An analysis of the potential to achieve expected reductions in life expectancy from recommended interventions (reviewing the implications of a national modelling exercise)

1. Understanding trends and potential for change in life expectancy Mark Lambert January 2010

2. National picture: life expectancy differences widening

3. Questions What impact should we expect? And when? What should we do to make a difference? What are the implications for planning and performance? What is driving changes?

4. Applying local knowledge management framework

5. Managing knowledge for better decisions Version 1.1 October 2009

7. Key elements Examines current and proposed performance targets Examines extent to which current plans will deliver requirements Explores the need for further work Explores the trends and interventions for improving life expectancy

8. Conclusions Care is needed to set aspirations that are ambitious and credible active management of those at highest risk holds significant potential. Current plans will deliver a tenth of the anticipated changes, more slowly than anticipated. Our current plans need to scale up in breadth and capacity lifestyle changes appear to be driving improvements in life expectancy

9. What’s driving the change

10. What are people dying from?

14. What is driving the change? Primary prevention- change in population level risk factors

15. Physical Activity Diet Smoking Deprivation Obesity (BMI) Diabetes or IGT Cholesterol LDL (& HDL) Blood Pressure Combined CVD Risk Unstable Angina Chronic Angina Early Heart Failure Severe Heart Failure MI survivors Acute MI Stroke PAD etc Additional CVD Risk Factors From any State Populations: UK>E&W>Regions>PCTs Outputs: Population-based incidence, prevalence; Deaths prevented; Life-Years; Life expectancy; Costs; Cost-effectiveness ratios Population Policies & Behaviours Biological Risk Factors Combined CVD Risk CVD Patient Groups OUTPUTS CHD Death Non-CHD Death Recurrent MI SUDS NON-SUDS From IMPACT 2: Capewell et al

16. Copyright ©2005 BMJ Publishing Group Ltd. Unal, B. et al. BMJ 2005;331:614 Falls in coronary heart disease mortality attributable to changes in risk factors England and Wales, 1981-2000

17. How to make a difference

18. Local overview Consensus of lead officers on potential

19. biggest quickest Most certain

20. Focus on short term Health inequalities toolkit & national support team analysis

22. Maximum possible effects in Sunderland

23. Priorities for short term? The two most significant interventions from national team analysis

24. Established cardiovascular disease: Pharmacotherapy in treatment naïve individuals Hypertension: Pharmacotherapy in treatment naïve individuals

25. How many people do we have to find and treat? Depends a little on the categorisation of cases…working backwards from stated sources

26. Source: local evaluation of APHO prevalence models

27. Source: local evaluation of APHO prevalence models

28. For maximum effect in Sunderland 30,000 people with hypertension without established disease 15,500 unknown individuals with diabetes and chronic kidney disease Identify and get on maximum preventive pharmacotherapy

29. How long before we see an effect?

30. What might this look like for individuals, and how long might it take?

31. Interventions for asymptomatic individuals Lifestyle change Low Pharmacotherapy Lifestyle change Medium Pharmacotherapy High Secondary Priority Risk profile

32. Identifying those at greatest need?

33. Characteristics of effective interventions systematic and intensive approaches to delivering effective interventions, improvement in accessibility, prompts to encourage use of services, multifaceted strategies, collaboration with interest groups, ensuring interventions address expressed or identified needs, involvement of peers in service delivery.

35. How does this match up for 2010? Priority programme: NHS Health Checks

36. NHS Health Checks Identification and management of cardiovascular risk Pilot schemes Commissioned community service Community programme Current GPs strategy: High risk, invitation & opportunism Coverage of 40-74 year olds in 5 years

37. NHS Health Checks: likely effects Brindle et al. Heart . 2006;92(12):1752-1759. Law et al. HTA 2003 ;7(31). Strong support from DH impact assessment No documented effect on clinical outcomes Significant potential in observational models has not been realised in formal trials

38. Anticipated coverage of NHS Health Checks in SOTW 2010 6,000 Commissioned services … and some with hypertension 3,000 GP: Invitation Will identify some with CKD or diabetes… 16,000 GP: Opportunism Will identify some with CKD or diabetes 67,000 GP: High risk (hypertension) Anticipated assessments Strategy

39. Anticipated coverage of NHS Health Checks in SOTW 2010 5,000 1,000 3,000 Anticipated new cases 6,000 Commissioned services 20% have unrecognised hypertension? 3,000 GP: Invitation 5% have unrecognised disease? 16,000 GP: Opportunism 5% have unrecognised disease? 67,000 GP: High risk (hypertension) Anticipated assessments Strategy

40. Implications for time line Applying two largest impact interventions from national support team

43. Implications for Planning

44. Some principles Have stuck to existing short term commitments on vital signs No more than one target Not always possible eg child obesity data Base this in a sound understanding of health and disease Maximise benefit in health and health care

45. Implications for future CQC ratings Current plans will deliver little change in mortality before 2012

46. For mortality in Sunderland: CQC rated

47. World class commissioning trajectories

50. Conclusions Care is needed to set aspirations that are ambitious and credible active management of those at highest risk holds significant potential. Current plans will deliver a tenth of the anticipated changes, more slowly than anticipated. Our current plans need to scale up in breadth and capacity lifestyle changes appear to be driving improvements in life expectancy