1. Nottingham City PCT1 Quality improvement to ensure health gain (and Health Inequalities reductions) an example: commissioning cardiovascular risk management Chris Packham Director of Public Health Nottingham

2. Nottingham City PCT2 DH, Health inequalities intervention tool: view your gap

3. Nottingham City PCT3 Health outcomes in context

4. Nottingham City PCT4

5. 5 QOF performance – cholesterol outcomes

6. Nottingham City PCT6 Nottingham

7. Nottingham City PCT7 Understanding unmet need and inequality Eg: Heart disease deaths and Statin prescribing by GP practice

8. Nottingham City PCT8 Commissioning Healthcare for Best Outcomes Population Focus Optimal Population Outcome 13.Networks,leadership and coordination 6.Known Intervention Efficacy 1.Known Population Health Needs 12. Balanced Service Portfolio 11.Adequate Service Volumes Challenge to Providers 5.Supported self- management 10. Engaging the public 4. Responsive Services 9. Accessibility 2. Expressed Demand 7. Local Service Effectiveness 3. Equitable Resourcing 8.Cost Effectiveness

9. Nottingham City PCT9 Design (Commissioning) challenges How to stop the CVD risk programme work widening inequalities? How to encourage people to turn up for assessment and then take part in interventions?

10. Nottingham City PCT10 Mosaic Group F: people living in social housing with uncertain employment in deprived areas Eg: Social marketing methodologies

11. Nottingham City PCT11 Getting the technical data right: understanding the CVD risk 40-74 task Local estimation NICE guideline 67 tool –http://www.nice.org.uk/guidance/index.jsp?act ion=download&o=40777http://www.nice.org.uk/guidance/index.jsp?act ion=download&o=40777 QRISK 40-74 –3% 40-54, 97% 55-74 Framingham 40-74 –7% 40-54, 93% 55-74 But –S Asian and AC groups may need DM case finding from age 30 –‘CKD’ From a population of 300,000… How many patients are we seeking for primary prevention? Existing CVD 11,000 For a population of 300,000, around 12,500 out of 35,000 55-74’s estimated at risk (Framingham)

12. Nottingham City PCT12 our ‘Intervention’: first stage started most deprived quintile – 14 practices: 8000 patients 45-74 Trained HCAs Computer generated lists of at risk patients 30% one or more risk factor recorded ABPI partnership project Called in, risk assessed, interventions agreed Referred on the GP/PN as necessary Outcomes monitored Targeted using successive 5-year descending age bands

13. Nottingham City PCT13 Results first 2 months attendance rate 73% (65% plus a further 8% on one reminder) 260 seen all>20% 40% already on treatment About 50% sent to GP/PN to date 1 in 5 put onto drug treatment immediately 4% new Diabetics

14. Nottingham City PCT14 our ‘Intervention’: second stage 50 practices - 27,000 patients 55-74 Locally Enhanced Service for 55-74’s Option to use HCA model 40-54’s ?Alternative model Year one –Hypertensives all ages –BMI>35 Year two –55-74 one or more risk factor –All BME 40-74 Year three –Rest 55-74

15. Nottingham City PCT15 Challenges and solutions Problems –The DNAs –Compliance –Clinical buy-in –Community awareness Must have supporting delivery –Healthier Communities Collaborative –Primary prevention –HEAs on hospital and tertiary end –Health trainers / PH nutrition teams / smoking cessation services –Look carefully at primary care data

16. Nottingham City PCT16 Commissioning Healthcare for Best Outcomes NST – HI support team Prof Chris Bentley Population quality –Empowering / Healthier Communities Collaboratives –Decent Health Equity Audits –Designed around populations as well as practices (eg BME) Individual care quality –QOF –Use Accepted interventions –Guideline audits –Patient satisfaction and accessibility For both make sure the supporting community services are in place and part of patient pathways and at industrial scale