Closing the gap: finding the missing thousands

Transcription

1 Closing the gap: finding the missing thousands Health Inequalities National Support Team Enhanced Support Programme

2 DH INFORMATION READER BOX Policy HR/Workforce Management Planning/Performance Clinical Estates Commissioning IM&T Finance Social Care/Partnership Working Document purpose Best Practice Guidance Gateway reference Title Closing the Gap: Finding the Missing Thousands Author Terry Blair-Stevens Publication date 05 Mar 2010 Target audience PCT CEs, NHS Trust CEs, Care Trust CEs, Foundation Trust CEs, Directors of PH, Local Authority CEs Circulation list Description SHA CEs, Medical Directors, Directors of Nursing, Directors of Adult SSs, PCT PEC Chairs, PCT Chairs, NHS Trust Board Chairs, Special HA CEs, Directors of HR, Directors of Finance, Allied Health Professionals, GPs, Communications Leads, Emergency Care Leads, Directors of Children s SSs, Voluntary Organisations/NDPBs One in a series of Masterclass Reports published as part of the Redoubling efforts to achieve the 2010 national health inequalities life expectancy target resource pack. Cross ref Superseded docs Action required Timing Contact details Systematically Addressing Health Inequalities N/A N/A N/A Health Inequalities National Support Team National Support Teams (NSTs) Wellington House Waterloo Road London SE1 8UG For recipient s use

3 Population health Population focus 10. Supported selfmanagement Optimal population outcome Challenge to providers 5. Engaging the public Systematic and scaled interventions by frontline services (B) Partnership, vision and strategy, leadership and engagement (A) Systematic community engagement (C) 9. Responsive services 7. Expressed demand 6. Known population needs 13. Networks, leadership and co ordination 12. Balanced service portfolio 4. Accessibility 2. Local service effectiveness 1. Known intervention efficacy Personal health Frontline service engagement with the community (D) Community health 8. Equitable resourcing 11. Adequate service volumes 3. Cost effectiveness Bentley C (2007). Systematically Addressing Health Inequalities, Health Inequalities National Support Team. Foreword The Health Inequalities National Support Team (HINST) has chosen to prioritise this topic as one of its Masterclasses for the following reasons: A significant proportion of the disadvantaged elements of populations, in Spearhead areas in particular, are failing to take advantage of the benefits that services can offer. The reasons for this are varied and complex, and strategies for addressing the problem need to be based on local intelligence and insight, and they also need to be systematic. Specifically, within the Christmas tree diagnostic it addresses the following components: accessibility (4) engaging the public (5) known population needs (6) expressed demand (7) responsive services (9). Action in this area of work will contribute to the Quality and Productivity Challenge by: engaging people at high risk of, or with, early established disease, to enable them to access effective preventive strategies. This can help prevent or at least defer major (costly) impacts, e.g. strokes; renal failure, blindness and amputations in people with diabetes. Successful adoption of processes similar to those outlined here would demonstrate good use of World Class Commissioning (WCC) competencies: collaboration with partners (2) patient and public involvement (3) clinical leadership (4) assessment of needs (5) procurement and contracting. (9) 1

4 BaCkgrouNd Closing the gap: finding the missing thousands masterclass explored systematic approaches to including as many people as possible with established disease onto general practice registers, and in doing so closing the gap between actual and expected numbers on chronic disease registers, by using: strategies to match actual numbers with estimates of expected numbers by practice strategies to sweat the asset of practice records to identify patients with disease a variety of segmented options to identify patients in the community, scaled up appropriately. The identification of patients who already have, or who are at risk of developing, disease and successful management of their condition/s are crucial to efforts to reduce premature mortality, morbidity and inequalities in health. A critical element to achieving optimal population health outcomes is to ensure that chronic disease registers are comprehensive, by addressing the barriers that prevent patients from coming forward. This may be easier to achieve in areas where there is minimal population movement. There are a number of population disease prevalence formulae, which estimate numbers that should be reflected on registers. The data they produce provide a valuable insight into the potential to save lives by providing a benchmark between estimated population disease prevalence and numbers on disease registers in the local context. Recommended population disease prevalence formulae include: Association of Public Health Observatories disease prevalence model Yorkshire & Humber Public Health Observatory PBS Diabetes Population Prevalence Model Phase 3 ModelS of MeCHaNISMS For CloSINg THe gap The Masters who participated in the Masterclass identified the key elements of their programmes aimed at closing the gap, including what had been successful, the challenges and barriers encountered, and the levers used to overcome these. The models outlined are summaries. For fuller details, please see the Masters presentations at Improving male life expectancy (MLE) in Birmingham Key points: At the start of this project, in 2005, life expectancy for men in Birmingham was not improving as quickly as the national average. The local authority was keen to address the biggest issues facing the city and, as a result, a target was included in the Local Area Agreement (LAA) to close the gap on male life expectancy by 10%. 2

5 Data analysis indicated that deaths from coronary heart disease (CHD) were affecting a younger than expected age group and, consequently, the project targeted men aged between 40 and 65 years in the 11 most deprived wards of the city. Although recorded prevalence of CHD was highest in the more affluent areas, deaths were higher in the more deprived areas the difference being that fewer people were on CHD registers in the deprived areas of the city and were therefore not receiving appropriate treatment. Figure 1 shows the prevalence and Figure 2 the mortality rate for CHD for men under 75 years across the city. The maps clearly demonstrate the stark difference between where men who are at risk of dying prematurely of CHD live, based on primary care Quality and Outcomes Framework (QOF) prevalence data (Figure 1), and actual mortality rates taken from data in public health mortality files (Figure 2). Mapping CHD mortality in this way helps to target preventive interventions and services for men in the neighbourhoods and communities where they are most needed. Figure 1: QoF prevalence for CHd by Super output area for men under 75 years in Birmingham Figure 2: Mortality rates for CHd by Super output area for men under 75 years in Birmingham Work with focus groups suggested that the low level of GP registration was due to a range of factors including dislike of accessing services/belief that the NHS would pass information to other government bodies, lack of knowledge of symptoms and concern about the implications of being diagnosed, e.g. loss of livelihood. 3

6 Five key interventions were identified reduce smoking, enhanced secondary prevention, delivery of primary prevention, improved access to primary care, and targeting those at highest risk. Armed with the knowledge of the barriers to access, the MLE programme set out to address the registration of the missing thousands. Substantial extra funding was made available through the Local Strategic Partnership for an intensive short-term programme, which enabled the commitment of designated staff. The Programme followed a systematic approach based on the expected rate of return on component parts: The process started with the recruitment of an independent company contracted to work with GP records. After some initial resistance, GPs were persuaded that, once afforded access, the company would effectively be doing some of their work for them, at someone else s expense. A record search identified those who: had been diagnosed, but missed off the register had been identified as possible cases, but without confirmed diagnosis attended the practice, but the issue had not been raised with them despite apparent risk factors rarely, if ever, attended the practice. (Other processes were used to identify whether substantial numbers were not registered with a practice. This was found not to be the case.) Patients identified as needing further screening or diagnostic work were then contacted in several ways, in the following order: invitation letter from the GP to attend the practice telephone call from the call centre visit from outreach staff, e.g. Health Trainer. This follow-up work was co-ordinated by the search contractor. While this systematic records-based search was under way, a framework of outreach mechanisms was also initiated, using a variety of methods to contact the target population away from formal medical care. The portfolio of approaches was not ad hoc, but designed to capture certain segments of the population not making frequent contact with GP services. Further reach was achieved through 29 pharmacies, working in the target areas, offering heart MOTs on a drop-in basis, with referral on to GPs for registration and action. 4

7 A series of campaigns (some designed by local men), targeting specific conditions and health-related behaviour, were developed, e.g. blood pressure and smoking. Quick wins were complemented by sustained approaches such as the health check bus. This targeted men in supermarkets and other nonhealth locations (e.g. health centres, football clubs and churches) including during the evenings, and proved very successful. Experience suggests that the NHS logo/brand was important in encouraging men to approach and have confidence in the service provided even if screening was being offered in a non-nhs location. Telephone contact was an important means of encouraging men to attend screening sessions. Birmingham was fortunate in having a call centre that could be used for this purpose and to support wider programmes for those with long-term conditions, such as telephone reminders to take medication. Results of tests undertaken at screening clinics were sent to the patient s GP. It is known that there has been an increase in the prescription of statins following the project, but no other data had been collected on follow-up. Scaling up interventions to take account of increased numbers on registers had workforce implications, as even routine follow-up was often outside the capacity of a practice. Few areas had addressed ways in which professionals could be freed from routine work to allow them to concentrate on more specialist tasks. For guidance on workforce planning see the How to guide, How to model need and develop a workforce plan to manage chronic disease registers as an industrial scale process. Key lessons from the project in terms of what could have been done differently: Data sharing sharing data was problematic. Agreement for a two-way movement of data between the Primary Care Trust (PCT) project and GPs would be useful. Quality control appropriate measures need to be in place, particularly where work is contracted out. Touch screens can avoid some of the problems found with paper recording methods. Cost costs per patient were higher than expected, partly due to unexpected consumables. Engaging GPs support of GPs is crucial and they need to be involved in discussions from the outset. A systematic approach that addresses all the potential problem areas should help to ensure that practitioners are willing to participate. Visiting practices to talk personally to GPs and their staff often paid dividends. Sustainability consideration should be given to whether the impact of the project can be sustained over the medium and longer term. Follow-up ways of ensuring that the results of screening are followed up appropriately should be factored into the project. 5

8 Primary care QOF data alone is not sufficient to gain a comprehensive picture of where men who are at risk of dying prematurely from CHD live. For additional insight into strategies for identifying those at risk of premature death from cardiovascular disease (CVD) (including CHD), please see the How to guide, How to undertake a retrospective cardio-vascular disease mortality audit to support more systematic delivery of secondary prevention. To see the full presentation on improving male life expectancy in Birmingham see Vascular checks in Bolton industrially scaled and systematically applied Key points: Inspired by the HINST diagnostic visit in 2007, partners in Bolton aimed to step up momentum in the drive to reduce premature mortality and reduce health inequalities. Life expectancy in Bolton was two years below the national average with an internal gap of 15 years (as measured by middle Super Output Area). 1 One of the priority areas they focused on was primary prevention of CVD. The Big Bolton Health Check was a key facet of the programme to increase life expectancy, targeting everyone 45 years and older and offering free health checks. A large scale local media campaign supported the Big Bolton Health Check and encouraged people to consult their GP directly. In addition Health Trainers assessed people in a variety of community settings, including workplaces, supermarkets, pubs, betting shops and mosques. This was supported by near patient testing. A Primary Prevention of CHD incentive scheme was introduced, challenging GPs to improve their position by 10 20%. An exponentially scaled payment system was used to encourage maximal achievement of assessments. The payment amounts and percentage achievement thresholds for primary prevention of CHD by general practices in Bolton are outlined in Figure 3 and the logarithmic scale is represented in Figure 4. Of 55 general practices, 10 did not participate and for a further 12 data quality was poor. In all, 31% of patients on the list were assessed. 6

9 Figure 3: Bolton primary prevention of CHd logarithmic payment incentivisation Figure 4: Bolton primary prevention of CHd exponential incentivisation scale 30% Logarithmic incentivisation 40% % % 70% Payment % % 100% % 40% 50% 60% 70% 80% 90% 100% Percent achieved Bolton produced a taxonomy of general practices that clustered those with similar demographics together (see appendix 1). Data showed not only the performance of individual practices, but also how they compared with their peer group. Consequently, practices could no longer argue that they were different. The data was used to identify what had worked well rather than focusing only on outliers showing them what could be done and encouraging them to do it. A variety of incentives were used to achieve this. The system was accepted by practices as none wanted to be seen to be performing worse than their peer group. For further insight into establishing taxonomies of practice please see the How to guide, How to develop a Taxonomy of General Medical Practices to support and encourage performance development. Practices also received a monthly audit report of their performance on a range of key measures for the management of conditions related to CHD see Figure 5. 7

10 Figure 5: Bolton monthly audit reports for general practice management of conditions related to CHd primary prevention audit diabetes CVd INCludeS CHd, TIa, occ CVa, pvd Ckd register Question a b c d e f g h i j k l m n o p q Practice Month Population > 45 yrs Exp CHD < > CVD & RA in last > 20% risk Prev for No. on Hb1ac < BP < Chol < E xp prev / No. on No. on No. on No. BP. Chol < prev/ No. egfr Exp prev Diabetes 5 yrs on PPR PPR Register /90 5mmol practice CHD reg CVD reg Asprin 150/90 5mmol practice < 60% /practice Apr-08 4,810 1,558 1, May-08 4,827 1,546 1, Jun-08 4,838 1,550 1, Jul-08 4,862 1,560 1, Aug-08 4,889 1,572 1, Sep-08 4,934 1,574 1, key CHD Coronary heart disease CKD Chronic kidney disease CVA Cerebrovascular accident CVD Cardiovascular disease PVD Peripheral vascular disease TIA Transient ischaemic attack Figures 6 and 7 demonstrate that within a one-year period, , the percentage of patients who were assessed as part of the CHD primary prevention scheme across practices in Bolton increased by over 30%. 8

11 Figure 6: percentage of patients assessed for primary prevention of CHd before the Big Bolton Health Check programme was introduced Primary Prevention Scheme Percentage assessed Figure 7: percentage of patients assessed for primary prevention of CHd after the Big Bolton Health Check programme was introduced Primary Prevention Scheme Date Percentage assessed Date 9

12 Learning points: Information Regular reports were vital for both the practices and the project team. Data quality Assume nothing, ensure searches are systematic, and provide the necessary support and training to run them. Clinical engagement is essential It takes time to build good working relationships, to understand the variability and dynamics of each practice and to identify a lead in each practice. The culture and ethos determine success. GPs are not fundamentally opposed to initiatives like this, but the approach needs to be pitched appropriately to ensure their commitment. The philosophy of visiting individual practices is being applied to other projects. Outreach Although the marketing exercise was successful, well received and provided information back to practices, it was at a cost and led to some duplication. With hindsight, a large scale marketing campaign at the beginning, followed by smaller targeted outreach activities, would be better, with practices themselves running events and identifying patients. Health Trainers The use of this group of staff was vital as they offered an adaptable, flexible resource. Other areas might prefer to use healthcare assistants to fulfil this role. The key issue was to try to recruit Health Trainers from local communities. Although Health Trainers had taken the measurements at screening, the results had been interpreted by GPs or practice nurses. Marketing The branding used was appealing and easily recognised, but relatively expensive against the total programme cost. The Primary Prevention of CHD incentive scheme was successful. Near patient testing Laboratory support was the only input from secondary care. If run again, the project would secure increased support from the labs. Clinical governance More training and support were needed on what to do with patients on the registers. Outcomes were monitored to ensure that patients received the right care. However, practices can hit their QOF targets even where patients conditions are poorly controlled. Bolton is therefore now moving to scoring practices and incentivising them to move beyond QOF as a means of addressing this anomaly. Select the project team carefully to ensure members share the same ambition. If services are available, people will come Concerns that health inequalities would be widened due to affluent patients flooding the system proved unfounded. Practices in deprived areas increased their work throughout the project. 10

13 Once the numbers screened exceed the 80% or 90% threshold it is necessary to address the reasons why the remainder do not attend. Solutions can be as simple as running sessions outside working hours and dealing with urban myths such as I m healthy so I m not at risk. In summary, to run a project like this you need a clinical leader, a project team, an incentive scheme, peer group cluster analysis, practice visits, Health Trainers, targeted outreach, and publicity all of which are equally important. A list of the key learning points for issues that were instrumental to the success of the vascular checks programme in Bolton are outlined in appendix 2. For the full Bolton presentation on Industrially Scaled and Systematically Applied Approaches to Implementing a Vascular Checks Programme Closing the gap a health equity audit approach in Nottingham In order to sweat the asset of general practice disease registers it is important to optimise the number of patients who are in receipt of regular assessments and care. Reducing inappropriate exceptions and exemptions to a minimum are crucial to achieving this. In recognition of the importance of the issue, HINST commissioned NHS Nottingham City to examine why certain vulnerable groups were systematically excluded from QOF chronic disease registers. Preliminary findings were presented and will be followed in due course by fully published results. 11

14 key learning points FroM discussion groups engage gps Identify ways of empowering GPs to play their part. Clinicians like to deal with other clinicians. Practice visits by a senior person can be very helpful. Taxonomy/clusters of practices Show practices how they compare with peers. Practices don t like being outliers. Needs to be done locally rather than at the national level. Driving up performance in primary care is critical. Need to move beyond QOF. Offer analytical support to group practices. Buddying of practices may help with taxonomy. Need good analysis to understand the problem and commission a range of services. Inequalities need to be built into predictive modelling. Clinical leadership Do not rely on a single leader. Project manager also key. Need a clinically astute manager and a managerially astute clinician. Identify local champions if no obvious candidate. ownership By everyone. Need clear vision and objectives. Board-level involvement important. Partnership approach may be more appropriate in some circumstances. Use range of staff including Health Trainers and use them flexibly. Financial incentives Need to be right. Plans need to be backed by evidence of cost effectiveness. Balance between incentivisation and clinical governance. Need to get the day job right before offering any incentives. Make use of national information on information governance, e.g. Royal College of General Practitioners (RCGP), British Medical Association (BMA), protocols for sharing information within the NHS. use screening as an opportunity to offer a range of interventions may not see people again. Use vascular checks to identify other issues. go to where people are Ask practices where their populations shop, etc. Value of telephone outreach. Get communication right know your audience. MaSTerS recommendations Ensure integration and performance management of what is commissioned not just a matter of finding people but ensuring services are in place to support them and that the funds going into those services are performance managed. All PCTs should review their criteria for exemption reporting and take action to reduce this to a minimum. Prevalence data needs to be accurate so that GPs know what they are working towards. It is possible to get people on registers and the evidence is that, once there, it can make a big difference to people at population level. Being on a chronic disease register is good for your health as your disease will be better managed. 12

15 appendix 1 Bolton taxonomy of general practice performance on preventing heart disease Practice Practice list size Number of patients > 45 years (no disease) > 45 years no disease patients as percent of list size Peer average: > 45 yrs no disease patients as percent of list size Number of risk assessments undertaken Percent risk assessed Peer Average of Assessed Number of patients on primary prevention register Percent on risk register Average of risk register p1 1, % 16.8% % 73.8% % 19.0% p2 1, % 16.8% % 73.8% % 19.0% p3 2, % 16.8% % 73.8% % 19.0% p4 2, % 16.8% % 73.8% % 19.0% p5 1, % 16.8% % 73.8% % 19.0% p6 1, % 16.8% % 73.8% % 19.0% p7 5, % 16.8% % 73.8% % 19.0% p8 1, % 16.8% % 73.8% % 19.0% p9 2, % 22.8% % 72.3% % 32.6% p10 2, % 22.8% 0 N/A 72.3% 0 N/A 32.6% p11 2, % 22.8% % 72.3% % 32.6% p12 5,632 1, % 22.8% % 72.3% % 32.6% p13 7,514 1, % 22.8% 1, % 72.3% % 32.6% p14 4,015 1, % 22.8% % 72.3% % 32.6% p15 2, % 22.8% % 72.3% % 32.6% p16 3,625 1, % 22.8% % 72.3% % 32.6% p17 2, % 22.8% % 72.3% % 32.6% p18 8,937 2, % 30.0% 1, % 68.9% % 26.5% p19 2, % 30.0% % 68.9% % 26.5% p20 2, % 30.0% /0% 68.9% % 26.5% p21 4,124 1, % 30.0% % 68.9% % 26.5% p22 2, % 30.0% % 68.9% % 26.5% p23 4,459 1, % 30.0% % 68.9% % 26.5% p24 4,206 1, % 30.0% % 68.9% % 26.5% p25 5,240 1, % 30.0% 1, % 68.9% % 26.5% p26 4,834 1, % 30.0% 1, % 68.9% % 26.5% p27 5,598 1, % 30.5% 1, % 60.5% % 29.0% p28 13,317 3, % 30.5% 2, % 60.5% % 29.0% p29 3, % 30.5% % 60.5% % 29.0% p30 6,738 2, % 30.5% 1, % 60.5% % 29.0% p31 18, % 30.5% % 60.5% % 29.0% p32 6,786 1, % 30.5% 1, % 60.5% % 29.0% p33 5,953 2, % 30.5% 1, % 60.5% % 29.0% p34 5,986 2, % 30.5% % 60.5% % 29.0% p35 4,768 1, % 33.1% % 53.5% % 26.9% p36 9,886 3, % 33.1%,1, % 53.5% % 26.9% p37 10,103 3, % 33.1% 1, % 53.5% % 26.9% p38 4,169 1, % 33.1% % 53.5% % 26.9% p39 5,369 1, % 33.1% 1, % 53.5% % 26.9% p40 3,409 1, % 33.1% % 53.5% % 26.9% p41 2, % 33.1% % 53.5% % 26.9% p42 7,740 2, % 33.1% 1, % 53.5% % 26.9% p43 13,198 4, % 33.1% 2, % 53.5% % 26.9% p44 7,649 3, % 36.3% 1, % 61.2% % 24.8% p45 2, % 36.3% % 61.2% % 24.8% p46 9,611 3, % 36.3% 1, % 61.2% % 24.8% p47 19,711 6m % 36.3% 4, % 61.2% % 24.8% p48 12,424 4, % 36.3% 2, % 61.2% % 24.8% p49 7,460 2, % 36.3% 2, % 61.2% % 24.8% p50 4,222 1, % 36.3% 1, % 61.2% % 24.8% p51 4,663 1, % 36.3% 1, % 61.2% % 24.8% p52 9,696 3, % 36.3% 1, % 61.2% % 24.8% p53 2,714 1, % 36.3% % 61.2% % 24.8% p54 4,805 1, % 36.3% 1, % 61.2% % 24.8% 286,239 88, % 54, % 14, % 13

16 appendix 2 Key learning points from the vascular checks programme in Bolton Workstreams Information Clinical engagement Health Trainers Near patient testing Locally Enhanced Scheme Data quality Regular reports vital for practice and project team Adapt information depending on outcomes Interpretation of information is variable Project team must focus on information and act accordingly Clinical Leadership is essential Time to build relationships Understand your primary care Get a lead in each practice Culture and ethos determines the success Vital Moveable resource Adaptable Flexible Resilient Enthusiastic One-stop shop Helps with needle phobics Training/quality assurance issues Cost Laboratory support Grabs attention Different logarithmic incentivisation Acknowledges work already done Acknowledges it gets harder No strings attached Aims for 100% Assume nothing Ensure searches are systematic Support is necessary for running searches Training requirements exposed Capacity of data quality facilitators 14

17 Workstreams Outreach work Marketing Clinical governance Good marketing exercise Well received everywhere Data quality and transfer Cost issue Duplication Targeted outreach the most effective Branding appealing, recognised, catchy Launch event success Publicity Media involvement Banners Cost Risk calculation tools Management of risk register patients Training Support National Institute for Health and Clinical Excellence (NICE) guidance 15

18 author and acknowledgements Written by: Terry Blair-Stevens, Associate Delivery Manager, with Anne Holroyd, Effective Practice Manager Health Inequalities National Support Team Acknowledgements: Jeanelle De Gruchy, Deputy Director of Public Health NHS Nottingham City John Grayland, Programme Manager Chronic Disease Management NHS Birmingham East and North Stephen Liversedge, PEC Chair and GP NHS Bolton If you want more information on the examples contained in this guide please contact HINST on or 16