1. Alcohol misuse, obesity and smoking: a social determinants approach to public health interventions Wednesday 10 th April 2013

8. Approach Practitioners’ feedback that, often because they have to show how they are meeting a health target or achieving a health related outcome, they are often drawn back to intervening downstream and in lifestyle behaviours – lifestyle drift - rather than taking action on ‘the causes of the causes’. There has been a dominance of lifestyle interventions with an emphasis on either downstream interventions or on approaches that have a socially neutral impact (Hunter et al. 2009). Evidence has shown that life style approaches will not make significant impact on health inequalities because they do not tackle the causes of health inequalities, which lie in the SDH. Responsibility for public health and processes for commissioning are currently changing in England with a view to come into effect in April 2013. Priorities for health improvement will be set within the local authority (Health & Wellbeing Boards) rather than by the NHS or at national level. It is envisaged that this system will enable commissioning and work outside the strict remit of health in the areas of the social determinants of health. The need for a SDH approach

9. The Health and Social Care 2012 Act also contains duties to integrate health services… “Each clinical commissioning group must exercise its functions with a view to securing that health services are provided in an integrated way where it considers that this would - (a) [improve quality]; (b) reduce inequalities between persons with respect to their ability to access those services; or (c) reduce inequalities between persons with respect to the outcomes achieved for them by the provision of those services.” …duties to integrate health with health-related or social care services… “Each clinical commissioning group must exercise its functions with a view to securing that the provision of health services is integrated with the provision of health-related services or social care services where it considers that this would - (a) [improve quality]; (b) reduce inequalities between persons with respect to their ability to access those services; or (c) reduce inequalities between persons with respect to the outcomes achieved for them by the provision of those services.” “Health related services” are broadly defined and can include services related to the wider determinants of health such as housing, fuel poverty, debt, education, employment etc. The practical effect should be that services are integrated around the needs of the individual.

10. … and duties around planning, reporting and assessment Planning The Act requires the NHSCB and CCGs to include, in their business plan and commissioning plans respectively, an explanation of how each proposes to discharge their duties as to reducing inequalities. Reporting The SofS, NHSCB and CCGs are required to include, in their respective annual reports, an assessment of how effectively they have discharged their duties as to reducing inequalities. Assessment The SofS, having considered the NHSCB’s annual report, is required to make an assessment of how well the Board has discharged its duty as to reducing inequalities.The NHSCB is required to undertake a similar annual assessment of how well CCGs have discharged their duty as to reducing inequalities The Health and Social Care Act 2012 contains the first ever specific legal duties on health inequalities. NHSCB and CCGs have duties to have regard to the need to reduce inequalities in access to health services and the outcomes achieved for patients. Secretary of State has a duty to have regard to the need to reduce inequalities covering his NHS and public health functions for the whole population. NHSCB, CCGs and Monitor have further duties around integration of health services, health-related services or social care services where they consider this would reduce inequalities. The Act also contains duties around health inequalities on, variously, SofS, NHSCB and CCGs concerning planning, reporting and assessment.

11. Opportunities for Intervention: SDH impact on PPHCand PPHC impact on Outcomes Approach

12. Early Years E.g. Increase children and family services. Employment and Work E.g. Address stress at work. Standard of Living E.g. Tackling debt problems. Education and Skill Development E.g. Reduce the number of NEETs. Communities and Places E.g. Reducing environmental inequalities. Prevention and Regulation E.g. Smoking ban in public places. Delivery system E.g. Swansea and Wrexham Delivery system E.g. Birmingham Brighter Futures E.g. Advertising campaigns E.g. Free NRT E.g. Stop smoking programmes E.g. School educational programmes Delivery system E.g. BLT Strategy Approach E.g. 5-a-day campaign E.g. Weight management programmes Delivery system E.g. Feeling good about where you live Downstream interventions Equity E.g. Reducing population groups’ differences in PPHCs

13. Describe health inequalities from the JSNA the socio economic gradient – inequalities in the distribution of alcohol misuse, obesity and smoking. Identify and analyse key social determinants affecting inequalities and health outcomes: the causes of the causes. Assess evidence and propose actions and interventions: evidence, feasibility, synergy, cost efficacy. Set metrics, targets and responsibility: timescales and indicators. Approach Process for developing interventions

14. PPHC SDH Alcohol MisuseObesitySmoking Early Years E.g. Universal free school meals.E.g. improved access to early years education. Education and Skill Development E.g. Reducing the number of NEETs. Employment and Work E.g. Managing stress at work.E.g. Develop pathways to work. Communities and Places E.g. Reducing environmental inequalities. E.g. Planning walkable neighbourhoods.E.g. Increase exposure to green space. Standard of living E.g. Minimum income for healthy diet.E.g. Tackle debt issues. Prevention and Regulation E.g. Reducing crime and fear of crime.E.g. Reducing salt and fat content in processed foods. E.g. Fire fighters in the community. Equality and Health equity Social Determinants Approach to PPHCs Matrix 1

15. Birmingham Brighter Futures Percentage of 5-year-olds achieving a good development score increased from 40% in 2007 to 55% in 2010. Strategic focus (strategy has been prepared by a multi-disciplinary leadership team of 35 people, supported by over 200 practitioners from across the city’s children's organisations). Identifying target groups and needs (in-depth analysis of need to secure the services people really need; a robust outcomes and planning- driven approach to improvement). Partnership working and information sharing (Local Authority, Careers Wales, JobCentre Plus, head teachers, teachers, Learning Coaches, Youth Workers, and Education Welfare Officers). Provision & support (radical changes to the way they organise, commission and deliver services, especially in how people from different organisations work together at the front-line). Early Years

16. Percentage of 5-year-olds achieving good development score* in Birmingham Local Authority, the West Midlands region and England. * in personal, social and emotional development and communication, language and literacy. Source: Department of Education. Percentage Early Years

17. Education and Skills Educational attainment is a predictor of health outcomes. Higher educational attainment is associated with healthier behaviour. There is a gradient in limiting illness by level of educational attainment. There is a gradient in mortality by educational attainment.

18. Swansea and Wrexham NEETs NEETs reduced by 68% over 5 years, in Swansea from 12.2% in 2004 to 4.2% in 2010 – well below the Welsh average. Strategic focus (priority at strategic level; clear targets set; resources shifted; work intensified; earlier intervention) Identifying target groups within the population of young people (Careers Wales advisers and school staff working together to identify pupils in Year 11 at risk of becoming NEETs) Partnership working and information sharing (Local Authority, Careers Wales, JobCentre Plus, head teachers, teachers, Learning Coaches, Youth Workers, and Education Welfare Officers) Provision & support (change in core service provision, greater emphasis on summer months, skills building provision, flexible start dates for training, work placement through project partners) People (enthusiastic and committed staff) Employment

19. Proportion of Year 11 school leavers known to be NEET in 2004 - 2010 Employment

20. Young people offending in Swansea Employment

21. Communities and Places EWDs are almost three times higher in the coldest quarter of housing than in the warmest quarter (21.5% of all EWDs are attributable to the coldest quarter of housing, because of it being colder than other housing). Children living in cold homes are more than twice as likely to suffer from a variety of respiratory problems than children living in warm homes. Mental health is negatively affected by fuel poverty and cold housing for any age group. More than 1 in 4 adolescents living in cold housing are at risk of multiple mental health problems compared to 1 in 20 adolescents who have always lived in warm housing. Cold housing increases the level of minor illnesses such as colds and flu and exacerbates existing conditions such as arthritis and rheumatism.

22. Feeling good about where you live Run by Greenwich Council and NHS Greenwich. Aims to understand the causality between built environment, social networks and mental well-being through providing a number of interventions in the environment. 3-years study which include a case control group. Based on postal survey to 1,600 households in 9 areas in Greenwich; response rate 38% (n=608). Focused on two estates - Baseline survey has been completed on two estates - 810 responses (from 1500 households); the ‘control’ estate will receive improvements at the end of the project. Delivery partnerships with NHS Greenwich, Metropolitan Police, Greenwich Council, local schools established. Communities and Places

23. The is a gradient in environmental disadvantage. Strong link between environmental factors and health (e.g. Pollution). Strong evidence that access to good quality green spaces improves mental health. Traffic accidents concentrated at the bottom of the gradient. Income group 4 is most deprived

24. Alcohol

25. Early Years E.g. Increase children and family services. Employment and Work E.g. Address stress at work. Standard of Living E.g. Tackling debt problems. Education and Skill Development E.g. Reduce the number of NEETs. Communities and Places E.g. Increase exposure to green space. Prevention E.g. Fire fighters in the community Equity E.g. Reducing ethnic difference in alcohol consumption Delivery system E.g. Swansea and Wrexham Delivery system E.g. Birmingham Brighter Futures E.g. Advertising campaigns E.g. Expand access to alcohol services. E.g. units and calories labelling E.g. School educational programmes Delivery system E.g. BLT Strategy Alcohol Downstream interventions

26. Areas of actionGeneral Influential FactorsMental well-being – control and confidence Early Years Education and Skill Development Employment and Work E.g. Address stress at work. Communities and Places E.g. Increase exposure to green space. Standard of living Prevention and Regulation Equality and Health equity E.g. Reducing ethnic difference in alcohol consumption Alcohol Social Determinants Approach to Alcohol Misuse

27. Obesity

28. Early Years E.g. Increase children and family services. Employment and Work E.g. Address stress at work. Standard of Living E.g. Universal free school meals Education and Skill Development E.g. Reduce the number of NEETs. Communities and Places E.g. Planning for walkable neighbourhoods Delivery system E.g. Swansea and Wrexham Delivery system E.g. Birmingham Brighter Futures E.g. 5-a-day campaign E.g. Weight management programmes E.g. School educational programmes Delivery system E.g. BLT Strategy Obesity Equity E.g. Reducing ethnic difference in obesity levels Delivery system E.g. Luton Nourishing Neighbourh oods objective Delivery system E.g. Gloucesters hire Active Planning Toolkit Prevention and Regulation E.g. Reducing salt and fat content in processed foods Delivery system E.g. Islington Pilot Downstream interventions

29. Obesity Social Determinants Approach to Obesity Areas of actionGeneral Influential FactorsMental well-being – control and confidence Early Years E.g. Universal Free School Meals. Education and Skill Development Employment and Work E.g. Address stress at work. Communities and Places E.g. Planning Walkable Neighbourhoods.E.g. Reducing crime and fear of crime. Standard of living E.g. Improving energy efficiency of homes. Prevention and Regulation Equality and Health equity

30. Smoking

31. Early Years E.g. Increase children and family services. Employment and Work E.g. Address stress at work. Standard of Living E.g. Tackling debt issues. Education and Skill Development E.g. Reduce the number of NEETs. Communities and Places E.g. Reducing crime and fear of crime. Prevention E.g. Fire fighters in the community Equity E.g. Reducing ethnic difference in smoking Delivery system E.g. Swansea and Wrexham Delivery system E.g. Birmingham Brighter Futures E.g. Advertising campaigns E.g. Free NRT E.g. Stop smoking programmes E.g. School educational programmes Delivery system E.g. BLT Strategy Smoking Delivery system E.g. BBBC Welfare and Benefits Advice Downstream interventions

32. Areas of actionGeneral Influential FactorsMental well-being – control and confidence Early Years Education and Skill Development Employment and Work Communities and Places E.g. Reducing crime and fear of crime. Standard of living E.g. Reducing fuel bills Prevention and Regulation Equality and Health equity E.g. Reducing ethnic difference in smoking Smoking Social Determinants Approach to Smoking

33. Principles for Selection and Prioritisation

34. Address the area’s needs: Intervention likely to impact on the greatest needs of the population as identified in the JSNA, regardless of what sphere the intervention takes place in and allowing for the fact that the timescale needed for an impact on health outcomes might be long Is universal and addresses the social gradient in health Intervention likely to impact on the whole population, but provides more intense support to those in greater need, with less socio-economic resources, or living in areas of greater economic or environmental deprivation Is aligned with other local and national policies Intervention does not interfere with other policy objectives, e.g. sustainability, and is likely to have positive impact on other social outcomes and performance indicators Is backed-up by evidence of efficacy Intervention considered because there is strong evidence base that it is likely to have an impact on the SDH and on health inequalities Is cost-beneficial Intervention likely to positively impact on long term costs to health and social services, and to provide significant social gains for its cost Takes advantage of existing assets and resources Intervention makes efficient use of existing service infrastructure and enhances the availability and quality of community resources Provides the population with control over their lives Interventions devised on the basis of clear community priorities as stated by consulted stakeholders and users; intervention engages the public in decision-making and delivery Falls within one of the following unifying themes: The importance of improving the physical, social and economic environment of deprived areas.  Early intervention and the long term public health benefits of intervening early in the life course particularly for prevention.  Looking at the close interplay between physical and mental health when designing strategies to reduce health inequalities.  The use of fiscal and financial policy instruments to enable deprived populations to live healthier lives.