The document discusses health inequalities in England, highlighting significant disparities in life expectancy within short geographical distances, especially in London. It emphasizes the importance of measuring various factors related to physical activity and health outcomes to inform decision-making and improve health interventions. Additionally, the paper outlines the complexities of public health commissioning against the backdrop of national and local priorities, stressing the need for data interpretation to drive health improvements.

1. It's not just a numbers game
Carl Bennett FCIMSPA
Senior Health Improvement Specialist
NHS Stoke on Trent
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2. It's not just a numbers game
• Health Inequalities ~ the challenge & health backdrop
• What should we be measuring?
• What is an Output, Impact or Outcome?
• Commissioning ~ a mysterious art form
• The Emerging Health Landscape
• National v Local

3. The New Health Structures - England

4. Regardless of where Public Health sits it’s all
about…
Inequalities

5. Travelling east from Westminster, each tube stop represents nearly
one year of life expectancy lost
Westminster
Waterloo
Southwark
London Bridge
Bermondsey
Canada
Water
Canary
Wharf
North
Greenwich
Canning Town
London Underground Jubilee Line
Differences in Life Expectancy within a small area in London
Electoral wards just a few miles apart geographically have life
expectancy spans varying by years. For instance, there
are eight stops between Westminster and Canning Town
on the Jubilee Line – so as one travels east, each stop, on
average, marks nearly a year of shortened lifespan. 1
River Thames
1
Source: Analysis by London Health Observatory using Office for National Statistics data. Diagram produced by Department of Health
Male Life
Expectancy
71.6 (CI 69.9-73.3)
Female Life
Expectancy
80.6 (CI 78.7-82.5)
Male Life
Expectancy
77.7 (CI 75.6-79.7)
Female Life Expectancy
84.2 (CI 81.7-86.6)

6. • Allied Dunbar National Fitness Survey (1992) = 58% of adults not
active enough to benefit their health
Participation over time
BIG Picture – Nothing has changed.
1 session a week (at
least 4 sessions of at
least moderate
intensity for at least
30 minutes in the
previous 28 days)
APS1
(Oct 2005-Oct 2006)
Apr 2012-Apr 2013
APS7
(Oct 2012-Oct 2013)
% n % n % n
Statistically
significant change
from APS 1
Changei
since Apr
2012-Apt
2013
NORTH EAST 32.7% 682,200 35.5% 759,300 34.7% 740,900 Increase Down
NORTH WEST 33.7% 1,859,100 35.5% 2,042,900 35.9% 2,063,000 Increase Up
YORKSHIRE 33.1% 1,350,200 35.2% 1,517,200 36.2% 1,562,200 Increase Up
EAST
MIDLANDS
33.6% 1,173,400 34.4% 1,279,600 33.9% 1,260,400 No change Down
WEST
MIDLANDS
31.9% 1,373,600 32.1% 1,457,500 33.3% 1,512,500 Increase Up
EAST 34.8% 1,556,100 35.4% 1,694,800 35.1% 1,677,000 No change Down
LONDON 35.0% 2,126,000 36.0% 2,391,400 37.2% 2,467,800 Increase Up
SOUTH EAST 36.7% 2,416,500 36.2% 2,554,800 36.9% 2,606,300 No change Up
SOUTH WEST 33.8% 1,402,300 35.4% 1,559,000 35.7% 1,571,900 Increase Up
National 34.2% 13,939,400 35.2% 15,256,400 34.7% 740,900 Increase Up

7. Who Should we be Targeting?
Refer back to my earlier slides re Inequalities – This is ‘THE’ key PH Aim.
• Health Check population ?
~17 to 74yr olds. Key focus on Over 40’s
• Those at increased risk of CVD or with established disease ~ what
groups might this include?
• Those on Mental Health Registers (Practice based register)
• Specific population Groups?
~ BME, Older people (at risk of falls), Physical / Mental disabilities,
Pre & Post Natal Mums and Families via NCMP and AP data
~ Elevated BP, Diabetics & those with an increase in IFG, BMI over 25,
Post Phase III Cardiac Rehab, Pre /Post Bariatric Surgery, Quota*, etc
It’s relatively safe to assume – most of the above will be inactive

8. What should we be measuring
as well as the numbers?
• Frequency ~ how many & how often
• Type of activity ~ does it have an evidence base
• Intensity ~ is it Moderate
• Adherence ~ over the longer term (> 6mths – ideally 12mths or longer)
• Who is inactive ~ how are you engaging / encouraging those who are least
active (the biggest proportion - over 65% - of your population is INACTIVE!!)
• Population Group ~ ethnicity, age, gender, social groupings
• Post Code ~ to the last digit (will help to inform ‘Hot Spot’, Super Output Area
& Community analysis)
• Benchmark ~ against other ‘similar’ organisations / LA’s / demographics

9. • We can be data rich, but information poor
• Why do we collect data? Ask! and ask again
• How do we interrogate, interpret and use the data we currently collect?
• Who do we share this data / information with ~ who has access to it?
• Who should have access or at least see it?
Key Point:
Data and Information itself is valueless. It requires translating into usable
knowledge. Knowledge gain must be used to inform decisions which lead
to a change in the way things are done.
Observations:
"information is now a more important measure of a company's worth than their tangible
assets… The truly mission critical processes for every enterprise involve capturing the
daily flood of data… Data must be stored and organised so that users can access it easily
and intuitively, evaluate it… and act upon the findings effortlessly" (Strassman P; The
Politics of Information Management: 1996)

10. Breaking the mould that has been used for
the past 20yrs is a Must Do
Many things we have done in the past just
don’t work… Fact!
We must use the available evidence and
knowledge and match this to local drivers for
health improvement.
It ain’t complicated its just complex…

12. National or Local?
The National Drivers are very much about austerity (reducing
the ‘Fat’) and devolving decisions to the local level
Localism is key – understanding how national drivers impact on local
action is crucial, but Localism means decisions are made at the local
level. This means there will be different systems of decision making
and priorities in each LA area – Therefore, a Confusing Landscape
Local decisions will mainly be made by the Health & Wellbeing
Board – there should be an Obesity Pillar which provides the
PA agenda a route into the decision making processes
Joint Strategic Needs Assessment (JSNA) – weaves the
strategic fabric to create a local picture of performance against
a number of priorities – ‘if it ain’t in the JSNA it ain’t a priority’

13. Public Health Framework – 2 key measures relate to PA
•Improving the wider determinants of health - 1.16: Utilisation of
green space for exercise/health reasons
•Health Improvement - 2.13: Proportion of physically active and
inactive Adults
National or Local?... continued
Public Health profiles are a key source of data and information to
help inform your understanding of health issues at the local level
www.healthprofiles.info
Information to assist your insight of local health issues

14. Assessing Need & Priorities
Whose view point is need assessed by?
Professional View Service Users
Defined by an expert
or professional ~
setting a standard
People
identify what
they want ~
ie regular BP
reading
following a
first reading
What people
‘say’ they want
or ‘demand’
Caveat ~ lack
of demand
should not be
equated with
lack of felt need
&

15. Understanding Needs ~ Market Segmentation
• Sport England 19 Market Segmentation Groupings ~ Experian (Mosaic Public
Sector) ~ Interactive Web Tool
• Develop ‘Insights’ and ‘Pen Portraits’ of your current and target users
• Develop Ward, Community and Locality level data (match with PCT priorities)
and allow these to inform your Programme of Offer
Impact Measurement
• Measure changes in ~ Knowledge, Attitude & Behaviour
• Active People provides great analysis for physical activity & opportunity to
benchmark

16. Output v Impact v Outcome
Output (out'p t')ʊ n. An amount produced or manufactured
during a certain time
A Production Analogy
Outcome (out'kŭm‘) n.
An end result; a consequence

17. Output v Impact v Outcome continued…
Impact
Measure of the tangible and intangible effects
(consequences) of one thing’s or entity’s action or influence
upon another (Business Directory)
This is how I see Impact: “What measurable effect has the
intervention / experience / education had on the individual?”
Output
The tangible or intangible product resulting from a planned
activity (MSP Handbook: OGC; 2007)

18. Output v Impact v Outcome continued…
The Health Outcome
“A change in the health status of an individual, group or
population which is attributable to a planned intervention
or series of interventions, regardless of whether such an
intervention was intended to change health status”
(HP Glossary; WHO: 1998)
Caveat ~ Generally a Health Outcome is likely to be achieved long after
the intervention/s have touched a person, groups of people or the
population as a whole
Outcome
The result of change, normally affecting real-world behaviour
and / or circumstances (MSP Handbook)

19. Commissioning ~ a mysterious art form
Department of Health “Commissioning is the strategic activity of assessing
needs, resources and current services and developing a strategy to make
best use of available resources to meet identified needs.”
Audit Commission “The process of specifying, securing and
monitoring services to meet individuals’ needs both in the short and
long term. As such it covers what might be viewed as the purchasing
process as well as a more strategic approach to shaping the market
for care to meet future needs.”
I see it as: The act of committing targeted resources (people and £)
with the aim of improving health, reducing inequalities and enhancing
patient experience using the best available evidence and ensuring
value for money for the outputs produced and the outcomes
achieved.

20. Specification
Contract
(Schedule2)
Tendering &
Contracting
Contract
M onitoring
and Review
User needs
Local
Commissioning
Strategy
M arket
M anagement &
Development
Performance
M anagement,
M onitoring
& Review
Populationneedsanalysis
Risk analysis
1.Analyse 2.Plan
4.Review 3.Do
Organisation(s) purpose
/ legislation
M arketanalysis
Commissioning
strategy
Strategic Level
Operational Level
The Commissioning Cycle
What do we need?
What does evidence say?
What does the
marketplace look like?
Select
Providers Monitor & Review
1 2 3 4

21. What works, what should we be doing different?
Remember what Albert said: “if you keep doing what you're doing, you'll keep getting the
results you've been getting” A Einstein 1879–1955
Note ‘Sport’ does not feature high on the evidence list ~ the most recent NAO
report ‘Report by the Comptroller and Auditor General; Increasing participation in
sport’ (NAO: 2010) painted a poor picture of the sport participation strategic
landscape ~ ‘When designing, developing and commissioning new initiatives we
need to look at all the reliable evidence we can and use it to inform investment
decisions’
• Start with the evidence ~ Ideas are ok. Innovation is great. When
dealing with Health (with a capital ‘H’) you need to base your ideas
on evidence and build from there.
• Where to find it?
My advice – Read The Marmot Review ~ FAIR SOCIETY, HEALTHY
LIVES (2010) ~ key focus on inequalities and the introduction of
‘Proportionate Universalism’ (action across the social gradient)

22. Web links to referenced documents:
http://strassmann.com/
http://www.ogc.gov.uk/guidance_managing_successful_programmes_4442.asp
http://www.who.int/hpr/support.material.shtml
http://www.nice.org.uk/PHI002
http://guidance.nice.org.uk/PH8
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_07360
0
http://www.cabe.org.uk/publications/physical-activity-and-the-built-environment
http://www.sportengland.org/research/market_segmentation.aspx
http://web.nao.org.uk/search/search.aspx?Schema=&terms=sport+participation+report
http://en.wikipedia.org/wiki/Return_on_Investment
http://www.marmot-review.org.uk/
http://programmeforgovernment.hmg.gov.uk/
http://www.cabinetoffice.gov.uk/publications/state-of-nation-report.aspx
& other useful descriptions of Costs / Benefits
http://en.wikipedia.org/wiki/Quality-adjusted_life_year

23. Thank You & Questions
Carl Bennett FCIMSPA
Senior Health Improvement Specialist
NHS Stoke on Trent