Addressing Inequalities in Health and Wellbeing through HWB/CCG Structures

1. Addressing Inequalities in Health and Wellbeing through HWB/CCG Structures Professor Chris Bentley HINST Associates

2. 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

3. 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

4. Primary Care Direct Action HWB JSNA/HWS Commissioning Primary Care Commissioned Services PH England

5. 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

6. 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

7. All age, all cause mortality rates, 3-year averages, Kent & Medway

8. The Threat of Winter DEATH Disability Hypothermia Accidents Illness Loneliness Misery Anxiety DEPRESSION

9. 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

11. 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

12. 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)

13. 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

14. 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

15. Estimating the scale of the challenge : Summary (Oldham) Reductions in mortality numbers necessary to meet 2013-15 targets

16. 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

17. Potential impact of evidence-based interventions on reducing mortality numbers for Oldham NNT = Number Needed to Treat to postpone one death

18. 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

19. 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

20. Maidstone – Excess deaths: most deprived 20% compared to the rest

21. 10 Steps to Population Level Outcomes • Whole system approach population level; through communities; services

22. 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

23. Population Level Interventions Systematic and scaled interventions through services Intervention Through Services Intervention Through Communities Producing Percentage Change at Population Level C. Bentley 2007

24. 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

25. 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

26. Population Level Interventions Systematic community engagement Intervention Through Services Intervention Through Communities Producing Percentage Change at Population Level C. Bentley 2007

27. Industrial Scale - Stalinist

29. Piecemeal Project Based Approach

30. Industrial Scale - “Small is beautiful”

31. Not infinite, but graded levels of Engagement

32. Population Level Interventions Intervention Through Services Intervention Through Communities Service engagement with the community Producing Percentage Change at Population Level C. Bentley 2007

33. 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

34. 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

35. 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).

36. 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

37. 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.

38. 10 Steps to Population Level Outcomes • Maximise impact: minimise inequalities service quality; population support; co-ordination

39. Improving Male Life Expectancy in Birmingham

40. Coronary Heart Disease Cold Damp Housing

41. 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

42. 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

43. C + D. Quality of Care

44. A High Performance PCT

45. A +B. ‘Missing thousands’

46. 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

47. 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?

48. 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

49. For video GoogleChris Bentley Christmas Tree For resources www.hinstassociates.com Other Chris.bentley19@gmail.com