Practical application of population health and wellbeing approaches in the new policy context

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Practical application of population health and
wellbeing approaches in the new policy context

• Professor Chris Bentley

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Messages from the Past
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Ronald Labonte
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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
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Population Level Interventions
Systematic community engagement
Systematic and scaled interventions through
services
Partnership, Vision and Strategy, Leadership and
Engagement
Intervention Through Communities
Intervention Through Services
Service engagement with the community
Producing Percentage Change at Population Level
C. Bentley 2007
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Achieving Percentage Change in Population
Outcomes

• 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

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T Hennell 2011
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Health and Wellbeing Boards

• A shaky start?

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A few early concerns

• Limited membership v. unmanageably large
• JSNAs very variable not bottom-up and top-down
  not driving the agenda
• Little knowledge or acknowledgement of Public
  Health Outcomes Framework
• Role not clear strategic forum (talking shop),
  or performance managing function
• Early HWS pink and fluffy missing tangible
  stated outcomes with strategy for delivery
• Who is accountable for delivery of each priority
  to the Board
• Missing opportunities on causes of the causes

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Social injustice is killing on a grand scale
Sir Michael Marmot 2010
With thanks to Mike Grady University College
London/ Marmot Review Team
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Inequality in Early Cognitive Development of
British Children in the 1970 Cohort, 22 months to
10 years
High SES Low SES
High Q at 22m
Low Q at 22m
Source Feinstein, L. (2003) Inequality in the
Early Cognitive Development of British Children
in the 1970 Cohort, Economica (70) 277, 73-97
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Per cent achieving 5 A - C grades inc Maths and
English at GCSE by IDACI decile of pupil
residence England 2007
achieving 5 A-C GCSEs inc Maths and English
Most deprived
Income Deprivation Affecting Children Index
(IDACI)
Least deprived
Source DCFS 2009
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Clinical Commissioning Groups

• Inherent Schizophrenia?

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A few early concerns

• Commissioner v Provider v Collaborative Partner
• Unequal pressures
• Leaders (hard-bitten experience v fresh faced
  enthusiast)
• Corporate memory v re-inventing wheels (flat
  tyres)
• Holistic overview v PPPs (personal perspective
  priorities)
• Transition (empowering possibilities) v Real
  World (reality/austerity bites)
• Variable mix of support/advice/guidance (CSS NHS
  CBA PH/PHE Commercial sector)
• Little previous engagement with population
  perspective

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Primary Care Contribution to Health Improvement
NHS Commissioning Board
Primary Care Direct Action
HWBB JSNA HWBS Commissioning
Primary Care Commissioned Service
CCG contribution
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Outline

• What is our ambition? What realistic but testing
  target are we aiming for?
• Can this be stated in terms that are easily
  understood and owned by local stakeholders? In
  particular can it be pinned down to numbers?
• What are the main contributory factors
  responsible for the current adverse situation?
• What interventions could contribute substantially
  to these sort of numbers? Can they be delivered
  with sufficient system, scale and sustainability
• Can a realistic business case be developed to
  demonstrate appropriate return on investment?

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Case Study 1

• Oldham CCG

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Setting Ambitions Best in Peer Group (Males)
Male All Age All Cause Mortality (AAACM) Rates by
GP Consortia, 2007-09
Oldham
South Birmingham
Peer group Former Spearhead PCTs in Centres
with Industry ONS area classification
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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
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Estimating the scale of the challenge Summary
Reductions in mortality numbers necessary to meet
2013-15 targets
2007-09 AAACM (rate) 2013-15 ambition (rate) 2007-09 deaths (number) 2013-15 ambition (number) Required reduction (number) Expected reduction (number) Additional reduction Required
Males 833.6 721.2 3100 2683 417 270 147
Females 597.7 497.8 3410 2774 636 297 339
Persons - - 6510 5457 1053 567 486
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Identifying excess mortality by age group
Number of excess deaths by age group in Oldham compared to England average, 2006-08
Source Derived from London Public Health
Observatory Health Inequalities Intervention Tool
data
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Identifying excess mortality by cause
Number of excess deaths in Oldham by cause, gender and broad age group compared to England average, 2006-08
Source Derived from NCHOD standardised mortality
ratios (SMR) and mortality numbers by age and
cause. Excess mortality observed minus
expected deaths
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Gap in male life expectancy in Barnsley by disease
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Potential impact of evidence-based interventions
on reducing mortality numbers
NNT Number Needed to Treat to postpone one death
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Using the model a worked example (1)

• 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

Source Rochdale PCT AAACM Recovery Plan, Nov 2010
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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)

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Case Study 2

• Atypical situation Blackpool PCT

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Setting Ambitions Best in Peer Group (Males)
Male All Age All Cause Mortality (AAACM) Rates by
GP Consortia, 2008-10
Peer group PCTs in Costal and Countryside
ONS area classification
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Setting Ambitions Best in Peer Group (Males)
Male All Age All Cause Mortality (AAACM) Rates by
GP Consortia, 2008-10
Peer group Former Spearheads in the NHS North
West Clinical Commissioning groups
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Estimating the scale of the challenge Summary
Reductions in mortality numbers necessary to meet
2014-16 targets
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Excess Male Mortality () Blackpool vs. All
Spearheads
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Excess Female Mortality () Blackpool vs. All
Spearheads
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Gap in male life expectancy in Blackpool by
disease
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Potential impact of evidence-based interventions
on reducing mortality numbers
NNT Number Needed to Treat to postpone one death
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Proportionate Need for Levels of ARH Service (not
to scale)
Tier 4
Tier 3
Tier 2
Tier 1
Average Borough
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Case Study 3

• Good average health with pockets of deprivation
• Kent CC

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All age, all cause mortality rates, 3-year
averages, Kent Medway
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Slope Index for Medway (Males)
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Slope Index for Medway (Males)
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Swale Circulatory disease mortality by ward
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Swale Causes of excess mortality, worst quintile
compared to rest
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(Dis-)Integrated Commissioning for Population
Health
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Primary Care Contribution to Health Improvement
NHS Commissioning Board
Primary Care Direct Action
Primary Care Commissioned Service
HWB JSNA HWBS Commissioning
CCG contribution
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Commissioning Services to Achieve Best Population
Outcomes
Optimal Population Outcome

• Population Focus

Challenge to Providers
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
1.Known Intervention Efficacy
6.Known Population Needs
12. Balanced Service Portfolio
8. Equitable Resourcing
3.Cost Effectiveness
11.Adequate Service Volumes
C Bentley 2007
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Improving Male Life Expectancy in Birmingham
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Identifying Primary Care performance to outcomes
QOF registered prevalence and CHD Mortality(lt75)
in Oldham (MSOAs)
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Disease management provided according to
evidence-based protocols e.g. NSFs or NICE
guidance
High Risk
Have LTC
Aware of LTC
Eligible for treatment
Optimal treatment
Compliant with treatment
High Risk
Have LTC
Aware of LTC
Eligible for treatment
Compliant with treatment
5.7m
2.6m
2.3m
1.3m
1m
CHD
10.2 m
10.2 m
2.8m
1.8m
1.8m
Diabetes
19.9 m
19.9 m
0.4m
Not known
2.6 m
0.9m
CHF
0.48m
0.21m
0.1m
0.08m
2.9m
COPD
17.1 m
0.9m
0.52m
0.26m
0.14m
NOTE Figures are for UK. Taken from Harrison W,
Marshall T, Singh D Tennant R The
effectiveness of healthcare systems in the UK
scoping study Department of Public Health
Epidemiology and HSMC University of Birmingham,
July 2006.
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Quality of delivery
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Wakefield
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CHD Expected vs QOF Registered Prevalence
(Percentage) A quarter of patients with a
history of CHD are estimated undiagnosed
(untreated)
Identifying the untreated patients (GP practice)
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WAKEFIELD PCT
Identifying the untreated patients (GP practice)
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ALW thousands missing dementia diagnosis