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It's not just a numbers game
Carl Bennett FCIMSPASenior Health Improvement SpecialistNHS Stoke on Trent
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It's not just a numbers game
• Health Inequalities ~ the challenge & health backdrop
• What should we be measuring?
• What is an Output, Impact or Outcome?
• Commissioning ~ a mysterious art form
• The Emerging Health Landscape
• National v Local
The New Health Structures - England
Regardless of where Public Health sits it’s all about…
Inequalities
Travelling east from Westminster, each tube stop represents nearly one year of life expectancy lost
Westminster
Waterloo
Southwark
London Bridge
BermondseyCanada
Water
CanaryWharf
NorthGreenwich
Canning Town
London Underground Jubilee Line
Differences in Life Expectancy within a small area in London
Electoral wards just a few miles apart geographically have lifeexpectancy spans varying by years. For instance, there are eight stops between Westminster and Canning Townon the Jubilee Line – so as one travels east, each stop, onaverage, marks nearly a year of shortened lifespan. 1
River Thames
1 Source: Analysis by London Health Observatory using Office for National Statistics data. Diagram produced by Department of Health
Male Life Expectancy71.6 (CI 69.9-73.3)
Female Life Expectancy 80.6 (CI 78.7-82.5)
Male LifeExpectancy77.7 (CI 75.6-79.7)
Female Life Expectancy84.2 (CI 81.7-86.6)
• Allied Dunbar National Fitness Survey (1992) = 58% of adults not active enough to benefit their health
Participation over time
BIG Picture – Nothing has changed.
1 session a week (at least 4 sessions of at
least moderate intensity for at least
30 minutes in the previous 28 days)
APS1(Oct 2005-Oct 2006)
Apr 2012-Apr 2013 APS7(Oct 2012-Oct 2013)
%
n
%
n
%
n
Statistically
significant change from APS 1
Changei
since Apr 2012-Apt
2013
NORTH EAST 32.7% 682,200 35.5% 759,300 34.7% 740,900 Increase DownNORTH WEST 33.7% 1,859,100 35.5% 2,042,900 35.9% 2,063,000 Increase UpYORKSHIRE 33.1% 1,350,200 35.2% 1,517,200 36.2% 1,562,200 Increase UpEAST MIDLANDS
33.6% 1,173,400 34.4% 1,279,600 33.9% 1,260,400 No change Down
WEST MIDLANDS
31.9% 1,373,600 32.1% 1,457,500 33.3% 1,512,500 Increase Up
EAST 34.8% 1,556,100 35.4% 1,694,800 35.1% 1,677,000 No change DownLONDON 35.0% 2,126,000 36.0% 2,391,400 37.2% 2,467,800 Increase UpSOUTH EAST 36.7% 2,416,500 36.2% 2,554,800 36.9% 2,606,300 No change UpSOUTH WEST 33.8% 1,402,300 35.4% 1,559,000 35.7% 1,571,900 Increase UpNational 34.2% 13,939,400 35.2% 15,256,400 34.7% 740,900 Increase Up
Who Should we be Targeting?
Refer back to my earlier slides re Inequalities – This is ‘THE’ key PH Aim.
• Health Check population ?
~17 to 74yr olds. Key focus on Over 40’s
• Those at increased risk of CVD or with established disease ~ what groups might this include?
• Those on Mental Health Registers (Practice based register)
• Specific population Groups?
~ BME, Older people (at risk of falls), Physical / Mental disabilities, Pre & Post Natal Mums and Families via NCMP and AP data
~ Elevated BP, Diabetics & those with an increase in IFG, BMI over 25, Post Phase III Cardiac Rehab, Pre /Post Bariatric Surgery, Quota*, etc
It’s relatively safe to assume – most of the above will be inactive
What should we be measuring as well as the numbers?
• Frequency ~ how many & how often
• Type of activity ~ does it have an evidence base
• Intensity ~ is it Moderate
• Adherence ~ over the longer term (> 6mths – ideally 12mths or longer)
• Who is inactive ~ how are you engaging / encouraging those who are least active (the biggest proportion - over 65% - of your population is INACTIVE!!)
• Population Group ~ ethnicity, age, gender, social groupings
• Post Code ~ to the last digit (will help to inform ‘Hot Spot’, Super Output Area & Community analysis)
• Benchmark ~ against other ‘similar’ organisations / LA’s / demographics
• We can be data rich, but information poor
• Why do we collect data? Ask! and ask again
• How do we interrogate, interpret and use the data we currently collect?
• Who do we share this data / information with ~ who has access to it?
• Who should have access or at least see it?
Key Point: Data and Information itself is valueless. It requires translating into usable knowledge. Knowledge gain must be used to inform decisions which lead to a change in the way things are done.
Observations:
"information is now a more important measure of a company's worth than their tangible assets… The truly mission critical processes for every enterprise involve capturing the daily flood of data… Data must be stored and organised so that users can access it easily and intuitively, evaluate it… and act upon the findings effortlessly" (Strassman P; The Politics of Information Management: 1996)
Breaking the mould that has been used for the past 20yrs is a Must Do
Many things we have done in the past just don’t work… Fact!
We must use the available evidence and knowledge and match this to local drivers for
health improvement.
It ain’t complicated its just complex…
National or Local?
The National Drivers are very much about austerity (reducing the ‘Fat’) and devolving decisions to the local level
Localism is key – understanding how national drivers impact on local action is crucial, but Localism means decisions are made at the local level. This means there will be different systems of decision making and priorities in each LA area – Therefore, a Confusing Landscape
Local decisions will mainly be made by the Health & Wellbeing Board – there should be an Obesity Pillar which provides the PA agenda a route into the decision making processes
Joint Strategic Needs Assessment (JSNA) – weaves the strategic fabric to create a local picture of performance against a number of priorities – ‘if it ain’t in the JSNA it ain’t a priority’
Public Health Framework – 2 key measures relate to PA
•Improving the wider determinants of health - 1.16: Utilisation of green space for exercise/health reasons
•Health Improvement - 2.13: Proportion of physically active and inactive Adults
National or Local?... continued
Public Health profiles are a key source of data and information to help inform your understanding of health issues at the local level www.healthprofiles.info
Information to assist your insight of local health issues
Assessing Need & Priorities
Whose view point is need assessed by?
Professional View Service Users
Defined by an expert or professional ~ setting a standard
People identify what they want ~ ie regular BP reading following a first reading
What people ‘say’ they want or ‘demand’ Caveat ~ lack of demand should not be equated with lack of felt need
&
Understanding Needs ~ Market Segmentation
• Sport England 19 Market Segmentation Groupings ~ Experian (Mosaic Public Sector) ~ Interactive Web Tool
• Develop ‘Insights’ and ‘Pen Portraits’ of your current and target users
• Develop Ward, Community and Locality level data (match with PCT priorities) and allow these to inform your Programme of Offer
Impact Measurement• Measure changes in ~ Knowledge, Attitude & Behaviour
• Active People provides great analysis for physical activity & opportunity to benchmark
Output v Impact v Outcome
Output (out'pʊt') n. An amount produced or manufactured during a certain time
A Production Analogy
Outcome (out'kŭm‘) n. An end result; a consequence
Output v Impact v Outcome continued…
Impact
Measure of the tangible and intangible effects (consequences) of one thing’s or entity’s action or influence upon another (Business Directory)
This is how I see Impact: “What measurable effect has the intervention / experience / education had on the individual?”
Output
The tangible or intangible product resulting from a planned activity (MSP Handbook: OGC; 2007)
Output v Impact v Outcome continued…
The Health Outcome
“A change in the health status of an individual, group or population which is attributable to a planned intervention or series of interventions, regardless of whether such an intervention was intended to change health status” (HP Glossary; WHO: 1998)
Caveat ~ Generally a Health Outcome is likely to be achieved long after the intervention/s have touched a person, groups of people or the population as a whole
Outcome
The result of change, normally affecting real-world behaviour and / or circumstances (MSP Handbook)
Commissioning ~ a mysterious art form
Department of Health “Commissioning is the strategic activity of assessing needs, resources and current services and developing a strategy to make best use of available resources to meet identified needs.”
Audit Commission “The process of specifying, securing and monitoring services to meet individuals’ needs both in the short and long term. As such it covers what might be viewed as the purchasing process as well as a more strategic approach to shaping the market for care to meet future needs.”
I see it as: The act of committing targeted resources (people and £) with the aim of improving health, reducing inequalities and enhancing patient experience using the best available evidence and ensuring value for money for the outputs produced and the outcomes achieved.
SpecificationContrac t
(Schedule 2)
Te ndering &Contrac ting
Contract M onitoring and Review
Us er ne eds
Loca l Commissioning
Strategy
M arket M anagement & Deve lopment
Performance M anagement, M onitoring& Re vie w
Popula tion needs analys isRisk analysis
1. Analyse 2. Plan
4. Review 3. Do
Organis ation(s) purpose/ legisla tion
M ark et ana lysis
Commissioning strategy
Strategic Level
Operational Level
The Commissioning Cycle
What do we need?What does evidence say?
What does the marketplace look like?
Select Providers Monitor & Review
1 2 3 4
What works, what should we be doing different?
Remember what Albert said: “if you keep doing what you're doing, you'll keep getting the results you've been getting” A Einstein 1879–1955
Note ‘Sport’ does not feature high on the evidence list ~ the most recent NAO report ‘Report by the Comptroller and Auditor General; Increasing participation in sport’ (NAO: 2010) painted a poor picture of the sport participation strategic landscape ~ ‘When designing, developing and commissioning new initiatives we need to look at all the reliable evidence we can and use it to inform investment decisions’
• Start with the evidence ~ Ideas are ok. Innovation is great. When dealing with Health (with a capital ‘H’) you need to base your ideas on evidence and build from there.
• Where to find it?
My advice – Read The Marmot Review ~ FAIR SOCIETY, HEALTHY LIVES (2010) ~ key focus on inequalities and the introduction of ‘Proportionate Universalism’ (action across the social gradient)
Web links to referenced documents:
http://strassmann.com/
http://www.ogc.gov.uk/guidance_managing_successful_programmes_4442.asp
http://www.who.int/hpr/support.material.shtml
http://www.nice.org.uk/PHI002
http://guidance.nice.org.uk/PH8
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073600http://www.cabe.org.uk/publications/physical-activity-and-the-built-environment
http://www.sportengland.org/research/market_segmentation.aspx
http://web.nao.org.uk/search/search.aspx?Schema=&terms=sport+participation+report
http://en.wikipedia.org/wiki/Return_on_Investment
http://www.marmot-review.org.uk/
http://programmeforgovernment.hmg.gov.uk/
http://www.cabinetoffice.gov.uk/publications/state-of-nation-report.aspx
& other useful descriptions of Costs / Benefits
http://en.wikipedia.org/wiki/Quality-adjusted_life_year
Thank You & Questions
Carl Bennett FCIMSPASenior Health Improvement SpecialistNHS Stoke on Trent
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