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What are the challenges for commissioning in a brave new world? Evolving relationships between public
health specialists and clinical commissioners
Dr John Middleton Vice President Faculty of Public Health
Director of Public Health Sandwell
Challenges for commissioning in a brave new world? Evolving relationships between public
health specialists and clinical commissioners: a public health view Challenges:
Reorganisation
Maintaining and developing new tools for Needs analysis in primary care
Clinical and preventive service redesign Paying for rare and expensive one off treatments
Major strategic reconfigurations Public health in the NHS on a slow but upward trajectory and
being asked to restart Public health is everybody’s business
Maintaining partnership working in the context of disintegration of local authority services, reform of health services and
tyranny of procurement
Challenges for commissioning in a brave new world? Evolving relationships between public
health specialists and clinical commissioners: a public health view
Challenges : Getting it off my chest 1
Reorganisation- QUIPP and Darzi Next Steps vs Clustering and institutional
change Legal context - Health Bill process, local
authority modus operandi vs NHS freedoms
Challenges :Get it off my chest now 2:
The NHS is favoured of all the public sector and
repays this in an appalling way - by messing about with its management, internally invented systems
like the national tariff and playing with large reserves when important functions of the public sector which can do much more to keep people healthy are being faced with enormous cuts - transport, housing, environment and economic
development at the front of cuts
Challenges: Get it off my chest now 3: What would you do in context of massive cuts
in public spending? Reorganise
Force organisations to keep money in their banks that they could be spending on services
Force reorganisations within reorganisations eg Transforming community services
Force organisations to behave to quasi-commercial rules that make money for accountants and lawyers
but do not save a life or save a pound
1974 NHS
1979 NHS
1983 NHS
1991 NHS
1996 NHS
1998 NHS
2002 NHS
Challenges: A government that is not disposed to intervene for healthy
public policy Reorganisation x 6, or is it 7? at once :
TCS, GP commissioning, Public Health move to Local authorities and Public health England, NHS commissioning Board, Foundation Trusts,
Clustering
Psychological state of corporate depression and bereavement
Differences of organisational culture If the management costs reduction didn’t get you , the
service efficiencies might, and if they don’t get you the running costs and straight cuts will
Addressing the real problems of health is an incidental
Challenges: Addressing the real problems of health is an incidental- we
are again rearranging deck chairs …: Climate chaos,
International security with particular and immediate reference to the Olympics in 2012
Seasonal flu and severe weather Overpopulation
The expanding over 65s and 75s but in addition, the expanding under 5s and fertility rate
Extraordinarily high levels of long term conditions with even greater inequalities
Unwillingness to combat excessive addictive behaviours, food, cigarettes, alcohol, gambling
Recession and damage to health immediate and long term
An office for public health
Opportunities
Keen interest in public health from politicians, media and public
Tackling Inequalities remains a national policy Heartening interest in health improvement from GPs,
social care, and from acute hospitals and mental health organisations
‘disorganisation’ is making people talk Localism
Mixed economy in preventive and improvement services
Opportunities
Interest by GPs- NST inequalities work is beginning to produce results
CVD risk reduction programmes Lifestyle referrals eg exercise, weight
management, welfare rights Data extraction tools in primary care making
preventive intervention in long term conditions possible
Opportunities
Health and wellbeing boards
A commissioning body not a cosy partnership (my view)
Major (only )chance for strategic planning GPs/CCGs as partners with local authorities
Chance for good joint commissioning And for robust challenge to each other’s plans
and investments
Skill sets for Consortia
• Good clinicians • Good commissioners (including rationing)
• Joint commissioning • Good partners
• Good ‘whole population’ perspective • Good local politicians
Public health in primary care
Health protection
• Routine immunisation • Sexually transmitted infections
• Communicable disease surveillance and control • Emergency planning – as commissioners in agreements
re emergency responses • As providers re business continuity and all risks- floods,
flu and foot and mouth
Health care public health
• Screening coordination • Measurement of need for health care services-
including community, social and primary care • Support for care pathway development
• An eye to preventive alternative interventions eg. housing and health, telecare, lifestyle interventions • Evaluation of clinical effectiveness in routine care • Evaluation of effectiveness of one off expensive
treatments
Public health in primary care
What GPs say to patients works
• Smoking prevention • Emerging evidence exercise on referral, weight management , primary care based
mental health • Carer support
• Health information • Welfare rights services
Public health in Clinical commissioning
• Building expectation of lifestyle
interventions in care pathways eg. Bariatric surgery, vascular surgery, and
‘stop before the op’
• Building lifestyle intervention into rehabilitation and reablement
Commissioning cycle
Annual public health reports
The Sandwell experience: integrating public health and local government: Middleton, HSMC, 09062011
Public Health: a new asset! • Priority setting
• Risk stratification
• Health impact assessment/ impact assessment
• Health inequalities assessment
• Intelligent interpretation of research
• Needs assessment and intelligent use of information
Tackling inequalities is everyone’s business (Marmot)
• Give every child the best start in life
• Enable all children, young people and adults to maximise their capabilities and have
control over their lives • Create fair employment and good work for all
• Ensure a healthy standard of living for all • Create and develop healthy and sustainable
places and communities • Strengthen the role and impact of ill-health
prevention
Disability free life years
Recommendation: DFLE information should be used to target social research to identify strategies for improving health
What are the causes of death?
Major causes of death by sex for all ages, Sandwell in the last five years (2002-2006)
Diabetes Mortality 2005-7 by Programme Budgeting Category per 100,000 population
16
15 121110
7
65
2
9
19
148 313
4
Sandwell PCT
17
18
0
50
100
150
200
250
300
0 10 20 30 40 50
Expected Deaths
Stan
dard
ised
Mor
talit
y R
atio
95% limit99.8% limitEngland averagePrimary Care Trust
All Cancer Mortality 2005-7 by Programme Budgeting Category per 100,000 population
9
8
13
17
4
67
1012
16
3
5Sandwell PCT
18 19
2
11
14
15
90
95
100
105
110
115
120
125
130
135
140
0 200 400 600 800 1,000 1,200 1,400 1,600
Expected Deaths
Stan
dard
ised
Mor
talit
y R
atio
95% limit99.8% limitEngland averagePrimary Care Trust
Challenges for commissioning in a brave new world? Evolving relationships between public
health specialists and clinical commissioners: a public health view
Needs assessment in primary care
Sandwell PCT
Smoking Prevalence Data as at 01/10/2009
Source: MSDi data extracts
PBC Cluster
Patients aged 16+
Patients ( aged 16+ ) Smoking
Status Recorded in the last 15
months
Patients ( aged 16+ )
Current Smokers
Percentage of patients ( aged 16+ ) Smoking
Status Recorded in the last 15
months
Percentage of patients ( aged 16+ ) Current
Smokers
Black Country Commissioning Network PBC Cluster 104,148 64,465 17,894 61.90% 27.76%
Smethwick Commissioning Alliance PBC Cluster 73,444 34,163 9,964 46.52% 29.17%
Wednesbury & West Bromwich PBC Cluster 92,660 50,733 12,262 54.75% 24.17%
Totals 270,252 149,361 40,120 55.27% 26.86%
CVD Baseline Audit
• 9% of Sandwell is currently treated for prevention of CVD
• Based on mortality and morbidity figures this should be 16%
• Currently miss 7% or 21,000 people
Risk Tool • Estimate CVD risk using risk factor data already in
electronic medical records • Targets people 35 to 74 years, Not on CVD register,
Not taking antihypertensive treatment
Projected benefit for Sandwell
Sandwell Eligible for treatment
CVD Events prevented over ten years
Aspirin 11,382 410
Antihypertensive therapy 6,860 288
Statin 11,694 947
Total 1,645
Total if attendance same as for pilot
1,020
If 30% of circulatory events result in death, then lives saved would be;
494 based on eligibility 306 based on eligibility and attendance
Challenges for commissioning in a brave new world? Evolving relationships between public
health specialists and clinical commissioners: a public health view
Who commissions for strategic redesign and how is it driven ?
• Right Care Right Here programme
• 500000 people sandwell and Western Birmingham
• Closing two hospitals, 2 A&Es • Replacing with one new one • With enhanced community facilities • Redesign of services towards
community settings • Reconfigured childrens, maternity and
acute vs cold surgery • Lifestyle services component of
service redesign • Major and multiple public consultations
5% for health: The 20th annual public health report for Sandwell
John Middleton Director of Public Health
The big five causes of years of life lost are the same for Heart of Birmingham and for Sandwell although not in the same rank order. They are: リ Infant deaths リ Cancer リ Cardiovascular disease リ Smoking and リ Alcohol
2010 Charter: Health services to health?
• Reduce alcohol problems- 20% of medical admissions and large % of ‘frequent flyers’
• Smart housing and telecare reduces admissions and lengths of stay
• Home safety and gentle exercise: 20% reduction in fractured hips
• Coronary risk reduction 670 events over 10years 260 deaths
• ‘Quit before your op’; smoking reduction and all admissions
• Reduce obesity or expect diabetes to explode • Expand self care, carer support and user led health
and care services towards the ‘fully engaged public’
Challenges for commissioning in a brave new world? Evolving relationships between public
health specialists and clinical commissioners: a public health view
How do we commission for multiple benefits ?
BDH Trend
Walkwell -Sandwell Healthy walks programme
Opportunities
Interest in prevention and independence from social care :
Personalisation makes health improvement
sessions more attractive to individual and social service
Reablement services need lifestyle intervention also
• Cyril • Started gardening again • Catching buses (for 1st time in 18 months) to Sutton Coldfield, Walsall, West Bromwich) • Re-establishing contact with all neighbours and local community centre • Planning a holiday • Has cut carer’s hours from 7 days a week to 2 or 3 • Very enthusiastic, and a great advert for the programme!
Lifestyle services for people in social care
Recommendations • Lifestyle assessment
integrated into initial social services assessment
• Train social care staff through Every contact Counts
• Postural stability instruction
The i-House, West Bromwich
i- House, demonstration house West Bromwich 2008
US VA Telehealth study • Results
– 68% reduction in hospitalizations – 72% reduction in ER (A/E) visits – 71% reduction in bed days of care – 81% reduction in nursing home admissions – 74% reduction in overall costs – 97% patient satisfaction – Clinical outcomes – Patients stayed well
• Now in volume implementation – 9,500 patients enrolled now – Adding over 11,000 participants per year
The Future? Easy to use Patient
Graphic interface Wireless or wired devices, POTS and IP Communications
Software based product – operates on a variety of devices in expanding applications
Standard protocols – easy customization
Tablet PC CareCompanion II Handheld devices
Housing and health indicators in Birmingham Sandwell Urban Living
Improving health through housing
Recommendations • Further research
needed to identify those at higher risk of housing related ill health and evidence to inform improvements
• CCGs should priorities housing interventions to reduce health inequalities and hospital activity
Challenges for commissioning in a brave new world? Evolving relationships between public
health specialists and clinical commissioners: a public health view
Challenges for the future
Good corporate citizen award 38 apprentices Rationalisation of offices : 6 leases surrendered 890 tonnes of CO2 reduction £200k saved