Health and fitness events and meetings in the coming week

AARP Driver Safety Course For age 50 and older, certificate given upon completion. Thursday, 9:30 a.m.-4 p.m., Lamond Recreation Center, 20 Tuckerman St. NE. 202-726-8095; Friday, 9:30 a.m.-5 p.m., Friendship Terrace Retirement Community, 4201 Butterworth Pl. NW. 202-362-0704; Monday, 8:30 a.m.-4:30 p.m., Fort Stevens Senior Center, 1325 Van Buren St. NW. 202-321-8265; and Tuesday-Wednesday, Hattie Holmes Senior Center, 324 Kennedy St. NW. 202-291-6170. $14 per course, registration requested.

Blood pressure checks and HIV screenings Thursday, 6:30 p.m. Community Education Group mobile medical unit, William O. Lockridge/Bellevue Library, 115 Atlantic St. SW. 202-543-2376. Free.

AARP driver safety course Friday, 9:30 a.m.-5:30 p.m., Friendship Terrace Retirement Home, 4201 Butterworth Pl. NW. Register: 202-362-0704. $14.

Line-dancing fitness for seniors For age 50 and older. Fridays, 10 a.m. Woodridge Library, 1801 Hamlin St. NE. 202-541-6226. Free.

Al-Anon meetings Fridays, 5 p.m., Metropolitan Memorial United Methodist Church, 3401 Nebraska Ave. NW. 202-363-4900; Tuesdays, noon, Church of the Epiphany, 1317 G St. NW. 202-347-2635; and Mondays, Thursdays and Fridays, noon, St. John’s Episcopal Church, Lafayette Square, 1525 H St. NW. 202-347-8766. Free.

Alcoholics Anonymous meeting for women Fridays, 6-8 p.m. St. Mark’s Episcopal Church, Third and A streets SE. 202-546-4964. Free.

Yoga for adults in Northeast Saturdays, 9:30 a.m. Dorothy I. Height/Benning Library, 3935 Benning Rd. NE. 202-281-2583. Free.

Black and Missing, Inc.: Keep kids safe. Foundation representatives discusses sex trafficking, how it affects the city’s African American, Latino and Asian communities and how to keep out young ones safe. Saturday, 10 a.m., Dorothy I. Height/Benning Library, 3935 Benning Rd. NE. 202-281-2583. Free.

Eating locally? A moderated discussion of community gardens, retail food and more; for adults. Saturday, 2 p.m., Cleveland Park Library, 3310 Connecticut Ave. NW. Free. 202-282-3080.

Alcoholics Anonymous Saturdays, 7 p.m., St. Mark’s Episcopal Church, Third and A streets SE. 202-546-4964; Sundays, 3 p.m., and Mondays, 8:30 p.m., St. Augustine’s Episcopal Church, Sixth Street and Maine Avenue SW. 202-554-3222. rector@staugustinesdc.org; Mondays and Fridays, 8:30 p.m., All Souls Memorial Episcopal Church, 2300 Cathedral Ave. NW. 202-232-4244; Mondays, 8 p.m., St. Ann Roman Catholic Church, 4001 Yuma St. NW. 202-966-6288; Mondays, Wednesdays and Fridays, noon, Church of the Epiphany, 1317 G St. NW. 202-347-2635.

Narcotics Anonymous Sundays, 7-8:30 a.m. Church of the Epiphany, 1317 G St. NW. 202-347-2635. Free.

Adult children of alcoholics Support meeting. Sundays, 5-6 p.m. St. Mark’s Episcopal Church, Classroom No. 6, Third and A streets SE. 202-546-4964. Free.

Look good .?.?. Feel better Tips on beauty techniques that can combat appearance-related side effects of cancer therapies using cosmetics, scarves and wigs. Monday, 9:30 a.m. MedStar Georgetown University Hospital, 3800 Reservoir Rd. NW. 202-444-3755. Free, registration required; free parking.

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