Developing a performance framework to support the life expectancy & health inequalities PSA target Dr Heather Grimbaldeston Deputy Director for Public Health North West NHS: Greater Manchester With thanks to : Alayne Robin – Assistant Director Christopher Harwood – PH intelligence manager

sections 1. Greater Manchester profile 2. Life expectancy and inequalities analysis 3. LDP process (£/activity) 4. Performance management framework 5. Developing a Delivery system 6. Outcomes, Challenges, Next Steps

England: Strategic Health Authority Boundaries & North West

Greater Manchester PCTs Bury PCT Ashton, Leigh and Wigan PCT Bolton PCT Salford PCT Oldham PCT Tameside & Glossop PCT Stockport PCT Manchester PCT Trafford PCT Rochdale PCT Local Authority boundary. Newly formed PCTs PCTs (unchanged)

Profile of Greater Manchester Population of approx 2.5 m (ONS, 2005; Mid-yr Pop. Est.) 1425 sq kms (550 sq.mls) The ethnicity profile: 8.8% compared to England figure of 9.1%. Variation: 1.3% (Wigan), 31.3% ( Central Manchester) (2001 census) 10 Acute Trusts, 1 Mental Health & Social Care Trust, 3 Mental Health Trusts 10 (from 14) Primary Care Trusts with a constituted Association of PCTs Previously 1 Ambulance Trust (Greater Manchester Ambulance Service) 10 Local Authorities with a constituted Association of Greater Manchester Authorities Greater Manchester Police Manchester Enterprises ( Greater Manchester Economic Development)

Programme Budget expenditure by PCT Total expenditure - £3b for weighted population of 2.8m (2004/5)

Percentage of Super Output Areas in the lowest quintile per Greater Manchester PCT (Index of Multiple Deprivation 2004)

My Challenge Implement a performance management framework PH Support the development of the PH network Improve health population and reduce inequalities (working with others) With –14 new PCTs –functioning but embryonic PH network –Cancer and CHD clinical networks GM wide leadership – aims/priorities (what did PH system need to do?) Coordination (how could the system deliver individually/together) Performance manage (develop role SHA) Step 1 - in house expertise Step 2 - set goal –Improve LE (hit target) –Stop being the worst

Life Expectancy at Birth,

LIFE EXPECTANCY & HEALTH INEQUALITIES ANALYSIS Current position, contributors: CHD, cancer with increasing contribution from alcohol Analysis of what’s required to achieve PSA target (increase life expectancy in England to 78.6 years for men and to 82.5 years for women and reduce the gap by 10%) Trawled for studies show that improving treatments and reducing risk factors works Calculation of additionality (what did we need to do to get off the bottom?)

Improvements are realistic & achievable Reducing the death rate from CVD

ANALYSIS OF IMPACT OF INTERVENTIONS Improving treatments and reducing risk factors works In 2000:30-60% eligible treated, 80% saves 21k more lives pa or ~ doubles benefit. (GM: 1000 pa / LE men 6mths, women 4mths) Local analysis shows lives saved from implementation of CVD predictive registers would save approximately 2000 lives over a 5 year period Reductions within 1-4 years of cholesterol reduction / quitting smoking impact of alcohol on life expectancy in north west – reducing life expectancy by 10.5 mths for males and over 6 mths for females

Planning & Prioritisation Analysis of position and intervention impact provided 10 point plan: Heart disease & stroke ( including diabetes as a risk factor) Cancers – lung, bowel and breast cancers Suicides and undetermined injuries Drug Misuse Reducing excess winter deaths Obesity Improving sexual health Alcohol misuse Infant mortality NHS as a Good Corporate Citizen

6 priority areas for action? Move from what to how Stopped talking about ph Started talking –NHS interventions –Small number of priorities –Things that would work quickly Link to mainstream –31/62 day cancer –4 hr A/E target Got LDP’itis –Manage LDP process internally (priority 1) –Offer to support all PCTs in crafting trajectories Identifying and treating people at 20% risk of cardiac event in next 10yrs using predictive registers Early identification and acceleration of diagnosis of cancers at start of care pathway Reduced impact of alcohol Reduced deaths from suicide (in contact with services) Reduce smoking prevalence Reduce obesity

Maximising the LDP process Negotiating local targets with PCTs Stretch targets for CVD & cancer mortality for ALL Early achievement of targets for CVD in primary care (predictive registers, BP, Chol.), CPA 7DFU Stretch target for smoking prevalence Stretch targets for contributors to infant mortality Securing the finances The Choosing Health indicative allocation for Choosing Health LDP was £22m (secured at 1 st cut) Now secured £18m in addition to £3m for CVD, cancer & suicide prevention

Achieving the PSA Target: LDP Stretch Targets

Engaging the drivers Presentations & papers to – SHA cancer, cardiac, MH network boards Non executive, chair champions Away day –No system wide mandate –No ‘non SHA translator’ –DsPH to work more collaboratively

Establishing the delivery system May 2005 PCT CEx –System wide mandate –Framed: ‘can do’, LDP –Commence managed hand over DsPH charged with presenting a delivery plan within 2 months July 2005 – joint papers to SHA and PCT CEx, delivery plan, delivery structure

Setting up a performance management process (1) Performance management framework Report card to chief executives Quarterly reports: what this includes: report card, movement card, trajectory report Escalated monitoring Communication to health economy: performance leads, DPH Group, CE’s PCT performance reviews

Performance Movement Card

Performance management (2) PCT performance reviews: With SHA senior team – DoP and DPH/Deputy, PCT CE and Directors Briefings provided before hand on areas of progress and concern Follow up actions Mechanism for raising profile and progressing priority areas.

Health inequalities gap in life expectancy: men

Health inequalities gap in life expectancy: women

Tensions in the process Appropriateness of using life expectancy as a performance management target Leadership - who Prioritisation - how much NHS contribution to life expectancy v wider determinants contribution Delivery systems: public health or project management? Added value of Greater Manchester collaboration LDP resources ( more than Choosing Health) Is there added value from focus on Spearheads Does the DH life expectancy health inequalities analysis add value at local level Does plurality & choice etc mitigate against inequalities agenda

Outcomes from the process Secured a mandate from key stakeholders Secured the financial resources (£18m choosing health, £3m other, >£500k mgt support) Set up a clear whole system delivery mechanism with project management Set up a performance management system Local engagement – talking, innovating, CHD brief intervention plans

How will success be measured? Achievement of local stretch targets Closing the health inequalities gap Greater Manchester life expectancy not worst in country What are the challenges? Maximising practice based commissioning Strengthening commissioning for health improvement Maintaining delivery during re-configuration, larger footprint, leadership v grip To strengthen role of Acute Trusts, IDS, FT etc in health inequalities agenda Manage impact of competing policy initiatives – choice, pleurality Keeping ahead of the game Incentivising success, penalties for failure

Next steps Further detailed analysis ( e.g. CVD prevalence) Regular and more frequent monitoring Maximising use of partners – City Regions, Audit Commission Engage with the public Develop chief executive /advocacy role Identifying and sharing the successes Supporting the delivery board

Questions and Certainties ?Less ‘in house’ testing ?More time collaborating with DsPH ?Secured the most appropriate leadership package for DsPH sooner ?Gone to CEx sooner (but after LDP) ?Target Acute/MH trusts ?Less time to get Director in post In house expertise Limited number of priorities, NHS focus Link to LDP Lead C.Ex Delivery plan and board Non PH Director Robust performance management DON’T GET DISTRACTED