Addressing Inequalities in Health and Wellbeing through HWB/CCG Structures

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


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


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


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





services


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






Industrial Scale - Stalinist

Piecemeal Project Based Approach

Industrial Scale - “Small is beautiful”

Not infinite, but graded levels of Engagement






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





services




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.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


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?


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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For resourceswww.hinstassociates.com

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Documents

Addressing Inequalities in Health and Wellbeing through HWB/CCG Structures