Nottingham City PCT 1

Quality improvement to ensure health gain (and Health Inequalities reductions)

an example: commissioning cardiovascular risk management

Chris Packham

Director of Public Health

Nottingham

Nottingham City PCT 2

DH, Health inequalities intervention tool: view your gap

Nottingham City PCT 3

Health outcomes in context

Nottingham City PCT 4

CHD 8 - % patients whose last measured cholesterol <= 5mmol/l (measured in last 15 months)

0%

20%

40%

60%

80%

100%

Practice code

Target Met Target Missed Exception Coded

Nottingham City PCT 5

CHD 8 - % patients whose last measured cholesterol <= 5mmol/l (measured in last 15 months)Nottingham City Practices 2006-07

0%

20%

40%

60%

80%

100%

Most deprived IMD 2004 quintiles Least deprived

Target Met Target Missed Exception Coded

QOF performance – cholesterol outcomes

Nottingham City PCT 6

Nottingham

DM 20 - % patients whose HbA1C <= 7.4 (measured in last 15 months)

0%

20%

40%

60%

80%

100%

Practice code

Target Met Target Missed Exception coded

Nottingham City PCT 7

Understanding unmet need and inequalityEg: Heart disease deaths and Statin prescribing by GP practice

0.000

2.000

4.000

6.000

8.000

10.000

12.000

practice

CHD death rates (DSR)

statin use (ADQ/STAR-PU)

most deprived least deprived

Nottingham City PCT 8

Commissioning Healthcare for Best Outcomes

Population Focus Optimal Population Outcome

13.Networks,leadership and coordination

6.KnownIntervention

Efficacy

1.KnownPopulation

Health Needs12. Balanced Service Portfolio

11.Adequate Service Volumes

Challenge to Providers

5.Supported self-management

10. Engaging the public

4. Responsive Services

9. Accessibility

2. Expressed Demand 7. Local Service Effectiveness

3. Equitable 3. Equitable ResourcingResourcing

8.Cost Effectiveness

Nottingham City PCT 9

Design (Commissioning) challenges

• How to stop the CVD risk programme work widening inequalities?

• How to encourage people to turn up for assessment and then take part in interventions?

Nottingham City PCT 10

Mosaic Group F: people living in social housing

with uncertain employment in deprived

areas

Eg: Social marketing methodologies

Nottingham City PCT 11

Getting the technical data right:understanding the CVD risk 40-74 task

• Local estimation

• NICE guideline 67 tool– http://www.nice.org.uk/guidance/index.jsp?act

ion=download&o=40777

• QRISK 40-74

– 3% 40-54, 97% 55-74

• Framingham 40-74

– 7% 40-54, 93% 55-74

• But – S Asian and AC groups may

need DM case finding from age 30

– ‘CKD’

• From a population of 300,000…

• How many patients are we seeking for primary prevention?

• Existing CVD 11,000

• For a population of 300,000, around 12,500 out of 35,000 55-74’s estimated at risk (Framingham)

Nottingham City PCT 12

our ‘Intervention’: first stage started

most deprived quintile – 14 practices: 8000 patients 45-74

• Trained HCAs• Computer generated lists of at risk patients• 30% one or more risk factor recorded• ABPI partnership project • Called in, risk assessed, interventions agreed• Referred on the GP/PN as necessary• Outcomes monitored • Targeted using successive 5-year descending

age bands

Nottingham City PCT 13

Results

• first 2 months • attendance rate 73% (65% plus a further 8% on

one reminder)• 260 seen all>20%• 40% already on treatment • About 50% sent to GP/PN to date• 1 in 5 put onto drug treatment immediately

• 4% new Diabetics

Nottingham City PCT 14

our ‘Intervention’: second stage50 practices - 27,000 patients 55-74

• Locally Enhanced Service for 55-74’s

• Option to use HCA model

• 40-54’s ?Alternative model

• Year one – Hypertensives all ages– BMI>35

• Year two – 55-74 one or more risk

factor– All BME 40-74

• Year three– Rest 55-74

Nottingham City PCT 15

Challenges and solutions

• Problems – The DNAs

– Compliance

– Clinical buy-in

– Community awareness

• Must have supporting delivery– Healthier Communities

Collaborative – Primary prevention– HEAs on hospital and

tertiary end – Health trainers / PH

nutrition teams / smoking cessation services

– Look carefully at primary care data

Nottingham City PCT 16

Commissioning Healthcare for Best OutcomesNST – HI support team Prof Chris Bentley

• Population quality– Empowering / Healthier

Communities Collaboratives

– Decent Health Equity Audits

– Designed around populations as well as practices (eg BME)

• Individual care quality – QOF– Use Accepted interventions – Guideline audits

– Patient satisfaction and

accessibility

For both make sure the supporting community services are in place and part of patient pathways and at industrial scale