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Public Health and the Commissioning Cycle: Getting benefit from getting together

Jim McManus

Director of Public Health

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Mary knew she wanted an equity audit but still thought the public health team could be a bit more accessible

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Starting Points• Commissioners are – or ought to be – big customers of Public

Health

• PH ought to see commissioners as a major constituency to influence

– Sometimes PH does too much “commissioning of its own”

– Sometimes PH becomes detached from commissioning

– Sometimes PH Depts are like Mini PCTs

• Things which prevent this are

– Not knowing what public health “do”

– Public Health not being clear of its role in commissioning

– Style issues

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What is Public Health?

• A team which brings together within ten key competencies for public health practice people who practice the art and science of supporting the improvement of the health of the population.

• Public Health Specialists have:

– A Population perspective – look to the population and see not just the whole but the nooks and crannies

– A Prospective perspective – look to the future

– A Preventive perspective – reduce ill health, promote good health

– A Prospective perspective – looking to the future of the area informed by the past (e.g. mortality trends)

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A “Typical” Public Health Dept

• Sometimes called Health Improvement Depts

• Director of Public Health

• Consultants in public health/ consultants in public health medicine – 8c or 8d – practice all ten competencies to the level of specialist registration. Higher specialist training usually including MFPH (www.fph.org.uk) May be medic or non-medic. May also be Assistant or Associate Directors

• Specialists – Band 8 usually have a Masters

• Advanced Practitioners Band 7s – may be doing an M.Sc

The technical workhorses of the dept

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Meet the Public Health Senior Team

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A Very Odd Mix of stuff

• May be working on equity audit of access to care at the same time as being responsible for emergency planning, business continuity, pandemic flu planning, immunisation uptake, commenting on pollution licence applications and other nerdy stuff that is sexy to people in public health but mightily P***** commissioners off when it derails a tightly scheduled project

• This is usually a symptom that the PH Dept’s own ability to keep continuity of core business during an emergency needs looking at

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Part of the Public Health day Job at present….• Chief Medical Officer Alerts – 24 – 48 hours

• Major Incidents, Pandemic Flu, CBRN……..

• Port Health Alerts – immigrants with TB etc

• IPPC (Pollution Control Licences) – we have 28 days to respond

• Controlled Drugs

• Child Death Panels

• Mortality Files, Suicide Audits, SUIS involving deaths

• Investigations

• Outbreaks (though managed by HPA pct has a role)

• Planning for major accident hazards/emergencies

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From 2013

• Healthcare Public Health Support to NHS CCGs (Mandatory)

• Needs Assessment (Mandatory)

• Commissioning some functions (Mandatory)

• Use of evidence and PH skills to support commissioners across the system (the big opportunity)

• Work with all sides of system

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Perceptions of PH by Commissioners• PH Needs to up its game

• Library dwellers!

• Don’t know how to access them

• Boundaries of when to involve and when not to

• Not sure they add anything

• Keep saying they’re too busy or don’t have skills

• Obsessed with their professional status

• Bit of a closed shop

• Prodigious amounts of data in the annual public health report, produced in almost untintelligble density

• Needs Assessments – never mind the message, look how pseudo-academic the document is!

• All you need is a sneeze in southwark and you can kiss goodbye to them

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Perceptions of Commissioners by PH

• Haven’t a clue what the population needs (but did we bother telling them?)Disregard the evidence (did we tell them what it is?)

• Contracting historically, not what’s needed

• Glorified

• Why won’t they read our stuff?

• Why don’t they love us?

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The Diagnosis

• This is usually the symptom of both sides not understanding what the other can offer, and not engaging with the other side.

• Commissioners may have more difficulty engaging public health because of the “mystique” of what they do

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Overcoming These

• Meet together to explore (today)

• Jointly articulate a cycle of input (today)

• Involve on projects rather than just sitting on steering groups

• Use the “Commissioning Framework for Wellbeing” document

• Work through the commissioning cycle with some PH colleagues and have the PH key competencies to hand

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Scope of Commissioning Interest

• Commissioning

• Business Plan

• Corporate Plan

• Health and Wellbeing Strategy

• National Service Frameworks (yes they still exist)

• QIPP

• CQUIN

• Transformation

• NICE

• Public Health

• Well, exactly the same. Our concern is that we increase independence, reduce mortality and morbidity in the population and increase longevity, as well as addressing health inequalities, through commissioning activities

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A (very) Simplified Commissioning Cycle

Monitor

Plan

Review Need for Service and

Effectiveness of existing services

ContractThe Commissioning Cycle

This is used just to introduce the concepts of what PH can help you with.

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Articulation of PH input…various models

• World Health Organisation Planning Wheel

• Kellog Foundation Planning Cycle

• DH Commissioning Cycle

• Hybrid model based on what HCC seems to be using (for discussion)…..

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Monitor/ Evaluate

Plan

Review Need for Service and

Effectiveness of existing services

Public Health Input into the Commissioning Cycle. Can be throughout or can be on

specific areas playing to the PH strengths

Community Engagement

Support in establishing meaningful indicators of

delivery and outcome

Model whether need willBe met by proposed volume

Check whether plans equateTo evidence and need andTest for equity / inequity

Support and advise onEvaluation and conductBits of it if enough resource

Needs AssessmentsEquity AuditingEvidence of Effectiveness

Health Impact Assessment

Triangle of critical influence – where public health should be most visible

Contract/Deliver

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The Public Health Toolbox

• Assessing Population Need

• Identifying Equity

• Critical Appraisal of Evidence

• Assessing Impact on Health

• Modelling Population and effects of interventions

• Community Engagement

• Economic Modelling of Interventions

• Access to wider sources of expertise

• Being Internal Consultants

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Health Needs Assessment

•Age Structure

•Morbidity

•Mortality

•Socio-economic data – Census– Housing

•Public Health data set

•Indices of health – Jarman– Townsend

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Performance monitoring

•Service Level Agreements

– Activity/Finance

•Quality

– Waiting Times/Access

– Waiting Numbers

•Validation

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Ad hoc requests

•Critical Appraisals– Does this drug or procedure work?– Is it cost-effective?– Should we fund it? For whom?

•Service developments/business cases– heart failure

•Impact of investment – CHD secondary Prevention/MI’s

•Analysis of variances – emergencies (secondary View/Primary View)

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Modelling

Impact of policy/planning

- Payment by results

- Capacity planning

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I know

What we

Need for

Our

Population

I know

How to

make it

happen!

Both commissioning andPublic health can comeFrom either side of thisconversation

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1. Commission for the whole person’s lived experience (housing, volunteering, leisure, transport,)

2. See Potentials not Problems, assets as well as needs

3. Transformation of current system through staged redesign to preventive and early intervention

4. Subsidiarity and Access

5. Co-production

6. Behavioural Sciences

7. Pathwayed

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Discussion example: Chronic Pain

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Some outcome we should look for

• A public health approach in adult social care should bring the following benefits:

– Less people in residential care

– More people independent– Less costs to NHS and

Social Care– Fewer costs to GPs for those

with long term conditions and disabilities

– A way of monitoring the new market and micro-commissioning

• A public health approach for children should bring the following benefits:

– Fewer children with avoidable behavioural disorders

– Evidence assessed interventions for troubled families

– Children looked after are healthier physically, psychologically and socially

– Standards for physical, cognitive and emotional development and resilience across all services

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Components of this model where we work together

• Population approach to – projecting need– Identifying risks – risk stratify– Identify priorities– Identify candidate interventions

• Intervention and outcome design

• Emphasise Prevention (science & art)

• Joining up (housing and social care, primary care and social care)

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Prediction

forecast / target services

Secondary Prevention

Pri

ma

ry P

reve

ntio

n

Un

ive

rsal

& W

ell-

be

ing

LOWMODERATE

SUBSTANTIAL CRITICAL

Reduce numbers of people coming into high-cost services and

moving along FACS banding

Intensive Home Support

Residential Care

Community Equipment Services

Telecare Service

Tertiary Prevention

How might Prevention look in Social Care?