Version 1.6


                     SERVICE SPECIFICATION

                                  November 2007

1.0       Background

Cardiovascular disease is a major cause of morbidity and mortality and is a
significant contributory factor towards the current level of health inequalities in

The development of a structured approach to cardiovascular risk management
has been identified as a priority by Doncaster Primary Care Trust (DPCT) in
the board paper Reducing Health Inequalities in Doncaster: Achieving Early
Impact (appendix 1).

This will contribute towards achievement of the 2010 Spearhead PCT targets
with regard to reduction in morbidity and mortality from cardiovascular disease
and reduction in health inequalities.

2.0       Specification

This specification

         Informs the provider of the services and standards that the
          commissioners require, and which the provider shall provide and meet
         Seeks to ensure that the provider is clear about its responsibilities and
          ensures co-ordination and development of the service
         Informs others of the scope of the service
         Requires the provider to cooperate and collaborate with others involved
          in the process of providing the service

3.0       Benefits of a structured cardiovascular risk management service

The commissioners of DPCT are keen to support the provision of a structured
cardiovascular risk management programme that will improve the health of
patients and reduce health inequalities.

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There is strong evidence that the use of Statins and Aspirin in adults with
above 20% 10 year risk of developing cardiovascular disease is both clinically
and cost effective.

DPCT wishes to establish the service in close collaboration with the needs
and requirements of practice-based commissioners (PBC) and enable service
delivery to take place that satisfies the development requirements of PBC
consortia and individual practices.

The anticipated outcomes of the service are:

         12,000 people living in the 20% most deprived communities being
          assessed for their risk of developing cardiovascular disease
         Increased number of the target population who have been assessed
          provided with a personalised education package to enable them to take
          action in order to reduce their risk factors, i.e lifestyle interventions
         Increased number of the target population who have been assessed
          and identified as being at increased risk of developing cardiovascular
          disease, prescribed appropriate medication to reduce their risk
         An increase in the number of referrals to appropriate mainstream
          services, for example stop smoking services
         Reduced non-elective admissions for cardiovascular conditions.
         A reduction in premature morbidity and mortality in the 20% most
          deprived communities
         Substantially reduce mortality rates from heart disease, stroke and
          related diseases by at least 40% in people under 75, with a 40%
          reduction in the inequalities gap between the fifth of areas with the
          worst health and the population as a whole (Public Service Agreement

4.0       Service required

4.1       Scope

The cardiovascular risk management programme is aimed at people living in
the 20% most deprived communities of Doncaster who are over 40 years old,
and who are not on an existing primary care disease register for CHD,
Diabetes or Hypertension. It is estimated that the number of people who fall
into this cohort is approximately 13,400. The service will assess 12,000 of
these people.

The 20% most deprived communities in Doncaster are:

Clay Lane
Denaby Main
Hyde Park
New Rossington

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Toll Bar & Almholme

4.2       Target Population

The target population is Doncaster residents who are potentially at risk of
developing cardiovascular disease; that is men and women over 40 years old
who live in the communities listed in 4.1. People who have been diagnosed
with diabetes, hypertension and coronary heart disease, and who are on an
existing primary care disease register are excluded from this programme, as
their health needs are managed within existing services.

The service provider will market the service to the target community. It is
estimated that the number of people who fall into this cohort is 13,400,
however the service aims to assess 12,000 of these people. Marketing
campaigns for the service must be in a language and style appropriate to the
target population, and should pay particular attention to ensuring that groups
who are at even greater risk, for example the South East Asian population are
effectively targeted.

4.3       Model of Service

The service will be delivered in a variety of locations within the communities
described in 4.1. The locations will be determined and organised by the
provider but must be community locations and must be appropriate for the
demographics of individual communities i.e. meet the needs of the target
population and their families. The service must be conducted in buildings
appropriate to the nature of the service.

The service will operate as an outreach service, therefore should not be
delivered exclusively within healthcare settings. The provider will operate
clinics at various times throughout the day and week (including evenings and
weekends) to ensure that the needs of local communities are met.

4.4       Detail of Service to be provided

The service provider will deliver a cardiovascular risk management
programme within the 20% most deprived communities in Doncaster (as
specified in 4.1). The service will include:

         Delivery of cardiovascular risk assessments and subsequent lifestyle
          advice/ management of referrals
         Management of the programme, including performance management
         Marketing the service to specified populations
         Managing communications with primary care and the wider health
          community regarding the service

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4.5       Delivery of cardiovascular risk assessments and subsequent
          lifestyle advice and management of referrals

At initial contact the service provider will establish if the client meets the
service criteria. Service criteria are:

         The client is over 40 years old
         The client is resident within 1 of the areas listed in 4.1
         The client has not been diagnosed with cardiac disease, hypertension
          or diabetes and is on a primary care disease register for one of these
         The client has not previously attended for a cardiovascular risk
          assessment under this programme

The provider will undertake consultations with clients who meet the service
criteria as described above. Consultations will be delivered in a clinic format in
community settings. Each consultation will last at least ½ hour. 12,000
consultations will be delivered over the duration of the project. Informed
consent must be obtained and documented prior to the consultation. Each
consultation will include:

1.            Clinical assessment which will include:
             Age
             Ethnicity
             Sex
             BP
             BMI
             Waist circumference
             Total cholesterol (near patient testing)
             Blood glucose monitoring (near patient testing)
             Medical history
             Family history
             Drug history

          Lifestyle assessment, which will include:
             Diet
             Exercise
             Smoking
             Alcohol

2.        From the clinical and lifestyle assessment calculate the persons 10-
          year risk of developing cardiovascular disease by using the JBS 2 risk
          assessment tool (1).

3.        If symptoms are present that represent an immediate clinical risk, for
          example hypertension, hyperglycaemia or chest pain, the person
          should be referred immediately for appropriate care via 999 ambulance
          or self-referral to A&E. The service provider will need to develop a
          management protocol for such scenarios and ensure that it is approved
          by DPCT.

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4.     If the person presenting has a < 20% 10 year risk of developing
       cardiovascular disease, but individual risk factors have been identified;
       the service provider will provide a comprehensive personalised advice
       and education package for the management of individual risk factors,
       and signpost to mainstream services such as the stop smoking service.
       The service provider will need to demonstrate a comprehensive
       education package. The service provider will need to demonstrate an in
       depth understanding of local services to enable them to signpost

5.     If the person presenting has > 20% 10-year risk of developing
       cardiovascular disease, the service provider will provide a
       comprehensive personalised advice and education package for the
       management of individual risk factors, and signpost to mainstream
       services such as the GP and stop smoking service. The service
       provider will provide advice and education regarding combined risk,
       and provide information to the patient on the management of combined
       risk, including the implications of long term pharmacological therapies,
       in order to assist them in making informed choices about their health.

6.     A proforma must be completed for all people who attend the service; a
       copy given to the person attending and a copy retained by the service
       provider for their records. It is not the responsibility of the provider to
       arrange routine follow up, and the individual presenting will need to be
       informed that they are required to arrange their own follow up, however
       In the event of an immediate clinical risk the person will be managed as
       per the protocol. The service provider will be required to produce the
       proforma and gain approval by DPCT prior to use.

7.     Contact people who have been assessed two weeks after initial
       assessment to identify what actions have been taken. The provider will
       need to develop a protocol for management of this process.

4.6   Management of the programme

The provider is expected to manage the programme in line with the
specification outlined in sections 5-14 of this document.

4.7    Marketing the service to specified populations

The service provider will market the service to people over 40 years old within
the areas outlined in 4.1. The provider will be responsible for ensuring that
any marketing materials and methods employed are appropriate for the target
population and are approved by DPCT prior to dissemination.

The provider will make information available to the public on their services,
provide people with suitable and accessible information on the care and
treatment they receive, and, where appropriate, inform people on what to
expect during and after their consultation.

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4.8   Managing communications with primary care regarding the service

The ongoing management of people identified as having individual risk factors
or having a combined 10 year risk of > 20% is the responsibility of mainstream

It is the responsibility of the service provider to have a comprehensive
understanding of mainstream services within the target communities to enable
them to signpost appropriately. It is the responsibility of the provider to work in
partnership with community services and GP practices to ensure that overall
objectives are met, including liasing with and informing individual GP practices
regarding the schedule of risk assessment clinics, and the most appropriate
methods of communicating information to enable them to manage individual
clients and any potential increase in demand for services appropriately. The
provider must inform the client that it is their responsibility to arrange their own

4.9   Equipment

The provider will be responsible for the procurement of all equipment and
consumables required to provide the service which is subject to this
specification. The funding for this procurement will be included within the
contract and it is the responsibility of the provider to ensure that they manage
within the agreed cost envelope.

The minimum equipment required to deliver a clinical assessment as
described is:

BMI and waist circumference measurement
Weighing scales
Height measure

BP measurement
Electronic sphygmomanometer

Near patient testing
Accutrend GC Meter kit
Cholesterol Strips
Glucose Strips
Cholesterol Controls
Glucose Controls
Soft clix pro lancets
Burn bins

Anti bacterial gels

The service provider will provide the equipment described above and any
other equipment that is required for the delivery of the service. The provider

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will be responsible for the safekeeping of all equipment, and will be
responsible for repairing or replacing any damaged, lost or stolen equipment.

It is the provider’s responsibility to ensure that all staff are trained to use the
equipment according to the manufacturers instructions.

It is the provider’s responsibility to maintain and calibrate equipment as per
manufacturers instructions.

The Provider will keep patients and staff safe by having systems to ensure

         The risk of health care acquired infection to patients is reduced, with
          particular emphasis on high standards of hygiene and cleanliness
         All risks associated with the acquisition and use of medical devices are
         All reusable medical devices are properly decontaminated prior to use
          and that the risks associated with decontamination facilities and
          processes are well managed

5.0       Quality of care and treatment

5.1        General

DPCT’s approach to quality assurance is underpinned by an agreed set of

         Clear lines of leadership and accountability
         Work will ensure patient safety
         Improving patient experience is central
         Clinical engagement is a critical success factor
         International best practice should be used to benchmark all
          standards agreed
         The work should be innovative and sustainable and applicable to
          the wider NHS family
         The work will meet organisational objectives around inequalities and
          fitness for purpose priorities

5.2       Standards

The provider shall carry out the services in accordance with the standards and

         Contained in the Statement of National Minimum Standards
         Contained in the Healthcare Commissions Standards for Better Health
         Issued by the National Institute of Clinical Excellence
         Issued by any relevant professional body
         Contained within HSC1999/065. Clinical Governance: Quality in the
          new NHS

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6.0        Key responsibilities

The Provider will provide overall management of the service and will maintain
a central point of contact for DPCT.

6.1        Information management

The Provider will ensure the co-ordination of IT, data collection and quality
assurance processes to allow for timely and comprehensive reporting to
DPCT on agreed service parameters.

6.2 Patient safety

The Provider will protect patients through systems that:

          Identify and learn from all patient safety incidents and other reportable
          Make improvements in practice and share any such improvements and
           any lessons learnt with the wider healthcare community
          Ensure that patient safety notices, alerts and other communications
           concerning patient safety, which require action, are acted upon within
           required time-scales
          Comply with the DPCT procedure for reporting serious untoward
          Provide a structure for the reporting, investigation and management of
           untoward incidents and complaints with appropriate notification to

6.3       Clinical responsibility

The Provider will ensure that:

          They conform to NICE technology appraisals, and, where it is available
           take into account nationally agreed guidance when planning and
           delivering treatment and care
          Clinical care and treatment are carried out under supervision and
          Clinicians continuously update skills and techniques relevant to their
           clinical work and maintain relevant professional registration
          Clinicians participate in regular clinical audit and reviews of clinical
          Development of clinical guidelines, policies and protocols for effective
           working practices within the service

6.4       Governance

The Provider will:

          Apply the principles of sound clinical and corporate governance
          Actively support all employees to promote openness, honesty, probity,
           accountability, and the economic, efficient and effective use of

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         Undertake systematic risk assessment and risk management
         Ensure financial management achieves economy, effectiveness,
          efficiency, probity and accountability in the use of resources
         Challenge discrimination, promote equality and respect human rights
         Meet the relevant existing performance requirements set out in the
          annex A, appendix 1 of Standards for Better Health

6.5       Client centred service

The Provider will have systems in place to ensure that:

         Staff treat clients with dignity and respect
         Appropriate consent is obtained when required for all contacts with
          clients and for the use of any confidential information
         Staff treat client information confidentially, except where authorised by
          legislation to the contrary
         Clients are assured that organisations act appropriately on any
          concerns, and, where appropriate make changes to ensure
          improvements in service delivery
         The views of clients are sought and taken into account in designing,
          planning, delivering and improving health care services
         The provider will conduct an ongoing user survey throughout the year,
          as agreed with the commissioner, and use the results to achieve a
          positive change and improvement in user experience and service

6.6       Complaints

      The provider will:

         Provide DPCT with a list of any complaints received relating to care
          provided under this contract, and any outcomes of the complaints
          process on a monthly basis
         Ensure that clients have suitable and accessible information about, and
          clear access to procedures to register formal complaints and feedback
          on the quality of services
         Ensure that clients are not discriminated against when complaints are

7.0       Performance monitoring and data collection

7.1       General

          The provider will develop and implement robust and efficient data
          collection systems to provide clinical data to support efficient
          monitoring, audit and reporting to take place. Data shall be transmitted
          to DPCT in an agreed electronic format. All electronic files submitted as
          email attachments must be encrypted prior to reporting.

          The provider will have a systematic and planned approach to the
          management of records to ensure that, from the moment a record is
          created until its ultimate disposal the provider maintains information so

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          that it serves the purpose it was collected, for and disposes of the
          information appropriately when no longer required.

          The provider will submit copies of monitoring returns to DPCT on a
          monthly basis and also on specific request. Additional indicators may
          need to be monitored dependant on the performance management
          requirements of the commissioners. The provider will be expected to
          amend its data collection as required. Initial monitoring information will

 7.2        Minimum dataset:

         Clinic identification
         Client name
         Client address
         Gender
         Ethnicity
         Date of birth
         Postcode
         Date of attendance
         Procedure carried out
         GP Details
         Cardiovascular 10 year risk score

7.2       Key Performance Indicators:

         The number of people who have accessed the service who are referred
          to mainstream services
         The extent to which the activity within the areas below reflects the
          demographics of the populations
         The uptake of the service as measured against an agreed trajectory.
          The trajectory will reflect the estimated percentage per area split of
          people eligible to access the service as illustrated below:

          Askern                     9.5%
          Carcroft                   7.5%
          Clay Lane                  1.6%
          Denaby Main                7.3%
          Stainforth                 11.2%
          Highfields                 2.1%
          Hyde Park                  6.8%
          New Rossington             15.6%
          Toll Bar & Almholme        1.9%
          Woodlands                  11.0%
          Mexborough                 25.5%

7.3       Quality indicators:

         A list of any Serious Untoward Incidents occurring and their outcomes
         A list of any audits conducted relating to the subject of this contract,
          and any results / recommendations of those audits - Providers should

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          regularly audit their services, and possible topics for audit include
          clinical outcomes
         Any relevant internal quality reports

8.0       Workforce

8.1       Leadership

The provider will have an identifiable lead clinician/manager who will be able
to demonstrate:

         Provision of clinical leadership of the overall clinical team
         Day to day management of all the functions commissioned
         Provision of clinical supervision and a clinical governance framework
          for staff to work within
         Relevant training and professional development for clinical and non-
          clinical staff to enable them to fulfill the service set out in this service
         All staff employed or engaged by the provider are informed and aware
          of the standard of performance they are required to provide
         All staff are trained in line with any national/professional
         Staff performance is routinely monitored and that any remedial action is
          taken where levels of performance are not in line the agreed standard
          of performance

8.2 Professional accountability

The provider will ensure that staff concerned with all aspects of the provision
of health care:

         Are appropriately recruited, trained and qualified for the work they
          undertake. Staff delivering the cardiovascular risk management
          programme will need to be trained as registered nurses as a minimum
         Participate in mandatory and statutory training programmes including
          infection prevention and control
         Participate in further professional and occupational development
          commensurate with their work throughout their working lives
         Undertake all appropriate employment checks and ensure that all
          employed or contracted professionally qualified staff are registered with
          the appropriate bodies
         Require that all employed professionals abide by relevant published
          codes of professional practice

8.3       Personal development

The provider will support their staff through:

         Having access to processes which permit them to raise, in confidence
          and without prejudicing their position, concerns over any aspect of

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          service delivery, treatment or management that they consider to have a
          detrimental effect on client care or on the delivery of services
         Organisational and personal development programmes which
          recognise the contribution and value of staff, and address, where
          appropriate, under-representation of minority groups
         Have a relevant system to monitor and maintain performance and
         Promoting healthy lifestyles and health promotion

9.0       Premises

DPCT expects to commission services that:

         Meet the needs of clients and their families
         Are conducted in buildings appropriate to the nature of the service
         Will include confidentiality, dignity and privacy arrangements (the
          provider must refer to the guidance contained in The Essence of Care

The provider will ensure that health care services are provided in

         Which promote effective care and optimise health outcomes by being
          a safe and secure environment, which protects clients and their
          property, and the physical assets of the organisation
         Which are supportive of client privacy and confidentiality
         Which promote effective care and optimise health outcomes by being
          well designed and well maintained with cleanliness levels in clinical and
          non-clinical areas that meet the national specification for clean NHS

10.0 IM&T

The cardiovascular risk management programme will need to provide its own
IT system. This will be a stand-alone system and will not link automatically
with any other NHS organisations. Communication with other organisations
will be by a hard copy proforma.

The provider will need to implement a system that ensures people are not
assessed on multiple occasions, as multiple assessments of the same client
will not be recognised by DPCT.

11.0      Decontamination

The provider will give assurance that the segregation, handling, transport and
disposal of any waste is properly managed so as to minimise the risks to the
health and safety of staff, clients, the public and the safety of the environment.

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12.0 Client notes

The provider will be responsible for storing and maintaining clients notes.

The provider will produce 2 sets of notes; one to be retained by the client and
one to be retained by the service provider. The original notes will be retained
by the provider.

The service provider must ensure that they comply with the DH Records
Management Code of Practice (2006) (2).

13.0   Contract period

The contract will be awarded as soon as possible on completion of the tender
process, and will run from the date of the agreement of the contract until the
31st March 2009.

The contract will be formally reviewed after a 3-month period.

14.0   Links to relevant documents

1. BHF Factfile: JBS2 Guidelines on Prevention of CVD

2. Records Management: NHS code of practice: Part 1

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                                                                 Appendix 1

                             Doncaster PCT
                         Trust Board 7 June 2007
       Reducing Health Inequalities in Doncaster:
                Achieving Early Impact
1. Introduction

This paper proposes a systematic approach to achieving early impact on
tackling health inequalities in Doncaster and is based on the approach
developed by Yorkshire and the Humber SHA. This approach will form a
component part of Doncaster’s longer-term strategy to tackle health

It is intended to help initiate a process of:
      Developing a local commitment to and vision of a systematic, evidence
         based approach to tackling health inequalities
      Supporting the creation of a local, systematic action plan

The early impact approach rests on three principles:
    There are three levels of intervention with people to drive change –
     personal, community and population
    Different approaches have different times for development and impact
    The NHS can have a significant initial impact by better targeting its
     interventions, however sustained change is only possible through
     partnership work focusing on the broader determinants of health

The early impact approach is based on:
    An understanding of local health inequalities
    Understanding what is effective in reducing inequalities
    Prioritising approaches that will have the biggest impact by 2010

2. The Life Expectancy Challenge

In line with the rest of England the health of Doncaster’s population has
continued to improve, as measured by life expectancy and more recently by
the Department of Health’s indicator All Age All Cause Mortality.

Despite this improvement there remains a persistent gap between the health
of the most disadvantaged people and the better off. Life expectancy is
calculated as the average age to which babies born today would live if current
death rates continue. Male life expectancy in Doncaster is 75.4 years, 1.5
years less than the national figure. Female life expectancy is 80.1, one year
lower than the national figure (2003-05 figures).

There are significant variations in life expectancy between Doncaster
neighbourhoods. More deprived neighbourhoods tend to experience higher
death rates. Doncaster has significantly higher death rates from lung cancer,

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circulatory diseases (including coronary heart disease) and chronic lung
disease (COPD).
The Department of Health has identified seventy districts that have a
significant number of disadvantaged local areas compared to the national
average and agreed to target action here to narrow the gap.       These
communities are designated as ‘spearhead’ communities and include
Doncaster. As part of our Local Area Agreement, Doncaster has targets for
focused on reducing the gap between our experience and the England

The Public Service Agreements (PSAs) on Health Inequalities require the
achievement of percentage change in a health indicator e.g. life expectancy,
cancer mortality; at population level e.g. Spearhead community; in a given
time period - by 2010.

3. Achieving Systematic Change in Public Health

Achievement of such measurable change will require systematic action with
interventions that are known to be effective. These interventions can be
delivered at three different levels to drive change at population level ('public
health') in Doncaster. These are illustrated in the following diagram:

                                  Population Health

                                    Public Health

   Personal Health                                            Community Health

Population Health        Some interventions can be instituted directly at population
                         level.   They are sometimes referred to as health
                         protection measures. They are usually societal changes
                         aimed at influencing behaviour or ‘making healthy choices
                         easy choices’. They include public policy; legislation and
                         regulation; fiscal measures e.g. taxation; media and

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Personal Health           Some treatments, therapies and technologies are now
                         highly effective at the personal level. Good examples are
                         the use of low-dose aspirin and statins to reduce the risk
                         of heart attack. As well as being effective at the individual
                         level, such measures can also add up to a population
                         level effect when interventions such as use of disease
                         registers and incentive systems make the use of these
                         measures systematic, so that they support as many
                         people as possible who might benefit.

                         Individuals will only choose to use and benefit from certain
Community Health         behaviours and treatments if they fit with the cultural and
                         belief system of their own community.            Community
                         development is a process of facilitating communities
                         awareness of the factors and forces that affect their health
                         and quality of life, and ultimately help to empower them
                         with the skills needed for taking control and improving
                         those conditions in the community that affect their health
                         and well-being.

In order to make a significant impact on health inequalities in Doncaster we
need to take a more coherent, systematic approach using an evidence base
of what works and making full use of all of the levers that we have available.

Yorkshire and the Humber are promoting a whole system approach that we
propose to adopt locally that has the following three strands:

Area of activity                                       When they will impact
      Improving the availability and capability of         Short to Medium
   front line NHS services who work with the             Term
   most disadvantaged.
      Supporting the work of local organisations             Short to Medium
   to engage and empower the most                          Term
   disadvantaged communities in improving their
   own health
      Working with local organisations to                    Medium to Long
   develop stronger actions that will address the          Term
   underlying determinants of health such as
   housing,     environment,      transport    and

4. Achieving Early Impact on Life Expectancy

Time is short if we are to meet the 2010 targets. That means we must work
through our existing services and give extra attention to extracting maximum
benefit from the delivery of interventions for which there is strong evidence of

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Analysis of the causes of death responsible for the mortality gaps between the
most deprived communities and national averages will point to which
interventions are most likely to have an impact on the gap. This work has
been done nationally for spearhead areas as a group, comparing them with
the national average.

Having identified the causes of mortality in excess of national averages, it is
then possible to establish which interventions will have an impact, if applied
efficiently and effectively to those individuals and communities identified as
having the particular health needs.

The approach of the National Support Team for reducing health inequalities is
that the emerging portfolio of interventions will then form the core of local
action on health improvement, and, when appropriately targeted, the health
inequalities programme.

The national picture, which identifies the differences between the Spearhead
communities as a group, and the national average are shown separately for
men and women in the ‘scarf ‘diagrams below. The first 'scarf' shows what is
contributing to the gap in life expectancy. Effective interventions are then
listed and the second scarf quantifies the impact of each area of intervention.

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Having established which interventions are to be focused on, it will then be
important to ensure that everything is being done to extract maximum impact
at population level from them.

A diagnostic tool, developed in South Yorkshire and now being used by the
National Support Team for Health Inequalities, enables systematic appraisal
of a range of contributory factors, that will influence outcomes. An outline of
this tool is included in the appendix 1 below – Commissioning Healthcare for
Best Outcomes. It is proposed that this tool is used to identify gaps in current
provision and use of services.

Another important component of what is often missing is the systematic
application of social marketing. Effective use of these techniques can
contribute to changing the behaviours of staff, patients and communities.

All interventions will have a lead in time or gestation period before their impact
is measurable. Thus, it may take ten years before a major reduction in
tobacco use has a visible impact on lung cancer. However its impact on heart
disease may be apparent in just a couple of years. Only a specific set of
interventions impact in time to meet a 2010 target, It will be important to
concentrate on these in the short term.

5. Achieving Early Impact in Doncaster

In Doncaster, in order to have the greatest chance of success in meeting our 2010
life expectancy targets, we have agreed to focus on the following short to medium
term interventions as our ‘achieving early impact’ programme within our overall

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approach to tackling inequalities. This will have a particular but not exclusive focus
on targeting the most deprived 20% of Doncaster’s population with additional
interventions designed to have the greatest impact on reducing the local life
expectancy gap. The programme will include structured approaches to the following:

      COPD management
      Cardiovascular risk reduction
      Smoking cessation
      Early identification of people at risk of lung cancer
      Increasing uptake of cancer screening
      Increasing uptake of breastfeeding
      Review of management and prevention of diabetic emergencies
      Social care interventions with quickly realised health impact

We know that to address health inequalities successfully will require sustained
activity over many years so we must not neglect interventions with a longer
gestation period required to achieve sustainable change in the medium and
long term. A paper describing the PCT’s longer-term strategy to tackle health
inequalities will be presented at a future date.

6. Recommendations

Trust Board is asked to:

   a) SUPPORT the achieving early impact approach to reduce the life
      expectancy gap for Doncaster.
   b) NOTE the development of business cases in relation to the additional
      interventions identified above.
   c) RECEIVE at a future date a paper describing the PCT’s longer-term
      strategy to tackle health inequalities.

Dr Tony Baxter
Director of Public Health
24 May 2007

                                                                               19 of 22
           APPENDIX 1

         Commissioning Healthcare for Best Outcomes

Population Focus                     Optimal           Challenge to Providers
      5.Informed Choice                                     10. Patient/Public
  4. Responsive Services                                     9. Accessibility

 2. Expressed Demand                                           7. Local Clinical

   1.Known                                                              6.Known
  Population               12. Balanced Service Portfolio             Intervention
 Health Needs                                                           Efficacy

3. Equitable Resourcing                                       8.Cost Effectiveness
                           11.Adequate Service Volumes

Commissioning healthcare for best outcomes
A Population focus                                                  B Challenge to
1 Known population need                                             6 Known intervention efficacy
The pct will work to ensure that                                    The PCT will work to ensure that
the level and type of service is                                    services are established,
based on knowledge of the                                           modified and maintained on the
health care need of the                                             basis of best current knowledge
population                                                          of the efficacy of interventions
                                                                    and national guidance

2 Expressed demand The pct                                          7 Local clinical effectiveness
will work to inform, educate and                                    The pct will work to ensure that
support the population to                                           service providers maintain high
encourage them to take action                                       standards of local effectiveness
to improve their own health and                                     through education and training
well-being and to access and                                        driven by systems of
utilise health services                                             professional and organisational
appropriately.                                                      governance and audit.
3 Equitable resourcing The                                          8 Cost effectiveness The pct
pct will work to make resources                                     will work to ensure that the
available for the population to                                     expenditure on health care is
benefit according to need, by                                       targeted so as to optimise the
targeting distribution of its                                       potential health gain available to
income.                                                             residents from resource
4 Responsive services The                                           9 Accessibility The pct will
pct will work to ensure that all                                    work with providers to develop
patients will be afforded equal                                     appropriate models and
access to beneficial                                                configurations of service,
interventions according to need.                                    balancing a drive to bring
                                                                    services closer to the patient
                                                                    with the need for efficiency and
                                                                    effectiveness of that service.
5 Informed choice The pct                                           10 Patient/public involvement
will ensure that, where                                             The pct will work with patients
appropriate, patients are                                           and communities to ensure that
empowered to make choices                                           the services place their needs
about their treatment and care                                      and requirements at the centre
plans on the basis of good                                          of their operation and that
information and are supported                                       quality assurance systems are
to utilise treatments and                                           in place to ensure the
therapies to best effect.                                           acceptability of services to
                                   11 Adequate service
                                   volumes The pct will
                                   commission adequate service
                                   volumes to at least
                                   accommodate national
                                   referral-to-treatment targets.
                                   12 Balanced service
                                   portfolio The pct will ensure
                                   a balance of services within
                                   patient pathways to avoid
                                   bottlenecks and delays.


Life expectancy in Doncaster is about 75½ years for men and about 80 years for
women. Within Doncaster’s most deprived communities, life expectancy is 2 years
lower for men and 1½ years lower for women.

Doncaster Public Health Intelligence Unit has calculated the contribution to these
gaps of each cause of death. In general there are three factors which underpin the
contribution of each cause of death:

i)     how unequally the deaths are distributed, i.e. how much higher are death
       rates in deprived areas?

ii) how many deaths are there? – the greater the number of deaths, the bigger the
    effect on the life expectancy gap.

iii) at what age do the deaths occur? – younger deaths have a much greater effect
     on life expectancy than deaths of older people.

There are many causes of death which kill more frequently in deprived areas,
including, CHD, COPD, lung cancer, diabetes, infant mortality.

Infant mortality delivers by far the biggest reduction in life expectancy gap per life
saved, but there are only around 20 deaths per year in Doncaster.

Similarly, the numbers of deaths caused directly by diabetes are small, but they
are inequitably distributed and tend to occur at quite a young age, so the effect on
life expectancy of reducing deaths is quite large.

COPD and lung cancer are both extremely inequitably distributed, and each cause
around 80 female deaths and over 100 male deaths per year in Doncaster.

CHD is by far the largest cause of death and has the greatest overall potential for
narrowing the gap, but the reduction in gap per life saved is very small, as the
deaths are mostly in old age.

By targeting interventions at all of the above causes, we can have the greatest
effect on narrowing the gap in life expectancy.


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