Presentation and discussion exercise from a workshop articulating how commissioners and public health can work together

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Public Health and the Commissioning Cycle:
Getting benefit from getting together
Jim McManus
Director of Public Health

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

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Starting Points
• Commissioners are – or ought to be – big customers of Public
Health
• PH ought to see commissioners as a major constituency to
influence
– Sometimes PH does too much “commissioning of its own”
– Sometimes PH becomes detached from commissioning
– Sometimes PH Depts are like Mini PCTs
• Things which prevent this are
– Not knowing what public health “do”
– Public Health not being clear of its role in commissioning
– Style issues

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What is Public Health?
• A team which brings together within ten key competencies for public
health practice people who practice the art and science of supporting
the improvement of the health of the population.
• Public Health Specialists have:
– A Population perspective – look to the population and see not just
the whole but the nooks and crannies
– A Prospective perspective – look to the future
– A Preventive perspective – reduce ill health, promote good health
– A Prospective perspective – looking to the future of the area
informed by the past (e.g. mortality trends)

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A “Typical” Public Health Dept
• Sometimes called Health Improvement Depts
• Director of Public Health
• Consultants in public health/ consultants in public health medicine –
8c or 8d – practice all ten competencies to the level of specialist
registration. Higher specialist training usually including MFPH (
www.fph.org.uk) May be medic or non-medic. May also be Assistant
or Associate Directors
• Specialists – Band 8 usually have a Masters
• Advanced Practitioners Band 7s – may be doing an M.Sc
The technical workhorses of the dept

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Meet the Public Health Senior Team

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A Very Odd Mix of stuff
• May be working on equity audit of access to care
at the same time as being responsible for
emergency planning, business continuity,
pandemic flu planning, immunisation uptake,
commenting on pollution licence applications and
other nerdy stuff that is sexy to people in public
health but mightily P***** commissioners off when
it derails a tightly scheduled project
• This is usually a symptom that the PH Dept’s own
ability to keep continuity of core business during
an emergency needs looking at

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Part of the Public Health day Job at present….
• Chief Medical Officer Alerts – 24 – 48 hours
• Major Incidents, Pandemic Flu, CBRN……..
• Port Health Alerts – immigrants with TB etc
• IPPC (Pollution Control Licences) – we have 28 days to
respond
• Controlled Drugs
• Child Death Panels
• Mortality Files, Suicide Audits, SUIS involving deaths
• Investigations
• Outbreaks (though managed by HPA pct has a role)
• Planning for major accident hazards/emergencies

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From 2013
• Healthcare Public Health Support to NHS CCGs
(Mandatory)
• Needs Assessment (Mandatory)
• Commissioning some functions (Mandatory)
• Use of evidence and PH skills to support
commissioners across the system (the big
opportunity)
• Work with all sides of system

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Perceptions of PH by Commissioners
• PH Needs to up its game
• Library dwellers!
• Don’t know how to access them
• Boundaries of when to involve and when not to
• Not sure they add anything
• Keep saying they’re too busy or don’t have skills
• Obsessed with their professional status
• Bit of a closed shop
• Prodigious amounts of data in the annual public health report,
produced in almost untintelligble density
• Needs Assessments – never mind the message, look how
pseudo-academic the document is!
• All you need is a sneeze in southwark and you can kiss goodbye
to them

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Perceptions of Commissioners by PH
• Haven’t a clue what the population needs (but
did we bother telling them?)
Disregard the evidence (did we tell them what it
is?)
• Contracting historically, not what’s needed
• Glorified
• Why won’t they read our stuff?
• Why don’t they love us?

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The Diagnosis
• This is usually the symptom of both sides not
understanding what the other can offer, and not
engaging with the other side.
• Commissioners may have more difficulty
engaging public health because of the
“mystique” of what they do

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Overcoming These
• Meet together to explore (today)
• Jointly articulate a cycle of input (today)
• Involve on projects rather than just sitting on
steering groups
• Use the “Commissioning Framework for
Wellbeing” document
• Work through the commissioning cycle with
some PH colleagues and have the PH key
competencies to hand

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Scope of Commissioning Interest
• Commissioning
• Business Plan
• Corporate Plan
• Health and Wellbeing Strategy
• National Service Frameworks
(yes they still exist)
• QIPP
• CQUIN
• Transformation
• NICE
• Public Health
• Well, exactly the same. Our
concern is that we increase
independence, reduce
mortality and morbidity in the
population and increase
longevity, as well as
addressing health inequalities,
through commissioning
activities

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A (very) Simplified Commissioning Cycle
Monitor
Plan
Review Need for
Service and
Effectiveness of
existing services
ContractThe Commissioning Cycle
This is used just to introduce the concepts of what PH can help
you with.

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Articulation of PH input…various models
• World Health Organisation Planning Wheel
• Kellog Foundation Planning Cycle
• DH Commissioning Cycle
• Hybrid model based on what HCC seems to be
using (for discussion)…..

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Monitor/
Evaluate
Plan
Review Need for
Service and
Effectiveness of
existing services
Public Health Input into the Commissioning
Cycle. Can be throughout or can be on specific
areas playing to the PH strengths
Community
Engagement
Support in establishing
meaningful indicators of
delivery and outcome
Model whether need will
Be met by proposed
volume
Check whether plans equate
To evidence and need and
Test for equity / inequity
Support and advise on
Evaluation and conduct
Bits of it if enough resource
Needs Assessments
Equity Auditing
Evidence of Effectiveness
Health Impact Assessment
Triangle of critical
influence – where public
health should be most
visible
Contract/Deliver

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The Public Health Toolbox
• Assessing Population Need
• Identifying Equity
• Critical Appraisal of Evidence
• Assessing Impact on Health
• Modelling Population and effects of interventions
• Community Engagement
• Economic Modelling of Interventions
• Access to wider sources of expertise
• Being Internal Consultants

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Health Needs Assessment
• Age Structure
• Morbidity
• Mortality
• Socio-economic data
– Census
– Housing
• Public Health data set
• Indices of health
– Jarman
– Townsend

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Performance monitoring
• Service Level Agreements
– Activity/Finance
• Quality
– Waiting Times/Access
– Waiting Numbers
• Validation

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Ad hoc requests
• Critical Appraisals
– Does this drug or procedure work?
– Is it cost-effective?
– Should we fund it? For whom?
• Service developments/business cases
– heart failure
• Impact of investment
– CHD secondary Prevention/MI’s
• Analysis of variances
– emergencies (secondary View/Primary
View)

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Modelling
Impact of policy/planning
- Payment by results
- Capacity planning

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I know
What we
Need for
Our
Population
I know
How to
make it
happen!
Both commissioning and
Public health can come
From either side of this
conversation

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1. Commission for the whole person’s lived experience
(housing, volunteering, leisure, transport,)
2. See Potentials not Problems, assets as well as needs
3. Transformation of current system through staged redesign
to preventive and early intervention
4. Subsidiarity and Access
5. Co-production
6. Behavioural Sciences
7. Pathwayed

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Discussion example: Chronic
Pain

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Some outcome we should look for
• A public health approach in adult
social care should bring the
following benefits:
– Less people in residential
care
– More people independent
– Less costs to NHS and
Social Care
– Fewer costs to GPs for those
with long term conditions and
disabilities
– A way of monitoring the new
market and micro-
commissioning
• A public health approach for
children should bring the following
benefits:
– Fewer children with
avoidable behavioural
disorders
– Evidence assessed
interventions for troubled
families
– Children looked after are
healthier physically,
psychologically and socially
– Standards for physical,
cognitive and emotional
development and resilience
across all services

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Components of this model where we work
together
• Population approach to
– projecting need
– Identifying risks – risk stratify
– Identify priorities
– Identify candidate interventions
• Intervention and outcome design
• Emphasise Prevention (science & art)
• Joining up (housing and social care, primary care and
social care)

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Prediction
forecast / target services
Secondary Prevention
PrimaryPrevention
Universal&Well-being
LOW
MODERATE
SUBSTANTIAL CRITICAL
Reduce numbers of people coming into high-cost services and
moving along FACS banding
Intensive Home Support
Residential Care
Community Equipment Services
Telecare Service
Tertiary Prevention
How might Prevention look in Social Care?