1. Joint Strategic Needs Assessment Bristol Case Study: Health Economics of Health Improvement? March 2012 Pat Diskett (Deputy DPH) Nick Smith (JSNA Project Manager)

2. Overview of the JSNA  JSNA is ongoing process to identify Bristol’s health and well-being needs - now & in the future  Jointly produced - City Council (Children Services and Adult Social Care ) and NHS Bristol, with input from LINk  Purpose is to help shape services, and inform future commissioning/development plans (resources)  Strengthened influence - new statutory Health and Wellbeing Strategy (plus CCG + NHS commissioning plans)

3. Bristol JSNA - Background  Joint Process – Council / NHS / partners /participatory  To improve health outcomes - now & in the future (priorities + re- position resources to meet changing needs) -> Strategic focus  Steering Group + “embedding” Strategy (as a Commissioning Tool)  2008 – 2010: 3-year cycle 2008 Baseline -> 2009 + 2010 Updates/refresh + gap filling  All JSNA Reports are at: www.bristol.gov.uk/JSNAwww.bristol.gov.uk/JSNA [or email: jsna@bristol.gov.uk]jsna@bristol.gov.uk

4. Joint Process - > JSNA Outputs Broad baseline report - minimum dataset Web based portal, data sharing, profiling tools Horizon scanning Pointers, address gaps –> work programme Workforce development and training Needs analysis; Evidence; Equity Audits Info + data sharing -> intelligence + dissemination Service review design and redesign Strategic Analysis + Prioritisation

5. JSNA 2010 and Economics  National policy changes + Recession  Difficult choices and efficiencies NHS = QIPP BCC = Re-Design (Quality Improvement, Productivity, Prevention)  Health Improvement versus Services?  Shift resources around the system?  Transparency and evidence?  Everything to everybody?

6. JSNA 2010  2010 Update is end product of 3-year cycle, building on JSNA Baseline and Atlas tool.  Strategic and economic elements to support Commissioning + Planning BUT need for worked local examples and a Conceptual Commissioning Model for Health and Wellbeing

8. The Approach (1)  Q 1: What are we spending now? (Benchmarks, Quality, Gaps, Outcomes)?  Q 2: Why are we doing this/What savings or efficiencies might be possible by doing things differently or investing differently? (Evidence + Assumptions + Outcomes -> Timeframe = “real” Efficiencies?)

9. The Approach (2)  Q.3 What might we need to spend in the future (what to include/exclude)? (Changing Needs, Trends, Projections, Evidence, new Technologies, Best Practice)?  Q.4 What if we do nothing?

10. The Approach (3)  Quick Wins (savings in year possible?)  Strategic Priorities – alignment ……………..a Pragmatic Approach  How good is good enough?

11. Economic Case Studies  Started with several (6-8 case studies) e.g. alcohol; smoking/cancer; diabetes; obesity/physical activity; dementia, children with disabling conditions and others (e.g. ageing and adapted housing)  How/Who: Volunteer Health Economist (Joe Ariyan) PH team (Consultants, ADsPH, PHIU, R&D, Clinical Effectiveness lead) BCC and PCT colleagues, Academic help

12. JSNA 2011: App’x 3– Lifestyles & Health Improvement  Rising trend in Bristol alcohol-attributable hospital admissions - indication of alcohol misuse in local pop’n:

13. Alcohol (1) Costs  April 2009 April 2010 = 3,278 admissions (Bristol hospitals) directly specific to /attributable to alcohol consumption (e.g. cirrhosis of the liver).  Each spell cost us on average £1,375 – a total bill for the year of about £4.5 million.  If able to prevent only 1 in 10 of these spells, this could still save us an estimated £0.5 million per annum at current costs.

14. Alcohol (2) Costs  ? Hospital spells partially due to excess alcohol consumption (e.g. a trip or a fall when drunk)  2009/10 = 6,966 spells in Bristol hospitals  Each spell cost on average £1,749 = total > £12.2 million  Programmes to reduce the level of drinking + prevent 1 in 10 of these spells could save an estimated £1.2 million of these costs.

15. Alcohol (3): But what if we do nothing?  Total NHS costs in Bristol attributable to alcohol admissions in 2009/10 = £16.7 million.  Projected costs in just 10 years’ time based on an analysis of recent trends and population changes are in the region of £22 - £33 million

16. Alcohol QIPP: Did it Work?  Impact on Commissioning Decisions and Resource Allocations?  A&E/Hospital based programme  Wet Clinic  Evaluation/Developing the Evidence-base

17. Alcohol related Harm (4): But what if we do nothing?  What about the total cost of health care of alcohol harm in Bristol, not just hospital stays?  It is estimated that this is £31 – £51 million in 2010, and, if we do nothing, it could rise to £43 – £97 million by 2020.

18. Obesity  Methodological Challenges  Modelling  Outcome/Results  Wider impact?

19. Dementia  Modelling – Scenario Generator  Care Pathway Issues  Programme Budgeting?

20. Challenges  Data and intelligence (Apples and Pears)?  Financial Information (NHS and LA)  Evidence of Effectiveness?  Tools, Benchmarking, Modelling and Assumptions  National Data Sets/Timeframes/Advice  Skills, Expertise, Methodological challenges (Obesity -> Academic Approach) and Version control

21. So how are we doing (1)?  JSNA Outputs and Outcomes - Fit for Purpose?  Do commissioning priorities reflect the JSNA? [evidence of effectiveness]  How to better integrate JSNA in current and new commissioning processes e.g. ? CCGs/GPs “wants”?  How can commissioners better contribute to JSNA (and economic analysis)?

22. How are we doing (2)?  Commissioning needs met? - What areas of need are priority for more economic information/Intelligence? - What intelligence would better support de- commissioning and re-commissioning?

23. What Next: How can we make the JSNA “Truly Strategic”?  Programme Budgeting?  New Tools/Techniques/Academic Support?  Role of CCGs? GP Data?  Role of Local Authority? PHE?  H&WB Strategy?

24. Baseline report Horizon scanning Horizon Joint Health & Wellbeing Strategy Taking the JSNA forward ows gap analysis JSR Joint Service Reviews JSNA Joint Strategic Needs Assess- ment Know- ledge gap + gap analysis

25. Final Thoughts  Good Intelligence and High Level Strategic (Economic) Analysis is …. still no guarantee of effective decision- making……………