Public Health, the “core offer” and supporting CCG commissioning – some thougths

Core offer and PH CCG Support

what do CCGs need and expect from PH

Answer from history, current, future.

 

This post gives some reflections on “the core offer” – that is the bit of the PH function that supports some aspects of CCG commissioning.

(apols it is long)

 

The exam question – what do CCGs need and expect from PH

Answer from history, current, future.

 

1          History –

PH used to be owned by the NHS.

DPH on PCT boards – corporate, totality of PH

Consultant on PEC or similar – technical.

 

Act – the law = “do the JSNA”

 

2          Current –

CCGs feel they have “lost” PH

Representing what – the authority / commissioning adults, children, PH services / PH corporate ie all PH functions / technical advice to CCG

 

3          Key points from our previous discussion on this matter

 

Capacity and functions varies from place to place. Historic arrangements and distribution. LTC commissioning, IFR input.

Extent of formality varies

 

Commonly occurring issues

  • economies of scale & footprints
  • subregional / regional perspectives into commissioning
  • operational vs strategic
  • relationship management is all – often regardless of the content. Being there matters
  • don’t distinguish between the “the council” and “PH”, and PH commissioned services vs “technical stuff”.
  • Establishing boundaries between “clean” population health care and broader agendas aren’t easy
  • make the invisible (PH input into commissioning) visible?
  • avoid paralysis by analysis
  • Broadly the “what is done” remains the same : a combination of evidence, epidemiology, economics, ethics, and evaluation. These are the sort of HCPH skills that are valuable to councils (we think) but do councils agree with us?
  • Protecting the NHS from itself!
  • £100bn budget – Population approach is right approach for clinical, moral and financial reasons
  • Nowhere else that this advice comes from: lots pretend they can, but few can deliver.

 

My answer to exam q of what does the future of the “core offer” look like

 

General

  • Want more but discrepancies between need, want and expectation
  • Becoming intelligent customers
  • Very variable expectations – depending on the CCG and knowledge/understanding of what PH is/can do.
  • Core offer is obsolete concept – its low value and largely pointless use of time
  • We cant solve all problems (and mostly aren’t expected to?)
  • Specific issues remain…– epi, business intelligence (and interpretation), evaluation, evidence base, economics.
  • value the “expert” tag – someone from the “outside”…. Helps that someone else says it?
  • Want to see PH grant as part of partnership Want DPH on GB but also support from HC expert more broadly
  • expect us to know everything about the Council (and vice versa)

 

Data and intelligence

  • lost connection with what the population data is telling them (focusing on activity and spend data). Sources and interpretation
  • BI – not just shiny graphs, but shiny graphs with meaning and interpretation.
  • dashboards etc – that show statistically significant change (as opposed to counting numbers and making spurious assumptions based on those numbers)

 

what goes around comes around

  • Help with decommissioning – Right Care etc, PCLV, Referral Management etc
  • The two forgotten letters in QIPP – namely Q and P
  • Expectation varies with historic functions – eg commissioning LTC and IFRs

 

New shiny things and nuances

  • New approaches- social marketing, nudge etc Support to providers- be health promoting hospitals (MECC)
  • Supporting CCGs to understand their role in prevention is also needed
  • Challenge CCGs – on what they are doing, on what they are not doing, to improve population health – so its not all about the acute contract
  • PH person at all the big meetings including private sessions of GB – In or out the tent? Varies from place to place.
  • PH offer should be to whole NHS system not just to them- PH advice on whole of NHS, focus on commissioner and provider. Multiple types of provider.
  • Area based plans, whole populations, accountable care etc – PH roles in this.
  • Evidence based commissioning versus shiny toy commissioning – for population health gain.
  • big transformational agenda – Vanguard, Transformation Plan (mental health), better care fund etc
  • Increasing focus on role of public health in demand management – suddenly prevention is all the rage

Areas of “difficulty” – mostly NOT related to HC PH…mostly related to HP and broader PH functions

  • EP
  • CCGs feel excluded from some of the commissioning of PH type of services…..sex, cigs etc etc….but…….. Lifestyle commissioning…. Letting us find our feet etc etc etc
  • interface between CCG / PH / NHSE…..proving problematic
  • VCS – needs streamlining??…………..Out of sync.
  • Vac and Imms / screening –Mixed communications…..WHO is responsible……………

 

Public health advice service – our LEGAL requirements

 (http://www.legislation.gov.uk/ukdsi/2012/9780111531679)

7.—(1) Each local authority shall provide, or shall make arrangements to secure the provision of, a public health advice service to any clinical commissioning group whose area falls wholly or partly within the authority’s area.

(2) A public health advice service is a service which consists of the provision of such information and advice to a clinical commissioning group as the local authority considers necessary or appropriate, with a view to protecting and improving the health of the people in the authority’s area.

(3) In discharging the requirement under paragraph (1), the local authority shall exercise—

(a)the public health functions of the Secretary of State pursuant to section 2A of the Act, to the extent that the public health advice service relates to the protection of the health of the people in its area; and

(b)its public health functions pursuant to section 2B of the Act where the public health advice service relates to the improvement of the health of the people in the authority’s area.

(4) The purpose of the public health advice service shall be to assist clinical commissioning groups in relation to—

(a)their duties to arrange for the provision of health services under section 3 of the Act(20) (duties of clinical commissioning groups as to commissioning certain health services); and

(b)their power to arrange for the provision of services or facilities for the purposes of the health service under section 3A of the Act(21) (power of clinical commissioning groups to commission certain health services).

(5) The range of matters which is to be covered by the public health advice service shall be kept under review by the local authority and shall be determined—

(a)having regard to the needs of the people in the local authority’s area; and

(b)by agreement between the local authority and any clinical commissioning group (whether acting alone or jointly with another clinical commissioning group) to which the advice service is required to be provided, or in default of such agreement, by the local authority.

(6) The range of matters which is to be covered by the public health advice service may in particular include the following—

(a)the creation of a summary of the overall health of the people in the local authority’s area which is designed to guide clinical commissioning groups in the commissioning of appropriate health services for persons for whom a clinical commissioning group has responsibility under section 3 of the 2006 Act(22);

(b)the provision of assessments of the health needs of groups of individuals within the local authority’s area with particular conditions or diseases;

(c)advice on the development of plans for the anticipated care needs of persons for whom a clinical commissioning group is responsible under section 3 of the 2006 Act, to improve the outcomes achieved for those persons by the provision of health services;

(d)advice on how to meet the duty on each clinical commissioning group under section 14T of the Act(23) (duties as to reducing inequalities).

 


“the Core Offer” – a view from one LA PH Dept.

 

This paper covers 4 areas

  1. Background and history. The provenance of the “core offer” and specifically the 40%
  2. Some specific examples of high impact / high profile work. These are parochial to Bradford. Only illustrative
  3. Some views on what capability it is reasonably to expect out of a “core offer”
  4. Some contemporary issues

 

It is intended to provide some background and backdrop and stimulate some discussion on “what a good core offer should look like”

 

 

1       Background and history – provenance of the core offer, specifically the “40%”.

 

  1. a) section 7 – The Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) Regulations 2012

http://www.legislation.gov.uk/ukdsi/2012/9780111531679

sets out the intended (in the eyes of our legislators) PH responsibilities of LA towards CCGs

 

  1. b) the DH “factsheets”

 

  1. c) DH advice  

an earlier draft is here

https://www.gov.uk/government/publications/healthcare-public-health-advice-to-ccgswhere the “40%” comes from (1WTE per 250k pop)

Was clearly drafted by someone with some expertise in this area

a little bit of residal uncertainty – its v clear here about 40% of the SPECIALIST workforce, not the whole PH Dept

this was the basis from which pretty much all MOUs are based

It should be noted that the DH guidance is not mandatory, and there appear no checks in the system that require local authorities to provide this type of support.

CCGs must draw their own risk assessment about the loss of functions, capacity and expertise.

 

 

There is no a priori process for formal agreement of this MOU. Ultimately it is recommended that the CCGs and LA agree this plan through the Health and Well Being Board.

 

CCGs need to 

identify their priorities for Public Health input to CCG for for healthcare public health, health improvement, and health protection – noting the balances set out above

use the outputs of this process to inform the PH offer to CCG work plan

Clarify the CCG offer back to PH and include in the MOU, specifically areas relevant to health improvement and health protection

ensure this work dovetails with the CSU development plans

2       the day job. What you can and should expect capability wise

The areas where PH department can and should have a significant role in implementing “the core offer” is as follows:

 

Health intelligence and analytics

  • Using and interpreting data to assess the population’s health and the impact of specific interventions or population change.
  • Undertaking/ advising on the production of Health Equity Audits, Equality Impact Assessments and Health Needs Assessments
  • Advise systems on the development and implementation of predictive modelling and risk stratification of populations using specific tools.
  • Undertake geo-demographic profiling to identify association between need and utilisation and outcomes for defined target population groups.
  • Identify the service and policy changes that are necessary to best improve against outcome indicators
  • Interpretation of health profiles, in collaboration with CCGs and local authorities
  • Modelling of the contribution that specific interventions make to defined outcomes within local pathways and service models,
  • Relative return on investment modelling
  • Modelling scenarios to predict future health need.
  • Support systems in the design monitoring and evaluation frameworks for services, collect and interpret results.

 

Clinical Effectiveness

  • Production of bespoke evidence reviews to inform commissioning policy, service specification and care pathway development. Critically appraise the evidence to support the implementation of new treatments, services, service models or new treatments.
  • Providing the evidence base and rationale for specific points on patient pathways across the health and social care spectrum to deliver best value
  • Work with systems to identify and assess population impact of implementing NICE guidance/guidelines
  • Shortened summaries of NICE guidelines – TA summaries, legal and commisisoning briefings on NICE Guidelines

 

Health Care Quality assurance and improvement

  • Undertake macro or micro service reviews of particular areas (specialties, population or disease groups)
  • Support specific Quality Improvement projects in primary and secondary care
  • Provide technical input to the development of quality indicators and quality targets for inclusion in service specifications
  • Support to systems on interpreting and understanding data on clinical variation in both primary and secondary care. Establishing and evaluating indicators and benchmarks to map service and system performance
  • Support the development or review of service specifications
  • Horizon scanning. Work with a range of stakeholders in identifying likely impact of new NICE guidance, new drugs/technologies in development, and changes in use of existing technologies, epidemiological, population or demographic change.
  • Working with clinicians and drawing on comparative clinical information to understand the relationship between demographics, epidemiology, patient needs, clinical performance and wider quality and financial outcomes.

 

HealthCare Transformation (HCT)

  • Services review and System redesign outcome focused
  • Services development
  • Pathways developments
  • Strategic reviews
  • Strategic planning
  • Strategy for value transformation
  • Healthcare services improvement
  • Evaluation of health care project and programmes

 

Value based health care. Prioritisation of resource allocation

  • Apply health economics and a population perspective to provide a legitimate context and technical evidence-base for the setting of priorities including identifying areas for disinvestments including using a range of techniques, including programme budgeting and marginal analysis (PBMA).
  • Work with systems to identify areas for disinvestment and enable the relative value of competing demands to be assessed
  • provide advice on how to use and interpret comparative economic analyses such as the NHS atlas of variations and the Spend and Outcome tool, the DH Programme Budgeting dataset.
  • Building the economic case for investment in health improvement programmes through the QIPP, Health & Wellbeing work strand
  • Provide advice on economic evaluation of new interventions or service models. Conduct simple economic analysis as per requests.
  • Develop prioritisation processes and providing frameworks to enable systems to take difficult commissioning decisions. This may including legal, ethical, economic and epidemiological perspectives.
  • Provide specialist support to systems to ensure they are able to participate in consultations on NICE TAs
  • Support systems develop a narrative to communicate and defend difficult decisions to the public
  • System analysis to increasing value by maximizing patients outcomes per pound spend
  • Technical health economics advice

 

System Transformation

  • Advice on the development and implementation of population healthcare management tools
  • Advice on system wide quality improvement targets

 

Transformation Commissioning   Model

  • Work with systems to develop the tools, techniques and specific products that will enable transformation to happen. This includes
  • Risk sharing models – risk and gain share
  • New models of contract – eg Primary and Alliance Contractor
  • New models of institutional design – eg Accountable Care Organization
  • New models of payment – eg value based payment, bundle payments for care cycles

Research and innovation

  • Provide expert advice on processes for dealing with trial exit strategy and excess treatment costs arising from trials
  • Provide input to trial design and specification
  • Provide input to requests for commissioner support for trials
  • Provide support and advice on developing and implementing a strategy on innovation
  • Development of innovative and creative ideas for higher quality and cheaper pathways.

 

Individual Funding Requests

  • Providing PH advice and expertise the IFR process– advice will cover legal, clinical and cost effectiveness, regulatory and ethical perspectives
  • Critically appraise the evidence and provide clinical support to appropriately respond to individual funding requests
  • Work with systems to refine the policy and procedures as required
  • Develop and implement training programmes for members of IFR panel.
  • Work with a range of stakeholders to review existing commissioning policies for specific treatments as needed and produce new commissioning policies

 


3          Some contemporary issues in “delivering the core offer”

 

Some “problematic areas”

EP, Sexual health commissioning, TB, obesity

CORPORTATE EP vs PH EP…….need to distinguish. MAJAX v PH Emergency. PH EP, business continuity

PHE roles in EP / NHSE roles in EP

Vaccination and screening – WHO is responsible.

SHOULD NOT include things that are NOT CCG responsibility

Pinch points are risk and money

Dealing with NHSE stuff and interface between CCG / PH / NHSE…..proving problematic

VCS – PH, LA more broadly, and NHS all commission from VCS – needs streamlining. Out of sync.

Data / PH intelligence / business intelligence / CSU vs PH vs PHE

 

 

Specificity in the question being asked.

Vague set of requests for PH, happening at a time of great uncertainty.

Expectation that we help” CCGs sort out 5yr views, 2 yr plans and all the other corporate planning docs.

Maybe at the expense of more valuable stuff

Who decides what is more valuable? More valuable to whom? The CCG? The population?

 

Should we explore the concept of “making a referral to the PH consultant”

Think of the question that is being asked of the PH consultant

Must be clear in what you are asking

Would you commit a large chunk of funds to a consultant in another speciality without asking them a question

If you were paying for it direct would it change how you think about it

 

Should we be more “research” focused? 

Specific and defined pieces of work…..

Or “part of the corporate infrastructure”

Being “on hand” vs specific pieces of work

 

Important to Remember we are not, any longer part of organisation

Part of a different culture

No amount of hygiene factors can address this

Don’t underestimate how difficult it is to do some of this stuff from the outside – especially when the message is what commissioner might not want to hear

May not be a popular message – But who else is going to say

 

delivering the core offer and misunderstandings of

PH as a “commissioner” of obesity, sexual h, drugs etc etc

PH as part of the broader corporate body that is LA

PH as technical expert re advice and support.

These are different. Very different.

 

The distinction between “what we get from the CSU” and “what PH dept does” often rather vague and difficult to define

Where one (free) stops and another (paid and contracted) starts is hard.

Esp when one is aggressively marketing wares to generate market share

Even more confused by the fact that some CCGs have kept some sort of intelligence function.

The CSU ‘offer’ is very different across the country.

Add to that the management consultancies who keep dazzling us with various shiny products

 

Advice vs pair of hands to do

We can be doer also – but means you get less advice

Sometimes hard to get others to do the doing as “it’s in my head”, “it’s part of the training”, others have a different perspective, it’s just easier to do it myself

Evidence and principles

 

maintenance of good local clinical networks

“the ability to simply pick up the phone”

we have exceptionally well developed networks with secondary care clinicians across most to all specialities.

This enables us to get detailed insight and intelligence into actually how systems work, that arguably many CCGs just don’t have.

For obvious reasons (position of trust) etc we have to use this carefully – and our role is skilled honest broker

 

What the evidence says versus what we want to believe

PH view vs “commissioner view”. Not always the same

 

governance and issues associated with core offer

in terms of “governance” of the core offer – how is this agreed and sorted. Whom is accountable to whom, for what.

DPH, Ch Ex, Leader

Dealing with disagreements – like any contract when its fine its fine, when it isn’t… What leverage do CCGs have

MOU just a document…. the business is in the conversations and the relationships

CCGs often not intelligent customers

interface between CSU / PH / CCG – lots of mixed messages and confusion etc etc

 

Balances to be struck

  • Reactive v proactive and planned programme
  • Specific interventions (eg new anticoagulants) vs broader “systems of care” (eg Intermed Care / telemedicine) etc
  • “strategic” vs “operational”
  • Specific topic areas vs “broader support” (for examples input to boards and strategic groups and………….
  • Support bespoke to each of the CCGs in a LA area vs more strategic approach for all three.
  • Specific clinical areas or population groups CCGs would wish to prioritise
  • Links and interface with existing clinical lead areas

 

How priorities are set

If priority areas had to be defined the a number of criterion might be used, for example

  • Is it in PH Outcomes Framework, NHS Outcomes Framework (esp domain 1, I am less interested in the rest) or Social Care Framework of relevance to CCGs
  • Is it a QIPP priority
  • Does PH dept have the capacity and capability to do the job
  • Does the function best sit with another part of the system.

 

 

Models across local authorities

    • interesting to look at different models of dept – v different across a range of Authorities.
    • A reflection of history / different backgrounds of DPH + team. No clear consensus on
    • Data that is currently available to PH teams
    • Team make up – size and scope
    • Balance between the 3 domains of PH (H Imp, H Protection, H Care)
  • Political priorities in that authority

 

 

Data risks and issues

Data from PHE, HSCIC and elsewhere.

stitch up re access to data sets?

expectations re what will / wont be available – Signif uncertainties in system re what will wont be left in the system. Can we (by which I mean “the system” afford to have multiple tiers.

Need to be clear what do we NEED from PHO, CSU and other stakeholder

Can we continue to deploy the things capacity and expertise that is currently tacitly shared

 

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