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Systematically Addressing Health Inequalities in Diabetes Care. The ‘Christmas Tree’ Diagnostic Model National Support Team Health Inequalities. The diagnostic model will support the systematic delivery of the best health outcomes from a given set of interventions.

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systematically addressing health inequalities in diabetes care

Systematically AddressingHealth Inequalities in Diabetes Care

The ‘Christmas Tree’ Diagnostic Model

National Support Team Health Inequalities

commissioning for best outcomes

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

Optimal

Population

Outcome

Challenge to Providers

Population Focus

commissioning for best outcomes3

This side of the diagram showsaspects of service provision that will influence achievement of best service outcomes from a particular set of interventions

Commissioning for Best 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 Clinical

Effectiveness

7. Expressed Demand

6.Known

Population

Health Needs

1.Known

Intervention

Efficacy

12. Balanced Service Portfolio

8. Equitable Resourcing

3.Cost Effectiveness

11.Adequate Service Volumes

commissioning for best outcomes4

Optimal

Population

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.

3.Cost Effectiveness

Commissioning for Best Outcomes

Challenge to Providers

5. Engaging the public

13. Networks, Leadership

and Co-ordination

2. Local Clinical

Effectiveness

1.Known

Intervention

Efficacy

commissioning for best outcomes5
Commissioning for Best Outcomes

Challenge to Providers

  • 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

2. Local Clinical

Effectiveness

1.Known

Intervention

Efficacy

commissioning for best outcomes6
Commissioning for Best Outcomes

Challenge to Providers

  • 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 than
  • referral; is professional support assertive; is there a menu of support options based on social marketing/insight research?

2. Local Clinical

Effectiveness

1.Known

Intervention

Efficacy

commissioning for best outcomes10
Commissioning for Best Outcomes

Challenge to Providers

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?

2. Local Clinical

Effectiveness

1.Known

Intervention

Efficacy

commissioning for best outcomes11
Commissioning for Best Outcomes

Challenge to Providers

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

2. Local Clinical

Effectiveness

1.Known

Intervention

Efficacy

commissioning for best outcomes12
Commissioning for Best Outcomes

Challenge to Providers

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?

2. Local Clinical

Effectiveness

1.Known

Intervention

Efficacy

commissioning for best outcomes13
Commissioning for Best Outcomes

Challenge to Providers

  • 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.

2. Local Clinical

Effectiveness

1.Known

Intervention

Efficacy

slide14

CHD Equity Audit 2006

Selected measures by z scores

Example of a good practice

2.5

3.9

4.6

4.3

3.3

2.0

1.5

1.0

0.5

Measures of Need

Primary Care

Secondary care

Tertiary Care

0.0

-0.5

-1.0

Z SCORE

-1.5

-2.0

IMD 2004

Outpatients

Aspirin

Angina

Statin

Beta Blocker

Acute MI

ACE Inhibitor

CABG/PTCA

who smoke

% aged 75+

20% deprived

Cardiac

CHD Register

CHD Register

CHD Mortality

Heart Failure

Standard Ratio

Crude Rate

% CHD patients

A1(a)

A1(b)

A2

A3

A4(a)

A4(b)

A4(c)

B1

B2

B3

B4

C1

C2

C3

C4

D1

Indicator

commissioning for best outcomes15

Interventions need to be affordable to treat all those who could benefit, and cost beneficial , justifying the opportunity cost against alternative ways to spend

3.Cost Effectiveness

Commissioning for Best Outcomes

Challenge to Providers

2. Local Clinical

Effectiveness

1.Known

Intervention

Efficacy

commissioning for best outcomes16

Has there been for diabetes, a prescribing cost-versus-QOF outcomes analysis by practice with tailored support to change for poor performers

h

3.Cost Effectiveness

Commissioning for Best Outcomes

Challenge to Providers

2. Local Clinical

Effectiveness

1.Known

Intervention

Efficacy

commissioning for best outcomes18

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. Accessibility

1.Known

Intervention

Efficacy

Commissioning for Best Outcomes

Challenge to Providers

2. Local Clinical

Effectiveness

3.Cost Effectiveness

commissioning for best outcomes19

5. Engaging the Public

Appropriate

Utilisaion

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.

Commissioning for Best Outcomes

Challenge to Providers

4. Accessibility

slide20

Addressing Diabetes Inequalities through Community Engagement

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

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

Coordination of inputs and output with strategic approach to Community Engagement

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

commissioning for best outcomes21

Challenge to Providers

5. Engaging the Public

10. Supported self-management

9. Responsive Services

4. Accessibility

2. Local Clinical

Effectiveness

7. Expressed Demand

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.

1.Known

Intervention

Efficacy

6.Known

Population

Health Needs

8. Equitable Resourcing

3.Cost Effectiveness

Commissioning for Best Outcomes

Population Focus

13.Networks, Leadership

and Coordination

commissioning for best outcomes22

10. Supported Self-

Management

13. Networks, Leadership

And Co-ordination

9. Responsive Services

7. Expressed Demand

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.

8. Equitable Resourcing

Commissioning for Best Outcomes

Population Focus

6.Known

Population

HealthNeeds

commissioning for best outcomes23
Commissioning for Best Outcomes

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.Known

Population

Health Needs

commissioning for best outcomes24

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.

Commissioning for Best Outcomes

Population Focus

7. Expressed Demand

6.Known

Population

Health Needs

commissioning for best outcomes25

Is 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 disease

Variety of ‘segmented’ options to identify patients in the community, scaled up appropriately

Commissioning for Best Outcomes

Population Focus

7. Expressed Demand

6.Known

Population

Health Needs

slide27

Blackburn with Darwen

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

nhs bolton
NHS Bolton

Dr.S.Liversedge

slide32
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 79.4

30-39 18 73.7

20-29 12 75.2

<20 11 74.3

It

commissioning for best outcomes33

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.

8. Equitable Resourcing

Commissioning for Best Outcomes

Population Focus

7. Expressed Demand

6.Known

Population

Health Needs

commissioning for best outcomes34

8. Equitable Resourcing

Commissioning for Best Outcomes

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 )

6.Known

Population

Health Needs

commissioning for best outcomes35

9. Responsive Services

When 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.

6.Known

Population

Health Needs

Commissioning for Best Outcomes

Population Focus

7. Expressed Demand

8. Equitable Resourcing

commissioning for best outcomes37

9. Responsive Services

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?

6.Known

Population

Health Needs

Commissioning for Best Outcomes

Population Focus

7. Expressed Demand

8. Equitable Resourcing

commissioning for best outcomes41

10 Supported Self-management

7. Expressed Demand

6.Known

Population

Health Needs

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.

8. Equitable Resourcing

Commissioning for Best Outcomes

Population Focus

Appropriate

Utilisation

9. Responsive Services

commissioning for best outcomes42
Commissioning for Best Outcomes

Population Focus

10. Supported Self-management

Appropriate

Utilisation

9. Responsive Services

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?

commissioning for best outcomes43

Challenge to Providers

5. Engaging the Public

4. Accessibility

2. Local Clinical

Effectiveness

7. Expressed Demand

Appropriate utilisation of service by the population may require adjustments to supply.

1.Known

Intervention

Efficacy

6.Known

Population

Health Needs

3.Cost Effectiveness

8. Equitable Resourcing

Commissioning for Best Outcomes

Population Focus

10. Supported Self-management

Appropriate

Utilisation

9. Responsive Services

commissioning for best outcomes44

12. Balanced Service Portfolio

Commissioning for Best Outcomes

Challenge to Providers

Population Focus

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.

8. Equitable Resourcing

3.Cost Effectiveness

11.Adequate Service Volumes

workforce planning
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
commissioning for best outcomes46

6.Known

Population

Health Needs

1.Known

Intervention

Efficacy

Commissioning for Best Outcomes

Challenge to Providers

Population Focus

13.Networks,leadership

and coordination

commissioning for best outcomes47

Optimal

Population

Outcome

Challenge to Providers

5. Engaging the Public

4. Accessibility

2. Local Clinical

Effectiveness

1.Known

Intervention

Efficacy

12. Balanced Service Portfolio

3.Cost Effectiveness

11.Adequate Service Volumes

Commissioning for Best Outcomes

=

Population Focus

10. Supported Self-management

+

+

+

13. Networks, Leadership

and Co-ordination

9. Responsive Services

7. Expressed Demand

+

6.Known

Population

Health Needs

8. Equitable Resourcing