Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
Aneurin Bevan Health Board
Living Well, Living Longer: Inverse Care Law Programme
1
Introduction
The purpose of this paper is to seek the Board’s agreement to a set of
priority statements for an Inverse Care Law programme and to the
development of a fully costed implementation plan to be considered at
the January 2014 meeting of the Board.
The Primary Care & Networks Division and Aneurin Bevan Public Health
Division are working together to develop and implement a programme
aimed at reduced the gap in life expectancy between the most and least
deprived areas in Aneurin Bevan University Health Board. Welsh
Government has set up an Expert Group, led by the Chief Medical Officer,
which provides advice on the direction, scale and pace of the programme.
The Board is asked to:
Note the contents of this paper.
Agree that the programme will commence in Blaenau Gwent West
Neighbourhood Care Network.
Agree the 5 Priority Statements.
Financial
Assessment
and link to
Financial
Recovery Plan
Risk
Assessment
Whilst there is a need to appoint a Programme
Manager, there will be no additional investment
required for the planning and design phase of the
programme. Costs will be met from the Division of
Primary Care and Networks and the Public Health
Division for 13/14. Additional investment will be
needed to fully implement the programme from
2014/15, although this is yet to be quantified. This will
be worked through and presented to the Board in
January 2014.
There is an expectation from Welsh Government and
partners that the Health Board will design a
programme for tackling the legacy of the Inverse Care
Law in services in deprived areas. The Chief Medical
Officer has written to the ABHB Chief Executive
regarding the challenges of capacity within primary
care services.
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Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
NHS Delivery
Framework
and
Annual Quality
Framework
NHS Delivery Framework
The NHS Delivery Framework for 2013-14 includes a
new Tier 1 target for smoking cessation. The target
is for 5 per cent of smokers making a quit attempt with
the support of any smoking cessation service, with at
least 40 per cent CO validated quit rate at 4 weeks.
Primary care has a major role in delivering this target
alongside Stop Smoking Wales, especially through
Community Pharmacy.
There is also an indicator
under the Quality & Safety domain on reducing
circulatory disease mortality rate in patients under 75
years.
Together for Health Delivery Plans
The Heart Disease Delivery Plan (2013) states that
develop and deliver local strategies and services to
tackle underlying determinants of health inequality and
risk factor for coronary heart disease. It sets out the
need to target resources in population areas of high
risk.
The Stroke Delivery Plan (2012) states that health
boards should work through their locality networks to
plan and deliver a more systematic and coordinated
approach to identifying those at risk of vascular
disease and manage that risk effectively.
Delivering Local Health Care
Delivering Local Health Care calls for a collaborative
approach to achieve a measurable closing of the gap in
health outcomes between the most and least deprived
areas. Aneurin Bevan University Health Board has
been identified by Welsh Government as a pathfinder
in action to tackle the Inverse Care Law with agreed
targets to be met by April 2016.
Poverty Action Plan for Wales (2012-16)
The Poverty Action Plan for Wales sets out an aim to reverse
the Inverse Care Law and identifies Communities First as a key
NHS partners.
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Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
Standards for
Health
Services
Wales
The programme aims to provide population scaled
primary care services that will meet the following
requirements in Standards for Health Services in
Wales:
Standard 3:
improvement
Health
promotion,
protection
and
Organisations and services work in partnership with
others to protect and improve the health and wellbeing
of citizens and reduce health inequities by:
a) supporting citizens to maintain and improve their
health, wellbeing and independence;
b) promoting healthy lifestyles and enabling healthy
choices;
c) ensuring that needs assessment and public health
advice informs
d) service planning, policies and practices;
e) having effective programmes to screen and detect
disease.
Standard 6: Participating in quality improvement
activities
Organisations and services reduce waste, variation and
harm by:
a) identifying and participating in quality improvement
activities and programmes;
b) supporting and enabling teams to identify and
address local improvement priorities;
c) using
recognised
quality
improvement
methodologies;
d) measuring and recording progress; and
e) spreading the learning.
Equality
Impact
Assessment
This programme will specifically reduce inequalities by
focussing on early detection of those at high risk of
developing disease and patients that are sub-optimally
treated or not in meaningful contact with services. It
has a specific focus on equality by understanding the
barriers people experience in accessing services that
will enable achievement of their full health potential.
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Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
2
Background/Policy Context
The ‘Inverse Care Law’ was first described by Julian Tudor Hart in 1971. It
states that, “the availability of good medical care tends to vary inversely
with the need for it in the population served”
‘Delivering Local Health Care: Accelerating the Pace of Change’, published
by Welsh Government, provides a framework for action for health boards,
local government and third sector partners to work together, to provide
high quality, safe and sustainable services to meet the needs of local
people.
The plan calls for a collaborative approach to achieve a
measurable closing of the gap in health outcomes between the most and
least deprived areas. Aneurin Bevan University Health Board and Cwm Taf
Health Board have been selected as pathfinders to tackle the health
inequalities that have arisen as a result of the legacy of the Inverse Care
Law. The following milestones in Delivering Local Health Care are relevant
to the Inverse Care Law programme:
By September 2013, Health Boards to develop a locality level assessment
of population need. Locality network plans to be updated to include specific
action to respond to this assessment.
By October 2013, Health Boards and locality network leadership teams to
assess the level of maturity of each locality network and agree a
development plan to achieve full maturity (level 4) by March 2015.
By December 2013, Health Boards in the two selected areas covered by
the Inverse Care Law programme [Aneurin Bevan University Health Board
and Cwm Taf], to take necessary action to ensure there is a review of
smoking prevalence, hypertension and cholesterol, with agreed targets to
be met by April 2016.
The Welsh Government’s Heart Disease Delivery Plan highlights the need to
develop and deliver local strategies and services to tackle underlying
determinants of health inequality and risk factor for coronary heart disease.
It sets out the need to target resources in population areas of high risk
(such as areas of deprivation) and focus on actions that have high impact.
The Stroke Delivery Plan also states that health boards should work
through their locality networks to plan and deliver a more systematic and
coordinated approach to identifying those at risk of vascular disease and
manage that risk effectively.
The Health Inequalities National Support Team in England has documented
examples of local authority areas in the North East of England where
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Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
targeted actions have closed the inequality gap in premature circulatory
disease mortality between the most and least deprived areas.
Reduction of health inequalities in North East England
Chart showing a reduction in the circulatory disease mortality rate in
Sheffield compared with England & Wales, between 1992-2010
Circulatory Disease Mortality Rates, 1993-2010
Sheffield and England & Wales
Rate per 100,000 resident population
220
200
180
160
140
120
100
80
60
40
20
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
E&W Rate
Sheffield Rate
Baseline (1995-97)
Forecast
95% Forecast Interval
E&W Forecast
Produced by Professor Chris Bentley, Health Inequalities National Support Team
5
OHN Target
Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
Chart showing gap in the circulatory disease mortality rates for local
authority areas in South Yorkshire in 1995-97 and 2002-05
Circulatory disease mortality rates
Mortality rate per 100,000 population
300
250
200
150
100
50
Whole communities
0
Barnsley
1995-97
Barnsley
2002-04
Doncaster
1995-97
Doncaster
2002-04
Rotherham
1995-97
Rotherham
2002-04
Sheffield
1995-97
Deprived quintile
Sheffield
2002-04
Produced by Professor Chris Bentley, Health Inequalities National Support Team
These areas have used focussed action on the main risk factors for
premature disease in developed countries – tobacco use, high blood
pressure, excess alcohol use and high cholesterol - and have demonstrated
an improvement in outcomes within 5 years of the programme starting.
Research from Glasgow University on the “GPs at the Deep End” project
suggests the importance of the following in improving primary care in
deprived communities:
closer working arrangements between primary care and area based
services (e.g. mental health, child health workers);
link worker roles between general practices and community resources;
protected time for General Practitioner clusters to review experiences
and joint improvement activity;
time for leadership roles within General Practitioner clusters to
contribute towards locality planning;
extra consultation time;
development of activity and outcome measures for audit of patients
with multi-morbidity; and
enhanced GP fellowship programmes.
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Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
3
Progress report
In November 2012, the Board agreed a proposal to submit to Welsh
Government to address persistent inequalities in health by tackling the
Inverse Care Law. The “Living Well, Living Longer” proposal highlighted
the gap in healthy life expectancy between the most and least deprived
areas within ABUHB. The bid was highly aspiration, focussing on increasing
capacity and skill mix in GP practices serving deprived communities.
In March 2013, a ‘1,000 Lives Plus’ workshop was held for Cwm Taf and
Aneurin Bevan Health Boards to revisit the approach for tackling health
inequalities in the light of no central funding being available. The session
was facilitated by Professor Chris Bentley who led the National Support
Team for Health Inequalities in England. There are a number of elements
in this systematic approach to addressing the causes of premature disease
and mortality that are relevant Aneurin Bevan University Health Board
Inverse Care Law programme. These were presented to Public Health &
Partnerships Committee in June 2013.
In October 2013, a follow-up programme design session was organised
with Professor Bentley to identify proposed priorities for the Aneurin Bevan
University Health Board Inverse Care Law programme. This session was
informed by the available local data analysis for the Aneurin Bevan
University Health Board area. These proposed priorities were presented to
the Public Health & Partnerships Committee meeting in October and are
now recommended for Board approval.
Local data analysis has an important role to play in clarifying the vision and
strategy for tackling health inequalities.
ABUHB and Cwm Taf have
requested data analysis support from the Public Health Wales Observatory,
NHS Wales Information Service (NWIS), Public Health Wales Primary Care
Quality Service and Welsh Government’s Health Statistics and Analysis
Unit. This data analysis with enable Aneurin Bevan University Health Board
to establish a baseline position and to:
Set a realistic target to reduce the inequality gap and quantify this
ambition using ‘best in class’ performance (e.g. number of individual
premature deaths to prevent in order to achieve best comparable life
expectancy rate).
Identify ‘excess’ deaths by cause and age, to show where the greatest
gains can be made (e.g. premature CVD mortality).
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Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
Identify variation in the systematic delivery of evidence based
interventions can impact on mortality (e.g. optimal management of
blood pressure, smoking cessation).
Quantify the scale of individual evidence based interventions needed to
reduce the inequality gap.
In addition to this baseline position, further analysis of data will be required
throughout the implementation of the programme. Clinical dashboards will
be needed to drive quality improvement in primary care. The Board will be
asked to agree a basket of indicators and system for data collection to
measure the impact of programme on premature mortality and
unscheduled care.
4
Framework for action
Lessons learnt from the Health Inequalities National Support Team in
England suggest that sustainable change must be driven by committed
leadership. This leadership is required to create a locally owned, coherent
vision and strategy, which is capable of being delivered through
partnership action. The strengthened role of Local Service Boards and
creation of Neighbourhood Care Networks provides the ideal strategic
environment for tackling health inequalities.
The list of priority statements below will form the basis of a strategic
framework for tackling the Inverse Care Law for the population served by
the Health Board (the programme).
Priority statement 1: The programme will focus on premature
mortality from heart disease in deprived areas, particularly
targeting men and women over 40 years, who have not visited their
GP for 3 years
Cardiovascular disease and cancer are the leading causes of death in
Aneurin Bevan University Health Board. Rates of premature mortality from
cardiovascular disease are highest in the most deprived areas and
significantly higher in males than females
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Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
Premature
mortality
from
CVD
by deprivation
Mortality from
cardiovascular
disease
(ICD-10
I00-I99), European agestandardised rate (EASR) per 100,000, by deprivation fifth (WIMD 2011),
Mortality
from
under
75, 2008-10
persons,
age CVD
under
75, Wales,
2008-10
European
age-standardised
rateObservatory,
per 100,000,
byADDE/MYE
deprivation
fifth,
persons,
Wales, ICD-10 I00-I99
Produced
by Public Health Wales
using
(ONS),
WIMD
(WG)
Males - rate ratio 2.4
Females - rate ratio 2.7
95% conf idence interval
69
28
83
38
104
Least deprived Next least deprived
47
Middle
123
59
165
76
Next most deprived Most deprived
Produced by Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD (Welsh Government)
The gap in the circulatory disease mortality rate between the most and
least deprived populations is not narrowing
Trends in mortality from circulatory disease
Mortality from circulatory disease, all ages, males, European age-standardised rate (EASR) per
100,000, Aneurin Bevan HB and Wales, 2001-09
Produced by Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD 2008 (WG)
500
Most deprived within Aneurin Bevan (95% CI)
Wales EASR
Least deprived within Aneurin Bevan
Aneurin Bevan overall
450
400
350
300
250
200
150
100
50
0
Rate Ratio - most deprived divided by least deprived
1.4
1.5
1.5
1.7
1.8
1.7
1.6
2001-03
2002-04
2003-05
2004-06
2005-07
2006-08
2007-09
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Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
Priority statement 2: The programme will initially target the 5
Neighbourhood Care Networks with the highest level of
deprivation, starting in Blaenau Gwent West
The main clustering of deprivation in Aneurin Bevan University Health
Board can be seen in the South Wales valleys areas of North Caerphilly,
Blaenau Gwent East, Blaenau Gwent West, North Torfaen and inner city
Newport.
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Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
Pattern of deprivation with ABUHB
Welsh Index of Deprivation 2011, Wales fifths, Aneurin Bevan Health Board
Area of North Caerphilly,
Blaenau Gwent and North
Torfaen
Inner city Newport
Produced by Public Health Wales Observatory
Percentage of patients living in the most deprived fifth of areas in Wales (using
WIMD, 2011), GP clusters (NCNs) in Aneurin Bevan Health Board in 2013
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Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
Within Aneurin Bevan University Health Board, of the patients living in the
most deprived fifth of areas in Wales, around 66 per cent were registered
within the catchment area of 5 Neighbourhood Care Networks – Blaenau
Gwent East, Blaenau Gwent West, Caerphilly North, Newport East and
Newport West. When looking at the distribution of mortality these areas
have the highest rates of premature death from circulatory disease and all
age mortality rate from coronary heart disease.
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Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
Distribution of premature mortality from circulatory disease, mortality from coronary heart disease
and NCNs serving the largest percentage of patients in the most deprived areas
NCNs with the highest percentage of
patients living in the most deprived fifth of
Welsh areas
Premature mortality from circulatory disease
(under 75 years) 2004-08, all persons, MSOA,
European age standardise rate per 100,000
population. Source: ADDE/ONS
Coronary heart disease mortality, 200408, all persons, all ages MSOA, European
age standardise
rate per
100,000
population. Source: ADDE/ONS
Caerphilly North, Blaenau Gwent West
and Blaenau Gwent East
Newport East and Newport East
Produced by Primary Care Division (map, right) and Public Health Wales Observatory (map, middle & left)
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Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
Priority statement 3: The programme will prioritise actions that
should be able to demonstrate outcomes within 5 years
For any intervention there will be a latency period between implementation
and improved outcomes. In order to gain momentum, the programme will
initially focus on interventions that, if applied systematically and at scale,
should demonstrate outcomes within the next 5 years. The evidence from
programmes in deprived areas in England suggests that improved
outcomes can be achieved within five years through the systematic delivery
of interventions that focus on patients with or at high risk of cardiovascular
disease, cancer and diabetes.
Gestational period between intervention and outcomes
Produced by Professor Chris Bentley, Health Inequalities National Support Team
Priority statement 4: The programme will focus on systematic and
population scale implementation of proven interventions
There are a number of evidence-based interventions that can prevent or
postpone deaths in people with or at high risk of cardiovascular disease,
cancer and diabetes. This will include smoking cessation and vascular risk
assessment. The contribution of selected interventions will be modelled to
quantify the potential impact on mortality rates and the scale of delivery
required (e.g. number needed to treat) to achieve the agreed target for
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Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
reduction in premature mortality. The costs of different models of care will
be calculated and a balanced portfolio of interventions developed.
Priority statement 5: In the initial phase, the programme will focus
on the determinants of inequalities in health that are within the
control and influence of primary care and the wider networks
Reducing mortality in deprived areas relies on getting the right system and
scale when implementing evidence-based interventions. A study into the
effectiveness of healthcare systems suggested that of the 5.7m people in
the UK with CHD only 1m (about one sixth) are compliant with evidencebased treatment. The programme will address this issue of ‘implementation
decay’ by engaging those that are demotivated or not in meaningful
contact with services and improving the quality of care provided which are
within the control of primary care or can be influenced through the wider
NCN
Appendix E – Implementation decay and action to improve the cost
effectiveness of healthcare systems
Effectiveness in management of long term conditions (LTCs) according to
evidence based protocols (e.g. NSF or NICE guidance)
Produced by Professor Chris Bentley, Health Inequalities National Support Team
Spheres of control and influence within primary care and wider NCNs
Key to tackle each stage of implementation decay:
A
B
C
D
Awareness and understanding
Presentation and assessment
Quality of services
Support for self-management
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Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
Produced by Professor Chris Bentley, Health Inequalities National Support Team
Within the control of primary care
Can be influence by primary care through the wider NCN
In terms of community engagement (see A & B, above) the programme will
find ways of reaching the ‘seldom seen, seldom heard’ to ensure they
present early in primary care and are comprehensively assessed. This will
need support from a variety of partners including Communities First, local
authorities and housing associations in the first instance. In relation to
quality of care (see C & D, above), the programme will improve lines of
communication between providers and ensure there are ‘no wrong
doors/blind alleys’ across the pathway. The programme will offer challenge
and support to create more responsive services that are committed to
reducing inequity in health outcomes. This will enable providers to develop
channels for engaging the ‘seldom seen, seldom heard’, raise the bar on
target achievement and reduce clinical variation.
5
Next steps
The Welsh Government produced an Inverse Care Law Programme Plan
following Ministerial commitment in the Tackling Poverty Action Plan (see
Appendix A). There is an expectation that local objectives, project plans
and innovative models of care will be proposed by April 2014. Welsh
Government suggests that this should be informed by a detailed locality
analysis and assessment of the maturity level of Neighbourhood Care
Networks in targeted areas.
Subject to Board approval, the Public Health Wales Improvement Unit
(formally NLIAH) has agreed to organise a session for Aneurin Bevan
University Health Board to work through the Cardiovascular Disease
Diagnostic Workbook produced by the Health Inequalities National Support
Team. This will allow a costed implementation plan to be produced for the
first phase roll out of the programme from April 2014.
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Aneurin Bevan Health Board
Wednesday 27 November 2013
Agenda Item: 2.15
In order to support this, there is a need for a Programme Manager to
support the development of this plan, this will be met from existing
resources within the Divisions of Primary Care and Networks and Public
Health.
It is important to note that the Inverse Care Law programme is focussed
on the contribution of primary healthcare to reducing health inequalities. It
will be additional to the Health Board’s wider programmes and work
through Local Service Boards to address the social and economic
determinants of health inequalities such as unemployment, poor housing,
child poverty and poor educational attainment, even though return on
investment may take up to 20 years.
6
Recommendation
The Board is asked to:
Note the contents of this paper.
Agree that the programme will commence in Blaenau Gwent West
Neighbourhood Care Network, but aims to cover the five Neighbourhood
Care Networks highlighted in time.
Agree the 5 Priority Statements.
Note that these will form the basis of a strategic framework and costed
implementation plan for the Inverse Care Law Programme, which will be
presented to the Board in January 2014.
Report Prepared by:
Bobby Bolt, Divisional Director, Primary Care
and Networks Division
Dr Sarah Aitken, Consultant in Public Health
Medicine
Will Beer, Principal Health Promotion
Specialist
Report Sponsored by:
Dr Gill Richardson, Director of Public Health,
Consultant in Public Health Medicine
Judith Paget, Chief Operating Officer/Deputy
Chief Executive
Date:
November 2013
17