The contribution of DPHs and teams to world class

commissioning

A regional perspective

11 September 2009

Dr Paul Cosford

The competencies (1/2)

1. Are recognised as the local leader of the NHS

2. Work collaboratively with community partners to commission services that optimise health gains and reductions in health inequalities

3. Proactively seek and build continuous and meaningful engagement with the public and patients, to shape services and improve health

4. Lead continuous and meaningful engagement with clinicians to inform strategy and drive quality, service design and resource utilisation

5. Manage knowledge and undertake robust and regular needs assessments that establish a full understanding of current and future local health needs and requirements

6. Prioritise investment according to local needs, service requirements and the values of the NHS

7. Effectively stimulate the market to meet demand and secure required clinical and health and well-being outcomes

8. Promote and specify continuous improvements in quality and outcomes through clinical and provider innovation and configuration

9. Secure procurement skills that ensure robust and viable contracts

10. Effectively manage systems and work in partnership with providers to ensure contract compliance and continuous improvements in quality and outcomes

11. Make sound financial investments to ensure sustainable delivery of priority outcomes

The competencies (2/2)

What do I hope for from the DPH and their teams?

• Source of objective advice– Based on agreed policy objectives, needs assessment and evidence

• Promotion of the wider health agenda– As a role for the NHS– As a role for local authorities– Illustrating the need to work across the public sector

• Monitoring effectiveness

• Taking responsibility for delivering health outcomes

• Corporacy – able to deliver through current priority programmes (eg QIPP)

• Able to react effectively to new problems (eg swine flu)

What do I hope for from the DPH and their teams?

• Source of objective advice– Based on agreed policy objectives, needs assessment and evidence

• Promotion of the wider health agenda– As a role for the NHS– As a role for local authorities– Illustrating the need to work across the public sector

• Monitoring effectiveness

• Taking responsibility for delivering health outcomes

• Corporacy – able to deliver through current priority programmes (eg QIPP)

• Able to react effectively to new problems (eg swine flu)

The context – policy underpinning commissioning

Survival in 20244 healthy men and women 40-79 years

EPIC-Norfolk 1993-2006 by health behaviour score

1 Non smoker1 Alcohol >0 <14 units/wk1 Not inactive1 Blood vitamin C >50 umol/l (5 servings fruit and vegetables daily)

0

0.2

0.4

0.6

0.8

1

1.2

0 1 2 3 4

Score

Re

lati

ve

ris

k

P<0.0001

Score 0-4

Equivalent 14 years

Khaw et al PLoS Med 2008 Jan 8;5(1):e12.

Costs across East of England:

72,000 elective admissions are smokers

Costs of Nicotine Replacement Therapy £300,000

Cost of staff time £430,000

Total for East of England £790,000

Cost per admission £3

 

Example – pre-op smoking cessation

 10% Quit rate 30 % Quit rate

  Episodes prevente

d

Cost saved Episodes prevente

d

Cost saved

HealthcareacquiredInfection

790 £2.3m 2400 £6.9m

Thrombo-embolism

95 £0.3m 280 £0.9m

Total 885 £2.6m 2680 £7.9m

Benefits of pre-op smoking cessation

What do I hope for from the DPH and their teams?

• Source of objective advice– Based on agreed policy objectives, needs assessment and evidence

• Promotion of the wider health agenda– As a role for the NHS– As a role for local authorities– Illustrating the need to work across the public sector

• Monitoring effectiveness

• Taking responsibility for delivering health outcomes

• Corporacy – able to deliver through current priority programmes (eg QIPP)

• Able to react effectively to new problems (eg swine flu)

Example – implementation of NICE falls guidance

Falls prevented 52,000

Admissions prevented 2,900

Costs saved £14m

Fractured neck of femur prevented

820

Bed days saved 21,500

Costs saved £3.6m

East of England data, if achieves 15% reduction in falls:

What do I hope for from the DPH and their teams?

• Source of objective advice– Based on agreed policy objectives, needs assessment and evidence

• Promotion of the wider health agenda– As a role for the NHS– As a role for local authorities– Illustrating the need to work across the public sector

• Monitoring effectiveness

• Taking responsibility for delivering health outcomes

• Corporacy – able to deliver through current priority programmes (eg QIPP)

• Able to react effectively to new problems (eg swine flu)

Luton

75767778798081828384

Low 20% Upp 80% Eoe

Monitor the life expectancy gap

Smoking prevalence - most deprived 20% vs other 80% by PCT

Source: East of England Lifestyle Survey 2008

What do I hope for from the DPH and their teams?

• Source of objective advice– Based on agreed policy objectives, needs assessment and evidence

• Promotion of the wider health agenda– As a role for the NHS– As a role for local authorities– Illustrating the need to work across the public sector

• Monitoring effectiveness

• Taking responsibility for delivering health outcomes

• Corporacy – able to deliver through current priority programmes (eg QIPP)

• Able to react effectively to new problems (eg swine flu)

Smoking Quitters 2008/09

PCT Actual Quitters Num Smokers Rate per 1000 Smokers1 2575 53784 47.9

2 2535 51542 49.2

3 2809 57779 48.6

4 3441 62399 55.1

5 1914 39366 48.6

Top performers 13274 264870 50.1

PCT Actual Quitters Num Smokers Rate per 1000 Smokers6 2707 56295 48.1

7 3049 76326 39.9

8 1768 77015 23.0

9 1432 37415 38.3

10 1454 31029 46.9

11 4263 117591 36.3

12 1312 28808 45.5

13 3870 82447 46.9

14 1454 71527 20.3

The rest 21309 578452 36.8

SHA Actual Quitters Num Smokers Rate per 1000 SmokersEast of England 34583 843322 41.0

Source: Quitters = Information Centre

Source: Number of smokers from East of England Lifestyle Survey

Focus on delivery

What do I hope for from the DPH and their teams?

• Source of objective advice– Based on agreed policy objectives, needs assessment and evidence

• Promotion of the wider health agenda– As a role for the NHS– As a role for local authorities– Illustrating the need to work across the public sector

• Monitoring effectiveness

• Taking responsibility for delivering health outcomes

• Corporacy – able to deliver through current priority programmes (eg QIPP)

• Able to react effectively to new problems (eg swine flu)

QIPP proposalsHeadline / Title:

Short description:

QIPP elements * Making it happen

• What are the main barriers for implementation?

• What needs to be in place in order to implement?

• What clinical engagement will be required?

• Is anyone doing it already?

• Estimated quality impact**

• Estimated productivity impact

• What innovation is required (if any)?

• Are there additional effects on the system?

* QIPP = Quality, innovation, productivity, and prevention** Initiatives should be quality-neutral or have a positive impact on quality

NHS Prevention

A systematic referral and service delivery system to address the four key lifestyle factors for health ( smoking, alcohol, diet & physical activity), and mental wellbeing. This would be available for referral by GPs & primary care professionals, clinicians in acute & mental health trusts, & healthy workplace leads within the NHS,wider public sector and private employers

• Practitioners do not know where to refer for effective interventions. This provides quality assured services & simple means of referral.

• Reduced demand for healthcare interventions.

• Reduced NHS sickness absence. • Increased productivity for whole economy.

• Links all clinical & social services, & health at work programmes to personalised assessment of lifestyle support needs & directory of approved lifestyle & IAPT services

• Supports culture of NHS as health as well as sickness service

• Delivers part of health and employment programme

• Impacts across NHS, public & private sector

• Lack of health & wellbeing advisors with consistent training (could be part of current role eg 2 nurses on a ward may take on this role for patients & peers)

• Inconsistent provision of effective services for all 4 lifestyle factors & IAPT

• Consistent definition & training for health advisers in primary & secondary care & within workplaces, inc behavioural psychology

• Directory of local approved services inc. IAPT, quitting support, alcohol brief interventions, free swimming etc

• Clinical support in primary & secondary care

• Occupational health support• Social care support

• No – this is an innovative & systematic development/alteration of health trainer role

CONFIDENTIAL AND PROPRIETARYAny use of this material without specific permission of McKinsey & Company is strictly prohibited

• Is it linked to the prevention agenda (if at all)?

• Systematises NHS prevention role • Underpins health at work for NHS, public &

private sector employers• Potential to improve lifestyle & reduce

dependency in older people

Falls preventionHeadline / Title:

Short description:

QIPP elements * Making it happen

• What are the main barriers for implementation?

• What needs to be in place in order to implement?

• What clinical engagement will be required?

• Is anyone doing it already?

• Estimated quality impact**

• Estimated productivity impact

• What innovation is required (if any)?

• Are there additional effects on the system?

* QIPP = Quality, innovation, productivity, and prevention** Initiatives should be quality-neutral or have a positive impact on quality

Falls prevention

Systematic implementation of NICE falls prevention guidance, with implementation co-ordinated between health and social care.

• Potential 15% reduction in falls, preventing 2,900 admissions, 820 fractures & 21,500 bed days in EoE.

• Potential £17m cost savings

• This is doing what we already know works but we don’t systematically implement.

• Innovation may be in engaging across health, social & third sectors to implement programmes.

• Reductions in costs of social care, attendance allowances, impact on carers and other support requirements

• Recognition of the potential impact• Prioritisation of reducing disability in

older people

• Leadership within PCT & co-ordination of approach across health & social care

• Training & capacity for falls risk assessments of community health & social care professionals

• Relevant clinical programme boards• Physicians in care of elderly• GPs, community nurses, social care

professionals

• SW Essex PCT & some others• Not systematic across all our services.

CONFIDENTIAL AND PROPRIETARYAny use of this material without specific permission of McKinsey & Company is strictly prohibited

• Is it linked to the prevention agenda (if at all)?

• Prevents exacerbation of ill health & maintains mobility & quality of life.

• Improves quality of life & reduces disability/dependency for older people

• Quality of health & social care interventions improved by attending to risks of wider harm to patients

Benefits of improving health & wellbeing at work

24

While most of the potential comes from GPs and pharmacies, there are large discrepancies in the performance of individual players

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GPs - Nr of referrals to PSSS and in-house service /Nr smokers in practice in 2008, Percent

Average today is 7%

Bottom of first quartile is 10%

If all reached bottom first quartile, average would be 12%

SOURCE: PSSS data: practice and pharmacy profiles, SmokingCessation2008, Team Analysis

Top quartile

Bottom 3 quartile

102

88

80

7266

47

3732

2928232020191616161614

88765542

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Pharmacies - Nr of smokers setting a quit date/Full time advisor over 12 months

Average today is 33

Bottom of first quartile is 37

If all reached bottom first quartile, average would be 45

31

25

There is a real opportunity to increase the number of quitters by engaging selected staff populations and improving the quality of the interventions

Pharmacies

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Hospitals*

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Today4 weeks quitters

GPs

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Potential4 weeks quittersIncrease Quantity

of interventions

IncreaseQuality ofInterven-tions

Potential to increase the number of quitters per year, Peterborough

Bases for impact calculation:

▪ GP practices: all reach minimum referrals levels achieved by practices in first quartile

▪ Pharmacy staff : all reach minimum ‘set quit date/advisor’ levels achieved by pharmacies in first quartile

▪ Midwives: refer 1 smoking mother out of 2 to the local stop smoking service (vs. less than 1 in 4 today)

▪ Nurses on other hospital wards: refer 40% of smoking patients to Stop smoking service, i.e. 8 patient per month per 25 bed ward or ~1 referral per staff per quarter (vs. 0.5 referral per staff per year today)

▪ Stop Smoking Service: Self referrals increasing by 50% (from 30 to 45 referrals per month) due to increased public awareness (halo effect)

* Includes midwifes, staff on in-patient wards and self referrals to local stop smoking service

SOURCE: Team analysis based on Peterborough Stop Smoking Service data

328

EoE FREE OF DEBT

-£290m-£152m

£90m

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2006 2007 2008

What do I hope for from the DPH and their teams?

• Source of objective advice– Based on agreed policy objectives, needs assessment and evidence

• Promotion of the wider health agenda– As a role for the NHS– As a role for local authorities– Illustrating the need to work across the public sector

• Monitoring effectiveness

• Taking responsibility for delivering health outcomes

• Corporacy – able to deliver through current priority programmes (eg QIPP)

• Able to react effectively to new problems (eg swine flu)

Able to manage a programme of change

Key elements of our approach8 steps leading to change (Kotter)

• Create a sense of urgency

• Develop a vision for the future

• Develop a powerful “guiding coalition”

• Communicate the vision

• Share the problem widely

• Empower people to act

• Get some short term wins

• Institutionalise the change

How can we do better?• Better co-ordination of evidence & policy at central

government level (IST model)

• New framework for integrated commissioning at a PCT/LA level

• NHS culture change to a stronger health as well as sickness treatment service

• New vision for primary care & general practice

• Incentives need better alignment

• Use of language