Public Health Intelligence What is it ? The role of PHI in the NHS Evidence- The key to v GP consortia commissioning Margaret Eames Head of Public Health Intelligence The Acorns Public Health Research Unit 1

PHI-what is it? 1.Information- to support PH and commissioning- 2.Inference – using statistical models to show how health variables ( eg obesity,and smoking) relate to other determinants for shaping fairer local health policy changes 3.Integration and Partnership working with DPHs, commissioners and LAs-saving money for better health outcomes 2

PHI-what is it ? 1.Information-  Produce local PH evidence.  GPs /LAs need to know benchmarks for their health profiles, time trends, comparative outcomes across LAs, within LAs, across Regions, and across England for best commissioning. 3

Child Health  An example  - not all health data is held by GPs 4

National Target – Childhood Obesity “To halt, by 2010, the year-on-year increase in obesity among children under 11” (from 2002 baselines)  GPs /LAs need to know baselines, and areas of most need  Joint responsibility health, education and sport.  Data – Information –PHI –communication- partnership – intervention- monitor data, (PHI) record evidence of improvement (or not)-  Evidence of what works. 5

Summary of Findings: Childhood Obesity in Bedfordshire & Hertfordshire (2005) Childhood Obesity in Bedfordshire & Hertfordshire (2005) Herts and Beds Public Health Intelligence Team (NHS) Margaret Eames & School nurses from Beds and Herts CHANGING CHILDREN’S LIFESTYLES- Reducing Childhood Obesity 6

Choosing Health Evidence from Bedfordshire & Hertfordshire  Changing Childrens’ Lifestyles 1.Measure the baselines Weights and heights measured by school nurses (for BMI) for Weights and heights measured by school nurses (for BMI) for 2.All Children aged 5 for entry to school in 1998 and 2002 in Herts, Beds and Luton 7

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Boys Overweight (including Obese) 9

Girls Overweight (including Obese) 10

Demography and Intelligence  Life expectancy  Census 2011 Results % aged 75+% aged 75+ Reporting Health not good (maps)Reporting Health not good (maps) Long term Limiting IllnessLong term Limiting Illness Carers in the adult populationCarers in the adult population  Living in Medical or Care Establishments 11

% Aged

% living in medical and care establishments 13

Proportion in care establishements against % aged 75+ by PCT in E.Region 14

Relationship between percentage of carers (>20hrs pw) and % of the population with LLT illness by PCT in E.Region 15

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PHI-in the NHS 2.Inference - using statistical models for evidence to change local health policy Health Needs Assessment ;Health Needs Assessment ; Health Equity Audit/impact assessmentHealth Equity Audit/impact assessment Priorities;Priorities; Cost-effectiveness;Cost-effectiveness; 17

Inequity?  Inequality – the difference in the distribution of a health measure (by person or place)-univariate measure  Inequity – an inequality in the distribution of health intervention in relation to health need that is considered unfair -bivariate 18

Objectives for Improving Health Inequalities NHS improvement, expansion and reform should narrow the health gaps by:  ensuring that service planning is informed by a health equity audit and supported by an annual public health report by the Director of Public Health. Improvement, Expansion & Reform: The Next Three Years. (2004) Page 20 19

Health Equity Audit compares the provision of a service with a measure of the need for it Service Measure of Need x y 20

Inequity : those with most need get the lowest level of service- the undesirable “inverse care law” (this case even worse than –ve linear relationship) Service x y Measure of Need 21

Equity : high need is matched by high service provision- the desirable situation Service x y Measure of Need 22

Review progress & assess impact Ensure effective monitoring systems are in place using indicators etc Use data on Health Inequalities to support decisions at all levels: make appropriate comparisons by area, ethnicity, socio-economic group, gender, age etc Secure changes in investment & service delivery Ensure changes in contracts & commissioning are reaching areas & groups with highest need assess impact on inequalities Develop service delivery to match need Move resources to match need 5 6 Agree partners and issues Relate issues to service planning & commissioning, take opportunities where changes are planned Identify factors driving low life expectancy Take on views of front line staff and users Scope for joining up services with local government 1 Choose issue(s) with highest impact eg cancer, CHD, primary care, over 50s, infant health Agree priorities for action Identify highest impact interventions for effective local action, for example: Diet & physical activity Promoting healthy life styles in over 50’s Ensure choice, responsiveness & equity for all 4 Smoking prevalence Screening ‘flu vaccinations accidents Statins & antihypertensive Review progress Agree high impact local action to narrow the gap Quality & quantity of primary care in disadvantaged areas Commission new services, change or amend existing contracts Develop LIFT projects where health need is highest holistic services through partnerships 3 Address inequalities through NSF implementation Use data to compare service provision with need, access, use & outcome measures including proxies for disadvantage, social class, ward in the bottom quintile,BME, gender or other population group Focus on the third of population with poorest health outcomes 2 Equity profile: identify the gap Health Equity Audit cycle Identify local areas or groups where more action is required Assess the impact of action, has change been made and is it fast enough? 23

Smoking Cessation Uptake: Health Equity Audit in Beds and Herts QUIT RATE IS NOT ENOUGH! M.Eames and C.Dummett Beds and Herts PHI team 24

Smoking cessation uptake data  DH should use % Uptake from high Smoking Attributable Mortality areas(for targets) rather than quit rate alone, to measure service access 25

Some examples of health equity audit – Smoking -Welwyn Hatfield PCT males Quit rate 59% (2002-3) 26

Health Equity audit: Smoking St Albans PCT males Note : St. Albans had the lowest overall SMR in the SHA and is considered a “healthy, rich PCT” (Fig 1). But this figure and the high quit rate of 68% disguises the inequity of uptake of SCS between wards within the PCT. The negative and low r indicates poor wards without smoking cessation services, SCS (e.g Sopwell). Quit Rate= 68% 27

St.Albans Male smoking cessation uptake against smoking attributable mortality for all males age 35 years and over ( ) Fig 2a)Fig 2b) 28

PHI-in the NHS and LAs 3.Integration and Partnership Sharing Intelligence with LA, GPs and other Partners.Sharing Intelligence with LA, GPs and other Partners. Sharing Resources, enabling joined up programme budgeting, observing overlapping rolesSharing Resources, enabling joined up programme budgeting, observing overlapping roles Participating in Communication, and decision- makingParticipating in Communication, and decision- making 29

Public Health Issues in Bedfordshire and Luton How to make a difference-by health partnerships Public Health Issues in Bedfordshire and Luton How to make a difference-by health partnerships Bedfordshire County Council – Bedfordshire County Council – GPC’s coterminous with LAs for meaningful partnership? 30

GP partnership with PH and LAs- for better health outcomes  Making healthy choices easier  Informed choice  Personalisation  Working together Key Health Areas  Stop smoking,  Reduce obesity,  Increase exercise,  Sensible drinking,  Improve sexual health,  Improve mental health 31

“Enabling children to choose health” “Enabling children to choose health” Local Policy – making a difference  Our local evidence was used to invite tenders from LAs (schools and communities with most need in Hertfordshire) for  “RUFit 4IT funding”.  Money allocated to projects based on evidence, aimed at reducing childhood obesity- within 6 months 32

Demography and Wider Determinants of Health  Age and Distribution of the Population  Black and Ethnic Minority distribution  Social Class- occupation  Public Transport accessibility  Housing  Access to play areas and green spaces  Education, knowledge of healthy eating  Lifestyle Choices e.g smoking, alcohol  Locus of control at work(improving working lives) 33

Bedfordshire Heartlands PCT Bedford PCT Luton PCT Total Population: 185,165 Over 75's: 5.20% Under 15's: 21.42% Total Population: 149,907 Over 75's:7.19% Under 15's: 19.12% Bedfordshire Population pyramids Age and Gender Distribution (2003) 34

Other Key Health Indicators  Low Birth weight  Teenage Pregnancy  All Cause Mortality  Life expectancy  All Cancer Mortality  Lung cancer mortality  Smoking attributable mortality  CHD and MI mortality 35

The Hub and Spoke Model of Public Health Intelligence for GP consortia within a Public Health Network  county councils or unitary authorities;  PH network –GP consortia- replacing PCTs 36

PHI- its role in the NHS Career, Training and recruitment – Valuing the skills and training needed for good statistical analysis in public health.Valuing the skills and training needed for good statistical analysis in public health. Understanding good design of data collection,Understanding good design of data collection, and quality of data Robust statistical analyses needed alongside finance data, projections and modelling for decision-making.Robust statistical analyses needed alongside finance data, projections and modelling for decision-making. for appropriate PCT, LA, and GP commissioning, for appropriate PCT, LA, and GP commissioning, (not just excel spread-sheet skills!) (not just excel spread-sheet skills!) 37

PHI- valuing statistical skills Career, training and recruitment – (ctd) PHI is a new career pathway in the NHS (AFC)PHI is a new career pathway in the NHS (AFC) Now a defined specialist area recognised by FPHNow a defined specialist area recognised by FPH Growing field of work in the NHS (most medical statisticians in academic or pharmaceutical world)Growing field of work in the NHS (most medical statisticians in academic or pharmaceutical world) but we NEED them in the NHS. PHI teams -nerve-centre – a place of trainingPHI teams -nerve-centre – a place of training 38

The current challenges: GP commissioning outcomes need to be measured by local PHI (past and future)- not much in White Paper. PHI –the bridge between PH and GPCs 1)Will consortia be co-terminous with LA boundaries to match PHI data ? 2) Can GPC’s share the role of commissioning across LAs by each having specialist clinical fields? 3) Joint programme budgets in the LA/GPC (social care/health) ? 39

Contact Address Margaret Eames Head of Public Health Intelligence The Acorns Public Health Research Unit 38, Hazel Grove Hatfield Herts AL10 9DN ( ) Website :

PHI for GP commissioning Over to you ! Any questions? 41