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PH input to CCGs –current state,future requirements
Dr Heather GrimbaldestonDPH, Medical Director
Central and Eastern Cheshire
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In summary:‘this is public health –but not as we know it!
World /Universe?
Coproducing thefuture is critical tosuccess
public health leadershipand technical skills are
equally important
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Why are we discussing this?Core business?
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• Treatment Prevention• Clinician centred patient centred• Quality/Safety low waste / hi value• Patient passive complier coproducer• Good care for patients equitable care for
populations• Hospital Systems (SE London)• Bureaucracy networks• Driven by finance driven by knowledge (CIP/QIPP)• Challenge met by growth challenge met by
transformation
Drivers… … .U know these…
Results… … ..
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AGENDA:Transformational Change what we do and how we do it… … together?
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Public Health RoleLeadership Technical
Dr J Sin Central Eastern Cheshire
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What should we be aiming for?
• Vision/Strategy Maximise healthgain/secure value/quality within limitedresources [paradigm]
• Change to commissioning and deliverymodel, shared ownership for healthe.g. community orientated primarycare, ‘i(ntegrated public) health,
• Robust governance / structures /infrastructure (places on boards,MOUs, joint commissioning / jsna /prog. budget , prioritisation
• Support delivery individual projects –QIPP, Oxford Hip Scores, etc
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(CO) LEADERSHIP 4HEALTH: RIGHTDIRECTION
Technical expertise:right action
2013
2011
but … .progressvariable &time limited
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Recognised:
• ‘public health will be central to mobilisingboth NHS and non health sector investmentagainst shared aspirations for healthimprovement… … … … .
• … ..unless we get also get to grips with thecomplex issue of health commissioning theopportunities for transformational change inhealth outcomes will be missed.
Dr C Clayton CCG Chair Blackburn wirh Darwin A Problem Shared HSJ Jan 2012
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What is happening at the moment? Current NW PH action(1 hour session plus e mail review)
• Pre authorisation NW PH input variable: most supportingoperational (right actions) and tactical (right choices)– Strategic commitment to prevention and reduce
inequality. ‘Vision states ‘we will be known for thereduction in inequalities of health outcome’ Stockport.
– Co location –Liverpool, Wirral– Board presence –‘the Conscience’– MOU, core offer CCG/CSS –Lancashire.– Public engagement –some joint presentations– Needs assessment– Prioritisation– IFR– Support for individual commissioning projects
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Q Is this what is wanted and needed now?Q Post authorisation is this sufficient to maximise health, reduceinequality and improve outcomes? ? Ongoing technical /Leadershipchallenge/both.
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Is this what CCGs want and need ?‘Market research –CCG/GP Views, pre ‘fact
sheet’
• Cheshire and Merseyside Public HealthNetwork Stakeholder Insight Survey August2011 –Dawn Leicester, Director.
• ‘Singing from the same hymn sheet’–NHSSefton 2011 –Hannah Chellaswamy, ElspethAnwar, Public Health Registrar, MoragReynolds, Public Health Development Lead
• Workshops –Oldham 2011 Andrea Fallon
• ‘CCG JSNA Champion’
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Methodology• Cheshire and Merseyside ChaMPs Network
– Commissioned specialist consultant to conduct one to one interviews– Local Authorities 18 telephone interviews x 30 minutes– Clinical Commissioning Groups 4 telephone interviews x 15 minutes– Research period –April to July 2011
• Sefton PCT– Focus groups were undertaken at a random sample of GP practices
from the clinical commissioning groups in North and South Sefton (9practices in the South, 8 practices in the North).
• Oldham –‘initial appreciative enquiry’
• Cheshire East JSNA Champion
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ChaMPs: CCGsMix of ‘right direction, choices and action
• Not totally convinced the new structure will work –wait andsee!
• PH in LA make sense –joined up commissioning, wideapproach to pop health
• Concerned: losing the medical perspective• PH is vitally important• GP lack of PH training is an issue
Want:• Better integration with knowledge and intelligence teams• To work alongside PH professionals (not PH training)• information, population stats etc to commission effectively.• Clear, concise, simple communications, what works• Focus on outcomes and delivery (not talking and process)• Promote public health messages to patients a key challenge
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Key findings: ChaMPs CCGSmix of ‘right direction, choices and action
“Health & Wellbeing Boards will be a vital interface between LA andClinical Commissioning Groups”
“It’s very important that PH professionals are represented at thehighest level on the Commissioning boards”
“PH Doctors are all trained to look at a whole population approach,GP’s are not”
“Statistics are useful but only if presented in a concise format. Nomore than one side of A4 and electronic information preferred”
“Going forward the LA’s need to share this information with theclinical commissioning groups. JSNA is a good starting point”
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Key Findings Sefton individual GP perspectiveQ4: How can public health work with you to improve outcomes on
those priorities?“It’s really knowing what public health services are offered to us, to
know how it could sit in with us. As I said to you my understanding ofit (public health) is about infectious diseases and that is a much as Iknow. I am not sure what involvement they would have within thepractice”.
“Well I think I would be interested to know what public health canoffer and what your position in the overall care of patients is beforeI could possible answer that question you know. Where do you lie in therespect of what access and what power do you have to promote allthese services that we have mentioned that would certainly help medecide what public health can do for us if that is the question”
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Key Findings Sefton individual GP perspective
Q5: The NHS is undergoing reforms do you think that will affect therelationship between public health and general practice?
“I think in some ways a big test of it will be to see how well we did indefining what public health is, because if you asked any of us whata gynaecologist does I can recite it in my sleep, if you ask us what apaediatric specialist does we can tell you because there is that closerlink and some of us in the past will have worked in paediatrics orgynaecology but public health is specialty we know is there, weknow it is helpful but I just get the feeling we are using you tomaybe 5 % of the potential we could use you for”.
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Key Findings Oldham –what is wanted
• Identify and address variation: in access, quality,outputs and outcomes of existing services
• Are the KPI’s and outcome measures right?• Appropriate spend in programme budget areas?• Performance of services: achieving outcomes for
which they were commissioned?• Evaluation (quadrant 4) with recommendations to
improve performance• Costeffectiveness e.g. is service high cost for a
programme budget area that may have low priorityin relation to need
• Public Health to have a bigger role in contractingto ensure service specifications will deliveroutcomes needed”
Significant appreciation of right choices, right action, wholecommissioning cycleAre outcomes / right direction being defined collaboratively?
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Key Findings Oldham what is important to GP’s
• Local Intelligence and knowledge of the local health economy is valued• Reliable and trusted robust quality assurance.• Single Point of Contact where in house resources are not available, this should be
sourced by the team.• Input needs to be scalable so that when commissioning services above borough
level there is public health expertise available (specialist services, observatories or inthe commissioning consortia or cluster)
• Timeliness do not want to wait for long periods (although recognise that noteverything can be delivered in 90 day cycles).
• Ease of access public health support should be ‘at hand’. Findings and analysispresented in easily understandable ways
• PH needs to clearly define what it’s products and services are and the offer toGPCC
• PH needs to market to GP’s more effectively and in ways in which GP’s want tobe marketed to. Eg website and brochures to describe who is in the team and whatthey do.
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… ..IN SUMMARY• Some GPs don’t know what we do/make or how
to use it or us, but do know PH is useful … .sometimes
• Some CCGs have a clear idea of what theyrequire. This tends to focus on the tactical andoperational support. We are matching some ofthese expectations.
• Some CCGs starting to encompass role of PH coproducing the ‘right direction/ vision for health.
• Some GPs /CCGs are going on this journey withus : ‘… people inside this house, I thought I kneweverything about their health. Actually, I have beenlooking through the keyhole –not really stood backto see house, where it is, what the healthpossibilities are and how we can really improvethem.’
• Do we recognise this picture?• Do we recognise the need to change?• How do we start to support transformational
change?
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SWAT what shape we are in?Does PH mirror GP views?
Strengths
History of good relationships
Taking a collaborative / partnershipapproach to problem solving
Track record achievement
Good knowledge & training pathway
Acknowledged credibility in publichealth intelligence, strategic /population level, think & do
Honest broker, advocacy roleResponding positively to criticism
• Did not see ourselves as coleaders/ visionaries or as partof a wider solution … thoughthis may have been implicit
Weaknesses
Lack of PH capacity
Disparate views of CCG, esp. if advising anumber of CCG's. Duplication of effort
• new organisations needing/wanting to maintainidentity v 'do once and share'
• Hard to look across service when no mechanismfor CCG's to collaborate
• Diversity of knowledge in CCG's; hard to 'pitch'interaction correctly
• Potential for 'hobby horses' to derail popular focus
Hard to achieve balance: quick wins and investto save and prevention CIP v QIPP
Lack of priority for smaller, low cost, 'quiet' ornon news worthy services,
• Did not see ourselves as isolated / out ofstep with the needs / requirements ofothers
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SWAT what shape we are in?Does PH mirror GP views?
Opportunities
Open doorRaise the profile of work on larger area, link to CSO etcDo once and share
Shape the direction of change in CCG'sShift CCG’s population perspective and integrated roleInfluence spend of budget and increase investment in
effective prevention
Gain clinical engagement in effective preventions
Use joint commissioning and share pathways
Develop our honest broker role
Enable professional development in Primary Care and in PHstaff
• Did describe the added value /health potential ofPH
• Did not talk about CCG responsibility to reduceinequalities, performance framework CCG leadingPH transition
Threats
Instability of systemWindow of influence closingCSO/cluster debate –crowded
pitchFragmentation training and
workforce developmentMissing R & D opportunitiesLoss of good staffLoss of performanceProfessional protectionism/
puritisationSeen as luddites
• Some clear insight into therisk not meeting othersrequirements
• Pre allocations but did notmention
– Historic diversity– funding
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How can we (all) take advantage of the health and socialcare modernisation programme to ensure services are
integrated around people's needs?
The current situation
• Organisations don’t recognise sharedresponsibility for deliveringoutcomes.
• Risk and reward sharing is notcommonplace. Costs and peopleshunted around the system.
• Lack information to be able tonavigate the system effectively –find itovertechnical, fragmented, frustratingand confusing.
• Services are delivered in anuncoordinated way. They are notalways personalised or integratedaround people’s needs.
• Services can be inefficient due tobureaucracy and lack of coordination.
• Evaluation is patchy anduncoordinated
Where we need to be
• Shared Coproduced culture, vision andleadership –Shared definition of integration andagreement on ‘what good looks like’.
• Consensus on the evidence base for howintegration achieves better health, better andbetter value for money.
• Joined up services and care pathwaysdesigned around people’s needs, (Marmot, lifecourse, community views).
• Commissioning for populations –localcommissioning strategies support pooling offunding for joint outcomes and best use ofresources.
• Quality Information –for local partners andusers to make informed choices.
• Performance management that promotescollaboration –incentives and levers thatunderpin delivery of outcomes across populationsnot organisations or sectors.
How can PH be the legitimate holder of this responsibility?
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What would you include in a strategy to influence/support CCGs:A few ideas
• Agreed clear vision and a coherent product which is coproduced (with public)– Agree the framework for population health gain– Make the economic as well as epidemiological case for investment– Agree Plans to reduce health inequalities –with jointly agreed outcomes– Clear focus on quality improvement –(whole commissioning cycle)
• Empower others –actions, partnerships (£ joint), advocacy
• Joint evidence based commissioning / practice/ needs assessment– Area profiles / analysis and interpretation – include the so what?– Use community conference, appreciative inquiry hear people’s stories to inform life course
as well as care path commissioning– Translate complex info into meaningful recommendations– Promote community led approach to service delivery (COPC)– Asset mapping to include NHS and LA estate within a locality to help with solutions
• Integrated workforce plan –every ‘contact counting’• Maximise use of IT capabilities Joint databases/referrals• Evaluation include explicit joint monitoring and risk sharing. Balanced scorecard• Research social marketing, understanding behaviours
PH integrated : drawing on all skillsright direction, right choices , right actions
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Success –‘i (integrated) PH’Little
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PH: conscience, interpreter, broker,integrator, innovator
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Vision for the future?Clic
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Strengths•Use the transition tostart to develop a newcoproduction modelfor health andWellbeing
•Establish focused,agreed prioritieswhich havemeaningful outcomesfor all partners
•Put in place amechanism andinfrastructure toensure effectivedelivery
•Build public healthcapacity across awhole range ofworkforces to deliverinterventions atindustrial scale
Challenges•Use intelligencedynamically,creatively andsuccinctly and inrelevant forms fordifferent audiences•Promote an assetbased approach tocommunities tounderstand andharnesstheir assets•The public healthworkforce has tochange –a newbusiness model thatis pragmatic, practicaland delivers solutionsto commissioners andproviders•Secure electedmembers’understanding andbuyin
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The World Health Report 2008 primary Health Care (Now More ThanEver) Chapter 3: Primary care Putting people first.Community Orientated Primary Care 2001
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Conclusion and RecommendationsSefton plus other
• There is recognition of the need for a population perspective when makingcommissioning decisions.
• GPs recognise the impact of the wider determinants of health but often feelpowerless to act upon them
• There is a lack of understanding of the role of public health. GPs are unsureabout what people in public health actually do; PH is ‘distant’so GPs find it hardto suggest how we can work together.
SO• Public health has a key role to play in engaging with partners in order to
support GPs to take action
• Public health needs to:– leave its “ivory tower”and improve relationships with general practice For example
developing a public health “key contact”
– let GPs know what it can offer and prove its worth
– show the beneficial outcomes of investing in public health both in terms of improvingpopulation health and reducing demand/workloads –’so what’
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