Ageing population lazy thinking for when you cant be bothered to understand the real issues

By me and Steve Laitner

I've (GF)  blogged a lot on the myth that is the "demographic timebomb", and set out a set of data and arguments to make up case argument wise. See references at the bottom.

 

 Here are our collected summary thoughts on why getting the narrative wrong on this is harmful

 

Lessons in demography

Despite popular conceptions, the age distribution of the population shifts very slowly from one year to the next. The population does grow, but the distribution of age shifts slowly. This slow growth in the age distribution of the population limits the magnitude of the impact on utilisation.

Many perceive that the impact of ageing during the next ten years will be higher than it was for the previous ten years; this perception is incorrect.

 Strunk et al estimate that ageing increased inpatient utilisation by 0.35% per year from 1995 to 2005. One can also assess the changing impact of ageing by comparing annual increases in inpatient utilisation for selected one-year periods. For 1994–95, 2004–05, and 2014–15, the ageing factors are 0.33%, 0.63%, and 0.80%, respectively

Ageing therefore accounts for a relatively small portion of the growth in hospital spending projected for the next decade. One USA estimate suggested only 11.8 percent of the total increase in inpatient spending from 2005 to 2015. (Ref 10 from Strunk)

In this country demand is going up year on year – c4%. The population age profile is shifting considerably more slowly than this.

 

To prove "the ageing population timebomb myth", you need to:

look at the data and who is actually using healthcare, and other factors

A&E – generally NOT older people

Hospital admissions

 it's important to consider the a) absolute number b) length of stay (perhaps older people for LOS but for admissions) and c) where the increases are in utilisation d) absolute numbers in a population, especially in e) a fixed capacity system 

 – you then need to demonstrate that it's AGEING per se that's driving this, not morbidity or demand side failures. 

In general, the effect of ageing effect on use of inpatient services will be small, but it will have a larger impact on use by patients with certain types of medical conditions that are more concentrated among the elderly.
Finally, and arguably critically, although the AGE of the population is increasing is the burden of disease increasing (NO, what limited data there is would suggest not) or is it just that 72 or the new 70 etc and its just numbers on the clock and mean nothing (probably)
 

Given all that, are you sure you can demonstrate the ageing timebomb? No, we thought not.



In a nutshell …..Cost, and cost growth, is driven by 

  • morbidity – incident and prevalent disease. Incident disease is CONSIDERABLY more important here
  • Low value expensive technology, 
  • over diagnosis and over treatment, 
  • unrealistic expectations,
  • degradation of the demand management functions, 
  • over use of supply sensitive care.
  • Preference sensitive care choices – an assumption is often made that people want the same care at 90 as they do at 40 – they don’t.
  • End of life intensive tx. 
  • Proximity to death – whether that's at 69 or 99, it doesn’t really matter doesn't matter.

 

These drive health cost inflation and NOT "the ageing population".

 A number of blogs on this are referenced at the bottom. They are fully referenced.

 And also even IF the ageing population is a reason for increasing demand on healthcare surely the improving health of the population which allows people to live longer should be REDUCING the demand on healthcare for slightly younger population
…and if technology means that people are living longer shouldn’t technological advances enable us to LOWER the cost of healthcare such as through non face to face means
How much is “living with disease” life increasing (if at all)?

 

This IS, however, proving a very difficult zombie to kill especially as far as popular media and NHS policy are concerned.
Its a fantastic cop-out - “its not our fault its those bloody citizens having the audacity to live longer”!

 

 

Here are 5 reasons why it matters that we get this narrative right, and matters a lot.

  1. If we focus on “the ageing population” the wrong response becomes more likely. If we are fatalistic, and accept it's an inevitable consequence of an ageing population, we will prepare wrongly by building bigger hospitals to cope with demand, not preventing demand. Hospitals are certainly not what the older population want and in most cases need, consider them as expensive hotels that sometimes add value, but often they don't and can do harm. – as a subset of this, if we get the narrative wrong we will loose focus on healthy ageing (in old money that's called health promotion) 
  2. We focus on what we CANT do much about, and we don't focus on what the problems driving demand actually are, ones that we CAN do something about – this becomes a sort of Moral Hazard and we just plead for more money as always. Take for example the recent Lancet commission on dementia. One of the points made in the accompanying editorial was that Dementia prevalence- halved if we delayed onset by 5y, furthermore this may be achieved with more assertive and ambitious mid-life interventn
  3. Stigmatising old people. It's ageist.
  4. It weakens the intergenerational, whole  society compact that underpins the establishment of the NHS. Why should I pay for all those old folk who are expensive to care for.
  5. A reliance on "the ageing population" hypothesis entrenches (as if it needed further entrenchment!) inequity in resource allocation as it (unfairly) further weights age per se over real drivers of need. Given that 1) the distribution of resource in healthcare between hospital and out of hospital is in itself a determinant of health and 2) the distribution of resource within primary care is inequitable – this 'ageing timebomb hypothesis' makes inequality worse.

 
Dear everyone, 

Change your narrative please.
 

 
 

 Postscript 1)

 Critique of these ideas

Of course this is all an unproven hypothesis. 
It's worth saying that despite this, feedback from our GP friends on twitter – and in real life – has been consistently along the lines of ….. "yep, that about reflects my reality"

One person summarised the ideas as a bit fast and loose

One of us (GF) wasn't very happy with that. We referred the person to the assiduously referenced blogs at then bottom of this one, and pointed out we were indeed writing s blog not a PhD thesis!

Another suggested that the focus on multi morbidity was a bit medical model. 

Fair critique. We could call it multi morbidity, we could call it loss of functional ability or ability to adapt, we could even call it health and well being. 

We maybe should characterise it as all of the above.

However our point is that those things are not driven by "the ageing process" (which is obviously not modifiable but by extraneous events that often are, but we choose to ignore them at both an individual and a societal level.

Muir Gray has been writing about this for years now – #sod70

This takes us back to place we give to the concept of "healthy ageing" in policy terms versus "preparing for the demographic timebomb". Guess which one gets more airplay in public consciousness?


Lastly on demonstrating the hypothesis with data.

Tricky, may not be a doable thing. We don't think we're clever enough to do it.

  • We think the analytic question is on of whether a robust AGE SPECIFIC measure of morbidity is changing over a long period. 
  • That measure would need to be adjusted for perverse screening programmes that lead to overdiagnosis, over treatment trends, insulated from the impact of changes in supply or demand side factors in the health and care system – i.e. Pure morbidity or functional ability / impairment.
  • This would test whether 72 is indeed the new 70 or whether 68 is the new 70. Ideally this would also need to be data that can be cut along socio economic deprivation and other lines 

Until such time as such analysis is available, our contention is that "the ageing pop" remains lazy shorthand for not addressing much more difficult issues 

 

Postscript 2) 

Further reflection and feedback from others

1)

Is the focus on multi morbidity the right focus.

Our original blog said that it was multiple morbidity that is driving cost, and that morbidity a proxy for disability and also proximity to death

Alf Collins consistently points out that morbidity is a proxy for disability, which is a proxy for functional impact (see Commonwealth Fund)

See here – Lancet editorial What is health? The ability to adapt:

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60456-6/fulltext
This has obvious implications for how we take forward the next steps.

Huber and colleagues went close to this in their 2011 article called "how should we define health" http://www.bmj.com/content/343/bmj.d4163

A subset of this is the "ahhh but it's all about frailty, and that's definately related to age" line 

Not in our view.

There are many old folk who are "frail", no doubt. There are many old folk who are definately NOT frail.

There are plenty of younger folk who are also frail.

Our view is that frailty is not an "age thing" per se, but about the accumulation of stuff earlier on in life, and is full of modifiable risk factors,

See here on the framing of frailty – helpful https://britishgeriatricssociety.wordpress.com/2017/06/26/framing-the-narrative-of-frailty-differently-will-help-to-promote-wellbeing/amp/


2)

Individual vs population approach to frailty and resilience

Of course individuals live in a social context. Many told me that it's actually about the social context in which individuals live. This leads to the question of whether we can build the resilience of communities to help individuals in those communities. Of course, is the obvious answer.

See this poster

Communities Fit for Frailty:
The Relationship between Community Resilience, Frailty, and the Use of Care
Wider still – social factors,……. is the need to take into account other changes in social structure are making life rather more difficult – no longer can rely on nuclear families to look after our old rellies, changing job market, melting of welfare state as we know it – and many other things all have profound effect

3)

There are many who take a different line

Eg see here http://www.bmj.com/content/357/bmj.j2759.short?rss=1

Can this be summed up as:

Some older people stay for and well and active

Some don’t

We need to think of the latter as well as the former

4)

The paper in the lancet was interesting.

Forecasted trends in disability and life expectancy in England and Wales up to 2025: a modelling study

http://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30091-9/abstract
The study is excellent and warrants a careful read. The cncousyiom line in the abstract – sadly only bit most people ever read – says "The number of older people with care needs will expand by 25% by 2025, mainly reflecting population
ageing rather than an increase in prevalence of disability. Lifespans will increase further in the next decade, but a quarter of life expectancy at age 65 years will involve disability."
There, said it – population ageing. 

Actually the study is one that puts together disease indecence, prevalence, life expectancy, healthy life expectancy and the number of people of a certain age. All projected into the future.

The sheer increase in numbers of people over 65 (25% in 10 years) must be an issue but this is more demographic than increases life expectancy is it not, and an economic and political issue and offset to some extent by less younger people.

The increase in years with disability (the major cost driver) is small -about 0.7 years increase in 10 years?

I still insist that neither account for 4% per year on year increase in NHS demand and we must get out of that Moral Hazard cul-de-sac quickly.
"Population ageing" doesn't even get close. You've got to distinguish net population growth, changing in disease profile and ageing per se.

There were a bunch of other limitations and caveats. Picked out in both the main paper and the editorial. Obviously nobody likes long lists of caveats – folk have short attention spans and get bored. Suffice to say caveats are important!
That starts with really understanding the causes of increased demand and what we need to do about it!

It is interesting to note the recommendations of the authors

 increased capacity in formal social care (making good cuts of last 7years?)

 improved support for informal social care arrangements

enhanced interventions against predictable risk factors 
Simple, but rather unpalatable stuff as we continue with our narrative around broken hospitals, must fix hospitals etc etc etc


So, all up……we (STILL) can't robustly, or with any credibility, pin the current problems in health and social care on the ageing pop etc

 
 

References

It's NOT about the ageing population – https://gregfellpublichealth.wordpress.com/2016/11/18/is-it-the-ageing-population-need-demand-or-supply/

It's NOT about the ageing population – volume 1 https://gregfellpublichealth.wordpress.com/2016/11/18/is-it-the-ageing-population-need-demand-or-supply/

the ageing population" conundrum volume 2 -https://gregfellpublichealth.wordpress.com/2016/03/25/the-its-all-about-the-ageing-population-conundrum-where-next/

prevention – ultimately futile in broad economic terms as folk will likely live longer and get dementia….discuss -  https://gregfellpublichealth.wordpress.com/2016/08/24/prevention-lets-not-bother-as-itll-never-save-money-how-much-money-will-you-save-in-our-stp-by-next-week-fell-12/

The epidemiology of multi morbidity https://gregfellpublichealth.wordpress.com/2017/03/09/on-the-epidemiology-of-multi-morbidity/

The transformation issues we don't talk about – https://gregfellpublichealth.wordpress.com/2016/11/18/the-transformation-that-are-missing-from-current-iterations-of-thinking/

The GP 5YFV and the deep end. The importance of inequality. https://gregfellpublichealth.wordpress.com/2016/12/10/the-gp-5-year-forward-view-the-importance-of-inequality-and-the-deep-end/ 

Using routinely collected data to demonstrate where the NHS is going wrong https://gregfellpublichealth.wordpress.com/2016/12/09/using-routinely-collected-data-to-demonstrate-where-the-nhs-is-going-wrong/
Strunk B, Ginsburg P, Banker M. The Effect Of Population Aging On Future Hospital Demand. Health Affairs 25, no.3 (2006):w141-w149. http://content.healthaffairs.org/content/25/3/w141

Preparing for later life today – The Lancet – http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31996-7/fulltext?rss=yes

Public health in 15 years time.

A few weeks ago I went to an excellent, small but perfectly formed session on “the future”.
It was Chatham house rules, so I won’t spill too many beans.

The upshot was fascinating and worth sharing

We spend a lot of time thinking about “the future” of the profession of public health.

1)
Opening thoughts
In 10y time there will be fewer off us than there are now
LG really pleased to own PH again. This will likely continue, despite financial carnage, as long as we continue to adapt to an ever changing world.
The value of PH is about allocative efficiency of spending and gravity of spending to get better allocative value
Our core job wont change = how we continue to get to allocative efficiency. Get more outomes out of £ envelope.
LG values these skill sets.

2)
Our job will be highly specialist or technical or creating relationships and trust. It might be both
Business partnering skills will be important.
Technical competency is key, but…..this competency is no use without ability to persuade and get trust.

3)
Get into analytics
Skillset of health intelligence likely to be critical skill in the future. What can and can’t be concluded from different streams of data.
Predictive analytics is a big feature of the future. New professions will develop to do this work. Can we keep up? We ought to try.
Also local contextual intervention as to how to contextualise data from big data predictive analysis is key.

4)
Tear up how you describe & communicate “public health”
People believe who and what they trust rather than experts

5)
Soft skills are as important as “anorak” skills.
Spend time understanding what drives those you are trying to influence, understand their arguments better than they can
Skillset of being bilingual across multiple worlds and ability to carry influence = critical skill
PH Professional of the future = complex systems, linking and joining agendas, sense making,

6)
The world will be more automated. The system in which we operate will be different
Critical job = TRUST in the assurance process that goes around automated systems
TRUST must be built on professional underpinning, and we need to keep our professional training and integrity.
So we still need to understand the basics of the profession….and how the system is put together.
As an accountant = TRUSTED as an advisor to assure automated accounting processes.
This is definitely an OPPORTUNITY.

7)
Think about this now. Be prepared for the future.
What are the new skills I need, what are the skills that already exist that we harness onto a job with a common outcome
Analytics, OD theory, complex systems

Read – Suskind and Suskind – the future of academics in the AI world

STPs, prevention and the the ever changing ask of “public health”

Been thinking a lot on this.
I’m thinking there’s a standard assumption that PH = “prevention” and thus prevention aspects of our STPs will be “done” by PH.

Two fab studies have focused my attention on this issue of prevention how it fits in STP world, one on obesity, one on hip fracture. I could have picked countless others.

Key points of both studies are noted at the bottom of the blog, to keep the main points of the blog short.

Both studies highlighted the lack of a population approach to managing risk and reducing disease incidence, as we spend our time “managing illness in the prevalent population”. We can choose to ignore this, but ever increasing cost of care is in no small part attributed to disease incidence (see many of my other blogs).

I’ve said it before, I’ll say it again in the future – the only surefire way to reduce cost in health care is to not provide health care.
You can either choose to stop providing some interventions and deal with the political and clinical consequences, or you can prevent the need for health care.
Again, again, and again in any system of care primary prevention is the most efficient way to reduce cost and improve outcomes.

“Public health” will not have the reach and depth to address these risk factors at the scale needed.

Thus “the system” needs to decide whether it wants to remain in the business of “providing excellent care” (which by and large it does) or managing and reducing population risk (i.e. Primary, secondary, tertiary prevention mindset) and thus reducing burden of disease and improving outcomes

“Public Health” is:

  • A Function – a responsibility of local government as a whole
  • A set of Services – things traditionally thought of as “public health services” – smoking, obesity, health visiting, sexual health etc. The line between those services as “public health” and any other service is pretty murky, esp if you have a broad definition of the concepts
  • Some source of Expertise – clinical, epidemiological, economic, other. To apply to any issue, problem or opportunity.
  • There’s also some Strategic leadership sort of stuff.

Public health is NOT

  • prevention
  • The public health grant
  • Health inequalities. How many meetings about health inequalities have you been to that are loaded with PH types (often as it’s seen that PH will sort this)
  • It is also not the medical model or the social model. It is both.

Doing public health (or anything) when there’s tons of cash is easy – do the right thing with the £ available
When there’s no £ – you have to do the right thing with what you’ve got but change the overall mission of the system.

My core job wont change over the years = how we continue to get to allocative efficiency i.e. to get more outomes out of £ envelope.

I should be clear here, I’m not really shirking out of my responsibilities- I accept them. I’m reflecting on what is doable, not doable and trying to get a common understanding. We should think about this when we are thinking who “does” prevention in your STP.

Studies

Hip Fracture
Hip fracture, falls, fear of falling is a big deal for both the NHS and social services.
Here is an awesome (mainly Scandinavian) epi study Papadimitriou et al considering the burden of hip fracture.

My key points are below.

  • Prospective cohort study aiming to quantify the Burden of hip fracture and risk factors.
  • 223 880 men and women aged 50+ were followed up
  • 3.5% risk of hip fracture (7,724 fractures) and 413 (5·3%) died as a result.
  • Significant disability (and consequent impact on health AND social care system – quantified in the paper)

Once again – same old risk factors….Cigs, lack of sweat etc
Current smoking was the risk factor responsible for 7.5% of the hip fracture burden, physical inactivity – 5·5%, history of diabetes – 2·8%, and low to average BMI 2·0%, 1·4–2·7), low alcohol consumption and high BMI had a protective effect.

Implications

  • hip fractures are an important cause primarily of disability & mortality
  • Many opportunities exist to ameliorate the burden of hip fractures via a focus on treatments that will facilitate a rapid and complete recovery.
  • Primary prevention measures should be strengthened to prevent falls, and individuals should be encouraged to avoid smoking and a sedentary lifestyle.
  • Secondary prevention should also focus on treatment of osteoporosis and coverage of effective interventions at population scale (there’s pretty low coverage of osteoporosis meds and falls is, well, pretty messy….overly focused on “specialist services” not generalist population approach)

Hip fracture
Papadimitriou et al – Burden of hip fracture using disability-adjusted life-years: a pooled analysis of prospective cohorts in the CHANCES consortium
http://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30046-4/fulltext?rss=yes

Cauley – Burden of hip fracture on disability
http://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30067-1/fulltext

Obesity & overweight
Closer to home Kent et al looked at hospital costs associated with overweight and obesity in a 1.1m women cohort. That’s quite a big study and a lot of person years!

Key points

  • Follow up of 1.1m women in England aged 50–64, recruited between 1996–2001
  • Followed up for c5 years starting in 2006.
  • 1·84 million hospital admissions were recorded in this cohort in that time
  • Every 2 kg/m2 increase in BMI above 20 kg/m2was associated with a 7·4% (7·1–7·6) increase in annual hospital costs.
  • Excess weight was associated with increased costs for all diagnostic categories, except respiratory conditions and fractures.
  • £662 million (14·6%) of the estimated £4·5 billion of total annual hospital costs among all women aged 55–79 years in England was attributed to excess weight
  • of this £517 million (78%) arose from hospital admissions with procedures.
  • £258 million (39%) of the costs attributed to excess weight were due to musculoskeletal admissions, mainly for knee replacement surgeries.
  • This cost looks likely to increase substantially especially with regard to diabetes complications.
  • Many health economists are now focusing on the broad societal costs of being overweight, including early retirement, efficiency at work, and prospects of promotion. These societal costs are now estimated to account for 60% of the total costs of being overweight or obese
  • i.e. The NHS costs quoted above (nb in a small slice of the whole population) is c40% of the total societal cost.
  • In 2014, the McKinsey Institute estimated the economic burden of being overweight or obese at US$2 trillion, matching that of smoking and all armed conflict.

Kent et al – Hospital costs in relation to body-mass index in 1·1 million women in England: a prospective cohort study – The Lancet Public Health
http://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30062-2/fulltext

James – The costs of overweight
http://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30068-3/fulltext

Improving the determinants of health and well being

I was once asked “why local government didn’t take the determinants of health seriously”. After I’d picked my jaw from the floor, I had think of an erudite answer. It was blogged (see references at the bottom) and I won’t revise or review that further.
 

Health policy is mostly focused (in the minds of the public) on the NHS. The Health Foundation published an excellent report from the Health Foundation that focused on three questions:

  • Why do governments focus on health care rather than health? 
  • Where has a shift to health started and what have been the contexts, drivers and benefits? Where that shift is held back, what have been the obstacles – funding mechanisms? 
  • What is the relationship of the state and the individual? What is the nature of evidence in complex systems

 

And to their credit, the HF have published an excellent strategy for health that is very refreshing. It is worth you reading it.

 

Sheffield City Council has now agreed a strategy for public health. It is referenced.

Health in all policies is a key focus of this. We are trying (again) to move “health policy” away from health care and more toward the things that determine our health – funnily enough often called “the determinants”.

 

Here I will focus a little energy on “the determinants”.

 

As we all know the determinants of health are complex. 

Each of the things known as “determinants of health” are 

  • complex, there are many moving pieces, many intersecting service delivery, capital investment and policy areas. 
  • Some of these are in direct control of local govt or other local actors, many are not.
  • This is true for all things considered “determinants” for example air quality, education, spatial planning, economic development, poverty, or housing policy.

To make progress you need to to be able to understand the drivers of those systems…..how they operate, the incentives, the power bases…..and what outcomes they are measured by…

So “addressing the determinants of health” is just as (arguably much more) complex than many who are outside this world might think.

Take “Education” for example . Education is an obvious determinant of health and well being (and lost of other socially useful outcomes!)

(I won’t dwell on the evidence for this statement. There’s rather a lot of it. Google will set you right if you look. See the ref from RAND as a starter.)
Two obvious indicators of “the problem” and markers of improvement – school readiness age 5, educational attainment age 16 – and the inequalities in both. Again, there’s plenty of evidence of inequality in school readiness and attainment.
Im told both are fundamental determinants of adult outcomes and life chances, and that improving school readiness changes life trajectory age 26 and is a good predictor of income tax paid (a proxy for income among other things). It’s an area I don’t have great expertise in, but have no reason to disbelieve it.

 

However, it’s complex. Schools are increasingly outside the control of local government. Early years services are not.

 There are no silver bullets, no single investment or intervention that will solve the problem. 

Many aspects of policy of service delivery overtly not within LA control. There are many crazy and perverse incentives and issues.
It is a complex system, difficult to “control”. Obviously this then takes us into complex system type of discussions and the extent to which they are “controllable”
So – some thoughts on improving health via addressing the determinants – here using school improvement as an  example, and a repute to improving educational attainment 

I should caveat that I’m no expert in “education”, nor should I be. If we’ve signed up to a health in all policies type of framework we need to ensure we have organisational competence and a plan.

There’s pretty much universal agreement that in the absence of a mega innovation, an Incremental change with right model of delivery and an intelligent / intelligence led approach is the way to go

Detailed understanding of the data matters
Some investment may be needed in key priorities, but not much.

There may be scope for social investment type models to try and test innovations, this shouldn’t replace state funding.
We have broadly a locality based approach to school improvement and partnership of schools in context of local community. This seems to matter, and I’d argue it’s the right approach.

Academy status doesn’t really matter (it may do if academy isn’t bought into the local vision – this is the bit that seems to matter.)

Leadership matters. A lot.

Accountability for improvement matters. Capacity to improve is inherent in all. We have a model of competitive collectivism, again this seems to matter.
Lastly, it cuts both ways – good health and healthy behaviours is important fundamental for learning (and thus downstream attainment). No shortage of evidence there either.
 
Message

  • Making improvements to “the determinants of health” is complex, tricky and there are no easy answers. Just like health care?!
  • The logic of improving school readiness and educational attainment leading to improved life chances and downstream health gain is pretty sound.
  • Like most other policy areas we won’t get population gain till we have addressed inequalities
  • If you want to improve “a determinant” you need to be able to understand the system and provide the right sort of help and support, but not necessarily be an “expert” (remember we all hate experts now etc)
  • The same basic principles apply to anything that is a determinant.

 
 

 References

If only local government took the determinants seriously – https://gregfellpublichealth.wordpress.com/2016/06/07/determinants-of-health-if-only-local-government-took-it-seriously/

 

Why are We Hooked on Health Care? Designing strategies for better health.

http://www.health.org.uk/publication/hooked-health-care-designing-strategies-better-health

 

The HF strategy for health

http://www.health.org.uk/publication/healthy-lives-people-uk

 

SCC Public Health Strategy

http://democracy.sheffield.gov.uk/documents/s25843/Public%20Health%20Strategy.pdf

http://democracy.sheffield.gov.uk/ieDecisionDetails.aspx?Id=1756

 

Implementing a  health in all policies approach in the context of a public health strategy https://gregfellpublichealth.wordpress.com/2017/04/02/what-does-health-in-all-people-policies-really-mean/
RAND- Investing in the Early Years: The Costs and Benefits of Investing in Early Childhood. http://www.rand.org/pubs/research_briefs/RB9952.html

 

Dear Generalist…changing cultures and attitudes in accountable care

Guest blog by @docant
Dear Generalist… 

Amongst all the talk of Accountable Care Systems within an STP environment and deconstructing the internal market and all that jazz: one of the key things that keeps getting mentioned is about changing cultures and attitudes.

 

We discuss it in terms of changing the ‘system’s’ view of General Practice: realising its value in addressing health inequalities and helping reduce overall system spend. Lots of hope that true investment will follow.

We fervently discuss cultural change when discussing the closer integration between primary and community care services and secondary care services. Hard to argue with that too much.

But it occurred to me during a discussion regarding behaviours within the hospital system that there’s one behavioural change we never discuss.

 This was lightbulb moment I had during a conversation with our  DPH  Greg Fell. (Some say he’s the new Muir Gray you know!)

 

………… So, we’re there discussing increasing super/sub specialisation in our hospital sector and how regional networking of hospital services in our STP future will accelerate this. We were lamenting how a consultant will often refer on to another speciality if another problem outside of their own rears its head and how they don’t call upon the patients GP when I hit upon the truth.

If we are to accept that GP’s are the last bastion of true general medicine and the home of the vast majority of contacts and interventions in the NHS. If GP’s are the diagnostic and management common sense specialists then there is one bit of cultural and behavioural change that must follow.

 GP’s will ring consultant specialist colleagues for advice. It can be the patient’s own consultant they are already under or it could be the on call registrar for advice in a more acute scenario. It’s sensible, it can avoid unnecessary referral or even admission. It can ensure the right diagnostic test is ordered. It can often just reassure the generalist that their instinct to do watch and wait was right. It can also reassure the patient.

It’s a fairly ingrained cultural thing on both sides that this behaviour happens. Nobody questions it. Everyone feels the value.

 

So here’s the thing:

 

I’ve been a partner in my practice for over 15 years with some other years in GP land before that and I have never…. ever…..genuinely….. been called by a specialist for advice.

So why don’t we change that? Why doesn’t a sub-speciality consultant faced with complex multi-morbidity call the generalist for a word of advice or reassurance?

Now before any GP’s that are reading this start whinging about being swamped or this being unpaid work think how little you actually call on a busy consultant colleague to give you unpaid advice. I think we would be called occasionally and appropriately once we give our colleagues permission to do so.

 

What would the benefits potentially be?

Well we know our customers. We may be able to contextualise a patient to the specialist so they understand the patients view about the Northern General. (husband died there)

We might be able to head off some overtreatment and polypharmacy problems before they occur. (very likely)

We might be able to reassure that Edith will be able to continue living at home despite her poor mobility and the place being an infection control nurses worst nightmare because we are aware it’s been like that for decades and she’s survived this long. (definitely)

We will on occasion be able to bring our renowned whole person care common sense to play and act in the patient’s best interest. (“don’t do that Mike, you have to think of her as terminally ill now, stop the drug, refer to palliative care…”)

Potentially this is a cost nothing quid pro quo we should be encouraging in our new joined up accountable care systems that has enormous impact improving satisfaction, preventing harm and yes, reducing cost.

All the best ideas are simple I’m told!

 

Anthony

 @docant

Dr Anthony Gore, GP, Clinical Director, NHS Sheffield CCG

Implementing a  health in all policies approach in the context of a public health strategy

What does health in all people policies really mean in the context of a  public health strategy

 

 

The original ask of the Leader of the Council and Chief Executive was:

·         Describe what SCC as a “public health organization” would look like

·         “transform ‘public health’ please, from an NHS facing model to a local government facing on.

·         “PH” is not “the PH grant”, it is the sum total of all that happens in Sheff that determines how healthy we are. Influence how the city works to achieve the goal

·        The goal is the 25yr difference in H Life Exp (and the things that lead to this)

·        write a strategy. The aim of the strategy is to describe “SCC as a public health organization” and to enable the public to hold SCC in this.

  • The strategy is now agreed and published:

http://democracy.sheffield.gov.uk/ieDecisionDetails.aspx?Id=1756

 

 

The approach taken in the strategy

The approach is, deliberately, tipped away from an NHS centric model of public health, through that model still has significant merit. This is an effort to redress the balance in approach to “public health” a bit, but mindful of the large gravitational pull of the NHS and the potential in terms of the staff that work in it. We have, however, made a concerted effect to shift the balance of the discussion and narrative on health away from the NHS and more towards other issues.

 

this blog sets out some thoughts on how to get on with a health in all policies approach in the context of a PH strategy. It is the attached document

 

 

HIAP GF note

 

success and failure issues to consider (from Hooked on Healthcare)

Capture

 

Capture2

The individualisation of public health and health policy.

This is a major and ongoing concern. It’s often termed “lifestyle drift”.

I’ll be clear here – lifestyles are a major risk factor for illness, and we shouldn’t mustn’t ignore “lifestyles” the question is what approach you take to be more equitable, effective and efficient. We should NOT ignore lifestyles in our rush to address the social determinants (see next blog).

Concern about individualisation is also much broader than “lifestyles”. It goes into every area of social policy

 

All political theories are visions of well being and set out ideas on how that visions is best actualised. there are different lenses on health and well being:-

  • Individualistic – fits well with market thinking
  • Medical – focused largely on physical and mental health
  • Social or ecological notion – broadens to take into account relationship between person and society (governance)

All three matter – but where you start and broaden out from has fundamental implications

 

Giving back control

There is lots of narrative around at the moment on the topic of giving individuals back control, empowering individuals and similar.

This is great.

The flip side of this is transferring risk from society or corporation to individuals. This may have perverse effects re equity and loss of efficiency in net social terms.

 

Here are three examples that articulate the drift towards individualistic approaches

 

Food banks

The growth of food banks has been controversial. A recent McKee lecture cites cabinet members quoted as saying the growth of banks is attributable to people who are unable to manage their money, or spending the money on booze and fags. This is obviously incredulous and not defendable, if true.

Others argue that food banks are a necessary response to austerity and food insecurity.

Arguably a Necessary but insufficient, arguably the wrong response. 

The right response is a policy response that addresses the determinants of food poverty. 

Obviously that is easier said than done, hence the fall back to what is more easily and readily done….setting up and running food banks.

 

 

SRE is now statutory. 

This is obviously welcome. But note the requirements around focused on resilience of individuals. 

What about the system & context in which those individuals live. 

It’s less efficient to increase the resilience of individuals than it is to alter the environment. Ideally both are needed.

 
 

Workplace well being 

Workplace health is more than a banana in the canteen, a bike shed, stress balls and a massage. It should easily – more – focus on toxic environments in which people work.

See the recent RAND study evaluating the Workplace Wellness Charter. There seemed a strong tendency of Focused interventions on where there is a tendency for individal paradigm approach – most obviously employee wellness checks.

Easier to measure. More visible, emblematic, (less meaningful)?

 

Message

It’s a straight message from my health promotion training of the 1990s from Keith Tones and Sylvia Tilford

  1. Individual behaviour matters. It matters a lot. But understand it, understand the context and don’t victim blame individuals if the social context is wrong.
  2. Secondly – addressing the social, economic, political and environmental context is considerably more equitable and efficient than focusing on individuals who may have limited power or motivation to change.
  3. We obsess with pathologising everything, this is at the expense of a broader econoligc approach.

 

 

Reading 
RSA – A happy society needs more than mindfulness https://www.thersa.org/discover/publications-and-articles/rsa-blogs/2017/03/a-happy-society-needs-more-than-mindfulness

RAND http://www.rand.org/pubs/research_reports/RR1661.html

McKee lecture – https://www.phc.ox.ac.uk/blog/jam-tomorrow-prospects-for-the-just-about-managing-in-britain

 

What outcome measure for an Accountable Care System – how will we know its working

Third go at this one. Th other two are referenced

This one attempts to distill the essence

We’re all on this path.

I keep getting ask d what outcome measures we should use……..

Hers my take 
This isn’t a paper about clinical performance measures. This short paper sets out some recommendations for how might we know a system is achieving its intended effect.

1)​Process measures Indicators

  • %of budget envelope that is subject to outcome based payment
  • % of physician salary at risk for qual outcomes
  • % of contracts that are subject to up and down side risk sharing
  • % of budget that is capitation
  • % of budget that is spent on hospital vs out of hospital.
  • £ / capita on district nursing.
  • What is the trajectory of GP v hospital v mental health expenditure.

 

2)​Efficiency measures

  • OP procedure rate (efficiency)
  • Day case rate (efficiency) – aim on cutting down on bed use. We may already fare well in this respect.
  • % of visits (OP and GP) conducted by phone as opposed to face to face
  • % of referrals that are e consultations.

3)​Cost measures –

cost / patient month – needs more sophisticated data than we currently have, and needs to be done in segmented pops 

4)​obviously – need measures of patient experience and outcomes in this mix

Good, validated Patient-provided measures of health, well-being, and functioning are available and sometimes routinely collected.

 measures do the degree to which care for complex pts addresses their goals. 

5)​Clinical indicators

  • • Obviously it would be expected that any ACO / ACS set out a suite of clinical indicators.
  • • Need a single set of xxx indicators. Size of xxx should be determined. Should be based on NHSOF, ASCOF and PHOF Mostly these are very fit for the purpose expected of them.
  • • CMS in USA provides a comprehensive set of real and proxy outcome and quality metrics for accountable care organisations. These can readily be adopted. There are no surprises in this. The foucs of such sets of indicators is VERY much on the “system” and NOT “doctor”. In an ACO context the “system” is the organisation, for an Accountable Care System we still need to focus on system level indicators. (see my blog referenced)
  • • Its worth saying that in the realm of clinical measures there’s a creep towards outcomes relevant to older people and service use (the measurable vs the important) and lack of attention to population risk indicators.
  • • Should expect a balanced suite of measures focused on quality, experience, outcome (population health) and cost. Not just service utilisation.
  • • KEY clinical indicators suggested as: The few summary indicators that are often used are patient satisfaction (quality), OP procedure rate (efficiency), 3d r readmission, non elective rate. Id also suggest something about long stay (DTOC and resultant decompensation)

 

 

 

Others include

  • • Unscheduled in-patient readmissions within 30 days of discharge for selected case mix groups – stroke, COPD, heart failure, cardiac, pneumonia, diabetes, gastrointestinal, asthma, mental health and addictions
  • • Repeat unscheduled ED use within 30 days for any reason (may focus on low acuity – minor, no imaging, no follow up) – actually, emerging evidence it’s a poor indicator unless the system can focus on low acuity.
  • • Percentage of hospital patients who know important discharge aspects, for example, danger signals to watch for after going home, medication-related information, when to resume usual activities, whom to call if they need help
  • • Percentage of patients with complex high care needs identified who are targeted/receiving appropriate care (e.g., intensive case management [in development

These are hospital centric… some of the issue is about 1) what’s measured vs what’s important, data availability and 2) complex system measures of quality, experience and outcome that apply to all organisations in a system  

 

6)​A consistent set of quality measures covering:

Effectiveness – the extent to which system delivers in terms of patient outcomes (e.g. people feeling treated with dignity and respect), and strategic outcomes (e.g. reduced readmissions, less people going into long-term restrictive care etc)

Economy – the extent to which the system is achieving value for money and delivering the required services on budget, on time and within other resource constraints

Efficiency – whether the overall system is working optimally – e.g. length of stay, number of negative-value days (red days) in each setting, unused capacity in services etc…

7)​practice level and cultural indicators of shift to personalisation and population risk management

  • • Lower-risk patients were offered disease management programmes that involved proactive management of care using guidelines with prompts to clinicians and
  • • Patients, decision-support systems for patients and clinicians, patient education and selfcare, electronic disease registries that identify affected patients and record details of
  • • Motivational Interviewing is a “norm” in terms of style of consultation
  • • A practice looking after a population has a clear plan re the risk profile of its population of patients with specific conditions. Can demonstrate it is making active use of risk profiling
  • • Visible commitment to seeing service users as part of the healthcare team
  • • Visible commitment to neighbourhood level partnerships with community groups
  • • visible commitment to including specialist nurses as part of community teams

It does boil down to knowing:-

  • • What outcomes and other things you want to achieve. Being really this. You’ve got to think hard, there are no shortcuts.
  • • what data is collected, readily (and sometimes less readily, but needs a bit of work) available
  • • What raw data can be turned into indicators. Knowing – in detail, real detail, how the datasets are derived from raw data, and what can / can’t be concluded.
  • • and the ability to backtrack all of the above, and backtrack clinical indiator sets.

References

Outcome measures for an ACOhttps://gregfellpublichealth.wordpress.com/2016/11/23/outcome-measures-for-aco/

My first effort http://www.yhahsn.org.uk/wp-content/uploads/2016/04/5.-GF-ACO-Performance-Metrics.pdf

  • This goes though how this is done in the states, especially the CMS data set.

Kings Fund –

CDC

IHI papers are also useful

Postcript

Like all folk that like to be evidence based and robust I like to get critique from others 

I asked a colleague who’s views I respect immensely

His take one the above was as follows
 Critique 1

I’m afraid I’m not a big fan of metrics bucket lists!

 

With system metrics especially, it’s much more meaningful to bring a systems approach to the problem and be clear on causal linkages e.g. attached (which includes the AS&R example – note the strategy mapping in particular).

 

In terms of outcomes, we should also ask from our service users / public standpoint what they would expect to see? So we need to include some PREMS (eg Picker Institute Qs) and PROMS (eg ICECAP-A / ICECAP-O).

 

Clinical measures would be at the service delivery outputs level I think (rather than at the outcome level), and I think a key part of that would be access – primary care access measures in particular. We need to secure access to data for that.

 

Some measure of the number of new care plans and care plan reviews would be important primary care clinical process measures.

 

Re strategic outcomes – a key thing is the ‘smaller hospitals’ outcome (eg number of acute beds used – this is not the same as acute bed-days – you can reduce bed-days with no change in the size of hospital by simply reducing LoS).

 

An output on the road to the smaller hospitals outcome (and to counter the trend in reduced acute bed-days leading to increased spells and therefore increased costs) is an aim of eliminating zero and short LoS admissions. So we need to keep a tally of those and recognise (contrary to current thinking) that more is not good, fewer is good.

 

Readmissions (readmission from IC and IC beds in particular) and reablement failures would be important output measures.

 

Need simplified measures of (unwarranted) variation in some of the above eg GP neighbourhoods.

 

I’ll stop there. Strongly think we need to take a systematic run at this.

 
And the thoughts of a second reviewer


Critique 2
 interesting
Covers a range of pertinent domains around which we can organise things.

As always there are more indicators available than are included in any specific dictionary

It’s the choice of the dictionary developer to include x,y or z which is always unknown. 

Would be good to have rationale as to what the selection process was 

As with all of these things, it boils down to detailed knowledge of what raw data is / isn’t collected, the robustness and data q issues associated with it, what level of granularity, how it can / can’t be used, what the smallprint says, what the caveats are and the questions you’re trying to answer with the dictionary

Like one of my mighty clever staff members, I’m not a fan of bucket list of indicator sets….that haven’t been bespoke designed for a purpose, with logic model that sets that out.

I’m a fan of understanding the raw data; having a specific job, question or system in mind; and design of indicator set in that context. 

There’s something also about micro, meso and macro.

Notes on the epidemiology of multi morbidity, and why it matters

Multi morbidity the new black.
Well, it’s not really. But it’s one of the defining features of modern healthcare. And if you stick multimorbidity in a social context – with all its social complexity, it’s one of the defining features of contemporary health and social care.
Given that, we know remarkably little about the epidemiology of it.
Arguably the ship that launched this was the Barnet et al study in the lancet. I use this study at least once a month. It’s a modern classic.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60240-2/abstract

It’s featured in many of my blogs – to remind you – ITS NOT THE AGEING POPULATION (I suspect I’ll need to say that a few more times yet).

The Barnet study gives us amazing insight into some aspects of the epidemiology, but not all. I’ve seen multiple iterations of similar to this study – most famously the SYMPHONY project in Somerset,
 @toniwilliams01 did it in Bradford using the data that was in the risk stratification tool that GPs and others were using.

Key points  

  • The Bradford data was consistent with Barnet. In the most deprived areas avg age of developing MM was fifties….
  • whilst prevalence of multimorbidity increases with age and highest in older people – absolute numbers highest in working age….this data underscores need for whole population approach
  • people living in more deprived areas ‘developed’ multimorbidity on avg 10 years before those on least deprived areas.

C/o @toniwilliams01



Implications of this data – four areas to start

  1. We can use this data plus risk strat to model need for intermediate care.
  2. We can better understand the mediators where we can intervene? Literacy and health literacy?..
  3. We can use to develop new models of care delivery for multimobidity and disability, 
  4. We might even think about prevention 




How is the epidemiology changing over time.

One of the burning pieces of work that – to my knowledge – remains not yet done is trends over time.

Given my grumpiness that we inappropriately use “ageing” to forward project certain doom, when we should use morbidity…..I’m really hoping someone somewhere is doing it.
It’s beyond both my competence and resource to do this epi study.
I did ask the team that did the original Barnet et al study if it had been done. The answer was not, sadly. The prof who got back to me did make some very helpful points and put me in the direction of some very useful references.

To summarise the issues in the email trail:-

  • Not being done in the UK,
  • the problem being that the prevalence that you get critically depends on the way you measure MM (which conditions, how many) and the dataset you use.
  • So the first attachment is a cross section based on CPRD where they get 16% (using QOF conditions alone) or 58% (counting all ACGs) whereas we got 25% (counting 40 conditions).
  • So you would need consistent measurement of MM in the same dataset, but of course datasets change over time (better recording will make the prevalence go up). Doesn’t really matter how you count MM though in the more general sense that all studies show similar things (commoner in older people, commoner in the more deprived, mental health interactions with physical in various ways etc.

 

Studies of note

He pointed me towards some studies. These are worth bringing to your attention.

1)

European Journal of General Practice. 2008; 14(Suppl 1): 28 32

Multimorbidity in primary care: Prevalence and trend over the last 20 years

Uijen & Van De Lisdonk. https://www.ncbi.nlm.nih.gov/pubmed/18949641
“increasing age, female sex, and low socio-economic class are associated with an increasing number of patients with multimorbidity. The prevalence of chronic diseases doubled between 1985 and 2005. The proportion of patients with four or more chronic diseases increased in this period by approximately 300%.

CONCLUSION:
The increasing amount of multimorbidity in primary care as well as the increasing number of chronic diseases per patient leads to more complex medical care…….”

Points:-

  • uses a Dutch research registry,
  •  it’s a “patients consulting” rather than “registered population” analysis (both are wrong in different ways of course).
  • rise, both in crude rates (which could just be ageing populations) and in age-sex standardised rates (which could be because of better survival from acute events, so live to have an LTC; could also be improving recording but to my knowledge this is a pretty tightly managed registry,
  • so that is less likely than it would be in routine GP data in the UK over the same period).

2).  Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study

Chris Salisbury, Leigh Johnson, Sarah Purdy, Jose M Valderas and Alan A Montgomery

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3020068/
“Sixteen per cent of patients had more than one chronic condition included in the Quality and Outcomes Framework, but these people accounted for 32% of all consultations. Using the wider ACG list of conditions, 58% of people had multimorbidity and they accounted for 78% of consultations. Multimorbidity was strongly related to age and deprivation. People with multimorbidity had higher consultation rates and less continuity of care compared with people without multimorbidity.
Conclusion

Multimorbidity is common in the population and most consultations in primary care involve people with multimorbidity. These people are less likely to receive continuity of care, although they may be more likely to gain from it.”

I’d encourage you to look at table 2

 

 

shows the independent relationships between consultation rate and age, sex, and deprivation before and after adjusting for multimorbidity. It demonstrates that the relationship between age and consultation rate is reduced, and that between deprivation and consultation rate almost disappears, after adjustment for multimorbidity. This suggests that the main reason that older patients and those in deprived areas consult more often is because they have more chronic health conditions.

 

For the epidemiology geeks (you know who you are…….) there’s also some useful content in the appendix on coding and classification

3) The rising tide of polypharmacy and drug-drug interactions: population database analysis 1995–2010

Guthrie et al. BMC Medicine 2015

http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-015-0322-7
This is a repeated cross-sectional analysis of community-dispensed prescribing data for all 310,000 adults resident in the Tayside region of Scotland in 1995 and 2010.

One might conclude changes in poly pharmacy as a proxy measure for multi morbidity. Of course that’s full of holes and flaws of all sorts (changes in prescribing predilections, over-diagnosis and over treatment etc). But it’s potentially useful data, and should be considered with the caveats.
See table 1

Numbers and class of drugs dispensed to adults in 1995 and 2010
As is Figure 1

Number of drug classes dispensed in the 84-day period in 1995 and 2010 by age of patient.


The conclusion is appropriately caveated. Go read it.







Can we do this analysis of epidemiology of multi morbidity over time – some thoughts.

It should be done. It can be done.

  • This could be done with CPRD or similar
  • Would need a v granular dataset with coded data for every consultation with a GP or primary care nurse, & external auditing/management of coding.
  • There would be a number of issues to contend with, most notably external factors such as QOF that changed the nature of general practice that may skew an analysis of morbidity over time per se (inbuilt incentives to case find “new” disease). Changes in QOF and other incentives over time will change the way we code things, and act. For example AF, CKD and the way in which we handle eGFR has changed the morbidity of CKD, whether this is a real change in epidemiology or “real” morbidity is moot. One might say the same about the QOF disincentivisation to record depression.
  • You could use the Electronic Frailty Index. I don’t know how far back the data has been crunched. And last time I talked to Andy Clegg on it he was clear it is a clinical tool, not an epidemiological one. I’ve heard one argument that the EFI isn’t really a frailty measure at all but rather a morbidity count which is a pretty good predictor of mortality, hospital admission and nursing home admission) and coprescribing,
  • We can also use the data that drives our risk stratification systems

Each has flaws and holes.
Profs guess is that multi morbidity is increasing, but that ageing populations are more important than increasing age-standardised rates. But he did say that is just a guess.




Why this matters

Someone somewhere definitely should do this. It is important in terms of framing (or more to the point reframing) the debate on “the ageing population demographic timebomb” myth.

The population is ageing, no doubt there.

If we think it’s all about something we can’t do anything about (ageing) we will simply prepare for a need for bigger shinier hospitals and the like. If we frame our narrative in terms of something we can do something about (i.e morbidity and multi morbidity) we sort out the risk and demand management first (like general practice and social care) and we might even give some Thought to prevention?

Take home messages:

Steve laitner later summarised pithily why this matters especially in our laziness around blaming the “ageing population” 

  1. really understand the segment needs & the individual needs 2) don’t do “bolt-on services” but complete care model
  2. Age (re health) is just a proxy measure of the amount of illness & disability we might have accumulated during our time on earth?
  3. AGE! – for when you don’t have the evidence or energy to really understand the changing health and care needs of society

 
THAT is why getting a handle on the epidemiology of multimorbidity is so very important!