Public health and the commissioning cycle nov 2012
www.hertsdirect.orgPublic Health and the Commissioning Cycle:Getting benefit from getting togetherJim McManusDirector of Public Health
www.hertsdirect.orgMary knew she wanted an equity audit but still thought the public healthteam could be a bit more accessible
www.hertsdirect.orgStarting Points• Commissioners are – or ought to be – big customers of PublicHealth• PH ought to see commissioners as a major constituency toinfluence– Sometimes PH does too much “commissioning of its own”– Sometimes PH becomes detached from commissioning– Sometimes PH Depts are like Mini PCTs• Things which prevent this are– Not knowing what public health “do”– Public Health not being clear of its role in commissioning– Style issues
www.hertsdirect.orgWhat is Public Health?• A team which brings together within ten key competencies for publichealth practice people who practice the art and science of supportingthe improvement of the health of the population.• Public Health Specialists have:– A Population perspective – look to the population and see not justthe whole but the nooks and crannies– A Prospective perspective – look to the future– A Preventive perspective – reduce ill health, promote good health– A Prospective perspective – looking to the future of the areainformed by the past (e.g. mortality trends)
www.hertsdirect.orgA “Typical” Public Health Dept• Sometimes called Health Improvement Depts• Director of Public Health• Consultants in public health/ consultants in public health medicine –8c or 8d – practice all ten competencies to the level of specialistregistration. Higher specialist training usually including MFPH (www.fph.org.uk) May be medic or non-medic. May also be Assistantor Associate Directors• Specialists – Band 8 usually have a Masters• Advanced Practitioners Band 7s – may be doing an M.ScThe technical workhorses of the dept
www.hertsdirect.orgMeet the Public Health Senior Team
www.hertsdirect.orgA Very Odd Mix of stuff• May be working on equity audit of access to careat the same time as being responsible foremergency planning, business continuity,pandemic flu planning, immunisation uptake,commenting on pollution licence applications andother nerdy stuff that is sexy to people in publichealth but mightily P***** commissioners off whenit derails a tightly scheduled project• This is usually a symptom that the PH Dept’s ownability to keep continuity of core business duringan emergency needs looking at
www.hertsdirect.orgPart of the Public Health day Job at present….• Chief Medical Officer Alerts – 24 – 48 hours• Major Incidents, Pandemic Flu, CBRN……..• Port Health Alerts – immigrants with TB etc• IPPC (Pollution Control Licences) – we have 28 days torespond• Controlled Drugs• Child Death Panels• Mortality Files, Suicide Audits, SUIS involving deaths• Investigations• Outbreaks (though managed by HPA pct has a role)• Planning for major accident hazards/emergencies
www.hertsdirect.orgFrom 2013• Healthcare Public Health Support to NHS CCGs(Mandatory)• Needs Assessment (Mandatory)• Commissioning some functions (Mandatory)• Use of evidence and PH skills to supportcommissioners across the system (the bigopportunity)• Work with all sides of system
www.hertsdirect.orgPerceptions of PH by Commissioners• PH Needs to up its game• Library dwellers!• Don’t know how to access them• Boundaries of when to involve and when not to• Not sure they add anything• Keep saying they’re too busy or don’t have skills• Obsessed with their professional status• Bit of a closed shop• Prodigious amounts of data in the annual public health report,produced in almost untintelligble density• Needs Assessments – never mind the message, look howpseudo-academic the document is!• All you need is a sneeze in southwark and you can kiss goodbyeto them
www.hertsdirect.orgPerceptions of Commissioners by PH• Haven’t a clue what the population needs (butdid we bother telling them?)Disregard the evidence (did we tell them what itis?)• Contracting historically, not what’s needed• Glorified• Why won’t they read our stuff?• Why don’t they love us?
www.hertsdirect.orgThe Diagnosis• This is usually the symptom of both sides notunderstanding what the other can offer, and notengaging with the other side.• Commissioners may have more difficultyengaging public health because of the“mystique” of what they do
www.hertsdirect.orgOvercoming These• Meet together to explore (today)• Jointly articulate a cycle of input (today)• Involve on projects rather than just sitting onsteering groups• Use the “Commissioning Framework forWellbeing” document• Work through the commissioning cycle withsome PH colleagues and have the PH keycompetencies to hand
www.hertsdirect.orgScope of Commissioning Interest• Commissioning• Business Plan• Corporate Plan• Health and Wellbeing Strategy• National Service Frameworks(yes they still exist)• QIPP• CQUIN• Transformation• NICE• Public Health• Well, exactly the same. Ourconcern is that we increaseindependence, reducemortality and morbidity in thepopulation and increaselongevity, as well asaddressing health inequalities,through commissioningactivities
www.hertsdirect.orgA (very) Simplified Commissioning CycleMonitorPlanReview Need forService andEffectiveness ofexisting servicesContractThe Commissioning CycleThis is used just to introduce the concepts of what PH can helpyou with.
www.hertsdirect.orgArticulation of PH input…various models• World Health Organisation Planning Wheel• Kellog Foundation Planning Cycle• DH Commissioning Cycle• Hybrid model based on what HCC seems to beusing (for discussion)…..
www.hertsdirect.orgMonitor/EvaluatePlanReview Need forService andEffectiveness ofexisting servicesPublic Health Input into the CommissioningCycle. Can be throughout or can be on specificareas playing to the PH strengthsCommunityEngagementSupport in establishingmeaningful indicators ofdelivery and outcomeModel whether need willBe met by proposedvolumeCheck whether plans equateTo evidence and need andTest for equity / inequitySupport and advise onEvaluation and conductBits of it if enough resourceNeeds AssessmentsEquity AuditingEvidence of EffectivenessHealth Impact AssessmentTriangle of criticalinfluence – where publichealth should be mostvisibleContract/Deliver
www.hertsdirect.orgThe Public Health Toolbox• Assessing Population Need• Identifying Equity• Critical Appraisal of Evidence• Assessing Impact on Health• Modelling Population and effects of interventions• Community Engagement• Economic Modelling of Interventions• Access to wider sources of expertise• Being Internal Consultants
www.hertsdirect.orgHealth Needs Assessment• Age Structure• Morbidity• Mortality• Socio-economic data– Census– Housing• Public Health data set• Indices of health– Jarman– Townsend
www.hertsdirect.orgAd hoc requests• Critical Appraisals– Does this drug or procedure work?– Is it cost-effective?– Should we fund it? For whom?• Service developments/business cases– heart failure• Impact of investment– CHD secondary Prevention/MI’s• Analysis of variances– emergencies (secondary View/PrimaryView)
www.hertsdirect.orgModellingImpact of policy/planning- Payment by results- Capacity planning
www.hertsdirect.orgI knowWhat weNeed forOurPopulationI knowHow tomake ithappen!Both commissioning andPublic health can comeFrom either side of thisconversation
www.hertsdirect.org1. Commission for the whole person’s lived experience(housing, volunteering, leisure, transport,)2. See Potentials not Problems, assets as well as needs3. Transformation of current system through staged redesignto preventive and early intervention4. Subsidiarity and Access5. Co-production6. Behavioural Sciences7. Pathwayed
www.hertsdirect.orgSome outcome we should look for• A public health approach in adultsocial care should bring thefollowing benefits:– Less people in residentialcare– More people independent– Less costs to NHS andSocial Care– Fewer costs to GPs for thosewith long term conditions anddisabilities– A way of monitoring the newmarket and micro-commissioning• A public health approach forchildren should bring the followingbenefits:– Fewer children withavoidable behaviouraldisorders– Evidence assessedinterventions for troubledfamilies– Children looked after arehealthier physically,psychologically and socially– Standards for physical,cognitive and emotionaldevelopment and resilienceacross all services
www.hertsdirect.orgComponents of this model where we worktogether• Population approach to– projecting need– Identifying risks – risk stratify– Identify priorities– Identify candidate interventions• Intervention and outcome design• Emphasise Prevention (science & art)• Joining up (housing and social care, primary care andsocial care)
www.hertsdirect.org28Predictionforecast / target servicesSecondary PreventionPrimaryPreventionUniversal&Well-beingLOWMODERATESUBSTANTIAL CRITICALReduce numbers of people coming into high-cost services andmoving along FACS bandingIntensive Home SupportResidential CareCommunity Equipment ServicesTelecare ServiceTertiary PreventionHow might Prevention look in Social Care?