A Picture Of Health

A successful transition into local authority control

Report of 3

A Picture Of Health

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This is the third in a series of three independentlywritten reports commissioned by Health Diagnostics, aleading provider of health check solutions. The first, Making sense of the complexities: A guide to successful commissioning of health screeningprovision, set out the forthcoming transfer of publichealth to top-tier local authorities.

The second, Making NHS Health Checks work for public health examined how the checks can be a powerful tool in managing public health, particularly when combined with the services and infrastructure that are already a part of the remit for local authorities.

This third and final report looks at the practicalities involved in making sure the checks work when local authorities will become responsible for them on April 1st, 2013.

In previous reorganisations of the NHS, making any change a successful transition has inevitably involved a real and meaningful understanding of di�erent organisational cultures. That has rarely been easy, even when the change has been one between two NHS organisations of the same kind, such as the mergers of primary care trusts and strategic health authorities in 2006 and 2010.

The transfer of public health sta� and of the commissioning of these programmes into the 150 ‘top-tier’ local authorities o�ers fresh challenges, in both cultural and practical terms. ‘Top-tier’ authorities have existing remits that cover education, adult social services, children’s social services - and now public health.

Local authorities will have new relationships to build with the NHS Commissioning Board, local clinical commissioning groups (CCGs), commissioning support units, regional clinical senates and local Health Watch presences which they must host. By April 2013, they must have set up a Health and Wellbeing Board, led a Joint Strategic Needs Assessment for their locality, and commented on the CCG / NHS Commissioning Board’s various plans. A Kings Fund study1 of their preparedness from 2012 showed all this to be in early development.

An evident area of overlap between health services and social care services is that the same group – frail elderly people – tend to be the significant net users of both kinds of services. An equally evident di�erence is that adult social care is means-tested in the NHS in England.

A successful transition into local authority control

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Introduction

If you are involved in the commissioning and transferring of Health Checks into local authority control you can register at www.healthdiagnostics.co.uk/pictureofhealth to receive reports 1 and 2 of the ‘Picture Of Health’ series as well as other insight and opinions.

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FinancialconcernsAs reported recently in the Health Service Journal, the move of public health into local government is accompanied by significant concerns over the budget. Local government has seen its grant from central government cut by 28%, so money is a massive issue for social care which it provides or commissions. Protected budgets, such as those for public health screening, may create issues.2

The Local Government Association and the Association of Directors of Adult Social Services warned on funding:

“Councils in some areas have serious and well-founded concerns that the future public health investment in their communities could fall well behind likely need.”

This is echoed in the Kings Fund submission:3

“There is no guarantee that the existing overall pot of £2bn is adequate to deliver the specific services required and broader responsibilities designated to public health… DH has not to our knowledge made any estimate of how much in total should be spent on public health … However, it has prescribed some mandatory functions to the sector … arguably, there should be a bottom-up assessment of how much a specified service should cost and it should then be resourced accordingly.”

As concerns exist about a�ordability, it has been widely suggested that local authorities should maximise use of existing providers to maintain quality of provision of health checks. By April 2013, these authorities must appoint a director of public health, plan for, and start to carry out their public health responsibilities (which had formerly sat in PCTs), deploy the ring-fenced public health budget, and receive transferred sta� and contracts from the shutting-down PCTs.

The financial transfer is very contested. Speaking at the recent Wellards Annual Conference, local government expert, Andrew Cozens, noted that local government has merely been told the minimum sum it will get. Cozens added that directors of public health’s general view of being transferred into the more overtly politicised (as led by elected councillors) world of local government is mixed. Cozens warned,

“When the going gets tough, boundary disputes resurface” between what is a health need and what is a social care need:

This point was echoed by Dr Peter Brambleby, a career NHS manager who worked as Director of Public Health across Croydon Council and Croydon PCT, and is now an independent public health consultant. Bramblebly does not think the financial ring-fence on public health budgets to local authorities will work in practice:

“I think people will get around it. It’s very di�cult to define exactly what meant by public health, and how much money is currently going into it. It’s a mix of money you can clearly identify (cost per immunisation) money you can’t – such as HIV prevention budgets as part of block contracts.

“The HSJ recently published comments from Steven Watkins and others saying ring-fenced budgets will be inadequate, will be raided, and will lead to greater expectations that the funding will be neither su�cient nor secure. After all, a ‘ring-fence’ is synonymous with cage or silo, and not the right metaphor where public health should be core business for NHS and local authorities, and the entire budget should be directed towards health and wellbeing - and audited in those terms”.

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The culture clashand creativity with venuesDr Ingrid Wolfe, a consultant in public health at Guys and St Thomas' NHS Foundation Trust; a research fellow at the London School of Hygiene and Tropical Medicine; and a paediatrician at Whittington, expresses concerns about the relocation of public health and screening into local authorities:

For some aspects of public health it makes sense, because local authorities a�ect or deal directly with so many of the determinants of health, such as housing and employment. However for health services, I do worry that services could become even more fragmented, perhaps dangerously so.

Dr Wolfe's concerns are operational:

"The risk in this shift of public health services - generally - is very much about the way it's being organised. Even with a ring-fenced budget for public health, it's not hard for clever people to get around that ring-fence - if not in this public funding cycle, then before too long".

She also perceives some practical sense in the change:

Local authorities should have a geographical population known to them by the voter registry - which is not as true any more with clinical commissioning groups (CCGs) because unlike their predecessors (PCTs) - they are not all geographically aligned with local authority boundaries.

"So hopefully, public health in local government will be able to find the deprived communities traditionally viewed as 'di�cult to reach', and may already have links to such communities, through things such as outreach groups for homeless people".

By contrast, Dr Peter Brambleby is optimistic:

“Local authorities may prove to be a good home for public health. Screening programmes such as the NHS Health Check pick up some people early with risk factors, but ideally before the disease has become established disease”.

He suggests,“The best response may be prevention, by changes in diet and exercise. Local government could exercise much more control in extant planning law. Environmental Health O�cers could start thinking more about how to encourage healthier meals and diet choices.

A really enterprising local authority might say ‘we’re going eliminate all hydrogenated fats in an area’”, Dr Brambleby adds.

As highlighted in the previous reports in this series, Dr Brambleby emphasises that getting screening uptake in the most at-risk groups is crucial:

“The issue is that we know non-attendance rates for screening are particularly high in certain groups. White, working-class men tend to be particularly bad at turning up, and the NHS brand lacks cachet with them. So part of e�ective screening is having as high a take-up rate as possible, which may require lateral thinking.

In Croydon, we bannered our Health Checks as invitations from brands more 'trusted' by this target group, such as Crystal Palace Football Club.

“Directors of public health and their local government colleagues need to think laterally about what will attract those groups, or how to incentivise screening. That might be setting up weight loss and exercise sessions with the local football club’s fitness professional instructor, with a competition for most weight loss winning a T-shirt, presented on the football pitch at half-time during a match. Another potentially e�ective non-traditional-NHS site is pharmacies, some of whom locally invested in gearing up to do the checks”.

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The importance of information and data sharingIn previous reports, the importance of providing screened patients with appropriate information has been highlighted. Dr Wolfe flags up her concern for whether all commissioners will successfully ensure that their providers of screening programmes can and will successfully marry up their health check data back with people's records in primary care - assuming that the people screened are indeed registered with a GP.

"These sorts of links are often very di�cult to get right - even more so when there are so many di�erent organisations involved. And the risk is that people will get lost in the system - and that can be dangerous".

Health Diagnostics provides NHS Health Check solutions to PCTs, and places end-to-end data management at the heart of its service. Patient data is collected by providers of the NHS Health Checks using its hardware (point of care analysers), and the Health Options software enables data to be fed into the systems of GPs immediately. This approach minimizes the risk of lost or misplaced data: a major step towards prevention of people being lost in the system. Having a flexible approach to clients’ needs is key: In the words of Julie Evason, Health Diagnostics’ MD,

“We are very quick to adapt when clients want new features from our service. Durham wanted to track the data from the activity programmes, so we introduced generic changes to the software so that all other providers could benefit from the new feature. It’s about having a flexible mind-set.”

On the subject of other practicalities, Dr Peter Brambleby observes, “Getting the target group at highest risk is one thing. Having services to refer them in to is just as important:

when the NHS Health Checks began, in Croydon we held back during Wave 1 until we had reliable smoking cessation and weight management services in place

(the latter was and is still the sticking point - ironically we can spend millions on the consequences of obesity but little or nothing on the causes). Those o�ers had to be in place.”

Sue Collins, health engagement lead at NHS South of Tyne and Wear, was interviewed for the case study of the North East accompanying this Report. Sue makes the other practical suggestion:

“Don’t underestimate the time it takes to set up a project: Good planning and lead-in time are essential for smooth implementation. Appropriate training, updates and quality control are essential for accurate near-patient cholesterol results. It is essential to give practise sta� enough time to deliver the check in one appointment, and to perform quality checks.”

(South Tyneside is one of over twenty PCTs to which Health Diagnostics provides health check solutions).

However, even when services are ‘linked up’ well, with the data explained clearly to the patient, a personalised approach should be used wherever possible. Jill Thornton, lead nurse with the Community Delivery team in NHS South of Tyne and Wear, uses Health Diagnostics’ systems to perform NHS Health Checks.

“A lot of the way you give advice is based on predicting how you think someone will react to what you say to them. It’s about not being judgemental, not telling but o�ering advice. Most people soften at that. It’s also about giving people 20 minutes dedicated just to their health and their future health, which they don’t normally get.”

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A role for more imaginative commissioningDr Brambleby suggests that this shows why

“We need much more imaginative commissioning. NHS Health Checks and other screening should not just be seen as a free-floating thing or a ring-fenced silo. We need to think about commissioning for health: diabetic health, heart health, mental health, lung health … and it’s a partnership model across directors of public health (DPHs) in local authorities, CCGs, GPs and the hospital sector.

GPs and DPHs need to think ‘we will go and find people with problems like these and refer into this service whose aim is to improve health of population. In that mode, you'd see GPs and hospital clinicians contractually obliged to get onto the front foot, identify and address problems before they turn into diseases or expensive interventions, and thereby prevent some of the avoidable loss in length or quality of life”.

Jill Thornton and her team of nurses worked alongside a wide variety of providers through one-o� or regular events.

“At Gateshead Library we have o�ered the NHS Health Checks alongside the likes of MIND, nutrition teams, drugs and alcohol services, and sometimes local gyms which o�er people free trials to incentivise them to exercise. We also do the Checks at summer fairs, ASDA warehouses, big factories, churches and working men’s clubs.”

The partnership model Dr Brambleby speaks of is reflected in Jill’s comment that

“A lot of people we come across say they’d never dream of taking up their GP’s time by asking for an NHS Health Check.”

Ethical and Cost IssuesDr Brambleby also points out that a successful transfer of screening programmes into local government requires attention to various ethical issues: “Informed consent to screening at the outset requires understanding the consequences of a positive (or negative) result, and what happens next. Since they impact on largely healthy (at the time of screening) populations and involve costs,

all screening programmes should be evaluated for value for money as well as sensitivity (finding as many true cases as possible), specificity (not finding too many false positives), and the positive or negative predictive value

("if my test is positive or negative what are the probabilities I do or don't have the disease, respectively?"). Those factors then feed back into informed patient consent, as well as policy-making and operational management of the programme”.

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Closing the loop: planning what happens after screeningDr Wolfe adds,

“Any screening programme must go beyond detection. Once the system has found someone with a problem, firstly the person who delivers the result needs to do so in an appropriate, respectful and meaningful way, with decent communications skills, and the ability to sort out what comes next for that person”.

She adds that thinking beyond the test is critical for screening to be part of a health economy really making a di�erence to the upstream determinants of ill-health:

"For each clinical area being screened, be it diabetes, CHD or just BMI index, the system needs to have an entire package of treatments or support available.

If screening results are delivered in real-time at the point of testing, the person delivering that test needs awareness of what should happen next to address what is found. It may be of little use to just say ‘go and make an appointment with your GP’: what would be more useful, and more secure, is preparation for the consequence of the test finding an un-met health need.

That probably involves a health professional adequately trained to discuss it at the point of testing.

"Then, there ought to be a package of services or clinical pathway for the screened condition: not only conformation checks, if necessary, but very often, what is found will be about a lifestyle issue.

If someone is overweight and their lipid levels are borderline raised and not necessarily requiring medicine yet, then they could be started on a diet and exercise plan and free sessions at a local gym, and followed up as necessary to check progress”.

The ability to track patients' progress through the lifestyle programmes they're signposted to is precisely the software functionality that has been developed for Health Options.

Jill Thornton points out this joined up approach can really benefit patients:

If people can then come back again in six months, after improving their diet, and see their bad cholesterol has dropped and their good cholesterol risen, that really motivates them.”

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Flexible Pathways - from prevention to treatmentDr Wolfe concludes that,

"It needs a level of detail for all conditions screened, to address all aspects. Much of screening is about things determined by lifestyle, so dealing with problems detected is complex - not necessarily just about prescribing a tablet.

The entire pathway from primary prevention to treatment needs to be thought of in advance and implemented, and flexible enough for more than one care pathway to put together, if patients are found to have more than one condition.

"In addition, if we target screening to those in most need, there should be some way of becoming aware of their personal circumstances, i.e. do they have a learning disability? Do they live in a high-floor flat but have di�culty managing stairs? Can they read and speak English? The need to do this is so as to make a package of care that is meaningful and feasible for that person.

Dr Peter Brambleby, meanwhile, leaves the take-home message that,

“Screening doesn’t have to be of the entire population, best to start with focus on those most likely to get ill: that would be most productive and cost-e�ective”.

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Lessons Learned

The interviews and findings documented in this series of three reports cast significant light over the challenges and opportunities which lie on the horizon of the new commissioning landscape. There has recently been much talk of the integration of health services in the commissioning and health-related press, however much of it has occurred at the political level with the realities yet to be implemented. As of April 1st however, these new structures will be required to be fully functional and interacting. In this regard, Dominic Harrison - Director of Public Health for Blackburn and Darwen – o�ered a series of highly pragmatic insights:

“The poorest 20% of the population is at most risk of ill-health, for reasons we all know. A local authority has a lot of contact with that vulnerable group, due to its work in management and delivery of social housing, revenues, benefits allowances, neighbourhood development services. Local government has huge investment in infrastructure and contacts where these people live and have leisure time.’’

It is perhaps in this manner that the coming shift to local authority control will make its most e�ective and targeted impacts. The requirement to target screening at those populations who most require it is a point that has been repeatedly stressed by a number of authoritative voices interviewed for the Picture of Health reports. By opening up the appropriate communication channels, local authorities are faced with a prime opportunity to improve the e�ciency and outcomes of population health screening.

A further important factor that was repeatedly mentioned is that providing NHS Health Checks through a limited range of settings or perhaps only through GP practices is likely to result in a campaign that fails to reach out truly to those most in need of the lifestyle intervention. Professor Maynard puts it eloquently:

“This is about the group, especially males, who don’t present to their GP often for social and cultural reasons, and then turn up seriously ill with heart attacks and stroke because they haven’t been screened... Take your delivery of screening down to pubs and betting shops.”

Despite the recent allegations made by the Cochrane Review that health checks don’t result in benefits to mortality rates, the findings made in the reports would suggest that the e�ectiveness of any health check programme is highly dependent on the approach taken. A patient-centred and widely available service that communicates the relevant lifestyle information to the screened individual, presents one of the best ways to tackle national health issues and inequalities. What’s more, taking the advice of Jill Thornton – a lead nurse at NHS South of Tyne and Wear’s community delivery team - o�ering someone ‘20 minutes dedicated just to their health, which they don’t normally get’ has been proven to achieve tangible results. As an NHS SOTW population study focussed on establishing how people receive and act on health advice following a health check found

‘45% reported they had followed ‘all or some’ of the advice. Interestingly, only 6% of those given advice on smoking cessation reported they hadn’t followed the advice.’

The capability to gather and record outcome data is a requirement that has been consistently cited by a number of those interviewed. As a result, Health Diagnostics have responded by further developing and enhancing the outcome trackers currently used by a number of PCTs that the solutions provider work alongside. There is further information on the specifics of these resources which can be found in the North East case study that accompanies the Picture of Health reports.

After a number of years working in partnership with the NHS to supply the solutions that enable the delivery of NHS Health Checks, Health Diagnostics commented that the reports had confirmed many factors that the company has long suspected to be crucial to the successful delivery of population screening. Moreover, Julie Evason, MD of Health Diagnostics states that ‘It is extremely important to recognise that each local authority has its own specific requirements.’ Therefore maintaining a flexible mindset that can respond and react to the nuances and health needs of any given area is an essential trait for both the commissioners, providers and organisations that supply the solutions. As such, two of the most pressing questions that commissioners and DPHs are likely to be asking are

‘Is the care package tailored to the community in which it is being delivered?’ and ‘Will the care be flexible enough to be truly personal?’

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References

1. http://www.kingsfund.org.uk/publications/health-and-wellbeing-boards

2. http://www.hsj.co.uk/5052025.article

3. http://www.publications.parliament.uk/pa/cm201213/cmselect/cmcomloc/writev/694/m07.htm

4. http://www.publications.parliament.uk/pa/cm201213/cmselect/cmcomloc/writev/694/m18.htm

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