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

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Presentation on theme: "Addressing Health Inequalities – From Mystery and Imagination to Practical Action Professor Chris Bentley Health Inequalities National Support Team."— Presentation transcript:

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

2 What is the Health 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 Well being and Health Physiological risks High blood pressure High cholesterol Stress hormones Anxiety/depression Behavioural risks Smoking Poor diet Lack of activity Substance abuse 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 Risk conditions – e.g.: Poverty Low social status Dangerous environments Discrimination Steep power heirarchy Gaps/weaknesses in services and support

6 Gestation from Input to Outcome A B C

7 COPD Seasonal excess deaths Cancer CVD Diabetes Infant Mortality AlcoholTobaccoObesity Income and Debt EmploymentHousing 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 Community Health Personal Health Producing Percentage Change at Population LevelC. Bentley 2007

10 Population Health Community Health Personal Health Partnership, Vision and Strategy, Leadership and Engagement Producing Percentage Change at Population LevelC. 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 Community Health Personal Health Systematic and scaled interventions through services Producing Percentage Change at Population LevelC. Bentley 2007

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

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

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

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

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

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

19 National Support Teams Wakefield PCT Barking and Dagenham PCT Number of GPs per Practice

20 NHS Bolton 2006/07

21 NHS Bolton Dr.S.Liversedge

22 National Support Teams 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 > < It

23 NHS Bolton 2008/09

24 National Support Teams Another Spearhead PCT - QOF Scores by Practice

25 National Support Teams Bradford

26 National Support Teams Liverpool

27 Quality of delivery

28 Wakefield

29 National Support Teams A PCT with problems

30 National Support Teams South Tyneside

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

33 Islington CVD Mortality Audit

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

35 Industrial Scale-“Small is beautiful”

36 Piecemeal Project Based Approach

37 Industrial Scale-“Small is beautiful”

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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 Community Consultation Minimal consultation A range of innovative methods for reaching seldom seen and heard groups. Elicited views demonstrably impacting on action. Consultation based on large meetings /events and the ‘usual suspects’, with feedback on results. ‘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. 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 Empowerment No /few community organisations –with limited lifespan 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. Devolution of assets from statutory sector to community organisation/s in support of developing community self- determination. Community organisations sustained by a mixture of income from trading and/or commissioned activities, and/or grant aid. Community organisations surviving mainly through voluntary effort Community Partnership Membership of community planning and implementation forums may be tokenistic with unequal power relationships Community planning and implementation groups have representative membership with systems of support back to their constituency. Community representatives feel that they influence decisions being taken about their community. 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. Effective partnership framework (or TOR) providing protocols and safeguards to ensure collaborative decision making and conflict resolution

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

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

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

44 Addressing Diabetes Inequalities through Community Engagement Raising community awareness of key health messages about prevention/early identification. Case finding and linking to life-style and primary care services 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 Support patient self- management and empowerment, targeting those not achieving treatment goals. Facilitating links to other supports where necessary Coordination of inputs and output with strategic approach to Community Engagement

45 WHO Commission on the Social Determinants of Health 2008 Report “Bridging the Gap in a Generation”

46 National Support Teams Bridging the Gap in a Generation Commission 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 National Support Teams 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 National Support Teams 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 National Support Teams 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: oEstablish mechanisms to finance cross-government action on social determinants oAllocate finance fairly according to need between geographical areas and social groups  Market responsibility: oVital social goods (health; education) governed by public sector, not left to markets oPublic sector leadership of regulation of harmful products and activities oInstitutionalisation 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 : oGuarantee a comprehensive set of rights oEnsure 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 National Support Teams 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

51 Mike Grady University College London

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53 Key themes Reducing health inequalities is a matter of fairness and social justice Action is needed to tackle the social gradient in health – Proportionate universalism Action on health inequalities requires action across all the social determinants of health Reducing health inequalities is vital for the economy – cost of inaction Beyond economic growth to well-being of society: sustainability and the fair distribution of health

54 Enable all children, young people & adults to maximise their capabilities & control their lives. Policy objectives Effective evidence-based delivery systems. Reduce health inequalities and improve health and wellbeing for all Policy Goals Create an enabling society that maximises individual and community potential. Ensure social justice, health and sustainability are at heart of policies. Create and develop healthy and environmenta lly sustainable places & communities. Ensure healthy standard of living for all. Create fair employm ent & decent work for all. Give every child the best start in life. Equality & health equity in all policies. Strengthen the role and impact of ill- health prevention. Policy mechanisms


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