Practical application of population health and wellbeing approaches in

the new policy context

Professor Chris Bentley

HINSTHINSTAssociatesAssociatesHINSTHINSTAssociatesAssociates

Messages from the Past

Ronald Labonte

Well being and Health

Physiological risksHigh blood pressureHigh cholesterolStress hormonesAnxiety/depression

Behavioural risksSmokingPoor dietLack of activitySubstance abuse

Psycho-social risks:IsolationLack of social supportPoor social networksLow self-esteemHigh self-blameLow perceived powerLoss of meaning/purpose of life

Risk conditions – e.g.:PovertyLow social statusUnemploymentDangerous environmentsDiscriminationSteep power heirarchyGaps/weaknesses in services and support

2005

2010 2015

2020

Health Inequalities

Different Gestation Times for Interventions

A

B

C

For example intervening to reduce risk of mortality in people with established disease such as CVD, cancer, diabetes

For example intervening through lifestyle and behavioural change such as stopping smoking, reducing alcohol related harm and weight management to reduce mortality in the medium term

For example intervening to modify the social determinants of health such as worklessness, poor housing, poverty and poor education attainment to impact on mortality in the long term

Partnership, Vision and Strategy,

Leadership and Engagement

Population LevelInterventions

Intervention Through

Communities

Intervention Through Services

Systematic and scaled interventions through

services

Systematic community engagement

Service engagement with the community

Producing Percentage Change at Population Level C. Bentley2007

Achieving Percentage Change in Population Outcomes

Programme characteristics will include being :-

– Evidence based – concentrate on interventions where research findings and professional consensus are strongest

– Outcomes orientated – with measurements locally relevant and locally owned

– Systematically applied – not depending on exceptional circumstances and exceptional champions

– Scaled up appropriately – “industrial scale” processes require different thinking to small “ bench experiments”

– Appropriately resourced – refocus on core budgets and

services rather than short bursts of project funding

– Persistent – continue for the long haul, capitalising on, but not dependant on fads, fashion and policy priorities

'Spearhead' deaths as a % of England total: 2006 to July 2011month by month counts and 12 months smoothed - ONS provisional death registrations

26.0%

26.5%

27.0%

27.5%

28.0%

28.5%

29.0%

29.5%

30.0%

% o

f E

ng

lan

d d

eath

s

month by month

12 month smoothed

population proportion

T Hennell 2011

Circulatory <75 standardised mortality: Spearhead Gapschange in absolute gap between annual mortality rates for spearhead areas and the England

average

-60%

-50%

-40%

-30%

-20%

-10%

0%

10%

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

ann

ual

cir

cula

tory

mo

rtal

ity

gap

co

mp

ared

to

th

at f

or

the

bas

elin

e ye

ars

1995

-97

persons

male

female

target reduction

Components of the <75 gap by broad category of deathstandardised mortality gaps for spearhead areas compared to each year's England <75 mortality

0%

5%

10%

15%

20%

25%

30%

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

ca

us

e o

f d

ea

th g

ap

s r

ela

tiv

e t

o E

ng

lan

d a

ve

rag

e <

75

mo

rta

lity

in

ye

ar

other

digestive

cancer

circulatory

Health and Wellbeing Boards

A shaky start?

A few early concerns• Limited membership v. unmanageably large• JSNAs very variable; not bottom-up and top-down;

not driving the agenda• Little knowledge or acknowledgement of Public

Health Outcomes Framework• Role not clear: strategic ‘forum’ (talking shop), or

performance managing function• Early HWS pink and fluffy; missing tangible stated

outcomes with strategy for delivery• Who is accountable for delivery of each priority to

the Board • Missing opportunities on ‘causes of the causes’

“ Social injustice is killing on a grand

scale “

Sir Michael Marmot

2010

With thanks to Mike GradyUniversity College London/Marmot Review Team

Inequality in Early Cognitive Development of British Children in the 1970 Cohort, 22 months to 10 years

0

10

20

30

40

50

60

70

80

90

100

22 26 30 34 38 42 46 50 54 58 62 66 70 74 78 82 86 90 94 98 102 106 110 114 118

months

Ave

rag

e p

osi

tio

n in

dis

trib

uti

on

High Q at 22m

Low Q at 22m

Source: Feinstein, L. (2003) ‘Inequality in the Early Cognitive Development of British Children in the 1970 Cohort’, Economica (70) 277, 73-97

High SES Low SES

Per cent achieving 5+ A* - C grades inc Maths and English at GCSE by IDACI decile of pupil residence: England 2007

25.329.9

34.239.2

44.749.5

53.857.8

61.968.4

0

10

20

30

40

50

60

70

80

0-10% 10-20%

20-30%

30-40%

40-50%

50-60%

60-70%

70-80%

80-90%

90-100%

% achieving 5+ A*-C GCSEs inc Maths and English

Income Deprivation Affecting Children Index (IDACI) Least deprived

Source: DCFS 2009

Most deprived

Clinical Commissioning Groups

Inherent Schizophrenia?

A few early concerns• Commissioner v Provider v Collaborative Partner• Unequal pressures• Leaders (hard-bitten experience v fresh faced

enthusiast)• Corporate memory v re-inventing wheels (flat tyres)• Holistic overview v PPPs (personal perspective

priorities)• Transition (empowering possibilities) v Real World

(reality/austerity bites)• Variable mix of support/advice/guidance (CSS; NHS

CBA; PH/PHE; Commercial sector)• Little previous engagement with population perspective

Primary Care Direct Action

HWBB

JSNA

HWBS

Commissioning

Primary Care

Commissioned Service

Primary Care Contribution to Health Improvement

CCG contribution

NHS Commissioning Board

18

• What is our ambition? What realistic but testing target are we aiming for?

• Can this be stated in terms that are easily understood and ‘owned’ by local stakeholders? In particular can it be pinned down to numbers?

• What are the main contributory factors responsible for the current adverse situation?

• What interventions could contribute substantially to these sort of numbers? Can they be delivered with sufficient system, scale and sustainability

• Can a realistic business case be developed to demonstrate appropriate return on investment?

Outline

Case Study 1

Oldham CCG

19

20

Setting Ambitions: Best in Peer Group (Males)

Male All Age All Cause Mortality (AAACM) Rates by GP Consortia, 2007-09

*Peer group = Former Spearhead PCTs in ‘Centres with Industry’ ONS area classification

Eng

land

ave

rage

500

550

600

650

700

750

800

850

900

950

GP Consortia in Peer Group*

Mo

rta

lity

Ra

te p

er

10

0,0

00

Oldham

SouthBirmingham

21

Estimating the scale of the challenge (Males)

Oldham Male AAACM rate 2001-2009, forecast and trajectory to 2013-15 ambition

500

550

600

650

700

750

800

850

900

950

1000

01-03 02-04 03-05 04-06 05-07 06-08 07-09 08-10 09-11 10-12 11-13 12-14 13-15

3 year average

Mal

e A

AA

CM

per

100

,000

Target

Actual

Forecast

Equivalent to 417 (13%) fewer male deaths in 2013-15

270 fewer deaths in 2013-15 expected based on current trend

22

Estimating the scale of the challenge : Summary

2007-09AAACM

(rate)

2013-15 ambition

(rate)

2007-09 deaths

(number)

2013-15 ambition(number)

Required reduction(number)

Expected reduction (number)

Additional reductionRequired

Males 833.6 721.2 3100 2683 417 270 147

Females 597.7 497.8 3410 2774 636 297 339

Persons - - 6510 5457 1053 567 486

Reductions in mortality numbers necessary to meet 2013-15 targets

23

Identifying ‘excess’ mortality by age group

Number of excess deaths by age group in Oldham compared to England average, 2006-08

0

50

100

150

200

250

<1yr

1-4 5-9 10-14

15 -19

20 -24

25 -29

30 -34

35 -39

40 -44

45 -49

50 -54

55 -59

60 -64

65 -69

70 -74

75 -79

80 -84

85+

Age group

Exc

ess

deat

hs 2

006-

08(p

erso

ns)

Source: Derived from London Public Health Observatory Health Inequalities Intervention Tool data

24

Identifying ‘excess’ mortality by cause

Number of excess deaths in Oldham by cause, gender and broad age groupcompared to England average, 2006-08

0

50

100

150

200

250

CH

D

Str

oke

All

canc

ers

CO

PD

Pne

umon

ia

Live

r di

seas

e

Dia

bete

s

Oth

er c

ause

s

CH

D

Str

oke

All

canc

ers

CO

PD

Pne

umon

ia

Live

r di

seas

e

Dia

bete

s

Oth

er c

ause

s

Exc

ess

num

ber

of d

eath

s 20

06-0

8

75+ years

<75 years

Source: Derived from NCHOD standardised mortality ratios (SMR) and mortality numbers by age and cause.Excess mortality = ‘observed’ minus ‘expected’ deaths

Males Females

Breakdown of the life expectancy gap by disease, males

3%

0%9%

0%

16%

10%

17%

46%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

00CC Barnsley MCD England Spearhead Group

All circulatory diseases, 33%

All cancers, 21%

Respiratory diseases, 16%

Digestive, 10%

External causes, 6% Infectious and parasitic diseases, 2%

Other, 9%

Deaths under 28 days, 4%

Gap in male life expectancy in Barnsley by disease

26

Potential impact of evidence-based interventions on reducing mortality numbers

InterventionDeaths

postponedTreatment population

NNT to postpone one death

Secondary prevention following CVD eventFour treatments (beta blocker, aspirin, ACE inhibitor, statin)

Currently untreated: CVD deaths averted 31 4,335 136

Currently partially treated: CVD deaths averted 61 15,335 253

Additional treatment for hypertensives

Additional hypertensive therapy 62Statin treatment for hypertensives with high CVD risk 27

Warfarin for atrial fibrillation >65 years

Stroke deaths averted 17 609 35

Improving diabetes management

Reducing blood sugars (HbA1c) over 7.5 by one unit 13 3,092 232

Treating CVD risk among COPD patients

Statins for eligible mild & moderate COPD patients 45 1,833 40

Total 258 - -

38,053 425

NNT = Number Needed to Treat to postpone one death

27

Aim: Deliver a short-term plan to place the PCT on a target AAACM trajectory for males

The Plan: Focus on six evidence based interventions:1. Full implementation of evidence based treatments for patients with CVD who are

currently untreated2. Full implementation of evidence based treatments for patients with CVD who are

currently partially treated3. Finding and treating undiagnosed hypertensives4. Moving patients on Atrial Fibrillation registers from aspirin to warfarin 5. Statins to address CVD risk among COPD patients. 6. Reducing blood sugar in diabetic patients

Expected Outcomes• Improved management of primary and secondary prevention of CVD• Postponement of up to 257 deaths from CVD if the interventions are fully

implemented, although this would depend on pace of incremental delivery • Achieving 38% of full implementation of all interventions would deliver the AAACM

target although again this depends on pace of incremental delivery

Using the model: a worked example (1)

Source: Rochdale PCT AAACM Recovery Plan, Nov 2010

28

Using the model: a worked example (3)

• Intervention:Statins to address CVD risk among patients with mild or moderate COPD

• Evidence Base: Observational studies show CVD is the leading cause of mortality among patients with mild and moderate COPD, yet CVD risk is often untreated among this patient group

• Treatment population: Aim to increase coverage from 26% to 66% of all COPD patients. (Current treatment coverage of 26% estimated from local audit of COPD registers plus estimate of undiagnosed COPD from APHO prevalence estimate.) Equates to an additional 2,450 COPD patients on a statin

• Outcomes: Estimated 55 deaths prevented (consistent with model which shows effect of additional 40% COPD patients on a statin)

• Costs: Recurrent costs of £95,000 (includes finding additional patients)

Case Study 2

Atypical situation – Blackpool PCT

29

30

Setting Ambitions: Best in Peer Group (Males)

Male All Age All Cause Mortality (AAACM) Rates by GP Consortia, 2008-10

*Peer group = PCTs in ‘Costal and Countryside ’ ONS area classification

31

Setting Ambitions: Best in Peer Group (Males)

Male All Age All Cause Mortality (AAACM) Rates by GP Consortia, 2008-10

*Peer group = Former Spearheads in the NHS North West Clinical Commissioning groups

32

Estimating the scale of the challenge : Summary

Reductions in mortality numbers necessary to meet 2014-16 targets

2008-10 2014-16 2008-10 2014-16 Required Expected Additional AAACM Ambition deaths Ambition reduction reduction reduction

(rate) (rate) (number) (number) (number) (number) requiredMales 932.3 693.9 2812 2093 719 281 438

Females 604.3 512.2 2771 2349 422 188 234

Persons 5583 4441 1142 469 673

Excess Male Mortality (%) Blackpool vs. All Spearheads

Excess Female Mortality (%) Blackpool vs. All Spearheads

Gap in male life expectancy in Blackpool by disease

36

Potential impact of evidence-based interventions on reducing mortality numbers

NNT = Number Needed to Treat to postpone one death

Proportionate Need for Levels of ARH Service Proportionate Need for Levels of ARH Service (not to scale)(not to scale)

Tier 1

Tier 2

Tier 3

Tier 4

er

Tier 1

Tier 2

Tier 4

Blackpool

Tier 3

Average Borough

Case Study 3

Good average health with pockets of deprivation

Kent CC

38

All age, all cause mortality rates, 3-year averages, Kent & Medway

Slope Index for Medway (Males)

Slope Index for Medway (Males)

Swale: Circulatory disease mortality by ward

Swale: Causes of excess mortality, worst quintile compared to rest

(Dis-)Integrated Commissioning for Population Health

Primary Care Direct Action

HWB

JSNA

HWBS

Commissioning

Primary Care

Commissioned Service

Primary Care Contribution to Health Improvement

CCG contribution

NHS Commissioning Board

Commissioning Services to Achieve Best Population Outcomes

Population Focus Optimal Population

Outcome

13.Networks,leadership and coordination

1.KnownIntervention

Efficacy

6.KnownPopulation Needs 12. Balanced Service Portfolio

11.Adequate Service Volumes

Challenge to Providers

10. Supported self-management

5. Engaging the public

9. Responsive Services

4. Accessibility

7. Expressed Demand 2. Local Service Effectiveness

8. Equitable 8. Equitable ResourcingResourcing

3.Cost EffectivenessC Bentley

2007

Improving Male Life Expectancy in Birmingham

48

Identifying Primary Care performance to outcomes

QOF registered prevalence and CHD Mortality(<75) in Oldham (MSOAs)

49

10.2 m

19.9 m

2.6 m

17.1 m

High Risk Have LTC Aware of LTC

Eligible for treatment

Optimal treatment

Compliant with treatment

5.7m2.6m 2.3m

1.3m 1m

2.8m1.8m 1.8m

0.4m Not known

0.9m 0.48m 0.21m 0.1m 0.08m

2.9m0.9m 0.52m 0.26m 0.14m

CHF

COPD

10.2 m

19.9 m

High Risk Have LTC Aware of LTC

Eligible for treatment

Compliant with treatment

CHD

Diabetes

NOTE: Figures are for UK. Taken from Harrison W, Marshall T, Singh D & Tennant R “The effectiveness of healthcare systems in the UK – scoping study”; Department of Public Health & Epidemiology and HSMC University of Birmingham, July 2006.

Disease management provided according to evidence-based protocols e.g. NSFs or NICE

guidance

Quality of delivery

CHD 6 - % patients whose last BP reading <= 150/90 (measured in last 15 months)

0%

20%

40%

60%

80%

100%

Practice code

Target Met Target Missed Exception Coded

CHD 6 - % patients whose last BP reading <= 150/90 (measured in last 15 months)

0%

20%

40%

60%

80%

100%

Practice code

Target Met Target Missed Exception Coded

Wakefield

52

Identifying the untreated patients (GP practice)

CHD: Expected vs QOF Registered Prevalence (Percentage)

A quarter of patients with a history of CHD are estimated undiagnosed (untreated)

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 Undiagnosed based on Expected Prevalence

53

Identifying the untreated patients (GP practice)

WAKEFIELD PCT

ALW – ‘thousands’ missing dementia diagnosis

54