Nottingham City PCT 1
Quality improvement to ensure health gain (and Health Inequalities reductions)
an example: commissioning cardiovascular risk management
Chris Packham
Director of Public Health
Nottingham
Nottingham City PCT 2
DH, Health inequalities intervention tool: view your gap
Nottingham City PCT 3
Health outcomes in context
Nottingham City PCT 4
CHD 8 - % patients whose last measured cholesterol <= 5mmol/l (measured in last 15 months)
0%
20%
40%
60%
80%
100%
Practice code
Target Met Target Missed Exception Coded
Nottingham City PCT 5
CHD 8 - % patients whose last measured cholesterol <= 5mmol/l (measured in last 15 months)Nottingham City Practices 2006-07
0%
20%
40%
60%
80%
100%
Most deprived IMD 2004 quintiles Least deprived
Target Met Target Missed Exception Coded
QOF performance – cholesterol outcomes
Nottingham City PCT 6
Nottingham
DM 20 - % patients whose HbA1C <= 7.4 (measured in last 15 months)
0%
20%
40%
60%
80%
100%
Practice code
Target Met Target Missed Exception coded
Nottingham City PCT 7
Understanding unmet need and inequalityEg: Heart disease deaths and Statin prescribing by GP practice
0.000
2.000
4.000
6.000
8.000
10.000
12.000
practice
CHD death rates (DSR)
statin use (ADQ/STAR-PU)
most deprived least deprived
Nottingham City PCT 8
Commissioning Healthcare for Best Outcomes
Population Focus Optimal Population Outcome
13.Networks,leadership and coordination
6.KnownIntervention
Efficacy
1.KnownPopulation
Health Needs12. Balanced Service Portfolio
11.Adequate Service Volumes
Challenge to Providers
5.Supported self-management
10. Engaging the public
4. Responsive Services
9. Accessibility
2. Expressed Demand 7. Local Service Effectiveness
3. Equitable 3. Equitable ResourcingResourcing
8.Cost Effectiveness
Nottingham City PCT 9
Design (Commissioning) challenges
• How to stop the CVD risk programme work widening inequalities?
• How to encourage people to turn up for assessment and then take part in interventions?
Nottingham City PCT 10
Mosaic Group F: people living in social housing
with uncertain employment in deprived
areas
Eg: Social marketing methodologies
Nottingham City PCT 11
Getting the technical data right:understanding the CVD risk 40-74 task
• Local estimation
• NICE guideline 67 tool– http://www.nice.org.uk/guidance/index.jsp?act
ion=download&o=40777
• QRISK 40-74
– 3% 40-54, 97% 55-74
• Framingham 40-74
– 7% 40-54, 93% 55-74
• But – S Asian and AC groups may
need DM case finding from age 30
– ‘CKD’
• From a population of 300,000…
• How many patients are we seeking for primary prevention?
• Existing CVD 11,000
• For a population of 300,000, around 12,500 out of 35,000 55-74’s estimated at risk (Framingham)
Nottingham City PCT 12
our ‘Intervention’: first stage started
most deprived quintile – 14 practices: 8000 patients 45-74
• Trained HCAs• Computer generated lists of at risk patients• 30% one or more risk factor recorded• ABPI partnership project • Called in, risk assessed, interventions agreed• Referred on the GP/PN as necessary• Outcomes monitored • Targeted using successive 5-year descending
age bands
Nottingham City PCT 13
Results
• first 2 months • attendance rate 73% (65% plus a further 8% on
one reminder)• 260 seen all>20%• 40% already on treatment • About 50% sent to GP/PN to date• 1 in 5 put onto drug treatment immediately
• 4% new Diabetics
Nottingham City PCT 14
our ‘Intervention’: second stage50 practices - 27,000 patients 55-74
• Locally Enhanced Service for 55-74’s
• Option to use HCA model
• 40-54’s ?Alternative model
• Year one – Hypertensives all ages– BMI>35
• Year two – 55-74 one or more risk
factor– All BME 40-74
• Year three– Rest 55-74
Nottingham City PCT 15
Challenges and solutions
• Problems – The DNAs
– Compliance
– Clinical buy-in
– Community awareness
• Must have supporting delivery– Healthier Communities
Collaborative – Primary prevention– HEAs on hospital and
tertiary end – Health trainers / PH
nutrition teams / smoking cessation services
– Look carefully at primary care data
Nottingham City PCT 16
Commissioning Healthcare for Best OutcomesNST – HI support team Prof Chris Bentley
• Population quality– Empowering / Healthier
Communities Collaboratives
– Decent Health Equity Audits
– Designed around populations as well as practices (eg BME)
• Individual care quality – QOF– Use Accepted interventions – Guideline audits
– Patient satisfaction and
accessibility
For both make sure the supporting community services are in place and part of patient pathways and at industrial scale