Putting Prevention and Health Promotion into Practice in EU Regions

North West England

Dominic HarrisonDeputy Regional Director for Public Health

Department of Health

Issues

• Paradigm Shifts – – Public Sector, NHS, Regions, Performance

Management systems.• NHS Reform

– The Darzi Review of NHS– World Class Commissioning– Future Scenario Testing

• Wider Health Strategy – Local Area Agreements/ Multi Area Agreements– Investment for Health / Health Inequalities– Health and well-being as economic development

Paradigm ShiftsFor the public sector

– From “detect and manage to predict and prevent”– From “How do we best make use of health sector resources to

secure health outcomes” to “How do we best mobilise all public sector investment (on this footprint) to secure the shared aspirations of this community (across all sectoral outcomes)”

– From “public as consumer to public as co-producer”

For the NHS– From a focus on “effective management of service delivery” to

effective commissioning of health outcomes.– From “commissioning services to commissioning outcomes”

For Regions– From “how do we command and control this system to deliver

health outcomes” to “how do we assure this system functions to deliver outcomes”.

For Performance Assessment – From “How well does this institution deliver its own target” to

“how well does this partnership deliver all agreed targets. (CAA)

Local Area Agreements

• Agreement between Central and local government for 3 years following Comprehensive Spending Review

• 35 targets agreed (out of a national indicator set of about 198)

• Negotiated by regions with Local Strategic Partnerships LSPs at local level

• Signed off by all Ministers with rewards for delivery.

Local priorities and targets

~35 targets

LAA

Local accountability to citizens

Local consultation through the LSP with Partners and Stakeholders

Better outcomesfor citizens

CSR07 national priority outcomes & 198 national

indicatorsLSP view of local priorities

Local targets monitored by LSP

'Designated’ targets monitored by LSP and GO

new LAAs

Local Challenges and AmbitionsSustainable Community

Strategy

Negotiation and agreementCross-Govt view through GOs on priorities

16 statutory education and early years targets

PRINCIPAL RELATIONSHIPS INTHE NEW LOCAL PERFORMANCE FRAMEWORK

LOCAL DELIVERY PARTNER

LOCAL DELIVERY PARTNER

LOCAL AUTHORITY

CENTRAL GOVERNMENT DEPARTMENT

CENTRAL GOVERNMENT DEPARTMENT

CENTRAL GOVERNMENT DEPARTMENT

CENTRAL GOVERNMENT DEPARTMENT

CENTRAL GOVERNMENT DEPARTMENT

GOVERNMENT OFFICE

Agree local priorities through a Sustainable Communities Strategy, informed by local context, national priorities and engagement with local citizensand business

Negotiate and agree proposed LAAs , selected MAAsand how they will deliver outcomes, through ongoing, evidence-based, system-wide dialogue

Agree national priorities through the Comprehensive Spending Review , PSAs and National Indicator Set

5

3

Deliver LAAs and MAAs, adapting to changing national and local contexts

4

OUTCOMES FOR PEOPLE AND PLACES

Audit Commission and other inspector-

ates

6

LGAIDeA

Leadership CentreRIEPs

CLG

GO Network

PMDU

LOCAL DELIVERY PARTNER

LOCAL DELIVERY PARTNER

1

2

Build system-wide capacity and capabilities

•National Improvement and Efficiency Strategy

•Government Office transformation

•Capability reviews of central government departments

Carry-out effective performance management and inspection

•Local performance management

•Government Office performance dialogues

•System leadership and oversight

•Risk-based assessment through CAA

CLG

GOs

Local Area Agreements

MAAs

7

Tyne and Wear

Hull and Humber

Tees Valley

Leeds

South Yorks

Leicester/Leicestershire

Bournemouth, Dorset and Poole

Fylde Coast

Pennine Lancs

Manchester

Liverpool

Black Country

West of England

PUSH – Partnership for Urban South Hampshire

South Essex

Olympic Boroughs

North Staffordshire

North Kent

Bedfordshire and Luton

Partnerships in discussion with Govt- no specified signing date

Partnerships negotiating MAAswith Govt- sign-off likely Spring 09

Partnerships negotiating MAAswith Govt- sign-off likely Autumn 08

MAAs signed off

Nottingham/Nottinghamshire

2000 2002 2004 2006 2008 2010 2012

The NHS journey

Targets and

performance management

Commissioning organisations

Autonomous providers

Payment by results

Patient choice

‘REFORM’Journey

Local Capability & Self-improvement

Breakthrough & Innovation

Social Movements

Co-creation

Some keyoutcomes

• key illnesses• throughput

• capacity

• health priorities• waiting times

• financial stability

• quality, safety• responsiveness•Joined up care

• health & well-being• equity

‘LEADERSHIP’ Journey

Technical LeadershipAdaptive Leadership

Target setter +

Performance manager +

Delivery leader

Regulator +

National Standards +

System leader

Transforming the service

Introducing the reform levers

Building capacity in the system

‘SERVICE” Journey

New National /Regional NHS Strategy

Healthier Horizons for the North West

We have designed a stratified approach to long-term conditions. If we successfully prevent & treat, equally

according to need, we would reduce the inequalities morbidity gap

Case-Management of vulnerable people most at

riskPreventing escalation to

emergency admission

Improved disease management

Preventing escalation to high complexity condition

Improved self-care

Preventing escalation to high risk condition

Level 3: High

ComplexityConditions

Level 2: High risk

Conditions

Level 1: 70-80% of LTC population

Have a LTC

EmergencyAdmission

Cost o

f Tre

atm

en

t

Distre

ss to P

atie

nt

Managing LTC Conditions

£

££££Case-Management of

vulnerable people most at risk

Preventing escalation to emergency admission

Improved disease management

Preventing escalation to high complexity condition

Improved self-carePreventing escalation to

high risk condition

Level 3: High

ComplexityConditions

Level 2: High risk

Conditions

Level 1: (70 -80% of LTC population)

Have a LTC

EmergencyAdmission

Cost o

f Tre

atm

en

t

Distre

ss to In

div

idu

al

Managing LTCs

£

££££

10.2 m

19.9 m

2.6 m

17.1 m

High Risk Have LTC (aware and unaware)

Aware of LTC

Eligible for treatment

Optimal treatment

Compliant with treatment

5.7m

2.6m 2.3m1.3m 1m

2.8m1.8m 1.8m

0.4m Not known

0.9m 0.48m 0.21m 0.1m 0.08m

2.9m

0.9m0.52m 0.26m 0.14m

DiseasePrevention

Patient identification and diagnosis

Treatment and ongoing management

CHD

Diabetes

CHF

COPD

Long-term conditions/Chronic Disease Management (England)

SHA/DHPCT DH

Our strategic ambition is becoming clearer – and should all be connected

Regional

Regional enablement, assurance and system management

‘Healthier horizons’NHS NW Strategic Framework

National

Darzi review

World class commissioning assurance process/guidance

System management paradigm and tools

Local

PCT as local leaders of the NHS

World class commissioners

Local system managers

Local delivery of strategic ambition for NHS in region, and national Darzi commitments

Effectiveness

Time business as usual reformed system transformed system

•‘big is best’, •User adapts to provider characteristics•Standardisation rules

•Example: mainframe computers

The ‘Three Horizons’ Model – Improving the present while preparing for the Future

•‘small can sometimes be beautiful•Greater user choice•Less uniformity•Focus on greater efficiency and on outputs

-Example: growth of market for personal computers

- Small is best •dispersed, flexible, local models •Services moulded around users•Dynamic user engagement•Focus on changed relationship between service/product and those who use it

Example: the digital revolution, internet

I will be living a healthier lifestyleI will receive more

personalised care

My NHS will maintain a

healthy financial position andperform the

best in class

I will have betterCustomer care

and an improved patient experience

I will receive the most informed technologies

as part of my care

I will be more involved in

decisions madeby the NHS

I will be givenhigher qualityclinical care My family will have

a better opportunityto live a longer and

healthier life

I will get more integrated seamless

care, when I need helpfrom more than one

organisation10 Public

TouchstonesI will receive more of my care closer

to my home

PCTs have to improve the present whilst simultaneously preparing for

the future

Improving the Present:

• PCTs have to manage the health care ‘machine’ more effectively.

Preparing for the Future:

• PCTs also have to lead their local health ‘system’

• NHS has to get smarter at enabling prevention and foster health in different environments

PCTs must learn to use the healthcare ‘machine’ to prepare for the future more effectively - prevention; consciously promoting independence and reducing dependency

Health care and prevention are not mutually exclusive

VISION AND COMPETENCIESVISION AND COMPETENCIES

ASSURANCE SYSTEMASSURANCE SYSTEM

SUPPORT ANDDEVELOPMENT MODEL

SUPPORT ANDDEVELOPMENT MODEL

PCTs as local leaders of the NHS

• The World Class Commissioning vision is to create self improving health commissioning organisations, responsive to the needs and aspirations of citizens, drawing on the best of public, private and third sector provision.

• Focused on, and held accountable for delivering outcomes for local people

• Freed from top-down ‘push’

Assess needs

Assess needs

Review current service

provision

Review current service

provisionDecide

prioritiesDecide

priorities

Strategic planningDesign serviceDesign service

Shape structure of

supply

Shape structure of

supply

Specify outcomes &procure services

Manage demand

and ensure appropriate access to

care

Manage demand

and ensure appropriate access to

care

Clinical decision making

Clinical decision making

Managing performance

(quality, performance,

outcomes)

Managing performance

(quality, performance,

outcomes)

Managing demand and performance

11 World Class Commissioning Competencies

CONTROL OVER MEANS OF DELIVERY?

The Four Scenarios

PO

LIC

Y E

MP

HA

SIS

?

Curing Sickness

Improving Health & Wellbeing

Co

mm

erc

ial P

rovid

ers

Are

D

om

inan

t

Lo

cal C

om

mu

nitie

s A

re D

om

inan

t

Scenario 1

“Corporate Cures”

Scenario 2

“CommunityCures”

Scenario 4

“Living for Health”

Scenario 3

“Shopping for Health”

Strategic Scenarios

www.internationalfuturesforum.com

Societal influencesIndividual psychology

Biology

Activity environment

Individual activityFood

ConsumptionFood Production

Male Life Expectancy Gaps

-7%

-6%

-5%

-4%

-3%

-2%

-1%

0%

1%

2%

1995-1997 1996-1998 1997-1999 1998-2000 1999-2001 2000-2002 2001-2003 2002-2004 2003-2005

three years (pooled_

Per

cen

tag

e d

iffe

ren

ce f

rom

En

gla

nd

Bolton

Bury

Manchester

Oldham

Rochdale

Salford

Stockport

Tameside

Trafford

Wigan

Components of the Male GapMale Reduced Life Expectancy - compared to E&W average

Persons under 75 dying in Manchester: trend 1995-97 through to 2003-2005

-8 -3 2 7 12

other causes

diabetes

other cancer

lip, oral and oesophagus cancer

colorectal cancer

prostate cancer

lung cancer

digestive disease (inc. cirrhosis)

other circulatory disease

stroke

coronary heart disease

other respiratory disease

bronchitis and copd

other accidents

self harm

violence

accidental overdose and poisoning

infant mortality

ca

teg

ory

of

de

ath

gap between local and national life expectancy in months of life lost (plus values indicate higher mortality)

1995-97

1998-00

2001-03

2003-05

Health and productivity costs of alcohol misuse are around £4 billion.

8%

24%

27%

33%

3%5%

0%

Inpatient

A & E

Outpatient

GPs

Other primary care

Dependency drugs

Alcohol services

Estimated annual cost of alcohol misuse (2003)

A&E

£510m

Inpatient

£618m

Alcohol Services

£96m

The Alcohol Harm Reduction Strategy (2003) estimated total annual healthcare

costs related to alcohol misuse to be up to £1.8bn. The bulk of these costs are born

by the NHS.

Estimated cost of alcohol-related productivity lost (2003)

Sou

rce:

Alc

oh

ol C

on

cern

(2

00

2);

Bri

tton

an

d m

acp

hers

on

(2

00

1);

WH

O

(20

00

); N

ett

en

an

d C

urt

is (

20

02

); H

AD

& M

OR

I (2

00

3);

Leon

tari

di (2

00

3)

all

qu

ote

d in

PM

SU

In

teri

m A

naly

tica

l R

ep

ort

Other

£64mGeneral Practice

£146m

Outpatient

£445m

Sickness absence

Reduced employment

Premature mortality

Alcohol-related premature death costs £2.4bn in productivity

foregone

Excess drinking is associated with unemployment. Costs arising from such

reduced employment are estimated to be in the region of £1.9bn per year.

Sickness absence costs

£1.5bn

A newnew attempt to make an impactimpact on

healthhealth in the North WestNorth West

To achieve:

• a public motivated and able to protect its own health

• an environment that supports healthy lifestyle choices.

• “Coalitions for better health” - Darzi

• “Social movement for health” - DH

• Social movements and large scale change in the NHS – Helen Bevan

• Public empowerment - Darzi

A new language for the public sector

1. Significant interest in Our Life from public sector and business leaders

2. Big Drink Debate – 33,000 responses

3. Enormous buy-in from NHS, police, fire, ambulance, local government and voluntary sector to the need for this new approach

Progress

We are the culture

We need to consider how our actions and decisions as leaders, parents, and role models establish and reinforce cultural norms

“We need a culture change”

A movement of “leaders”

From the public sector, businesses, faith groups, community groups and among the public

People willing to commit themselves and their organisations and networks to action to change cultural norms

Leading by example