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John Middleton: A public health view on commissioning


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Dr John Middleton, Sandwell Primary Care Trust, offers a public health view on the challenges of commissioning in the context of the Government’s NHS reforms.

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John Middleton: A public health view on commissioning

  1. 1. What are the challenges forcommissioning 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
  2. 2. 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
  3. 3. 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
  4. 4. Challenges :Get it off my chest now 2: The NHS is favoured of all the public sector andrepays 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
  5. 5. 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 servicesForce organisations to behave to quasi-commercialrules that make money for accountants and lawyers but do not save a life or save a pound
  6. 6. 2002 1996 NHS 19981974 1979 1983 1991 NHS NHSNHS NHS NHS NHS
  7. 7. 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
  8. 8. 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 OverpopulationThe 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 inequalitiesUnwillingness to combat excessive addictive behaviours, food, cigarettes, alcohol, gambling Recession and damage to health immediate and long term
  9. 9. An office for public health
  10. 10. 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
  11. 11. 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 makingpreventive intervention in long term conditions possible
  12. 12. Opportunities Health and wellbeing boardsA 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
  13. 13. Skill sets for Consortia • Good clinicians• Good commissioners (including rationing) • Joint commissioning • Good partners • Good ‘whole population’ perspective • Good local politicians
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. Commissioning cycle
  19. 19. The Sandwell experience: integrating public health and local government: Middleton, HSMC, 09062011Annual publichealth reports
  20. 20. 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
  21. 21. 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
  22. 22. Disability free life yearsRecommendation: DFLE information should be used to targetsocial research to identify strategies for improving health
  23. 23. What are the causes of death? Major causes of death by sex for all ages, Sandwell in the last five years (2002-2006)
  24. 24. Diabetes Mortality 2005-7 by Programme Budgeting Category per 100,000 population 300 4 250Standardised Mortality Ratio 13 200 14 18 8 3 Sandwell PCT 95% limit 16 19 17 99.8% limit 2 10 6 150 England average 11 15 5 12 Primary Care Trust 9 100 7 50 0 0 10 20 30 40 50 Expected Deaths
  25. 25. All Cancer Mortality 2005-7 by Programme Budgeting Category per 100,000 population 140 14 135 130Standardised Mortality Ratio 125 120 2 95% limit 15 16 99.8% limit 115 4 Sandwell PCT 11 5 England average 18 19 110 3 Primary Care Trust 8 17 12 105 6 10 7 100 13 9 95 90 0 200 400 600 800 1,000 1,200 1,400 1,600 Expected Deaths
  26. 26. 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
  27. 27. Sandwell PCT Smoking Prevalence Data as at 01/10/2009 Source: MSDi data extracts Percentage of Patients ( aged Patients ( patients ( aged 16+ ) Smoking Percentage of patients ( Patients aged 16+ ) 16+ ) Smoking Status Recorded aged 16+ ) Current aged 16+ Current Status Recorded in the last 15 Smokers Smokers in the last 15 months monthsPBC ClusterBlack 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%
  28. 28. 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
  29. 29. Projected benefit for SandwellSandwell Eligible for CVD Events treatment prevented over ten yearsAspirin 11,382 410Antihypertensive therapy 6,860 288Statin 11,694 947Total 1,645Total if attendance same as 1,020for pilotIf 30% of circulatory events 494 based on eligibilityresult in death, then lives 306 based on eligibilitysaved would be; and attendance
  30. 30. 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 ?
  31. 31. • 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
  32. 32. 5% for health: The 20th annual public health report for Sandwell John Middleton Director of Public HealthThe big five causes of years of life lost are the samefor Heart of Birmingham and for Sandwell although notin the same rank order. They are:リ Infant deathsリ Cancerリ Cardiovascular diseaseリ Smoking andリ Alcohol
  33. 33. 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’
  34. 34. 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 ?
  35. 35. BDH Trend
  36. 36. Walkwell -Sandwell Healthy walksprogramme
  37. 37. Opportunities Interest in prevention and independence from social care : Personalisation makes health improvementsessions more attractive to individual and social service Reablement services need lifestyle intervention also
  38. 38. • 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!
  39. 39. 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
  40. 40. The i-House,West Bromwich
  41. 41. i- House, demonstration houseWest Bromwich 2008
  42. 42. 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
  43. 43. 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 Tablet PC CareCompanion II Handheld devices  Standard protocols – easy customization
  44. 44. Housing and health indicatorsin Birmingham Sandwell UrbanLiving
  45. 45. 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
  46. 46. 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
  47. 47. Good corporate citizen award38 apprenticesRationalisation of offices : 6leases surrendered890 tonnes of CO2 reduction£200k saved