needs assessment and opportunity analysis€¦ · uses of epidemiology ... • identifying...

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



Overview of PHM Academy

Lucy Hawkins

3

https://midlandsphmacademy.nhs.uk/

Useful resources

https://midlandsphmacademy.nhs.uk/

...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!!


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


And then in

November moving on

to Implementation

and Evaluation




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



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



Mentimeter QuestionsGareth Wrench, PHE



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]


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?


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


outcomes

resources

benefits

harms


27


outcomes

resources

benefits

harms

benefits - harms


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

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?


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


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

http://www.birmingham.ac.uk/research/activity/mds/projects/HaPS/PHEB/HCNA/index.aspx

What’s the ultimate aim?

43

Need Demand

Supply

Need Demand

Supply

Healthcare Needs Assessment: one definition (of many!)


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


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


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.


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


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



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


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


al notes

Upper limit of


Focuses attention on

upstream interventions,

which tend to be less

invasive and less resource

intensive.

Identifying signals of

missed opportunities in

routine datasets not


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


al notes

Upper limit of


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


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



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

http://www.https/www.nomisweb.co.uk/census/2011

https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates

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

https://digital.nhs.uk/data-and-information/publications/statistical/patients-registered-at-a-gp-practice

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)

https://www.poppi.org.uk/index.php

https://www.pansi.org.uk/index.php

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

https://www.healthknowledge.org.uk/public-health-textbook/research-methods/1a-epidemiology/numerators-denominators-populations

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)

https://digital.nhs.uk/data-and-information/publications/statistical/quality-and-outcomes-framework-achievement-prevalence-and-exceptions-data

Source: https://fingertips.phe.org.uk/profile/diabetes-ft

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

https://www.hqip.org.uk/a-z-of-nca/

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)

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

https://datashine.org.uk/

https://maps.cdrc.ac.uk/

https://www.nomisweb.co.uk/

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”


• 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


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


What is a JSNA?

How is a JSNA different to a HNA?


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


How are JSNAs

used?


Joint Strategic

Needs Assessment

How are JSNAs

used?


Joint Strategic

Needs Assessment

Joint Health & Wellbeing

Strategy

How are JSNAs

used?


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?


Joint Strategic

Needs Assessment

• Understanding population

need at ‘place’ level

• Prioritisation of needs

• Identification of areas for

greater collaboration


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?


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


Are Health and Wellbeing Strategies in England Fit For Purpose? (JPH 37,3, pp461-469)

https://academic.oup.com/jpubhealth/article/37/3/461/2362725

JSNAs in the West Midlands


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

https://www.birmingham.gov.uk/info/50120/public_health/1337/jsna_themes

http://www.coventry.gov.uk/info/190/health_and_wellbeing/1878/coventry_joint_strategic_needs_and_assets_assessment_jsna

https://www.allaboutdudley.info/

https://understanding.herefordshire.gov.uk/

http://www.shropshiretogether.org.uk/jsna/

https://www.sandwelltrends.info/jsna-2/

http://www.solihull.gov.uk/About-the-Council/Statistics-data/JSNA

https://www.staffordshireobservatory.org.uk/publications/healthandwellbeing/yourhealthinstaffordshire.aspx#.XNWBh5hKiUk

http://webapps.stoke.gov.uk/jsna/

http://www.telford.gov.uk/info/20121/facts_and_figures/424/joint_strategic_needs_assessment_jsna

https://www.walsallintelligence.org.uk/jsna/

http://hwb.warwickshire.gov.uk/2019/04/05/8474/

https://www.wolverhampton.gov.uk/health-and-social-care/strategies/joint-strategic-needs-assessment-jsna

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)


https://fingertips.phe.org.uk/profile/public-health-outcomes-framework

http://www.localhealth.org.uk/

https://beta.digital.nhs.uk/data-and-information/publications/ci-hub/nhs-outcomes-framework

https://beta.digital.nhs.uk/data-and-information/publications/ci-hub/social-care

https://www.gov.uk/guidance/phe-data-and-analysis-tools

https://fingertips.phe.org.uk/

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

www.r-project.org

Statisticalprogramming language

http://www.r-project.org/

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)

https://dataingovernment.blog.gov.uk/2017/03/27/reproducible-analytical-pipeline/

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



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)



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)

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



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?

needs assessment and opportunity analysis€¦ · uses of epidemiology ... • identifying...

Documents