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CCG Series: Liverpool's healthcare plan of attack

CCG Series: Liverpool's healthcare plan of attack

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Dr Nadim Fazlani, chair of Liverpool CCG explains how they are working to improve local health inequalities through an innovative multi-agency approach

Clinical commissioning groups (CCGs) are now in the second year of establishment but let us go back to the time before CCGs became a statutory body. 

It would be fair to say that at that time many had doubts about the wisdom of clinical commissioning, yet towards the end of the first year, even the sceptics recognised the positive impact that CCGs are having in the local health landscape. 

In Liverpool we have been working to see how we can support system transformation. Society is at a crossroads and an ageing population, rising expectations, changes in society itself and medical advances make it inevitable that we need to take a different path. From 2012 to 2032 the populations of 65- to 84-year-olds and over 85s is set to increase by 39% and 106% respectively. 

Across the European Union there are currently four people of working age to every person over 65 and by 2050 this is projected to be a ratio of 2:1. Add to that the increasing geographical movement of children away from parents; the changing roles of women, (who have traditionally made up 80% of informal carers) and in some cases marital or partnership decisions leaving more people living alone, there will be fewer people to care for the sick and vulnerable, so that responsibility will inevitably fall to the state.

Liverpool is a city of contrasts. A vibrant city and home to approximately 70,000 students however a city where 27% of households are in Mosaic Group ‘O’, which is more than five times the national proportion. Group ‘O’ is characterised by low income, high unemployment, long term illness, and one parent families. The second largest group is ‘young, well-educated city dwellers,’ generally young singles or students, working in creative jobs. 

We also have a low life expectancy for men, almost four years lower than the national average. And males living in the ward with highest life expectancy are expected to live more than 12 years longer than those in the ward with the lowest life expectancy.

The Healthy Liverpool Programme was launched on 11 April 2013 in response to a challenge to health from Liverpool‘s elected Mayor. Over the last three years Liverpool City Council has had to make savings of £156 million, will cut a further £150 million over the next three. These draconian cuts have prompted a challenge for health providers and Liverpool City Council. We must work together to improve the health of the people of Liverpool. The Healthy Liverpool Programme is not just a transformational programme for Liverpool but it is THE plan for health for the city.

The focus on planning has been on outcomes and value, in particular, population outcomes along with clinical and process outcomes supporting this.

The following illustrates the outcomes: 

 
 

For example, one of our population outcome targets is to reduce life years lost by 24.2%. This is challenging but realistic – the targets were arrived at by adding up tangible interventions that will improve quality of life. 

We know that the main areas with premature mortality are chronic heart disease (CHD), stroke, breast cancer, colorectal cancer and pneumonia. In 2012 there were 190 premature deaths in Liverpool from CHD, 58 in people younger than 60. In 2012 there were 53 premature deaths from stroke, 16 in people younger than 60. 

In terms of primary prevention, if we improve physical activity in 50% of the population this would save 159 lives. Optimising treatment for all atrial fibrillation patients could avoid 50 cases of strokes, a prime example of secondary prevention. The case fatality for stroke is 20%, so therefore 10 deaths  could be avoided. 

It is clear that population outcomes are driven far more by what happens out of hospital than in hospital, but far more resources and attention are directed at hospital services. This is the inversion of care paradigm which all our transformational programmes are driving at - getting the right balance of spend between hospital and outside of hospital services. 

This programme is agnostic as to who delivers care out of hospital and is not wedded to a primary/ secondary care divide. The out of hospital focus is on specialist skills and knowledge supporting generalist knowledge and skills. We describe this for over thirty services. 

Here is our mental health ‘onion’: 

 

The ‘onions’ are arranged by the four settings (prevention/self-care; neighbourhoods; specialist community services and hospital services) because we recognise the challenge of multi-morbidity in a changing society. We are planning to describe the blueprint for the city in terms of what services to be provided at any early setting. 

Having described the optimum service model, we are in the process of commissioning economic modelling and communications engagement. Once the blueprint is in place by September then we will need to ensure programme support to deliver this is in place. 

Then the real work to implement this will start.

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