The document discusses the challenges of commissioning in a changing healthcare landscape, including maintaining public health tools and needs analysis in primary care during organizational changes. It also addresses challenges like paying for rare treatments, strategic reconfigurations, and maintaining partnerships during service reforms and procurement changes. Opportunities discussed include interest in public health from various groups, tackling inequalities remaining a priority, and the potential of initiatives like health and wellbeing boards and joint commissioning between local authorities and clinical groups.

1. What are the challenges for
commissioning in a brave new world?
Evolving relationships between public
health specialists and clinical
commissioners
Dr John Middleton
Vice President Faculty of Public Health
Director of Public Health Sandwell

2. Challenges for commissioning in a brave new world? Evolving relationships between public
health specialists and clinical commissioners: a public health view
Challenges:
Reorganisation
Maintaining and developing new tools for Needs analysis in
primary care
Clinical and preventive service redesign
Paying for rare and expensive one off treatments
Major strategic reconfigurations
Public health in the NHS on a slow but upward trajectory and
being asked to restart
Public health is everybody’s business
Maintaining partnership working in the context of disintegration
of local authority services, reform of health services and
tyranny of procurement

3. Challenges for commissioning in a brave new world? Evolving relationships between public
health specialists and clinical commissioners: a public health view
Challenges : Getting it off my chest 1
Reorganisation- QUIPP and Darzi Next
Steps vs Clustering and institutional
change
Legal context - Health Bill process, local
authority modus operandi vs NHS
freedoms

4. Challenges :Get it off my chest now 2:
The NHS is favoured of all the public sector and
repays this in an appalling way - by messing about
with its management, internally invented systems
like the national tariff and playing with large
reserves when important functions of the public
sector which can do much more to keep people
healthy are being faced with enormous cuts -
transport, housing, environment and economic
development at the front of cuts

5. Challenges: Get it off my chest now 3:
What would you do in context of massive cuts
in public spending?
Reorganise
Force organisations to keep money in their banks
that they could be spending on services
Force reorganisations within reorganisations eg
Transforming community services
Force organisations to behave to quasi-commercial
rules that make money for accountants and lawyers
but do not save a life or save a pound

6. 2002
1996 NHS
1998
1974 1979 1983 1991 NHS NHS
NHS NHS NHS NHS

7. Challenges:
A government that is not disposed to intervene for healthy
public policy
Reorganisation x 6, or is it 7? at once :
TCS, GP commissioning, Public Health move to Local authorities and
Public health England, NHS commissioning Board, Foundation Trusts,
Clustering
Psychological state of corporate depression and
bereavement
Differences of organisational culture
If the management costs reduction didn’t get you , the
service efficiencies might, and if they don’t get you the
running costs and straight cuts will
Addressing the real problems of health is an incidental

8. Challenges:
Addressing the real problems of health is an incidental- we
are again rearranging deck chairs …:
Climate chaos,
International security with particular and immediate reference to
the Olympics in 2012
Seasonal flu and severe weather
Overpopulation
The expanding over 65s and 75s but in addition, the expanding
under 5s and fertility rate
Extraordinarily high levels of long term conditions with even
greater inequalities
Unwillingness to combat excessive addictive behaviours, food,
cigarettes, alcohol, gambling
Recession and damage to health immediate and long term

9. An office for public health

10. Opportunities
Keen interest in public health from politicians, media
and public
Tackling Inequalities remains a national policy
Heartening interest in health improvement from GPs,
social care, and from acute hospitals and mental health
organisations
‘disorganisation’ is making people talk
Localism
Mixed economy in preventive and improvement
services

11. Opportunities
Interest by GPs- NST inequalities work is
beginning to produce results
CVD risk reduction programmes
Lifestyle referrals eg exercise, weight
management, welfare rights
Data extraction tools in primary care making
preventive intervention in long term conditions
possible

12. Opportunities
Health and wellbeing boards
A commissioning body not a cosy partnership
(my view)
Major (only )chance for strategic planning
GPs/CCGs as partners with local authorities
Chance for good joint commissioning
And for robust challenge to each other’s plans
and investments

13. Skill sets for Consortia
• Good clinicians
• Good commissioners (including rationing)
• Joint commissioning
• Good partners
• Good ‘whole population’ perspective
• Good local politicians

14. Public health in primary care
Health protection
• Routine immunisation
• Sexually transmitted infections
• Communicable disease surveillance and control
• Emergency planning – as commissioners in agreements
re emergency responses
• As providers re business continuity and all risks- floods,
flu and foot and mouth

15. Health care public health
• Screening coordination
• Measurement of need for health care services-
including community, social and primary care
• Support for care pathway development
• An eye to preventive alternative interventions eg.
housing and health, telecare, lifestyle interventions
• Evaluation of clinical effectiveness in routine care
• Evaluation of effectiveness of one off expensive
treatments

16. Public health in primary care
What GPs say to patients works
• Smoking prevention
• Emerging evidence exercise on referral,
weight management , primary care based
mental health
• Carer support
• Health information
• Welfare rights services

17. Public health in Clinical
commissioning
• Building expectation of lifestyle
interventions in care pathways eg.
Bariatric surgery, vascular surgery, and
‘stop before the op’
• Building lifestyle intervention into
rehabilitation and reablement

18. Commissioning cycle

19. The Sandwell experience: integrating public health and
local government: Middleton, HSMC, 09062011
Annual public
health reports

21. Public Health: a new asset!
• Priority setting
• Risk stratification
• Health impact assessment/ impact
assessment
• Health inequalities assessment
• Intelligent interpretation of research
• Needs assessment and intelligent
use of information

22. Tackling inequalities is
everyone’s business (Marmot)
• Give every child the best start in life
• Enable all children, young people and adults
to maximise their capabilities and have
control over their lives
• Create fair employment and good work for all
• Ensure a healthy standard of living for all
• Create and develop healthy and sustainable
places and communities
• Strengthen the role and impact of ill-health
prevention

26. Disability free life years
Recommendation: DFLE information should be used to target
social research to identify strategies for improving health

27. What are the causes of
death?
Major causes of death by sex for all ages,
Sandwell in the
last five years (2002-2006)

28. Diabetes Mortality 2005-7 by Programme Budgeting Category per 100,000
population
300 4
250
Standardised Mortality Ratio
13
200 14
18 8 3
Sandwell PCT 95% limit
16 19 17 99.8% limit
2 10 6
150 England average
11 15 5
12 Primary Care Trust
9
100
7
50
0
0 10 20 30 40 50
Expected Deaths

29. All Cancer Mortality 2005-7 by Programme Budgeting Category per 100,000
population
140 14
135
130
Standardised Mortality Ratio
125
120 2 95% limit
15
16 99.8% limit
115 4 Sandwell PCT
11 5 England average
18 19
110 3 Primary Care Trust
8
17
12
105 6
10
7
100 13
9
95
90
0 200 400 600 800 1,000 1,200 1,400 1,600
Expected Deaths

30. Challenges for commissioning in a brave new world? Evolving relationships between public
health specialists and clinical commissioners: a public health view
Needs assessment in primary
care

31. Sandwell PCT
Smoking Prevalence Data as at 01/10/2009
Source: MSDi data extracts
Percentage of
Patients ( aged
Patients ( patients ( aged
16+ ) Smoking Percentage of patients (
Patients aged 16+ ) 16+ ) Smoking
Status Recorded aged 16+ ) Current
aged 16+ Current Status Recorded
in the last 15 Smokers
Smokers in the last 15
months
months
PBC Cluster
Black Country Commissioning Network PBC Cluster 104,148 64,465 17,894 61.90% 27.76%
Smethwick Commissioning Alliance PBC Cluster 73,444 34,163 9,964 46.52% 29.17%
Wednesbury & West Bromwich PBC Cluster 92,660 50,733 12,262 54.75% 24.17%
Totals 270,252 149,361 40,120 55.27% 26.86%

32. CVD
Baseline Audit
• 9% of Sandwell is currently treated for prevention of
CVD
• Based on mortality and morbidity figures this should
be 16%
• Currently miss 7% or 21,000 people
Risk Tool
• Estimate CVD risk using risk factor data already in
electronic medical records
• Targets people 35 to 74 years, Not on CVD register,
Not taking antihypertensive treatment

33. Projected benefit for Sandwell
Sandwell Eligible for CVD Events
treatment prevented over ten
years
Aspirin 11,382 410
Antihypertensive therapy 6,860 288
Statin 11,694 947
Total 1,645
Total if attendance same as 1,020
for pilot
If 30% of circulatory events 494 based on eligibility
result in death, then lives 306 based on eligibility
saved would be; and attendance

34. Challenges for commissioning in a brave new world? Evolving relationships between public
health specialists and clinical commissioners: a public health view
Who commissions for strategic
redesign and how is it driven ?

35. • Right Care Right Here
programme
• 500000 people sandwell and Western
Birmingham
• Closing two hospitals, 2 A&Es
• Replacing with one new one
• With enhanced community facilities
• Redesign of services towards
community settings
• Reconfigured childrens, maternity and
acute vs cold surgery
• Lifestyle services component of
service redesign
• Major and multiple public consultations

36. 5% for health: The 20th annual public health report for Sandwell
John Middleton Director of Public Health
The big five causes of years of life lost are the same
for Heart of Birmingham and for Sandwell although not
in the same rank order. They are:
ﾘ Infant deaths
ﾘ Cancer
ﾘ Cardiovascular disease
ﾘ Smoking and
ﾘ Alcohol

37. 2010 Charter: Health services to health?
• Reduce alcohol problems- 20% of medical
admissions and large % of ‘frequent flyers’
• Smart housing and telecare reduces admissions and
lengths of stay
• Home safety and gentle exercise: 20% reduction in
fractured hips
• Coronary risk reduction 670 events over 10years 260
deaths
• ‘Quit before your op’; smoking reduction and all
admissions
• Reduce obesity or expect diabetes to explode
• Expand self care, carer support and user led health
and care services towards the ‘fully engaged public’

38. Challenges for commissioning in a brave new world? Evolving relationships between public
health specialists and clinical commissioners: a public health view
How do we commission for
multiple benefits ?

40. BDH Trend

43. Walkwell -Sandwell Healthy walks
programme

44. Opportunities
Interest in prevention and independence from
social care :
Personalisation makes health improvement
sessions more attractive to individual and social
service
Reablement services need lifestyle
intervention also

45. • Cyril
• Started gardening again
• Catching buses (for 1st time in 18 months) to Sutton Coldfield, Walsall, West Bromwich)
• Re-establishing contact with all neighbours and local community centre
• Planning a holiday
• Has cut carer’s hours from 7 days a week to 2 or 3
• Very enthusiastic, and a great advert for the programme!

46. Lifestyle services for people in
social care
Recommendations
• Lifestyle assessment
integrated into initial
social services
assessment
• Train social care staff
through Every contact
Counts
• Postural stability
instruction

47. The i-House,
West Bromwich

48. i- House, demonstration house
West Bromwich 2008

49. US VA Telehealth study
• Results
– 68% reduction in hospitalizations
– 72% reduction in ER (A/E) visits
– 71% reduction in bed days of care
– 81% reduction in nursing home admissions
– 74% reduction in overall costs
– 97% patient satisfaction
– Clinical outcomes – Patients stayed well
• Now in volume implementation
– 9,500 patients enrolled now
– Adding over 11,000 participants per year

50. The Future?
 Easy to use Patient
Graphic interface
 Wireless or wired devices, POTS and IP Communications
 Software based product – operates on a variety of
devices in expanding applications
Tablet PC CareCompanion II Handheld devices
 Standard protocols – easy
customization

51. Housing and health indicators
in Birmingham Sandwell Urban
Living

52. Improving health through housing
Recommendations
• Further research
needed to identify those
at higher risk of
housing related ill
health and evidence to
inform improvements
• CCGs should priorities
housing interventions
to reduce health
inequalities and
hospital activity

53. Challenges for commissioning in a brave new world? Evolving relationships between public
health specialists and clinical commissioners: a public health view
Challenges for the future

55. Good corporate citizen award
38 apprentices
Rationalisation of offices : 6
leases surrendered
890 tonnes of CO2 reduction
£200k saved