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Addressing Inequalities in Health and Wellbeing through HWB/CCG Structures. Professor Chris Bentley. HINST Associates. 10 Steps to Population Level Outcomes. Governance: who is running the show? e.g. strategic forum or performance driver Programme planning: who is accountable?

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addressing inequalities in health and wellbeing through hwb ccg structures
Addressing Inequalities in Health and Wellbeing through HWB/CCG Structures

Professor Chris Bentley

HINST

Associates

10 steps to population level outcomes
10 Steps to Population Level Outcomes
  • Governance: who is running the show?

e.g. strategic forum or performance driver

  • Programme planning: who is accountable?

responsible and empowered

  • Information Governance: sharing intelligence

data flows; communication strategy

slide3

NHS Commissioning Board

Chief Medical

Officer

DH Policy

Public Health

England

NHS System

Sub-national

structures

GP

Commissioning

Health and

Wellbeing

Board

Integrated

Provision

LA

Commissioning

LA System

Structures for Commissioning of Public Health (Bentley 2011)

SoSH

Cabinet PH Sub-Committee

DPH

SoSH - Secretary of State for Health

- Director of Public Health

DPH

slide4

Primary Care Direct Action

HWB

JSNA/HWS

Commissioning

Primary Care Commissioned Services

PH England

ccg legal obligations on health inequalities 2012 act
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
10 steps to population level outcomes1
10 Steps to Population Level Outcomes
  • Joint Strategic Needs Assessment

bottom-up and top-down

  • Priority setting: how does it really work?

evidence; ethics; politics

the threat of winter
The Threat of Winter

DEATH

Disability

Hypothermia

Accidents

Illness

Loneliness

Misery

Anxiety

DEPRESSION

slide9

Public Health

Adult Social Care and Public Health:

Maintaining good health

and wellbeing.

Preventing avoidable ill

health or injury, including

through reablement or

intermediate care services

and early intervention.

NHS and Public Health:

Preventing ill health

and lifestyle diseases

and tackling their

determinants.

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.

Adult Social Care

NHS

ASC, NHS and Public Health:

The focus of Joint Strategic Needs Assessment: shared local

health and wellbeing issues for joint approaches.

Alignment of National Outcomes Frameworks

slide11

Health Inequalities

Different Gestation Times for Interventions

For example intervening to reduce risk of mortality in people with established disease such as CVD, cancer, diabetes

A

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

B

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

C

2005

2010

2015

2020

10 steps to population level outcomes2
10 Steps to Population Level Outcomes
  • Setting targets: locally relevant and meaningful

measureable; ambitious; do-able

  • Select interventions: strongly evidence based

offer major contribution to change required

  • Develop business plan: economic case for change

cost benefit; cost utility; Return on Investment; Cost Consequence Analysis (CCA)

slide13

Setting Ambitions: Best in Peer Group (Males)

Male All Age All Cause Mortality (AAACM) Rates by GP Consortia, 2007-09

Oldham

South

Birmingham

13

*Peer group = Former Spearhead PCTs in ‘Centres with Industry’ ONS area classification

slide14

Estimating the scale of the challenge (Males)

Oldham Male AAACM rate 2001-2009, forecast and trajectory to 2013-15 ambition

270 fewer deaths in 2013-15 expected based on current trend

Equivalent to 417 (13%) fewer male deaths in 2013-15

14

slide15

Estimating the scale of the challenge : Summary (Oldham)

Reductions in mortality numbers necessary to meet 2013-15 targets

slide16

Identifying ‘excess’ mortality by cause

Females

Males

Source: Derived from NCHOD standardised mortality ratios (SMR) and mortality numbers by age and cause.

Excess mortality = ‘observed’ minus ‘expected’ deaths

slide17

Potential impact of evidence-based interventions on reducing mortality numbers for Oldham

NNT = Number Needed to Treat to postpone one death

slide18
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:

Full implementation of evidence based treatments for patients with CVD who are currently untreated

Full implementation of evidence based treatments for patients with CVD who are currently partially treated

Finding and treating undiagnosed hypertensives

Moving patients on Atrial Fibrillation registers from aspirin to warfarin

Statins to address CVD risk among COPD patients.

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)

18

Source: Rochdale PCT AAACM Recovery Plan, Nov 2010

slide19

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)

19

10 steps to population level outcomes3
10 Steps to Population Level Outcomes
  • Whole system approach

population level; through communities; services

slide22

Population Level

Interventions

Systematic community engagement

Systematic and scaled interventions through

services

Partnership,

Vision and Strategy,

Leadership and Engagement

Intervention Through

Services

Intervention Through Communities

Service engagement

with the community

Producing Percentage Change at Population Level

C. Bentley

2007

slide23

Population Level

Interventions

Systematic and scaled interventions through

services

Intervention Through

Services

Intervention Through Communities

Producing Percentage Change at Population Level

C. Bentley

2007

achieving percentage change in population outcomes through services
Achieving percentage change in population outcomes through 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
commissioning services to achieve best population outcomes
Commissioning Services to Achieve Best Population Outcomes

Optimal

Population

Outcome

Challenge to Providers

Population Focus

5. Engaging the public

10. Supported self-management

13.Networks,leadership

and coordination

9. Responsive Services

4. Accessibility

2. Local Service

Effectiveness

7. Expressed Demand

6.Known

Population

Needs

1.Known

Intervention

Efficacy

12. Balanced Service Portfolio

8. Equitable Resourcing

3.Cost Effectiveness

11.Adequate Service Volumes

C Bentley

2007

slide26

Population Level

Interventions

Systematic community engagement

Intervention Through

Services

Intervention Through Communities

Producing Percentage Change at Population Level

C. Bentley

2007

slide32

Population Level

Interventions

Intervention Through

Services

Intervention Through Communities

Service engagement

with the community

Producing Percentage Change at Population Level

C. Bentley

2007

system and scale into community empowerment ten point plan
System and Scale into Community EmpowermentTen point plan
  • Prioritisation

most in need, not ‘beauty contest’ winners

  • Defining Communities

should be self-defining where possible

        • Community profiles

collating top-down and bottom-up

        • Asset mapping

stocktake of the positive resources in place

        • Community based research

train residents to be involved in assessing needs/wants

system and scale into community empowerment ten point plan1
System and Scale into Community EmpowermentTen point plan
  • Neighbourhood Action Plans (NAPS)

linking bottom-up aspirations and top-down objectives

  • Community Links Strategy

gathering intelligence from community infrastructures

  • Outreach models

using preferred community venues where possible

  • Behaviour of Partners

agreed common ways of working; shared generic staff; unified case management; sharing intelligence;

  • Transfer of Service Ownership

appropriate segments e.g. through social enterprise

categories of seldom heard people
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).
slide36

Population Level

Interventions

Systematic community engagement

Systematic and scaled interventions through

services

Partnership,

Vision and Strategy,

Leadership and Engagement

Intervention Through

Services

Intervention Through Communities

Service engagement

with the community

Producing Percentage Change at Population Level

C. Bentley

2007

leadership and coordination
Leadership and Coordination
  • Partnership

Not 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’

  • Leadership

At all levels. Develop skills. Succession plan

  • Vision and Strategy

Not ‘pink and fluffy’. Tangible, with numbers.

10 steps to population level outcomes4
10 Steps to Population Level Outcomes
  • Maximise impact: minimise inequalities

service quality; population support; co-ordination

slide40

Coronary Heart Disease

Cold Damp Housing

slide41

Benefit from evidence based interventions across populations

(not to scale)

Compliance

with therapy

Have the

problem

Eligible for

treatment

Optimal

therapy

Aware of

problem

A

B

C

D

slide42

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

slide46

Benefit from evidence based interventions across populations

(not to scale)

Compliance

with plan

Have the

problem

Eligible for

intervention

Optimal

intervention

Aware of

problem

A

B

C

D

Chris Bentley 2012

10 steps to population level outcomes5
10 Steps to Population Level Outcomes
  • Governance: who is running the show?
  • Programme planning: who is accountable?
  • Information Governance: sharing intelligence
  • Joint Strategic Needs Assessment
  • Priority setting: how does it really work?
10 steps to population level outcomes6
10 Steps to Population Level Outcomes
  • Setting targets: locally relevant and meaningful
  • Select interventions: strongly evidence based
  • Develop business plan: economic case for change
  • Whole system approach
  • Maximise impact: minimise inequalities
for video google chris bentley christmas tree

For video GoogleChris Bentley Christmas Tree

For resources

www.hinstassociates.com

Other

Chris.bentley19@gmail.com