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