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