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. 1
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. 2
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: Health promotion, protection and improvement 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. 3
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 4
Rate per 100,000 resident population Aneurin Bevan Health Board 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 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) OHN Target Forecast 95% Forecast Interval E&W Forecast Produced by Professor Chris Bentley, Health Inequalities National Support Team 5
Mortality rate per 100,000 population Aneurin Bevan Health Board Chart showing gap in the circulatory disease mortality rates for local authority areas in South Yorkshire in 1995-97 and 2002-05 300 Circulatory disease mortality rates 250 200 150 100 50 0 Barnsley 1995-97 Barnsley 2002-04 Doncaster 1995-97 Doncaster 2002-04 Rotherham 1995-97 Rotherham 2002-04 Whole communities 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. 6
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). 7
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 8
Premature mortality from CVD by deprivation Mortality from CVD under 75, 2008-10 European age-standardised rate per 100,000, by deprivation fifth, persons, Wales, ICD-10 I00-I99 Males - rate ratio 2.4 Females - rate ratio 2.7 95% confidence interval 69 28 83 38 104 47 123 59 165 76 Least deprived Next least deprived Middle 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) 500 450 400 350 300 250 200 150 100 50 0 Most deprived within Aneurin Bevan (95% CI) Wales EASR Least deprived within Aneurin Bevan Aneurin Bevan overall 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 9
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. 10
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 Produced by Public Health Wales Observatory Inner city Newport 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 11
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. 12
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 Caerphilly North, Blaenau Gwent West and Blaenau Gwent East 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, 2004-08, all persons, all ages MSOA, European age standardise rate per 100,000 population. Source: ADDE/ONS Newport East and Newport East Produced by Primary Care Division (map, right) and Public Health Wales Observatory (map, middle & left) 13
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 14
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 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. 16
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: Report Sponsored by: Bobby Bolt, Divisional Director, Primary Care and Networks Division Dr Sarah Aitken, Consultant in Public Health Medicine Will Beer, Principal Health Promotion Specialist Dr Gill Richardson, Director of Public Health, Consultant in Public Health Medicine Judith Paget, Chief Operating Officer/Deputy Chief Executive Date: November 2013 17