Addressing Health Inequalities – From Mystery and Imagination to Practical Action

1. Addressing Health Inequalities – From Mystery and Imagination to Practical Action Professor Chris Bentley Health Inequalities National Support Team

2. What is theHealth Inequalities National Support Team? • One of a number of Public Health National Support Teams which provide tailored delivery support to health partnerships in England – PCTs / NHS Trusts and Local Authorities • Areas offered support identified principally on performance, and who would most benefit. HI NST has offered visits to all spearhead areas • Team members drawn from the NHS, Local Government and Third sector with expertise in relevant topic areas, change management, commissioning and public health • Style genuinely supportive, identifying and supporting strengths as well as weaknesses/gaps. High challenge, high support. • Recommendations based on evidence / good practice but with local practical solutions • Good working understanding with regional teams

3. Spearheads we have visited so far… • Health Inequalities visits so far have included 59 Spearhead areas: Tower Hamlets, Rotherham, Leicester, Hull, Hartlepool, Rochdale, Wolverhampton, Newham, Bolton, Wear Valley, Sedgefield, Hammersmith and Fulham, Birmingham, Wakefield, Barking and Dagenham, Wigan, Bradford, Bolsover, Liverpool, Corby, Nottingham, Oldham, Burnley, Pendle, Hyndburn, Rossendale, Newcastle, North Tyneside, Greenwich, Doncaster, South Tyneside, Sunderland, Gateshead, North East Lincolnshire, Stoke-on-Trent, Preston, Blackburn with Darwen, Wirral, Halton & St. Helens, Sandwell, Salford, Lambeth, Manchester, Tameside & Glossop, Blackpool, Islington, Carlisle, Barrow in Furness, Southwark, Warrington, Barnsley, Tamworth, Coventry, Walsall, Warwickshire (Nuneaton & Bedworth), Knowsley, Haringey and Bury

4. Enhanced Support Programme • Supporting Spearhead Communities to hit the PSA Health Inequalities Target for 2010 • Initial focus on 13 Spearheads (‘Baker’s Dozen’) responsible for 40% of the national gap in Life Expectancy • Identified list of interventions most likely to have an impact on short term mortality targets (the Priority Action List) • Stocktake based on Priority Action List being carried out with Baker’s Dozen, to identify areas for targeted support • Masterclasses and Learning Sets being run on 8 major interventions from the Priority Action List • 12 Toolkits being developed to assist with elements of Priority Action List • Diagnostic Workbooks revised and updated with Policy and NHS Specialist Teams • Dissemination events scheduled to role out learning to remaining Spearhead communities

5. Physiological risks High blood pressure High cholesterol Stress hormones Anxiety/depression Well being and Health Behavioural risks Smoking Poor diet Lack of activity Substance abuse Risk conditions – e.g.: Poverty Low social status Dangerous environments Discrimination Steep power heirarchy Gaps/weaknesses in services and support Psycho-social risks: Isolation Lack of social support Poor social networks Low self-esteem High self-blame Low perceived power Loss of meaning/purpose of life

6. Gestation from Input to Outcome A B C 2005 2010 2015 2020

7. CVD Seasonal excess deaths Diabetes COPD Cancer Infant Mortality Alcohol Tobacco Obesity Income and Debt Employment Housing Community Safety

8. Achieving Percentage Change in Population Outcomes Programme characteristics will include being :- • Evidence based – concentrate on interventions where research findings and professional consensus are strongest • Outcomes orientated – with measurements locally relevant and locally owned • Systematically applied – not depending on exceptional circumstances and exceptional champions • Scaled up appropriately – “industrial scale” processes require different thinking to small “ bench experiments” • Appropriately resourced – refocus on core budgets and services rather than short bursts of project funding • Persistent – continue for the long haul, capitalising on, but not dependant on fads, fashion and policy priorities

9. Population Health Personal Health Community Health Producing Percentage Change at Population Level C. Bentley 2007

10. Population Health Partnership, Vision and Strategy, Leadership and Engagement Personal Health Community Health Producing Percentage Change at Population Level C. Bentley 2007

11. Vision and Strategy • Is there a coherent plan which ‘demystifies’ how goals are to be reached? • Have the goals been clarified in terms of numbers? • Have the numbers been modelled to establish the potential contributions from contributory interventions? • Have the modelled numbers been used to cost various options including combinations of interventions? • Have the modelled numbers and resulting outline plan been used as the basis of a Communication Plan?

12. Population Health Systematic and scaled interventions through services Personal Health Community Health Producing Percentage Change at Population Level C. Bentley 2007

13. Commissioning Services to Achieve Best Population Outcomes Optimal Population Outcome Challenge to Providers Population Focus 5. Engaging the public 10. Supported self-management 13.Networks,leadership and coordination 9. Responsive Services 4. Accessibility 2. Local Service Effectiveness 7. Expressed Demand 6.Known Population Needs 1.Known Intervention Efficacy 12. Balanced Service Portfolio 8. Equitable Resourcing 3.Cost Effectiveness 11.Adequate Service Volumes C Bentley 2007

14. Commissioning Services to Achieve Best Population Outcomes Optimal Population Outcome Challenge to Providers 5. Engaging the public 4. Accessibility 2. Local Service Effectiveness 1.Known Intervention Efficacy 3.Cost Effectiveness C Bentley 2007

15. Commissioning Services to Achieve Best Population Outcomes Optimal Population Outcome Population Focus 10. Supported self-management 9. Responsive Services 7. Expressed Demand 6.Known Population Needs 8. Equitable Resourcing C Bentley 2007

16. 12. Balanced Service Portfolio 11.Adequate Service Volumes Commissioning Services to Achieve Best Population Outcomes Optimal Population Outcome Challenge to Providers Population Focus 5. Engaging the public 10. Supported self-management 9. Responsive Services 4. Accessibility 2. Local Service Effectiveness 7. Expressed Demand 6.Known Population Needs 1.Known Intervention Efficacy 8. Equitable Resourcing 3.Cost Effectiveness C Bentley 2007

17. Commissioning Services to Achieve Best Population Outcomes Optimal Population Outcome Challenge to Providers Population Focus 13.Networks,leadership and coordination C Bentley 2007

18. Commissioning Services to Achieve Best Population Outcomes Optimal Population Outcome Challenge to Providers Population Focus 5. Engaging the public 10. Supported self-management 13.Networks,leadership and coordination 9. Responsive Services 4. Accessibility 2. Local Service Effectiveness 7. Expressed Demand 6.Known Population Needs 1.Known Intervention Efficacy 12. Balanced Service Portfolio 8. Equitable Resourcing 3.Cost Effectiveness 11.Adequate Service Volumes C Bentley 2007

19. Number of GPs per Practice Wakefield PCT Barking and Dagenham PCT

20. NHS Bolton 2006/07

21. NHS Bolton Dr.S.Liversedge

22. The activity has continued, with the latest figures, for January, continuing the trend. It is estimated that 83-85% of all patients would have been assessed by end March 2009 The figures also show that practices in the more deprived neighbourhoods have been supported to achieve the best results: Deprivation Score No. Practices % Assessed >40 14 79.4 30-39 18 73.7 20-29 12 75.2 <20 11 74.3 It

23. NHS Bolton 2008/09

24. Another Spearhead PCT - QOF Scores by Practice

25. Bradford

26. Liverpool

27. Quality of delivery

28. Wakefield

29. A PCT with problems

30. South Tyneside

32. Cardiac Rehabilitation Programme Patients remaining through the programme 100% 80% 55% 25% Phase 2 Phase 1 (Hospital) Phase 3 Phase 4 (Leisure services)

33. Islington CVD Mortality Audit

34. Population Health Systematic community engagement Personal Health Community Health Producing Percentage Change at Population Level C. Bentley 2007

35. Industrial Scale - “Small is beautiful”

36. Piecemeal Project Based Approach

37. Industrial Scale - “Small is beautiful”

39. Community Engagement The NST has developed a community engagement good practice framework which identifies those elements that are necessary to achieve a systematic, comprehensive and effective strategic approach to community engagement. This includes the following elements : Structures and Profiling: Neighbourhood Structures Neighbourhood Management Communities of Identity and Interest Neighbourhood and Community Profiling Neighbourhood Action Planning Community Engagement and Building Social Capital Development of Human Capital Development of Social Capital Community consultation Community partnership Community empowerment Service Delivery and Strategic Support Staffing for community and neighbourhood engagement Service delivery for community and neighbourhood engagement Neighbourhood Service Centres e.g. Primary Care, Healthy Living Centre or LIFT, BSF or Extended School, Employment and Training Access Point Service organisation for community and neighbourhood engagement

40. Engagement strategy/ies extended into stakeholder engagement involving front line staff across partnerships (statutory and VCF sector) with feedback on action taken. “We asked, you said, we did, this is the difference you made”.Toolkit guidance available to organisations undertaking consultation.Cross-partnership calendar of consultations established. • Community based organisations delivering local services with an asset base for future sustainability. E.g. a local CIC (Community Interest Company) or IPS (Industrial and Provident Society) delivering services for Health and Well-being.Toolkit guidance available to organisations promoting community self-determination. • Community level partnerships contributing and being influential at strategic level i.e. across City /Borough /District.E.g. issue-driven partnerships e.g. Healthy Communities Collaboratives.Toolkit guidance available to organisations working in partnership. • 4 • Devolution of assets from statutory sector to community organisation/s in support of developing community self-determination. • A range of innovative methods for reaching seldom seen and heard groups. Elicited views demonstrably impacting on action. • Effective partnership framework (or TOR) providing protocols and safeguards to ensure collaborative decision making and conflict resolution • 3 • ‘Range of reach’ – a strategy involving a menu of methods of engagement other than large meetings e.g. citizens panels, patient liaison/user groups, household surveys. Elicited views demonstrably impacting on action. • 2 • Community representatives feel that they influence decisions being taken about their community. • Community organisations sustained by a mixture of income from trading and/or commissioned activities, and/or grant aid. • Community planning and implementation groups have representative membership with systems of support back to their constituency. • 1 • Consultation based on large meetings /events and the ‘usual suspects’, with feedback on results. • Community organisations surviving mainly through voluntary effort • Membership of community planning and implementation forums may be tokenistic with unequal power relationships • 0 • No /few community organisations –with limited lifespan • Minimal consultation Community Partnership Community Consultation Community Empowerment

41. Community and Neighbourhood Engagement Warrington Local Profile Engagement and Capital Building Structures and Profiling Organising for Delivery • Structures • (for communities of place) • Service Organisation for Community and Neighbourhood Engagement • Service Delivery for Community & Neighbourhood Engagement • Communities of Interest and Identity • Community Empowerment • Neighbourhood Action Planning • Development of Social Capital • Neighbourhood Management • Community Consultation • Community Partnership • Neighbourhood Service Centres • Development of Human Capital • Neighbourhood and Community Profiling • Stock-take of Neighbourhood Infrastructure • Staffing for Community and Neighbourhood Engagegment

42. Population Health Personal Health Community Health Service engagement with the community Producing Percentage Change at Population Level C. Bentley 2007

43. Grass-roots Community Work Professional infrastructure Overview & Co-ordination Community Infrastructure Organisation Development Strategic Framework for Community Engagement

44. Addressing Diabetes Inequalities through Community Engagement Support patient self-management and empowerment, targeting those not achieving treatment goals. Facilitating links to other supports where necessary Raising community awareness of key health messages about prevention/early identification. Case finding and linking to life-style and primary care services Coordination of inputs and output with strategic approach to Community Engagement Outreach to identify reasons for non-engagement with services. Advocacy to improve accessibility of clinical care and ongoing quality of services Improve the skills of primary and specialist care professionals to better meet the needs of patients and make the links to lifestyle change support resources

45. WHO Commissionon the Social Determinants of Health2008 Report “Bridging the Gap in a Generation”

46. Bridging the Gap in a GenerationCommission on the Social Determinants of Health Overarching Recommendations • Improve Daily Living Conditions • Tackle the Inequitable Distribution of Power, Money and Resources • Measure and Understand the Problem and Assess the Impact of Action

47. Improve Daily Living Conditions • Equity from the start Comprehensive approach to early child development, including: • Physical • Social/emotional • Language/cognitive • Healthy places, healthy people Planning promotes healthy and safe behaviours equitably, including: • Affordable housing • Investment in active transport • Retail planning to manage access to healthy and unhealthy foods • Good environmental design • Regulatory control (including alcohol outlets) • Universal Healthcare • Healthcare systems based on equity, disease prevention and health promotion • Strengthen health workforce, with capability to act on social determinants of health :

48. Improve Daily Living Conditions • Fair employment and decent work Maximise opportunities for healthy employment, embracing: • Safe, secure and fairly paid work • Year-round work opportunities • Healthy work-life balance for all Improve working conditions for all, reducing: • Exposure to material hazards • Work-related stress • Health-damaging behaviours • Insecurity of those in precarious work arrangements • Social protection across the lifecourse Social protection schemes reduce poverty, and local economies benefit: • Address those qualifying for, but not accessing, welfare benefits • Bridge across the low-pay gap to encourage employment • Address those in precarious work, including informal • Consider carer and household work

49. Tackle the Inequitable Distribution of Power, Money, and Resources • Health equity in all policies, systems and programmes • Place responsibility for health and health equity at highest level of government • Ensure its coherent consideration across all policies as a corporate responsibility • Fair finance: • Establish mechanisms to finance cross-government action on social determinants • Allocate finance fairly according to need between geographical areas and social groups • Market responsibility: • Vital social goods (health; education) governed by public sector, not left to markets • Public sector leadership of regulation of harmful products and activities • Institutionalisation of competent regular health equity impact assessment of policy making and market regulation • Political empowerment - inclusion and voice Top-down and bottom-up approaches are equally vital: • Statutory sector must : • Guarantee a comprehensive set of rights • Ensure fair distribution of essential material and social goods • Community or civil society organising against injustices suffered by the disadvantaged can be empowering and generate leadership

50. Measure and Understand the Problem and Assess the Impact of Action • Ensure routine monitoring systems for health equity and social determinants of health are in place • Invest in generating and sharing new evidence on • Influence of social determinants on population health and health equity • Effectiveness of measures to reduce health inequities through action on social determinants • Provide training on the social determinants of health • To policy ‘actors’, stakeholders and practitioners • Invest in public awareness