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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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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.
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 OutcomesOptimal
Population
Outcome
Challenge to Providers
Population Focus
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 OutcomesOptimal
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
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 OutcomesChallenge to Providers
5. Engaging the public
13. Networks, Leadership
and Co-ordination
2. Local Clinical
Effectiveness
1.Known
Intervention
Efficacy
Challenge to Providers
2. Local Clinical
Effectiveness
1.Known
Intervention
Efficacy
Challenge to Providers
2. Local Clinical
Effectiveness
1.Known
Intervention
Efficacy
Spearhead PCT where insufficient focus on BP management
in patients with Diabetes
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
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
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
Challenge to Providers
2. Local Clinical
Effectiveness
1.Known
Intervention
Efficacy
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
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 OutcomesChallenge to Providers
2. Local Clinical
Effectiveness
1.Known
Intervention
Efficacy
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 OutcomesChallenge to Providers
2. Local Clinical
Effectiveness
1.Known
Intervention
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. Accessibility
1.Known
Intervention
Efficacy
Commissioning for Best OutcomesChallenge to Providers
2. Local Clinical
Effectiveness
3.Cost Effectiveness
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 OutcomesChallenge to Providers
4. Accessibility
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
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 OutcomesPopulation Focus
13.Networks, Leadership
and Coordination
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 OutcomesPopulation Focus
6.Known
Population
HealthNeeds
Population Focus
6.Known
Population
Health Needs
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 OutcomesPopulation Focus
7. Expressed Demand
6.Known
Population
Health Needs
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 OutcomesPopulation Focus
7. Expressed Demand
6.Known
Population
Health Needs
ThisPCT has been able to to close the register gaps for CVD and Diabetes
Dr.S.Liversedge
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
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 OutcomesPopulation Focus
7. Expressed Demand
6.Known
Population
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 )
6.Known
Population
Health Needs
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 OutcomesPopulation Focus
7. Expressed Demand
8. Equitable Resourcing
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 OutcomesPopulation Focus
7. Expressed Demand
8. Equitable Resourcing
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 OutcomesPopulation Focus
Appropriate
Utilisation
9. Responsive Services
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?
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 OutcomesPopulation Focus
10. Supported Self-management
Appropriate
Utilisation
9. Responsive Services
12. Balanced Service Portfolio
Commissioning for Best OutcomesChallenge 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
Population
Health Needs
1.Known
Intervention
Efficacy
Commissioning for Best OutcomesChallenge to Providers
Population Focus
13.Networks,leadership
and coordination
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