addressing inequalities in health and wellbeing through hwb/ccg structures
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Addressing Inequalities in Health and Wellbeing through HWB/CCG Structures. Professor Chris Bentley. HINST Associates. 10 Steps to Population Level Outcomes. Governance: who is running the show? e.g. strategic forum or performance driver Programme planning: who is accountable? - PowerPoint PPT PresentationTRANSCRIPT
Addressing Inequalities in Health and Wellbeing through HWB/CCG Structures
Professor Chris Bentley
HINSTHINSTAssociatesAssociatesHINSTHINSTAssociatesAssociates
10 Steps to Population Level Outcomes
1. Governance: who is running the show?e.g. strategic forum or performance driver
2. Programme planning: who is accountable?responsible and empowered
3. Information Governance: sharing intelligencedata flows; communication strategy
Structures for Commissioning of Public Health (Bentley 2011)
DPH
Sub-nationalstructures
Public Health England
Cabinet PH Sub-CommitteeSoSH
DH Policy NHS Commissioning BoardChief Medical
Officer
Health and Wellbeing
Board
NHS System
GP Commissioning
LA Commissioning
LA System
IntegratedProvision
SoSH - Secretary of State for Health
DPH - Director of Public Health
Primary Care Direct
Action
Primary Care Commissioned
Services
HWB
JSNA/HWS
Commissioning
PH England
CCG Legal Obligations on Health Inequalities
2012 Act
• Reduce inequalities between patients in access to and outcome from services
• CCG to include in their business plan and commissioning plans an explanation of how each proposes to discharge their duties as to reducing inequalities
• CCG include in its annual report an assessment of how effectively it has discharged its duty as to reducing inequalities
• NHSCB required to undertake an annual assessment of how effectively a CCG has discharged its duty in reducing health inequalities
5
10 Steps to Population Level Outcomes
4. Joint Strategic Needs Assessmentbottom-up and top-down
5. Priority setting: how does it really work?evidence; ethics; politics
All age, all cause mortality rates, 3-year averages, Kent & Medway
The Threat of Winter
DEATH
Illne
ssDEPRESSION
Anxiety
Hypothermia
Misery
Accidents
Dis
abili
ty
Loneliness
Adult Social Care
Public Health
NHS
Adult Social Care and Public Health:Maintaining good healthand wellbeing.Preventing avoidable ill health or injury, including through reablement orintermediate care servicesand early intervention.
Adult Social Care and NHS:
Supported discharge from
NHS to social care.Impact of reablement or
intermediate care services
on reducing repeat emergency admissions.Supporting carers and
involving in care planning.
ASC, NHS and Public Health:The focus of Joint Strategic Needs Assessment: shared localhealth and wellbeing issues for joint approaches.
NHS and Public Health:Preventing ill healthand lifestyle diseasesand tackling theirdeterminants.
Alignment of National Outcomes Frameworks
2005
2010 2015
2020
Health Inequalities
Different Gestation Times for Interventions
A
B
C
For example intervening to reduce risk of mortality in people with established disease such as CVD, cancer, diabetes
For example intervening through lifestyle and behavioural change such as stopping smoking, reducing alcohol related harm and weight management to reduce mortality in the medium term
For example intervening to modify the social determinants of health such as worklessness, poor housing, poverty and poor education attainment to impact on mortality in the long term
10 Steps to Population Level Outcomes
6. Setting targets: locally relevant and meaningfulmeasureable; ambitious; do-able
7. Select interventions: strongly evidence basedoffer major contribution to change required
8. Develop business plan: economic case for changecost benefit; cost utility; Return on Investment; Cost Consequence Analysis (CCA)
13
Setting Ambitions: Best in Peer Group (Males)
Male All Age All Cause Mortality (AAACM) Rates by GP Consortia, 2007-09
*Peer group = Former Spearhead PCTs in ‘Centres with Industry’ ONS area classification
Eng
land
ave
rage
500
550
600
650
700
750
800
850
900
950
GP Consortia in Peer Group*
Mo
rta
lity
Ra
te p
er
10
0,0
00
Oldham
SouthBirmingham
14
Estimating the scale of the challenge (Males)
Oldham Male AAACM rate 2001-2009, forecast and trajectory to 2013-15 ambition
500
550
600
650
700
750
800
850
900
950
1000
01-03 02-04 03-05 04-06 05-07 06-08 07-09 08-10 09-11 10-12 11-13 12-14 13-15
3 year average
Mal
e A
AA
CM
per
100
,000
Target
Actual
Forecast
Equivalent to 417 (13%) fewer male deaths in 2013-15
270 fewer deaths in 2013-15 expected based on current trend
Estimating the scale of the challenge : Summary (Oldham)
2007-09AAACM
(rate)
2013-15 ambition
(rate)
2007-09 deaths
(number)
2013-15 ambition(number)
Required reduction(number)
Expected reduction (number)
Additional reductionRequired
Males 833.6 721.2 3100 2683 417 270 147
Females 597.7 497.8 3410 2774 636 297 339
Persons - - 6510 5457 1053 567 486
Reductions in mortality numbers necessary to meet 2013-15 targets
0
50
100
150
200
250C
HD
Str
oke
All
canc
ers
CO
PD
Pne
umon
ia
Live
r di
seas
e
Dia
bete
s
Oth
er c
ause
s
CH
D
Str
oke
All
canc
ers
CO
PD
Pne
umon
ia
Live
r di
seas
e
Dia
bete
s
Oth
er c
ause
s
Exc
ess
num
ber
of d
eath
s 20
06-0
8
75+ years
<75 years
Number of excess deaths in Oldham by cause, gender and broad age groupcompared to England average, 2006-08
Identifying ‘excess’ mortality by cause
Source: Derived from NCHOD standardised mortality ratios (SMR) and mortality numbers by age and cause.Excess mortality = ‘observed’ minus ‘expected’ deaths
Males Females
Potential impact of evidence-based interventions on reducing mortality numbers for Oldham
InterventionDeaths
postponedTreatment population
NNT to postpone one death
Secondary prevention following CVD eventFour treatments (beta blocker, aspirin, ACE inhibitor, statin)
Currently untreated: CVD deaths averted 31 4,335 136
Currently partially treated: CVD deaths averted 61 15,335 253
Additional treatment for hypertensives
Additional hypertensive therapy 62Statin treatment for hypertensives with high CVD risk 27
Warfarin for atrial fibrillation >65 years
Stroke deaths averted 17 609 35
Improving diabetes management
Reducing blood sugars (HbA1c) over 7.5 by one unit 13 3,092 232
Treating CVD risk among COPD patients
Statins for eligible mild & moderate COPD patients 45 1,833 40
Total 258 - -
38,053 425
NNT = Number Needed to Treat to postpone one death
18
Aim: Deliver a short-term plan to place the PCT on a target AAACM trajectory for males
The Plan: Focus on six evidence based interventions:1. Full implementation of evidence based treatments for patients with CVD who are
currently untreated2. Full implementation of evidence based treatments for patients with CVD who are
currently partially treated3. Finding and treating undiagnosed hypertensives4. Moving patients on Atrial Fibrillation registers from aspirin to warfarin 5. Statins to address CVD risk among COPD patients. 6. Reducing blood sugar in diabetic patients
Expected Outcomes• Improved management of primary and secondary prevention of CVD• Postponement of up to 257 deaths from CVD if the interventions are fully
implemented, although this would depend on pace of incremental delivery • Achieving 38% of full implementation of all interventions would deliver the AAACM
target although again this depends on pace of incremental delivery
Using the model: a worked example (1)
Source: Rochdale PCT AAACM Recovery Plan, Nov 2010
19
Using the model: a worked example (3)
• Intervention:Statins to address CVD risk among patients with mild or moderate COPD
• Evidence Base: Observational studies show CVD is the leading cause of mortality among patients with mild and moderate COPD, yet CVD risk is often untreated among this patient group
• Treatment population: Aim to increase coverage from 26% to 66% of all COPD patients. (Current treatment coverage of 26% estimated from local audit of COPD registers plus estimate of undiagnosed COPD from APHO prevalence estimate.) Equates to an additional 2,450 COPD patients on a statin
• Outcomes: Estimated 55 deaths prevented (consistent with model which shows effect of additional 40% COPD patients on a statin)
• Costs: Recurrent costs of £95,000 (includes finding additional patients)
Maidstone – Excess deaths: most deprived 20% compared to the rest
10 Steps to Population Level Outcomes
9.Whole system approachpopulation level; through communities; services
Partnership, Vision and Strategy,
Leadership and Engagement
Population LevelInterventions
Intervention Through Communities
Intervention Through Services
Systematic and scaled interventions through
services
Systematic community engagement
Service engagement with the community
Producing Percentage Change at Population Level C. Bentley2007
Population LevelInterventions
Intervention Through Communities
Intervention Through Services
Systematic and scaled interventions through
services
Producing Percentage Change at Population Level C. Bentley2007
Programme characteristics will include being :-
– Evidence based – concentrate on interventions where research findings and professional consensus are strongest
– Outcomes orientated – with measurements locally relevant and locally owned
– Systematically applied – not depending on exceptional circumstances and exceptional champions
– Scaled up appropriately – “industrial scale” processes require different thinking to small “ bench experiments”
– Appropriately resourced – refocus on core budgets and
services rather than short bursts of project funding
– Persistent – continue for the long haul, capitalising on, but not dependant on fads, fashion and policy priorities
Achieving percentage change in population outcomes through services
Commissioning Services to Achieve Best Population Outcomes
Population Focus Optimal Population
Outcome
13.Networks,leadership and coordination
1.KnownIntervention
Efficacy
6.KnownPopulation
Needs12. Balanced Service Portfolio
11.Adequate Service Volumes
Challenge to Providers
10. Supported self-management
5. Engaging the public
9. Responsive Services
4. Accessibility
7. Expressed Demand 2. Local Service Effectiveness
8. Equitable 8. Equitable ResourcingResourcing
3.Cost EffectivenessC Bentley
2007
Population LevelInterventions
Intervention Through Communities
Intervention Through Services
Systematic community engagement
Producing Percentage Change at Population Level C. Bentley2007
Industrial Scale - Stalinist
Piecemeal Project Based Approach
Industrial Scale - “Small is beautiful”
Not infinite, but graded levels of Engagement
Population LevelInterventions
Intervention Through Communities
Intervention Through Services
Service engagement with the community
Producing Percentage Change at Population Level C. Bentley2007
System and Scale into Community EmpowermentTen point plan
1. Prioritisationmost in need, not ‘beauty contest’ winners
2. Defining Communities
should be self-defining where possible3.Community profiles
collating top-down and bottom-up4.Asset mapping
stocktake of the positive resources in place5.Community based research
train residents to be involved in assessing needs/wants
System and Scale into Community EmpowermentTen point plan
6. Neighbourhood Action Plans (NAPS)linking bottom-up aspirations and top-down objectives
7. Community Links Strategygathering intelligence from community infrastructures
8. Outreach modelsusing preferred community venues where possible
9. Behaviour of Partnersagreed common ways of working; shared generic staff;
unified case management; sharing intelligence; 10. Transfer of Service Ownership
appropriate segments e.g. through social enterprise
Categories of ‘seldom heard’ people
• Hard to identify and contact (e.g. rough sleepers, illegal immigrants)
• Not available, no time (e.g. families with young children, people working long hours, carers)
• Hard for public agencies to communicate with (e.g. non -English speakers, people with learning disabilities, people unable to read or write, those with hearing difficulties, those who are visually impaired)
• Resistant to involvement with statutory bodies (e.g. because they feel threatened), (e.g. tenant in arrears, mother in an abusive relationship)
• Hard to engage on public bodies’ agendas (e.g. young people on health issues)
• Taken for granted. Not hard to reach or engage with, but at risk of under-representation (e.g. white working class men).
Partnership, Vision and Strategy,
Leadership and Engagement
Population LevelInterventions
Intervention Through Communities
Intervention Through Services
Systematic and scaled interventions through
services
Systematic community engagement
Service engagement with the community
Producing Percentage Change at Population Level C. Bentley2007
Leadership and Coordination
• PartnershipNot just at the top of organisations, or on the
frontline. Middle management often maintain silo working. Attention to governance.
‘Top down; bottom-up; middle-out’
• LeadershipAt all levels. Develop skills. Succession plan
• Vision and StrategyNot ‘pink and fluffy’. Tangible, with numbers.
10 Steps to Population Level Outcomes
10.Maximise impact: minimise inequalitiesservice quality; population support; co-ordination
Improving Male Life Expectancy in Improving Male Life Expectancy in Birmingham Birmingham
Coronary Heart Disease
Cold Damp Housing
Have the problem
Aware of problem
Eligible fortreatment
Optimaltherapy
Compliance with therapy
Benefit from evidence based interventions across populations(not to scale)
AB C D
Health and Wellbeing Boards should provide an excellent
platform for more systematic engagement with communities,
families and individuals currently not connecting appropriately with
health services
C + D. Quality of CareCHD 6 - % patients whose last BP reading <= 150/90 (measured in last 15 months)
0%
20%
40%
60%
80%
100%
Practice code
Target Met Target Missed Exception Coded
A High Performance PCT
CHD 6 - % patients whose last BP reading <= 150/90 (measured in last 15 months)
0%
20%
40%
60%
80%
100%
Practice code
Target Met Target Missed Exception Coded
A +B. ‘Missing thousands’CHD 8 - % patients whose last measured cholesterol <= 5mmol/l (measured in last 15
months)
0%
20%
40%
60%
80%
100%
P85
001
P85
002
P85
003
P85
004
P85
005
P85
006
P85
007
P85
008
P85
009
P85
010
P85
011
P85
012
P85
013
P85
014
P85
015
P85
016
P85
017
P85
018
P85
019
P85
020
P85
021
P85
022
P85
024
P85
025
P85
026
P85
028
P85
029
P85
601
P85
602
P85
603
P85
605
P85
606
P85
607
P85
608
P85
610
P85
612
P85
613
P85
614
P85
615
P85
619
P85
620
P85
621
P85
622
P89
006
Old
ham
PC
T
Practice code
Target Met Target Missed Exception Coded Undiagnosed based on Expected Prevalence
Have the problem
Aware of problem
Eligible forintervention
Optimalintervention
Compliance with plan
Benefit from evidence based interventions across populations(not to scale)
AB C D
Chris Bentley 2012
10 Steps to Population Level Outcomes
1. Governance: who is running the show?2. Programme planning: who is accountable?3. Information Governance: sharing intelligence4. Joint Strategic Needs Assessment5. Priority setting: how does it really work?
10 Steps to Population Level Outcomes
6.Setting targets: locally relevant and meaningful7.Select interventions: strongly evidence based8.Develop business plan: economic case for change9.Whole system approach10.Maximise impact: minimise inequalities
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