HINST
Associates
Finding the missing thousands to
address health inequalities
Professor Chris Bentley
Well being
and Health
Physiological risks
High blood pressure
High cholesterol
Stress hormones
Anxiety/depression
Behavioural risks
Smoking
Poor diet
Lack of activity
Substance abuse
Risk conditions – e.g.:
Poverty
Low social status
Unemployment
Dangerous environments
Discrimination
Steep power heirarchy
Gaps/weaknesses in
services and support
Ronald Labonte
Psycho-social risks:
Isolation
Lack of social support
Poor social networks
Low self-esteem
High self-blame
Low perceived power
Loss of meaning/purpose of life
Health &
Well being
Health Seeking
Behaviour
Risk conditions – e.g.:
Poverty
Low social status
Dangerous environments
Discrimination
Poor education
Unemployment
Steep power hierarchy
Gaps/weaknesses in
services and support
Physiological risks
High blood pressure
High cholesterol
Stress hormones
Anxiety/Depression
Behavioural risks
Smoking
Poor diet
Lack of activity
Substance abuse
Psycho-social risks:
Isolation
Lack of social support
Poor social networks
Low self-esteem
High self-blame
Low perceived power
Loss of meeting/purpose of life
After Labonte
Health Inequalities
Different Gestation Times for Interventions
For example intervening to reduce risk of mortality in
people with established disease such as CVD, cancer,
diabetes
A
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
B
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
C
2005
2010
2015
2020
Improving Male Life Expectancy in Birmingham
Disease management provided according to evidence-based
protocols e.g. NSFs or NICE guidance
High Risk
Have LTC
Aware of
LTC
Eligible for
treatment
2.6m
2.3m
Optimal
treatment
Compliant with
treatment
5.7m
CHD
1.3m
1m
0.4m
Not known
0.21m
0.1m
0.08m
0.52m
0.26m
0.14m
10.2
m
2.8m
Diabetes
CHF
1.8m
19.9
m
2.6 m
0.9m
0.48m
1.8m
2.9m
COPD
17.1
m
0.9m
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.
6
Benefit from evidence based interventions across populations
(not to scale)
Have the
problem
Aware of
problem
Eligible for
intervention
Aware of
problem
Eligible for
treatment
Optimal
input
Best use
of systems
Cold damp housing/
Affordable warmth
Have the
problem
Managing alcohol
Related harm
Optimal
therapy
Compliance
with therapy
Benefit from evidence based interventions across populations
(not to scale)
Have the
problem
Eligible for
treatment
Aware of
problem
A
B
Compliance
with therapy
Optimal
therapy
C
D
A. Discovery and presentation
Reasons why people do not present to services
• Geographical eg distance from clinic/practice; complex journey
• User unfriendly service access: frosty, bureaucratic reception;
cultural/interpreter problems; perceived discrimination; appointment
systems; access delays; opening hours; cost barriers
• Community knowledge, understanding, beliefs and expectation:
about condition; about services; about life; stigma
• Personal beliefs and skills: demotivation; low expectations; low selfconfidence; poor literacy; low-IQ etc
(Angela Tod, 2001)
Corrective strategies need to explore each of these elements
systematically
Similarities and differences between clinical
audit and equity audit
Health equity audit is different
Health equity audit is similar to
from clinical audit because it:
clinical audit because it:
• Is a tool primarily for resident
• Involves a cyclical process for
populations, not just service users
improving health-related services
• Includes setting targets or standards • Focuses on defined local populations
(by socioeconomic group, age,
for particular groups or services
gender, geography or Protected
• Is undertaken by partners who
Equity Group)
deliver the services
• Has the primary aim of improving
• Aims to facilitate positive learning
health outcomes for disadvantaged
about evidence-based practice
communities
• Is concerned with the wider
determinants of health, as well as
health and social care issues and
services
Supporting discovery and presentation
• Community engagement and support
Doncaster Early Lung Cancer Identification & Diagnosis (ELCID)
•
•
•
Insight
Intelligence based promotional materials
Conscript community leadership/Champions
Community Health Champions programmes
• Service outreach
Use of community venues (Knowsley Tobacco –’Help is just
around the corner’)
Health trainers
Supporting discovery and presentation
• Making Every Contact Count
–
–
–
–
–
Do programmes include?:
Systematic training on strategies and key screening questions
Brief intervention training and updates for some
Specific referral pathways from all major sites and teams
A monitoring system of referrals to specialist support
measures to drive improvements in staff health
5 level delivery plan (Government response to Future Forum 2)
Does the approach involve collaboration between commissioners and
providers in health, but also extend to Local Authority commissioned
services?
• Systematic search
– E.g. Gravesend pulse check – note flagging
NHS Bolton 2006/07
Expected v Registered Prevalence of major QOF conditions
25%
22.9%
20%
15%
PCT Registered
PCT Expected
10%
5.2%
4.5%
11.9%
5%
4.2%
3.7%
0%
Coronary Heart
Disease
Hypertension
Diabetes
Vascular Checks in Bolton
• Everyone must be
involved
– Staff
– Public
– Local media
•
•
•
•
Outreach
Health trainers
Local enhanced service
Near patient testing
• Bolton PCT are clear that the following outcomes were
achieved:
– Preventing Heart Disease
– Improved performance ‘Beyond QOF’
– Better Diabetes, Hypertension, CKD registers (eg 800
more registered diabetics by)
– Better Primary Health Care Teams
– Better Primary Prevention Registers
– 9,097 on register at 2007
– 24,000 on register at 2009
– Expectation of lives saved
www.NHSInstitute/NSTresources/Masterclasses
Health and Wellbeing Boards should
provide an excellent platform for more
systematic engagement with
communities, families and individuals
currently not connecting appropriately
with health services
Benefit from evidence based interventions across populations
(not to scale)
Have the
problem
Eligible for
treatment
Aware of
problem
A
B
Compliance
with therapy
Optimal
therapy
C
D
B. Diagnosis and Registration
Reasons for non-registration
• They have been diagnosed, but missed off the register
• They have been identified as possible, but without confirmed
diagnosis
• They attend the practice, but the issue has not been raised
• They rarely, if ever, attend the practice
• They are not registered with a practice
BP control in CHD
BP control in CHD
The most deprived patients are not recorded with
higher disease burden (except for COPD and Mental Health)
Prevalence of major diseases in upper and low er quartile
QOF 2006/07
35%
most deprived
least deprived
30%
25%
20%
15%
10%
5%
R
A
C
AN
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TI
EN
D
EM
R
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YP
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EL
BE
D
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TU
TY
SI
PD
O
C
TA
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H
EA
LT
H
0%
21
Islington CVD Mortality Audit
Benefit from evidence based interventions across populations
(not to scale)
Have the
problem
Eligible for
treatment
Aware of
problem
A
B
Compliance
with therapy
Optimal
therapy
C
D
F840
F84004
0
F840 6
09
F840
F84010
1
F840 4
1
F840 7
2
F840 2
F84032
4
F840 7
5
F840 0
F84052
5
F840 3
F84070
7
F840 4
77
F840
F84086
8
F840 8
8
F840 9
9
F840 0
F84091
9
F840 2
9
F840 3
F84197
2
F841 1
F84624
3
F846 1
41
F846
F84642
5
F846 4
5
F846 7
5
F846 8
6
F846 0
F84661
6
F846 2
F84666
6
F846 9
7
F846 0
7
F846 1
72
F846
F84673
7
F846 7
F84679
8
F846 1
9
F847 9
F84700
0
F847 6
F84707
0
F847 8
1
F847 3
1
F847 7
22
F847
F84724
2
F847 7
F84728
2
F847 9
3
F847 0
F84734
3
F847 5
F84736
3
F847 9
4
F847 0
4
F847 1
4
F847 2
Y00 2 49
25
C. Quality of Care
CHD 6 - % patients whose last BP reading <= 150/90 (measured in last 15 months)
100%
80%
60%
40%
20%
0%
Practice code
Target Met
Target Missed
Exception Coded
C 8 60
01
C 8 60
02
C 8 60
03
C 8 60
05
C 8 60
06
C 8 60
07
C 8 60
09
C 8 60
11
C 8 60
12
C 8 60
13
C 8 60
14
C 8 60
15
C 8 60
16
C 8 60
17
C 8 60
18
C 8 60
19
C 8 60
20
C 8 60
21
C 8 60
22
C 8 60
23
C 8 60
24
C 8 60
25
C 8 60
26
C 8 60
29
C 8 60
30
C 8 60
32
C 8 60
33
C 8 60
34
C 8 60
37
C 8 60
38
C 8 60
39
C 8 66
03
C 8 66
04
C 8 66
05
C 8 66
06
C 8 66
09
C 8 66
11
C 8 66
12
C 8 66
13
C 8 66
14
C 8 66
16
C 8 66
21
C 8 66
23
C 8 66
25
C 8 66
26
C 8 66
29
A High Performance PCT
CHD 6 - % patients whose last BP reading <= 150/90 (measured in last 15 months)
100%
80%
60%
40%
20%
0%
Practice code
Target Met
Target Missed
Exception Coded
Spearhead City
QOF % non-clinical points
achieved
QOF non-clinical score by GP practice and de priv ation
100.0
95.0
90.0
85.0
80.0
75.0
70.0
65.0
60.0
55.0
50.0
0.0
20.0
40.0
60.0
Ward deprivation s core (2004)
80.0
Diabetes care in a low deprivation HWB area
DM 23 - % patients whose HbA1C <= 7 or equivalent test/reference range depending
on local laboratory (measured in last 15 months)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Practice code
Target Met
Target Missed
Exception coded
Falling through the
referral gap and
duplication of care.
Level 1
Level 2
Level 3
Level 4
Level 5
Primary Care
Specialist Care
Level 1
Level 2
Specialists working in
Primary Care improve
skills within primary care.
Level 3
Level 4
Level 5
Primary Care
Specialists working in
Primary Care
Specialist Care
Referral for advice
and management plan
Result is reduction of
specialist input
Benefit from evidence based interventions across populations
(not to scale)
Have the
problem
Eligible for
treatment
Aware of
problem
A
B
Compliance
with therapy
Optimal
therapy
C
D
D. Support for Self Management
What support is systematically available
to improve self-management?
• Education and training for patients
• Support materials
• Supportive staff time
• Support groups
Is adherence to treatment followed up?
Are social marketing principles applied?
Case Study
• London Borough. Local High Profile Teaching Hospital
with Award Winning diabetes services, including Beaconstatus Self-managed Care Training (Daphne;Desmond)
• Patients through training annually = 230
• Newly diagnosed diabetes annually = >1000
• Patients with HbA1c < 7.4 = < 40%
Missing system, scale and sustainability
Inequality (in access) is an important part of quality
Case Study
• Hospital based Pulmonary Rehab programme for COPD.
Long waiting list. High drop-out rate.
• Patient based review, specifically targeting nonattenders/non-completers. One size didn’t fit all.
• So:
Mild
Moderate
Severe
Good Self
Manager
Fair Self
Manager
Poor Self
Manager
Pursuing Perfection 2005
Commissioning Services to Achieve Best Population Outcomes
Population Focus
10. Supported selfmanagement
9. Responsive Services
Optimal
Population
Outcome
Challenge to Providers
13.Networks,leadership
and coordination
12. Balanced Service Portfolio
8. Equitable Resourcing
C Bentley
2007
4. Accessibility
2. Local Service
Effectiveness
7. Expressed Demand
6.Known
Population
Needs
5. Engaging the public
1.Known
Intervention
Efficacy
3.Cost Effectiveness
11.Adequate Service Volumes
For video Google
Chris Bentley Christmas Tree
For resources
www.hinstassociates.com