Systematically Addressing Health Inequalities in Diabetes Care The ‘Christmas Tree’ Diagnostic Model National Support Team Health Inequalities

Systematically AddressingHealth Inequalities in Diabetes

Care

The ‘Christmas Tree’ Diagnostic The ‘Christmas Tree’ Diagnostic ModelModel

National Support Team Health InequalitiesNational Support Team Health Inequalities

The diagnostic model will support the systematic delivery of the best health

outcomes from a given set of interventions.

It is based on the assumption that the aim is to achieve optimal health

improvement at population level, embracing minimal health

inequalities.

Commissioning for Best Outcomes

Population Focus Optimal Population

Outcome

Challenge to Providers



Outcome

13.Networks,leadership and coordination

1.KnownIntervention

Efficacy

6.KnownPopulation

Health Needs12. Balanced Service Portfolio

11.Adequate Service Volumes


10. Supported self-management

5. Engaging the public

9. Responsive Services

4. Accessibility

7. Expressed Demand 2. Local Clinical Effectiveness

8. Equitable 8. Equitable ResourcingResourcing

3.Cost Effectiveness

This side of the diagram

shows

aspects of service

provision that will influence

achievement of best service

outcomes from a

particular set of

interventions


1.KnownIntervention

Efficacy


5. Engaging the public

2. Local Clinical Effectiveness

OptimalPopulation Outcome

4. Accessibility


Services should be based where possible on strong

evidence. However, efficacy, based on experimental trials must translate into effective

local intervention. This must be constantly

checked through local audit and systems of governance.

13. Networks, Leadershipand Co-ordination


1.KnownIntervention

Efficacy



To have the maximum impact on mortality and morbidity, as many patients with diabetes should be assessed and managed for the following:

•Still smoking•Raised BP•Raised cholesterol•Raised HbA1c•possible benefit from low-dose aspirin

Attention should be given to ensuring that patients have been assessed and controlled for all, not just one or two


1.KnownIntervention

Efficacy



Are diabetes registers being used to identify potential for multiplicative risk reduction in relation to:

•Smoking cessation support?•Alcohol harm reduction?•Physical activity?•Cold/damp housing; fuel poverty in the elderly?

Is there a focus on outcome, rather thanreferral; is professional support assertive; is there a menu of support options based on social marketing/insight research?

A PCT with problems

DM 6 - % patients whose HbA1C <= 7.4 (measured in last 15 months)

0%

20%

40%

60%

80%

100%

Practice code

Target Met Target Missed Exception coded

South Tyneside


0%

20%

40%

60%

80%

100%

Practice code


DM 12 - % patients whose BP <= 145/85

0%

20%

40%

60%

80%

100%

Practice Code


Spearhead PCT where insufficient focus on BP management

in patients with Diabetes


1.KnownIntervention

Efficacy



Is there a strong focus on performance

management of QOF outcomes, with

verification sampling where maximum points

are claimed, and recovery plans where

outcomes are sub-optimal?


1.KnownIntervention

Efficacy



Is there a diabetes ‘dashboard’ of key

information by practice bringing together actual

v expected register numbers, QOF outcomes data, prescribing data, and selected hospital

admission data, all compared with the

district averages (z-score), is seen to be an

effective tool for change


1.KnownIntervention

Efficacy



Are there teams of specialist professionals working in the

community to support improved management of diabetes by primary care,

maintaining updated manuals, guidelines and

protocols; ongoing induction and professional

development training; action planning support; evaluation

and audit; assistance on procurement , maintenance

and effective use of equipment?


1.KnownIntervention

Efficacy



Where standards are patchy, best practice engages primary and secondary care together as a compensatory system:• Where primary care cannot offer fully

effective care for all patients, this is recognised in a scaled accreditation system eg L1 - L5.Intermediate/ secondary services then provide the missing elements proactively.

• All patients can therefore receive effective and comprehensive care. Incentives should support development up the competency scale, which is supported by primary and secondary care practitioners working closely together providing shared care in the community.

• The whole system should share responsibility for population level outcomes eg in QOF. This information should be available to all involved.

CHD Equity Audit 2006Selected measures by z scores

Example of a good practice

-2.0

-1.5

-1.0

-0.5

0.0

0.5

1.0

1.5

2.0

2.52

0%

de

priv

ed

IMD

2

004

% a

ge

d 7

5+

CH

D M

ort

alit

y

CH

D R

eg

iste

rC

rud

e R

ate

CH

D R

eg

iste

rS

tan

da

rd R

atio

% C

HD

pa

tient

s

who

sm

oke

Asp

irin

Bet

a B

lock

er

Sta

tin

AC

E I

nhi

bito

r

Ang

ina

Hea

rt F

ailu

re

Acu

te M

I

Car

dia

cO

utp

atie

nts

CA

BG

/PT

CA

A1(a) A1(b) A2 A3 A4(a) A4(b) A4(c) B1 B2 B3 B4 C1 C2 C3 C4 D1

Indicator

Z

SC

OR

E

4.6 4.3 3.93.3

Measures of Need Primary Care Secondary care Tertiary Care


1.KnownIntervention

Efficacy




Interventions need to be affordable to treat all those who

could benefit, and cost beneficial , justifying the opportunity cost against

alternative ways to spend


1.KnownIntervention

Efficacy




Has there been for diabetes, a prescribing cost-versus-QOF outcomes analysis by

practice with tailored support to change for poor

performersh

Fig 7a - Prescribing Costs per Diabetic Pt (Apr 06-Mar 07) v Percentage of diabetic patients whose HbA1C has been 7.4 or less in the last 15 months (Apr 06-Mar 07)

16

1

25

15

2622

8

21

27

11

20

14306

4

17

19

5

10

33

7

3

2

18

32

28

29

24

31

13

129

23

30

35

40

45

50

55

60

65

70

75

80

£150 £200 £250 £300 £350 £400 £450

NIC (£) per diabetic patient

% ta

rget

met

Higher % pts at target - Low prescribing

Low er % pts at target - Low prescribing

Higher % pts at target - High prescribing

Low er % pts at target - High prescribing





4. Accessibility

1.KnownIntervention

Efficacy

Bringing services closer to patients and communities may substantially improve uptake, presentation and utilisation. Patient pathways should be designed with this in mind.

However, there will possibly be tradeoffs between effectiveness,as interventions are moved away from specialists and specialist facilities, and cost effectiveness if the efficiencies of centralisation are lost.



4. AccessibilityAppropriate

Utilisaion

5. Engaging the Public

Delivery systems for interventions should be based around, and directly respond to, the needs and wants of the person, rather than the person having to fit around the

needs of the service.

Patient and community inputs should be drawn in systematically, not as a

tokenistic add-on.

Addressing Diabetes Inequalities through Community Engagement

Raising community awareness of key health messages about prevention/early identification. Case finding and linking to life-style and primary care services

Outreach to identify reasons for non-engagement with services. Advocacy to improve accessibility of clinical care and ongoing quality of services

Improve the skills of primary and specialist care professionals to better meet the needs of patients and make the links to lifestyle change support resources

Support patient self-management and empowerment, targeting those not achieving treatment goals. Facilitating links to other supports where necessary

Coordination of inputs and output with strategic

approach to Community Engagement


13.Networks, Leadership and Coordination

1.KnownIntervention

Efficacy



4. Accessibility



10. Supported self-management

6.KnownPopulation

Health Needs


7. Expressed Demand


Population Focus

Attention given to this array of provider-side aspects of

delivery should produce good health service outcomes.

However, good population health outcomes will not be

achieved without also addressing the way

communities use the service.


6.KnownPopulation

Health Needs

13. Networks, LeadershipAnd Co-ordination

10. Supported Self-

Management9. Responsive Services

7. Expressed Demand


Population Focus

It is now possible to get good estimates of health need, either

from census, local survey, extrapolation from national surveys or, increasingly, from local clinical systems. Geographical systems can

map down to tailored neighbourhoods, census output areas and population quintiles.

There are still problems of obtaining good intelligence by

ethnicity and other social groupings.


6.KnownPopulation

Health Needs

Population Focus

a) Neighbourhood Cluster Types eg:

• Older large estates

• New estates

• Rural and small towns

• Ex-Coalfields communities

• Mixed young families

• Established non-caucasian ethnic

• Mobile young

b) Segmentation Groups


6.KnownPopulation

Health Needs

7. Expressed Demand

Population Focus

One of the major problems of obtaining optimal population health outcomes from service

delivery is that people in deprived circumstances often

do not present with major health problems until too

late.

Barriers to presentation include structural issues such as poor access and transport;

language and literacy problems; poor knowledge;

low expectation of health and health services; fear and

denial , and low self esteem.


6.KnownPopulation

Health Needs

7. Expressed Demand

Population FocusIs there a systematic and

ongoing strategy to include as many people as possible

with established disease onto Diabetes registers?

Actual numbers compared to estimates of expected numbers by practice

Systematic strategies to ‘sweat the asset’ of practice records to identify patients

with diseaseVariety of ‘segmented’

options to identify patients in the community, scaled up

appropriately

Spearhead PCT – Registration Gaps for Major Conditions

5.1%

22.4%

4.95%

4.2%

12.5%

3.6%0%

5%

10%

15%

20%

25%

Coronary Heart Disease Hypertension Diabetes

Expected v Registered Prevalence of major QOF conditions

PCT Registered

PCT Expected


5.5%

15.0%

4.6%

2.5% 3.1%

28.7%

4.6%5.5%

0%

5%

10%

15%

20%

25%

30%

35%

Coronary HeartDisease

Hypertension Diabetes* COPD

PCT Registered 16+

PCT Expected

Blackburn with Darwen

This PCT has been able to to close the register gaps for CVD and Diabetes

0%

1%

2%

3%

4%

5%

6%

7%

% p

reva

lenc

e

AmberValley

Bolsover Chesterf ield

DerbyshireDales

Erew ash High Peak North EastDerbyshire

SouthDerbyshire

Practices by district

Diabetes PrevalenceGP Practice prevalence compared to locally expected prevalence by ward

QOF Prevalence Expected Diabetes Prevalence

4.5%

22.9%

5.2%

3.7%

11.9%

4.2%

0%

5%

10%

15%

20%

25%


Hypertension Diabetes


PCT Registered

PCT Expected

Nati

onal Support

Team

s NHS Bolton

Dr.S.Liversedge

Nati

onal Support

Team

s

Bolton 2008/09


4.6%

16.4%

4.8%

2.5%

4.8%

31.0%

4.7%6.1%

0%

5%

10%

15%

20%

25%

30%

35%


Hypertension Diabetes* COPD

PCT Registered 16+

PCT Expected

Nati

onal Support

Team

s

The activity has continued, with the latest figures, for January, continuing the trend.

It is estimated that 83-85% of all patients would have been assessed by end March 2009

The figures also show that practices in the more deprived neighbourhoods have been supported to achieve the best results:

Deprivation Score No. Practices % Assessed>40 14 79.430-39 18 73.720-29 12 75.2<20 11 74.3

It


6.KnownPopulation

Health Needs

7. Expressed Demand


Population Focus

In order to achieve equitable outcomes for deprived populations, resources applied need , firstly, to be proportionate to need . But they

also need disproportionate supplements to reflect the extra

effort and support required.


6.KnownPopulation

Health Needs


Population Focus

Is there a local mechanism to ‘raise the bar’ beyond QOF

maximum for target outcomes, for Diabetes measures. Where extra

incentives are used, do they recognise the

disproportionate effort/resource to achieve

outcomes in disadvantaged elements of the register population ( e.g. using

exponential incentives )


7. Expressed Demand



6.KnownPopulation

Health Needs

Population FocusWhen patients do express demand and present for

service appropriately, and with resources targeted and

available, services should respond actively to channel

them effectively to interventions they will benefit

from. This should happen regardless

of entry point chosen.Patients should receive

culturally sensitive help to navigate to relevant service, and should be followed up to

ensure arrival and engagement.

A PCT with problems


0%

20%

40%

60%

80%

100%

Practice code



7. Expressed Demand



6.KnownPopulation

Health Needs

Population Focus

Is there a Diabetes QOF Exception Strategy, with

clear transparent interpretation of criteria,

regular monitoring of outlier levels, and a

strongly enforced validation process, including notes

audit?

Gateshead - Total QOF Scores by Practice

Analysis of QOF Non-Clinical Points earned by GP Practice

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Practice Code

Points Earned Points Missed

Another Spearhead PCT - QOF Scores by Practice

QOF non-clinical score by GP practice and deprivation

50.055.060.065.070.075.080.085.090.095.0

100.0

0.0 20.0 40.0 60.0 80.0

Ward deprivation score (2004)

QO

F %

no

n-c

linic

al p

oin

ts

ach

ieve

d

Liverpool



Appropriate Utilisation

10 Supported Self-management

6.KnownPopulation

Health Needs

7. Expressed Demand


Population Focus

Commissioners and providers should ensure that patients are empowered to

make informed choices about their treatment, and are educated and

supported to utilise treatments and therapies to best effect.

This should take into account factors such as literacy, language, culture and

IQ.



10. Supported Self-management


Population Focus

Is the provision of self-management training scaled-up so as to be able to offer support to all newly diagnosed

patients with diabetes? Is there a menu of quality assured options,

designed with insight into the preferences of the main range of

segmental groups?


Population Focus


6.KnownPopulation

Health Needs

7. Expressed Demand


1.KnownIntervention

Efficacy


4. Accessibility






Appropriate utilisation of service

by the population may require

adjustments to supply.


Population Focus





12. Balanced Service Portfolio

Capacity of services needs to be commissioned to accommodate

appropriate demand while meeting national standards.Service pathways should be

balanced to avoid bottlenecks and engineered to allow smooth and

efficient progress.

Workforce planning

• Is there PCT support to practices in developing a sustainable workforce, with appropriate skill mix to maintain effective, efficient and affordable register management, recognising the industrial scale of activity– Modelling of person-hours of activity necessary by

practice per annum– Modelling of necessary workforce, with skill-mix

review– PCT/PBC alliance commissions training eg of NVQ3

Care Technicians, for subsequent employment by practice/practice cluste


Population Focus

13.Networks,leadership and coordination


1.KnownIntervention

Efficacy

6.KnownPopulation

Health Needs

++

=

+ 13. Networks, Leadership and Co-ordination



Outcome

12. Balanced Service Portfolio



1.KnownIntervention

Efficacy


4. Accessibility



6.KnownPopulation

Health Needs



7. Expressed Demand


+

Documents

Systematically Addressing Health Inequalities in Diabetes Care The ‘Christmas Tree’ Diagnostic Model National Support Team Health Inequalities