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Population Health Management
NHS England and NHS Improvement
Needs assessment and opportunity analysis
The Analysts Development Programme for Population Health Management
• Overview of PHM Academy & Analysts Development Programme
• Learning objectives and programme for today
• Look ahead
Outline
2
Population Health Management
NHS England and NHS Improvement
Overview of PHM Academy
Lucy Hawkins
3
...improves population health by data driven planning and delivery
of proactive care to achieve maximum impact
It includes segmentation, stratification and impactability modelling to identify local ‘at
risk’ cohorts - and, in turn, designing and targeting interventions to prevent ill-health
and to improve care and support for people with ongoing health conditions and
reducing unwarranted variations in outcomes*
So: better evidence = better decisions = better outcomes
Population Health Management…
1: REGIONAL
RESOURCES AND
LEGACY
Programme Director
and management
support
Engage with
stakeholders
Supporting lasting
regional networks –
especially analytical
2: INDIVIDUAL STP/ICS SUPPORT
Understand progress on PHM and support planning
Programme budget and regional comparative analysis
Analytical support and review economic model
Coaching support to ‘Core Team’ running PHM project
3: PHM ACADEMY
‘Core Team’ programme (x6 sessions)
Analyst programme (x6)
Leadership ‘taster sessions’ (x2)
OD professionals (x2)
Open event, webinars, microsite, legacy
The Midlands PHM Support Programme
STP/ICS Projects
STP PHM Project PHM Core team lead (name) PHM Analyst Programme lead
(Name)
Birmingham and Solihull Homelessness Anna Hammond Anna Hammond / Sue Keogh
Black Country and West
Birmingham
0-11 year olds health and well-being (focus on
physical literacy)
Anthony Nicholls Anthony Nicholls
Coventry and Warwickshire Children in Mental Health Crisis (prevention) Valerie De Souza
Andrew Harkness
Debbie Dawson
Valerie De Souza
Derbyshire Development of a PHM strategy / approach for the
'Place' level of the system.
Alison Wynn Alison Wynn
Herefordshire and
Worcestershire
High Intensity Users Ruth Lemiech Ruth Lemiech / Neill Crump
Nottinghamshire Frailty Maria Principe Maria Principe / Andrew Haw
Shropshire and Telford and
Wrekin
Diabetes (Sub-group TBC) Penny Bason Helen Potter / Penny Bason
Staffordshire and Stoke-on-Trent Social Isolation Debbie Danher (CCG), Lorna
Clarson and Paddy Hannigan
(Clinical Leads)
Mark Owens
We’re working through the PHM Project cycle
We’re currently
here
But there is still
a lot of work
going on here!
1. Get together. Teams do not just ‘become’, but must be formed. Team composition should also be
reviewed as the design process progresses
2. Document their understanding of the population sub-group to be supported, through:
o Engagement; and
o Analysis of needs and opportunities.
3. Define desired outcomes and start thinking about measures
4. Map stakeholders to begin engagement.
Tasks set following the July event…
What you learn
today will be key
for 2 & 3!!
We’re working through the PHM Project cycle
In September we’ll be
looking at further
understanding the
population needs; how
to use evidence from
research; stakeholders;
and clinical experience
to make decisions; and
starting to plan the
next steps for their
project
We’re working through the PHM Project cycle
And then in
November moving on
to Implementation
and Evaluation
Population Health Management
NHS England and NHS Improvement
Population Health Management
Analysts Development Programme
Programme structure and content
To provide analysts in the 8 STP areas with opportunities to;
• reframe their existing skills towards the PHM policy agenda
• develop new technical skills
• develop soft skills to ensure that analysis is well designed, targeted at the most important questions and framed to maximise utility
• take up the opportunity to play a more significant role in local decision making
• build on / reinforce existing networks
Objectives – formal and informal
Analysts Programme
Launch session 09 Jul 2019Introduction to population health management and the science of
improvement
Session 1 03 Sep 2019 Needs assessment and opportunity analysis
Session 2 08 Oct 2019 Impact assessment and evaluation
Session 3 12 Nov 2019 Population segmentation and risk prediction
Session 4 10 Dec 2019 Introduction to actuarial modelling
Session 5 14 Jan 2020 Problem structuring and communicating analytical results
Joint session (1/2 day
TBC) 19-20 Nov 2019 Strategic resource allocation methods
Population Health Management
NHS England and NHS Improvement
Needs assessment and opportunity analysis
The Analysts Development Programme for Population Health Management
•To understand the Healthcare Needs Assessment process
•To explore the distinction between need, demand and supply of healthcare
•To learn about sources of data to derive population need
•To learn about the purpose, content and production of JSNAs
•To explore methods of identifying and measuring improvement opportunities
Objectives for today’s session
16
08:45 – 09:15 Arrival and Registration Lead
09:15 – 09:30 Welcome & introduction to the day
Mentimeter questions
MA Mohammed & L Hawkins, SU
G Wrench, PHE
09:30 – 10:00 Need, demand & supply S Wyatt, SU
10:00 – 10:30 An epidemiological approach to needs assessment G Wrench, PHE
10:30 – 11:05 Approaches to opportunity analysis S Wyatt, SU
11:05 – 11:30 Coffee/Tea Break
11:30 – 12:00 Data sources - population & prevalence rates Andy Hood, SU
12:00 – 13:00 Lunch
13:00 - 13:30 Overview of Joint Strategic Needs Assessments (JSNAs) † G Wrench, PHE
13:30 – 14:45 JSNA’s in Practice David Whiting, Medway Council
14:45 - 15:30 Learning from each other’s JSNA’s
(World Café, round robin)
M A Mohammed &
L Hawkins, SU
15:30 - 15:50 Coffee/Tea Break
15:50 - 16:30 Tabletop reflections
Mentimeter questions
Review and look ahead to Session 2
L Hawkins, SU
Gareth Wrench, PHE
M A Mohammed, SU
16:45 – 18:00 Optional informal networking to include a 40 min Seminar on “Mental and
Physical Health” at 16:45
Andy Hood, SU
Population Health Management
NHS England and NHS Improvement
Mentimeter QuestionsGareth Wrench, PHE
Population Health Management
NHS England and NHS Improvement
Need, Supply and DemandSteven Wyatt, The Strategy Unit
20
Definitions of Healthcare Need, Demand and Supply
Need Demand Supply
the healthcare
services that
an individual
has the
capacity to
benefit from
the healthcare
services an
individual
might wish to
use or pay for
the healthcare
services that
are provided
21
need demand
supply
Stevens A, Raftery J, Mat, J, Simpson S, Healthcare needs assessment, 2004
22
need demand
supply
needdemand
supply
PHM
23
need demand
supply
[1] [2]
[3]
[4]
[5][6]
[7]
Stevens A, Raftery J, Mat, J, Simpson S, Healthcare needs assessment, 2004
24
need demand
supply
[1] [2]
[3]
[4]
[5][6]
[7]
Exercise
Think of an example
service or scenario for
each segment [1-7] in the
diagram?
Stevens A, Raftery J, Mat, J, Simpson S, Healthcare needs assessment, 2004
25
Underuse and overuse of healthcare
outcomes
resources
benefits
Watson J, Salisbury C, Jani A, Gray M, McKinstry B, Rosen, R, Better value primary care is needed now more than ever, BMJ 2017; 359, Nov 2017
26
Underuse and overuse of healthcare
outcomes
resources
benefits
harms
Watson J, Salisbury C, Jani A, Gray M, McKinstry B, Rosen, R, Better value primary care is needed now more than ever, BMJ 2017; 359, Nov 2017
27
Underuse and overuse of healthcare
outcomes
resources
benefits
harms
benefits - harms
Watson J, Salisbury C, Jani A, Gray M, McKinstry B, Rosen, R, Better value primary care is needed now more than ever, BMJ 2017; 359, Nov 2017
28
need demand
supply
[1] [2]
[3]
[4]
[5][6]
[7]underuse
29
need demand
supply
[1] [2]
[3]
[4]
[5][6]
[7]
overuse
?
30
need demand
supply
cost
effective
Distinction between need, demand and supply
Definition of need for healthcare = ‘capacity to benefit’
Role of PHM is to increase the overlap between need, demand and supply…
…but there may be exceptions
• where potential harms outstrip potential benefits
• where ratio of costs to benefits are very high.
31
Key points to remember
An epidemiological approach to needs
assessment
Gareth Wrench, Associate Director, Local Knowledge & Intelligence Service West Midlands
Learning objectives
1.To understand why its important to be able to assess the health
needs of populations
2.To be able to define what a health needs assessment is in the
context of PHM
3.Develop a practical understanding of the Stevens & Raftery
approach to Healthcare Needs Assessment
4.Understand how to practically undertake a healthcare needs
assessment
33
Outline
1.What is epidemiology?
2.Defining need
3.Need, supply & demand – a recap!
4.Needs assessment: aims & objectives
5.Three practical approaches to needs assessment
6.HNA & PHM
7.Summary
34
What is Epidemiology?
Derived from three Greek words:
Epi – on, upon
Demos – people
Logy – Study
“The study of the occurrence and distribution of health-related events,
states, and processes in specified populations, including the study of the determinants influencing
such processes, and the application of this knowledge to control relevant health problems.”
Miquel Porta, A Dictionary of Epidemiology
35 Epidemiological methods
Source: Porta M. A Dictionary of Epidemiology[Internet]. New York: Oxford University Press; 2014 [cited 2018 Aug 17]. 344 p.
Available from: http://irea.ir/files/site1/pages/dictionary.pdf
Uses of epidemiology
• Describing the health status of populations
• How common is diabetes and does it vary over time, by place & person?
• Identifying causation
• What factors increase the risk of ischaemic heart disease?
• Disease surveillance
• Warning of epidemics
• Assessing needs for health care
• How does COPD prevalence & provision of pulmonary rehabilitation vary by CCG?
• Evaluating services
• How effective is a local stop smoking service?
36 Epidemiological methods
37
Using epidemiological methods to understand your
population
In 2018, the number of people living in a local authority was 1,142,000.
• Is knowing this helpful in planning local health services?
• What more would you like to know?
Epidemiological methods
38
Here are some examples of other questions you may
have thought of:
• How does the size of this population compare to elsewhere?
• Has it changed over time, how is it likely to change in the future?
• How does the age structure of the population compare to elsewhere, are
there more older people, or children?
• Are there different ethnic groups in the population?
• Is the area fairly affluent or are there high levels of socioeconomic
deprivation?
Epidemiological methods
39
• Is this a big number? • Put population data in context by comparing to other populations
• Time, place, person• Can compare how populations have changed over time, or
• How populations differ in different places, or,
• How the characteristics of the population vary (e.g. age,gender) by person
Looking at these characteristics helps you to decide whether you are comparing ‘like
with like’
• Important when you start to try to understand differences in health outcomes between
populations
Epidemiological methods
Key epidemiological concepts to remember
Defining need
The need for health care is:
• The population’s ability to benefit from health care.
Important to distinguish between the need for health, & the need for
health care.
• The former term includes health problems where there is no realistic or available treatment, and
which do not inform the planning of health care services.
40
Need, demand & supply
41
• Need – what people benefit from
• Demand – what people ask for
• Supply – what is provided
Need
DemandSupply
Health need, supply & demand
42 Health Needs Assessment
Ability to benefit is the
amount by which met need
can be increased as a result
of implementing a new
health intervention or
modifying an existing
intervention
Thinking about the
population’s ability to
benefit from different
actions is one way of
prioritising
recommendations
Adapted from: Stevens A, Raftery J, Mant J. An introduction to HCNA.
http://www.birmingham.ac.uk/research/activity/mds/projects/HaPS/PHEB/HCNA/index.aspx
Need
DemandSupply
Met need
What’s the ultimate aim?
43
Need Demand
Supply
Need Demand
Supply
Healthcare Needs Assessment: one definition (of many!)
44 Health Needs Assessment
A systematic review of the health issues facing a
population leading to agreed priorities and resource
allocation that will improve health & reduce
inequalities.Cavanagh and Chadwick (2005) Health Needs Assessment: A Practical Guide
What is Healthcare Needs Assessment (HNA)?
• An assessment of the needs of a defined population in relation to a specified group of conditions
• Identifies vulnerable groups
• Maps service provision
• Identifies groups not currently accessing services
• Identifies gaps in service provision, or areas where current provision should be modified
• Suggests effective (evidence-based) and cost-effective interventions that could meet the identified gaps in need
45 Health Needs Assessment
Healthcare needs assessment may focus on…
…a disease e.g. CVD, eye health
…a service e.g. urgent care, social care
…a community e.g. older people, a specific faith community
…a social experience e.g. social isolation
…a health-related behaviour e.g. smoking, alcohol consumption
46 Health Needs Assessment
Characteristics
• A tool to inform commissioning & service planning.
• A systematic method of identifying the unmet health and healthcare needs of a population, and making changes to meet those unmet needs.
• Enables targeting of resources.
• Enables identification of where services should be modified or new services provided
• Gathering information to inform service planning with the aim of improving health and/or reducing inequalities.
• Practical, evidence based, applied research, triangulated.
47 Health Needs Assessment
HNA involves…
• The assessment of the size of the problem - How many people and which groups need the service/intervention
• The assessment of baseline services - Knowing what already exists, and how to free up resources
• The assessment of the effectiveness & cost-
effectiveness of interventions - Do they confer any benefit, and if so at what cost?
• The identification of community assets- What do they contribute, how to maximise their contribution in the future
48 Health Needs Assessment
Need, Supply & Demand
• A common mistake in HNA is to equate demand for a service with
need for the service.
• If a service is supplied (accessible and free) and patients believe it is
effective, there will be demand for it: even if the service is ineffective.
• There may be little or no demand for an effective service simply
because patients are unaware that it is effective or because it is
difficult to access.
• Measuring existing service provision as if it were an indication of need
is likely to be misleading.
49
The Stevens & Raftery Approach to HNA
50
1. Epidemiological approach
2. Comparative Approach
3. Corporate Approach
1. Epidemiological approach
• Description of problem – scale, severity, complexity,
inequalities
• Prevalence, incidence, morbidity, mortality on a ‘Time,
Place, Person’ basis
• Availability, effectiveness and cost-effectiveness of
interventions/services
• Possible models of care
• Outcome measures
51
2. Comparative approach
• Compares service provision between different populations, taking
into account any variations in health status.
• How does the level of need compare with elsewhere?
• Benchmarking need v other similar areas (e.g. use of nearest
neighbours)
• Analysis / comparison of routine data
52
3. Corporate Approach
• Qualitative approach
• Assessment of stakeholder perception (incl. professional
and patient/public groups) of what services are needed
• Assess what national, local policies exist
• Corporate memory
• Qualitative insights on needs
• Baseline services
• Involvement / engagement
53
Don’t forget about assets!
• The asset-based approach
• Recognise the existing and potential contribution of community
assets to improving health and wellbeing.
54
Factors that influence ability to benefit
There are many, but some key ones are…
• Number of people affected by a health condition• Severity of impact on quality of life• Amount that an intervention will improve quality or length of life• Number of (additional) people that can access a new or modified service• Cost of intervention• Ability of intervention to reduce health inequalities
55
Doing a needs assessment – initial considerations
• Who is going to do the needs assessment?
• What is the scope of the needs assessment?
• What resources will be needed for the needs assessment and
where will they come from?
• When should the needs assessment work be done?
56
What a HNA should cover
1.What is the problem?
2.What is the size and nature of the problem?
3.What are the current services?
4.Patient/community views
5.Review and appraise evidence base
6.Consult with professionals and other stakeholders
7.What are the cost effective solutions?
8.Resource implications
9.Recommendations and plan for implementation
10.What outcomes will be evaluated?
57
Where HNA fits into the PHM cycle…
58
Infrastructure
Needs AssessmentOpportunity
Analysis
Impact
Assessments
ImplementationEvaluation and
Feedback
Transparency
Infrastructure
Interventions
Intelligence
Scales of HNA for PHM
59
System: 1+m
Place:~250-500k
Neighbourhood: ~50k
Individual
Summary
•Main objective of a HNA is to provide information to plan,
negotiate and change services for the better, and
improve health in other ways (Stevens et al 1998).
60
Conclusion/Summary
1. Purpose of needs assessment is to improve health services
2. Health care need = the ability to benefit
3. Measured as how many and how effective
4. Allows us to prioritise fairly and rationally
5. Part of a cyclical process – need changes over time – need to evaluate how well the
needs have been addressed.
6. Overriding benefit is to take into account different perspectives of need, and generate
balanced recommendations
7. Remember that a comprehensive HNA is time and resource intensive - more than just
the production of a profile of health needs
8. Typically HNA process may overlap and feed into JSNA, Health Equity Audit (HEA)
and/or Health Impact Assessment (HIA).
61
Acknowledgements
Thanks to Dr Sue Robinson, Warwickshire County Council, Steven Wyatt and
Mohammed Mohammed for their input and advice. Also to PHE LKIS
colleagues for putting together the base material.
62
Population Health Management
NHS England and NHS Improvement
Approaches to opportunity analysis
Steven Wyatt, SU
How might we identify opportunities….
… to improve population health
… to reduce health inequalities
… to reduce overuse / underuse of healthcare
… to reduce the costs of healthcare without reducing outcomes
… to improve technical efficiency
… to reduce the incidence of harms
… to increase the return on our investment
… to reduce waste
... to improve service performance, responsiveness, patient satisfaction
….
For the purposes of this session, consider opportunity analysis as a means of generating options and
prioritising opportunity for further analysis.64
A Proposed framework
65
Benchmarking where do we compare poorly to others?
Time series where have things got worse?
Failures where have interventions not worked as planned?
Missed
opportunitieswhere have opportunities to avoid preventable poor
outcomes been missed?
Vs. standardswhere does our practice differ from accepted clinical
standards?
consider both positive and negative deviance
Exercise
In groups of two or three, discuss some of the benefits and limitations of the each
approach.
10 minutes
No feedback
66
Benchmarking: Is there an opportunity for South Worcestershire CCG to reduce spend on hip
replacements, and how might we estimate the scale of the opportunity?
67
Time series: is there an opportunity for Birmingham Children’s hospital to improve the timeliness of care in
A&E and how might we estimate the improvement opportunity?
68
0%
5%
10%
15%
20%
25%%
of
pati
en
ts d
iscr
ag
ed
/ad
mit
ted
in
4 h
rs
Performance against the 4hr A&E targetBirmingham Children's Hospital
Benchmarking & time series approaches
69
Advantages LimitationsMethodologic
al notes
Conceptually simple.
Can incorporate
assessment of uncertainty
to distinguish between
common and special
cause variation.
Can incorporate casemix
adjustments.
Not normative.
Where performance,
usage etc. is ubiquitously
suboptimal then
opportunities for
improvement may be
missed.
Casemix adjustment not
always straightforward.
Even after adjustment for
casemix, residual variation
may still be warranted.
Does not directly support
case-finding.
Consider (cross-sectional
/ time series) statistical
process control.
Consider structured
approach to explaining
residual (special cause)
variation.
Assessment against mean
– or some other point of
a distribution.
Failure: Is there an opportunity for UHCW to improve the quality of its knee replacement operations,
and how might we estimate the scale of the opportunity?
70
Failure
71
Advantages LimitationsMethodologic
al notes
Upper limit of
opportunity is evident.
Wasted costs of failed
intervention + cost
consequences of failure.
Identifying signals of
failure in routine datasets
not always
straightforward.
Costs of remedial action
may not be obvious.
Interventions to reduce
failure are never 100%
effective. Need to
incorporate concept of
NNT/ARR into
opportunity estimates.
Missed opportunity: is there an opportunity for Dudley CCG to reduce the number of
hospital admissions for vaccine preventable conditions, and how might we estimate the
scale of the opportunity?
72
Missed opportunities
73
Advantages LimitationsMethodologic
al notes
Upper limit of
opportunity is evident.
Focuses attention on
upstream interventions,
which tend to be less
invasive and less resource
intensive.
Identifying signals of
missed opportunities in
routine datasets not
always straightforward.
Effectiveness of
interventions that were
not delivered are . Need
to incorporate concept of
NNT/ARR into
opportunity estimates.
foresight hindsight
Need to incorporate
estimate of predictive
accuracy.
Need to distinguish
between failure to
intervene and failure of
intervention.
Vs. standards: Is there an opportunity for Coventry CCG to improve the quality of
treatment for patients with osteoarthritis and a history of fragility fracture and how might
we estimate the scale of the opportunity?
The percentage of patients aged 75 or over with a record of a fragility fracture on or after 1 April 2014 and a
diagnosis of osteoporosis, who are currently treated with an appropriate bone-sparing agent
74
Coventry CCG 2017-18
Number of people aged 75 or over with a record of a fragility fracture
on or after 1 April 2014 212
Exception reported 21
The number of patients aged 75 or over with a record of a fragility
fracture on or after 1 April 2014 and a diagnosis of osteoporosis, who
are currently treated with an appropriate bone-sparing agent
166
Vs. standards
75
Advantages LimitationsMethodologic
al notes
Upper limit of
opportunity is evident.
Clear / referenceable
source of standards -
fewer assumptions
required.
Clinical guidelines are
often based on expert
opinion as much as on
evidence.
Identifying failure to
deliver against standards
in routine datasets not
always straightforward.
There are always
exceptions to clinical
guidelines – identifying
these may be tricky.
NICE standards often
supplied with cost
effectiveness / ROI
estimates.
Points to remember
Analysts are frequently asked to identify improvement opportunities.
We have set out five potential approaches;
• Benchmarking
• Time series
• Failures
• Missed opportunities
• Vs. standards
Don’t forget to look for positive deviance.
Analysts should be sighted on the strengths and limitations of each approach.76
Population Health Management
NHS England and NHS Improvement
Information sources -population & prevalence
ratesAndy Hood, SU
77
Lets play top trumps!
Total population
Population sub-
group
Speed deficiency
syndrome (< 10)
Prevalence SDS
MARVEL DC
MARVEL DC
MARVEL DC
n =
Why is knowing about a population important?
1. Understand the scale of potential need and how it’s changing
2. Enable judgment of relative need (denominators)
3. Funding and allocation of resources
4. Targeting of resources
5. Observe the distribution of people geographically
6. Identify specific groups with specific needs
Population - how many now [1]
Census of resident population (2011)
www.https://www.nomisweb.co.uk/census/2011
Mid-year estimates (2017)
https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates
269,323 283,378
Population - how many now [2]
Patients registered with GP practice
https://digital.nhs.uk/data-and-information/publications/statistical/patients-registered-at-a-gp-practice
290,141
Over-registration is associated with high mobility areas with greater health needs
• Cross-border patients?
• Double-counting e.g. Nursing Home pts. & students?
• Slow removal of deaths from register?
Burch et al. Regional variation and predictors of over-registration
in English primary care in 2014: a spatial analysis. NIHR
https://digital.nhs.uk/data-and-
information/publications/statistical/patients-registered-at-a-gp-
practice/july-2019
Population - who are they?
• Gender
• Age
• Ethnic background
• Religion
• Education
• Housing and tenure
• Access
• Physical or mental impairments or disability
Nature and distribution of all these population characteristics will determine:
what services we provide
how we provide them and
where we provide them
Population - how many in the future
Growing = Increased demand
Ageing = Different (complex) demands
Social = Different settings and modes of engagement
https://www.poppi.org.uk/index.php
https://www.pansi.org.uk/index.php
Projecting Older People Population Information (POPPI) and Projecting Adult Needs and Service Information (PANSI)
Why is knowing [disease] prevalence important?
Enable you to better understand the characteristics of your population of interest
• The personal characteristics - matching evidence of effective interventions
• The places where prevalence is most frequent - matching services to need
• The change in prevalence over time - candidates for primary or secondary prevention programmes, de/re-commissioning plans?
Prevalence
…refers to the total number of individuals in a population who have a particular characteristic, usually expressed as a percentage of the population of interest.
Point Period
https://www.healthknowle
dge.org.uk/public-health-
textbook/research-
methods/1a-
epidemiology/numerators-
denominators-populations
Cases at a given
point in time
Existing and new
cases over a given
time interval
Prevalence @ 1st
Oct?
Prevalence
between 1st April
and 31st March?
7/100 (7%) 10/100 (10%)
NB. Total pop
= 100
1st April 1st October 31st March
Measure Description
Incidence rate
the number of new cases per population at risk in a given time period. When
the denominator is the sum of the person-time of the at risk population, it is
also known as the incidence density rate.
Infection ratethe probability or risk of an infection in a population. It is used to measure the
frequency of occurrence of new instances of infection within a population
during a specific time period
Birth ratethe number of babies born every year per 1,000 people in a population. The
most commonly used population denominator in UK is females aged 15-44.
Mortality rate
a measure of the number of deaths in a particular population, scaled to the
size of that population. Can be crude or most commonly standardised by age
and gender and also stratified by cause of death
Other commonly used measures of [event] frequency
Diagnosed prevalence
Someone’s already done the hard work for you! For the most common long-term/chronic conditions, GP’s submit annual data on disease registers and management of their patients as part of the Quality and Outcomes Framework (QOF, 2004/05 onwards)
https://digital.nhs.uk/data-and-information/publications/statistical/quality-and-outcomes-framework-achievement-prevalence-and-exceptions-data
Covers:• Cardiovascular diseases (atrial fibrillation, blood pressure, CHD, heart failure, hypertension, peripheral arterial
disease, stroke & TIA)
• Respiratory diseases (asthma, COPD)
• Lifestyle (obesity, smoking)
• High dependency (cancer, CKD, diabetes, palliative)
• Mental health and Neurology (dementia, depression, epilepsy, LD, SMI)
• Musculoskeletal (osteoporosis, rheumatoid arthritis)
• Fertility, obs & gynae (cervical screening, contraception)
Source: https://fingertips.phe.org.uk/profile/diabetes-ft
Other ‘quasi-prevalence’
Routine clinical audits:
• Stroke Sentinel audits (SSNAP)
• Diabetes audit (NDA)
• Asthma and COPD (NACAP)
• Anxiety and depression (NCAAD)
Full list at:
https://www.hqip.org.uk/a-z-of-nca/
Surveys:
• GP patient survey (self-reported LTC)
• Psychiatric morbidity
• General lifestyle survey
• Health survey for England
• Life opportunities survey (people with disabilities)
Fuller list at:
https://www.ukdataservice.ac.uk/get-data/key-data/uk-survey-series.aspx
Estimated / modelled / synthetic prevalence
When you want to identify or explore levels of unmet need* (and you don’t have the resource for bespoke whole-population prevalence studies).
Compare what we believe to be the total prevalence of condition A with what the diagnosed prevalence of condition A is.
Generally, the estimated prevalence will require;
a) A suitably generalisable prevalence study
b) Current and accurate population counts or estimates
* CHE (York) discussion paper - Defining and measuring unmet need to guide healthcare funding: identifying and filling the gaps, 2017
e.g. Diabetes
Is this a
genuine gap in
need?
How can we
close this gap?
Estimated or modelled prevalence
‘Off the shelf’:
PHE fingertips provides ready modelled whole-population estimates of a range of long-term conditions for local authorities and GPs.
++ Diabetes Prevalence Model for local areas (2016)
++ CKD prevalence model (UK renal registry)
Estimated or modelled prevalence
‘Bespoke’: e.g. dementia
Population study = CFAS and CFAS II, Cognitive function and Ageing Study, 1991-92 and 2008-10.
but this is only older adults 65+, what about early/young onset dementia?
+ Alzheimer Society Dementia UK delphi study, 2014 for those aged 30-64.
Age Male Female
30-34 0.0001 0.0001
35-39 0.0001 0.0001
40-44 0.0001 0.0001
45-49 0.0005 0.0005
50-54 0.0006 0.0006
55-59 0.0018 0.0010
60-64 0.0090 0.0090
64-69 0.0120 0.0180
70-74 0.0300 0.0250
75-79 0.0520 0.0620
80-84 0.1060 0.0950
85+ 0.1280 0.1810
Estimates prev.
Male Female
8,601 7,815
8,055 8,216
8,043 8,242
10,647 10,669
11,801 12,010
11,609 11,424
10,015 10,416
9,815 10,546
9,876 10,614
6,649 7,528
4,670 5,588
3,573 6,219
Population
Male Female
1 1
1 1
1 1
5 5
7 7
21 11
90 94
118 190
296 265
346 467
495 531
457 1,126
Modelled prev.
4,536
Can be used as an input feed to more complex analysis or modelling of a population of interest.
e.g. Markov model cohort simulation:
• Incidence rates
• Mortality rates
• Diagnosis rates
• Population projections
Other resources (PHM perspective)
Other resources (PHM perspective)
Other resources (PHM perspective)
Other resources (PHM perspective)
Other resources (PHM perspective)
Other resources (PHM perspective)
Additional interesting resources:
Datashine - census visualisations - https://datashine.org.uk/
Consumer Data Research Centre - thematic maps and ‘stories’ - https://maps.cdrc.ac.uk
Nomisweb - labour market statistics (and more) - https://www.nomisweb.co.uk/
Environmental and health atlas - exposure to agents and health outcomes -http://www.envhealthatlas.co.uk/homepage/gotoatlas.html
Understanding population health in your
place
Joint Strategic Needs Assessment
(JSNA) session
Gareth Wrench, Associate Director, Local Knowledge & Intelligence Service West Midlands
Learning objectives
By the end of this afternoon, you will :
• Learn about the purpose, content & production of JSNAs
• Understand why JSNAs are a critical tool for PHM
• Have the opportunity to peer-review local JSNAs
103 Joint Strategic Needs Assessment
What is a JSNA?
“a systematic method for reviewing the health and
wellbeing needs of a population, leading to agreed
commissioning priorities that will improve the health
and wellbeing outcomes and reduce inequalities”
104 Joint Strategic Needs Assessment
• JSNAs are produced by LAs and CCGs via Health &
Wellbeing Boards
• A local assessment of current & future health, care &
wellbeing needs
• Describes health status of the local population,
inequalities & wider determinants
105 Joint Strategic Needs Assessment
What is a JSNA?
• Identifies assets as well as deficits
• It is a statutory requirement
• 2007 Local Government and Public Involvement in Health Act
• 2012 Health and Social Care Act
• It is a health needs assessment which provides the
evidence base for local strategies & commissioning
106 Joint Strategic Needs Assessment
What is a JSNA?
How is a JSNA different to a HNA?
107 Joint Strategic Needs Assessment
JSNA HNA
Discovery of issuesStarts with a specific
issue/problem/condition/disease
Focus on supporting strategy /
prioritisationFocus on driving local improvement
Global understanding of needs
(wider determinants)More focussed study
Well-being as well as health Health(care) focus
Strategic overview In-depth analysis
Continuous Process More finite project
Spot the difference!
Why do we carry out JSNAs?
108
“They are not an end in
themselves, but a
continuous process of
strategic assessment and
planning …
… the core aim is to
develop local evidence-
based priorities for
commissioning which will
improve the public’s
health and reduce
inequalities”
Joint Strategic Needs Assessment
109 Joint Strategic Needs Assessment
How are JSNAs
used?
110 Joint Strategic Needs Assessment
Joint Strategic
Needs Assessment
How are JSNAs
used?
111 Joint Strategic Needs Assessment
Joint Strategic
Needs Assessment
Joint Health & Wellbeing
Strategy
How are JSNAs
used?
112 Joint Strategic Needs Assessment
Joint Strategic
Needs Assessment
One of the
most important roles of the JSNA
is to inform the Joint Health &
Wellbeing Strategy
Joint Health & Wellbeing
Strategy
How are JSNAs
used?
113 Joint Strategic Needs Assessment
Joint Strategic
Needs Assessment
• Understanding population
need at ‘place’ level
• Prioritisation of needs
• Identification of areas for
greater collaboration
Population Health Management
How are JSNAs
used?
Joint Strategic Needs Assessments
There is no prescriptive guidance on what a JSNA
should look like…..
…but what makes a good JSNA?
114 Joint Strategic Needs Assessment
What makes a good JSNA?
1. Availability
2. Timeliness
3. Includes a community profile
4. Breadth (describes the range of needs affecting
different geographical communities & different
life stages)
5. Balanced evidence base, evidence of
engagement and user voice
6. Identifies assets and deficits
7. Prioritises key health, care and wellbeing issues
8. Contains evidence of effectiveness and cost-
effectiveness of different public health
interventions
9. Appraises alternative actions (including doing
nothing)
10.Speaks to different audiences
115 Joint Strategic Needs Assessment
Are Health and Wellbeing Strategies in England Fit For Purpose? (JPH 37,3, pp461-469)
JSNAs in the West Midlands
116 Joint Strategic Needs Assessment
Local Authority Link
Birmingham https://www.birmingham.gov.uk/info/50120/public_health/1337/jsna_themes
Coventry http://www.coventry.gov.uk/info/190/health_and_wellbeing/1878/coventry_joint_strategic_needs_and_assets_assessment_j
sna
Dudley https://www.allaboutdudley.info/
Herefordshire https://understanding.herefordshire.gov.uk/
Shropshire http://www.shropshiretogether.org.uk/jsna/
Sandwell https://www.sandwelltrends.info/jsna-2/
Solihull http://www.solihull.gov.uk/About-the-Council/Statistics-data/JSNA
Staffordshire https://www.staffordshireobservatory.org.uk/publications/healthandwellbeing/yourhealthinstaffordshire.aspx#.XNWBh5hKiUk
Stoke-on-Trent http://webapps.stoke.gov.uk/jsna/
Telford & Wrekin http://www.telford.gov.uk/info/20121/facts_and_figures/424/joint_strategic_needs_assessment_jsna
Walsall https://www.walsallintelligence.org.uk/jsna/
Warwickshire http://hwb.warwickshire.gov.uk/2019/04/05/8474/
Wolverhampton https://www.wolverhampton.gov.uk/health-and-social-care/strategies/joint-strategic-needs-assessment-jsna
Worcestershire http://www.worcestershire.gov.uk/info/20122/joint_strategic_needs_assessment
Resources to support JSNA
• Public Health Outcomes Framework – PHOF tool
• Local Health (for geographies smaller than local authorities)
• NHS Outcomes Framework (NHS Digital)
• Adult Social Care Outcomes Framework (NHS Digital)
• PHE data and analysis tools
• PHE profiles – topic specific / area based
• ‘Best practice & opportunities for innovation in local JSNAs’ – PHE
(to be published shortly)
117 Joint Strategic Needs Assessment
JSNAs in practiceDavid Whiting
Consultant in Public HealthMedway Council
I'm lazyAnd I want my analytical team to be lazy too
Good analysts should get bored easily
Medway's JSNA
• About 800 pages long if printed (similar to Game of Thrones, but with a bit less violence)
• Three collections of background chapters
• Lifestyle and wider determinants
• Children
• Adults
• Main summary, including demographics
• Infographics and Profiles
• Far from perfect, but we're always trying to make it better
• Public Health Intelligence team are the "custodians" of the JSNA
• Editorial role
JSNA is a continuous process
• It will never be finished
• Much of it will be updated, at different intervals
• Many parts of it will have the same structure
• There are opportunities to be constructively lazy by automating parts of the process
Data Analysis Outputs
• Clean separation of data, analysis and outputs• R encourages and enables sharing• Can create reproducible analytical pipelines
You don’t have to do the whole pipeline in one go
• Reproducible analytical pipelines: see– https://dataingovernment.blog.gov.uk/2017/03/27/reproducible-
analytical-pipeline/
• You can automate part of the pipeline, then next time do the next bit, and so on.
• Look for the bits of your workflow that are time-consuming, repetitive, error-prone, and boring
Data Output(s)
Practicalities: File system and team-work
• Single shared set of folders, no work on local machines
• Everything we work on is a project• Active
• Archived (finished)
• All local data saved in Datasets• Don’t change data or use specific
scripts to do so
• Other data in servers, local and remote
• Change who is working on a given project
Embedding code in narrative• Avoid transcription errors
• A perfect audit trail• Facilitates shared-working
• Our default practice, for short or long reports
There is one main hospital (“Acute Trust”), Medway NHS Foundation Trust, located about halfway between Chatham and Gillingham railway stations.
Population sizeThere were approximately 277,855 people resident in Medway in 2018, according to figures produced by the Office for National Statistics[1].
The 2018 mid-year population estimate shows an increase of 13,930 (5.3%) from the 2011 Census (263,925), and an increase of 28,367 (11.4%) since the Census in 2001 (249,488).
Compared to England the population of Medway has a smaller proportion of people over the age of 65 years (Medway 15.9% and England 18.2%). Medway has a larger proportion between the ages of 0 and 14 years than England (19.7% and 18.1% respectively) and between the ages of 15 and 24 years (9.4% and 9.2% respectively). The population of Medway is therefore younger than the population of England overall.
Build process
• Each sub-section is in a folder and has a 0.Rmd (fragment) file
• We work on the various 0.Rmd files locally, commit, pull, merge, push• Two branches: master; next_release
• Build script finds all 0.Rmd files, renders them to create HTML code, and stitches them all together into a small number of larger HTML files
• Word versions are built and converted to PDF
• The whole lot is copied to a local site location
• This can then be viewed and checked before the whole thing is uploaded as a static website (no CMS). Costs £5 per month.
Other profiles
• First version:• LSOA-based
• Very flexible• Wards
• Adult social care
• Child social care
• Locality care teams (have become PCNs)
• Arbitrary areas, e.g. for local community groups
• We use the officer package in R for this
WHEN TO AUTOMATE
When you have repeated tasks
• Automate when you need to do something repeatedly and want to save time.
– Self-evident?
– How often is “repeatedly”?
• Time to automate <= time to do it manually ntimes
– n is probably larger than you might expect
When you need an audit trail
• Using code to create outputs means you have an audit trail, you will know for certain where any given part of your output, and calculation, came from.
• No transcription errors
When you want to delegate
• Automation, and more generally creating tools, means you can delegate work to people who don’t have the same level of skills and knowledge as you but can use the tool or system you have produced
• Also makes it easier to share work within a team
When you want sustainability
• If you have a process that is done in code, you can lose your team and still keep the systems running while you train up new staff
When you have a tedious task
• If a task involves boring repetition there’s a good chance you’ll make a mistake. – Automating it means you can make more mistakes
more efficiently ☺
– It also means you have a record of how it went wrong and will be able to fix it, and run it again.
Key points
• Look for opportunities to automate your analysis so the computer does the hard, boring work
• You don’t have to automate the whole analytical pipeline in one go
• R is a very good tool to use for this, • rmarkdown + knitr: docx, html, etc.
• officer: powerpoint
• Use git if you can for version control• You can use a local central repository if using github etc. is a problem
Population Health Management
NHS England and NHS Improvement
Learning from each other’s JSNA’s
(World Café, round robin)Mohammed A Mohammed, SU
Lucy Hawkins, SU
World Café Rules:
•This is an environment of sharing and learning
•Invite and honour differing opinions
•Seek to understand rather than persuade
Format:
•15 minute ‘rounds’
•‘Host’ briefly shares their JSNA; the approach to development and format of the document
•Participants have time to ask questions and compare and contrast their own experiences
•After 15 minutes move to the next room
JSNA World Cafe
• For delegates (Post-it notes)
• What did you like most about this JSNA?
• What learning do you take away from this JSNA?
• How does it compare with your JSNA?
• How might this JSNA be improved?
• How might your JSNA be improved?
Possible prompts/questions
• For presenters
• Some background to how the JSNA was developed
• How it is constructed (who populates its) and updated?
• How decision makers use it / what impact does it have?
• What difficulties/challenges have you faced?
• Future plans for the JSNA?
• Any particularly innovative or novel work?
• (e.g. automation/data visualisation)
Population Health Management
NHS England and NHS Improvement
Reflections and reviewLucy Hawkins, The Strategy Unit
• For delegates (Post-it notes)
• What did you like most about this JSNA?
• What learning do you take away from this JSNA?
• How does it compare with your JSNA?
• How might this JSNA be improved?
• How might your JSNA be improved?
Possible questions
• For presenters
• Some background to how the JSNA was developed
• How it is constructed (who populates its) and updated?
• How decision makers use it / what impact does it have?
• What difficulties/challenges have you faced?
• Future plans for the JSNA?
• Any particularly innovative or novel work?
• (e.g. automation/data visualisation)
153
What? So What? Now What?
© Liberating Structures
WHAT? What have you heard
today? What have you discussed?
What has stood out for you?
SO WHAT? Why is what you have
heard important to you? What
patterns or conclusions can you
now draw?
NOW WHAT? What are you
going to do with what you have
heard today?
What? So What? Now What?
© Liberating Structures
Analysts Programme
Launch session 09 Jul 2019Introduction to population health management and the science of
improvement
Session 1 03 Sep 2019 Needs assessment and opportunity analysis
Session 2 08 Oct 2019 Impact assessment and evaluation
Session 3 12 Nov 2019 Population segmentation and risk prediction
Session 4 10 Dec 2019 Introduction to actuarial modelling
Session 5 14 Jan 2020 Problem structuring and communicating analytical results
Joint session (1/2 day
TBC)
19-20 Nov
2019Strategic resource allocation methods
Population Health Management
NHS England and NHS Improvement
Mental and Physical Health – Informal Networking
Andy Hood, SU
Chicken or the egg?
Mental and physical health?
Understanding the nature and extent of inequality in physical health for people with mental health needs - case study
Background:
Some explanatory analysis for clinical strategy in Black Country STP looking at linked data -MHLDDS, HES and ONS mortality.
The aim of highlighting inequality in outcomes for those with mental health issues compared to those without:
•Life expectancy
•Causes of death
•Acute (physical) hospital utilisation
NHSE interest in the analysis led to a commission to produce reports for each STP in England.
Data sources and linkage
Defining the population of interest…
Anyone appearing in the mental health minimum data set (MHLDDS) is deemed, in this analysis, to be in one of the following five mental health cohorts:
• Cognitive impairment including dementia
• Psychoses
• Personality disorders
• Common and other mental health conditions
• Mental health conditions, unassigned
The cohorts are assigned based on a mixture of the mental health clusters as described in the Department of Health’s Mental Health Clustering Tool (MHCT) (see appendix 1) and clinical coding from inpatient and outpatient data HES data sets.
This results in nearly 80% of mental health patients within England being assigned to a defined cohort. The remainder were designated the unassigned group.
Applied algorithms in the following order:
1. ICD-10 diagnosis codes found in Mental Health datasets
2. PbR cluster codes found in Mental Health ‘episodes’ of care tables
3. PbR cluster codes found in Mental Health ‘events’ tables
4. Types of care episode provided in Mental Health datasets
5. ICD-10 diagnosis codes found in linked inpatient datasets
6. Mental Health specialty treatment codes found in linked outpatient datasets
Key findings:
Life expectancy
• The life expectancy of mental health services users across the whole of England is 63.1 (males) and 69.2(females).
• This represents a gap to the rest of the population of 19.1 years in men and 16.1 years in women. These gaps have decreased by a small but significant amountsince 2006.
Mortality patterns
• Age-adjusted mortality rates are higher for mental health services users than the rest of the population for all underlying causes of death.
• The largest differentials in mortality are for external causes (injury, poisoning, suicide), digestive diseases and endocrine diseases. For the biggest killers (circulatory disease and cancer) death rates for mental health service users are 2-3 times higher.
Acute utilisation
• Mental health services users use acute hospital services disproportionately. This is particularly so for attendances to A&E and emergency admissions to hospital. The use of diagnostics is also relatively high, as are the ‘did not attend’ (DNA) rates for outpatient appointments.
Saving and re-investment opportunities
• the difference in acute healthcare utilisation compared to non-mental health services users for just a small sub-set of hospital activity that is particularly amenable to preventative or demand management strategies represents £65m on activity in Emergency Departments and by up to £1.45bn for emergency inpatient admissions – around 9.3% of total CCG spend on Mental Health disorders according to programme budgeting data.
Population descriptors:
The nucleus of variables to feed into a segmentation model?
Variation in outcomes
Nested inequalities!?
Variation in hospital utilisation
Identifying opportunities for reducing demand & costs…
Subsets of activity for which there are evidence-based demand management approaches - a realistic view of saving opportunities (albeit not accounting for investment requirement).
The summary below represents, for England, the difference in activity between mental health service users and the rest of the population for each defined sub-set of activity after adjustment for age and gender and provides the associated costs of that activity.
Monetising ‘opportunities’ is a good way to kick-start an economic appraisal (and excite commissioners!)
Over to you….
•Thoughts on the mental-physical health dynamic. What could be interesting to explore further?
•Experiences of your own population profiling, needs and opportunity analysis?
•Communication and dissemination, hints and tips?
top related