1. Bromley by Bow Centre and Social Prescribing
The essentials of our model

2. Where are we?
Canary Wharf
Bromley by Bow
Olympic Stadium

3. This is Charles Booth He was a social researcher
In 1889 he created a poverty map of east London
One of the hotspots of deprivation was Bromley by Bow
It still is

4. Charles Booth’s poverty map 1898
Lowest class
Very poor
Poor
Mixed
Fairly comfortable
Middle class. Well-to-do
Upper-middle and Upper
classes. Wealthy

5. Index of Multiple Deprivation 2010
Dimensions of deprivation:
Income deprivation,
employment deprivation,
health deprivation and disability,
education, skills and training deprivation,
barriers to housing and services,
living environment deprivation,
crime.
Today 28% of Londoners live in poverty, with 40% of children living in poverty.
Tower Hamlets is the 7th most deprived local authority area out of 326 local authority districts in England.
16 out of 17 of its wards are amongst the 20% most deprived in the country with 12 wards in the 10% most deprived wards.
almost 50% of children in tower hamlets live in poverty.

6. The Marmot Review 2010
Professor Michael Marmot

7. Social determinants of health
Marmot Review Priorities
Every child needs the best start in life
People to need to be able to maximise their capabilities
People need to feel in control over their lives
Having a good and fair job is vital
Everyone needs a healthy standard of living
People need to live in homes and communities that promote health and are sustainable and stable
There needs to be effective, accessible and sufficient clinical provision in communities
Tower Hamlets Reality
At age 5 only 50% of children have a good level of cognitive development
Attainment at Key Stage 5 it is 4th lowest in London
Unemployment: 33% above London average. High proportion of residents work in low paying sectors
20% of households have income <£15,000.
50% of Tower Hamlets children are in poverty
Second highest population density in London. 35% of the borough’s households are overcrowded
10% of the population eat 5 portions of fruit or vegetables a day; 30% exercise to the recommended level ; 42 fast food outlets per secondary school

8. the wider determinants of health, including behaviour, have a greater influence on health outcomes than genetics and healthcare combined
Notes are repeated on following slide
The previous slide shows the distribution of deprivation, as mentioned, the indicators of deprivation (income, employment, skills etc) are amongst the key determinants of health.
The Marmot Review, Fair Society, Healthy Lives, developed a significant level of understanding of the relationship between social determinants and health
People with poor social determinants of health will have poorer health outcomes through their life course.
Areas of high deprivation, such as Tower Hamlets, represent concentrations of people with poor social determinants of health.
What are the social determinants of health, the Marmot Review emphasises?
The critical importance of every child having the best possible start in life 
Enabling people to maximise their capabilities and have control over their lives 
Having fair employment and good work for all 
Ensuring that everyone has a healthy standard of living
Having communities and places promote health and sustainable   
Ensuring that ill‐health prevention has a strong and effective role in our communities
What do the social determinants of health look like for our community?
The critical importance of every child having the best possible start in life
Tower Hamlets has significantly poorer levels of child development at the age of 5 than the London average
Enabling people to maximise their capabilities and have control over their lives 
Whilst attainment at Key Stage 4 is above average, it still lags behind at Key Stage 5 and higher education. There is a significant skills gap in the adult population with 16% of adults holding no qualification. Social inequality can lead to people feeling disempowered with little influence over their community or control over their lives.
the prevalence of low wage employment
95% of households are considered to be financially vulnerable, including very low savings levels.
The changing nature of employment is having a significant effect on the health and wellbeing of our community. Reductions in wage rates over past 5 years, (20% of jobs in London are now below living wage) combined with the increasingly precarious nature of employment, with substantial increase in zero hours, part time and short term contracting has a profound effect on the health and wellbeing of our community.
Unemployment in Tower Hamlets is 33% higher than London average, considerably higher in some groups such as BME young people and women with up to 50% unemployment.
Ensuring that everyone has a healthy standard of living
The levels of income in Tower Hamlets mean that a significant proportion of the population do not have a healthy standard of living. 20% of households on less than £15,000, and 50% on less than £30,000. Almost 50% of children in poverty
Having communities and places promote health and sustainable
There is an acute shortage of affordable housing in Tower Hamlets with 23,000 people/households on the housing waiting list
35% of households in Tower Hamlets are overcrowded (of 100,000 dwellings in Tower Hamlets, 10,000 are overcrowded by 2 bedrooms).
Tower Hamlets is the second most densely populated borough in London and has less than half the recommended amount of green space per resident
It has 42 fast food outlets per secondary school, the 2nd highest number in London
It has high levels of social isolation
30% of violent crime is domestic violence
Ensuring that ill‐health prevention has a strong and effective role in our communities
Whilst much work has been done on health prevention, for example the borough has one of the highest vaccination rates in the country
however only 10% of the population eat 5 pieces of fruit or vegetables a day and only 30% exercise to the recommended level
Child obesity levels are amongst the highest in the country, indicating that more that needs to be done

9. the effects of the determinants of health are cumulative over the life course, and interventions need to respond to this
Notes are repeated on following slide
The social determinants of health, including behaviour, are considered to be a stronger influence on health outcomes than genetics and healthcare combined.
The social determinants of health have a cumulative effect on people’s health outcomes over the life course.
The effects of the social determinants are magnified by concentration and aggregation.
The four healthy lifestyles factors (clustering effect in individuals):
Exercise, healthy eating, not smoking, moderate drinking
25% of the population do not adopt any of these and less than 10% adopt all four.
Low levels of people doing physical activity 5 times a week
Only 10% of the population eat 5 a day, with a considerable percentage reporting regularly eating almost no fruit or vegetables
Above average levels of smoking and the highest level of smoking related mortality in London
Of the 50% of the population who drink, 43% had alcohol consumption patters that were hazardous or harmful to health
For those in social housing (aggregation effect within the community)
In Bromley by Bow almost 60% of residents live in social housing, (Tower Hamlets is 40%).
Chance of being a current smoker is 1½ times higher
Chance of having a BMI of 30+ is 1.4 times higher
Chance of being physically active 3 times a week is 20% lower
Chance of drinking 2+ units a day is 40% higher

10. 70% of our community are amongst the 20% most deprived in England
20% of households in Tower Hamlets living on less than £15,000, and 50% on less than £30,000, almost 50% of children in poverty, 70% of the borough’s residents located in the most disadvantaged quintile.
That gives one an idea of the health impact across the population of the social determinants of health in our community. That impact is demonstrated by an 10 year life expectancy difference and a 17 year disability-free life expectancy difference in Tower Hamlets between the most and least deprived men in our community.
Effectively 70% of Tower Hamlets residents are in the quintile that is at risk of developing Long Term Conditions from their 50s onwards, compared to those at the opposite end who develop them around 65 years old. That implies a huge reduction in quality of life, and a huge cost to the health service. More than half the inequality of life expectancy is due to the different rates of smoking between social economic groups.
The impact has huge implications, not least for our health services that are ever more stretched by the increasing level of demand. Whilst some of that increase in demand is the result of increases in longevity, much of it is the result of the effects social inequality and health inequalities, for example the growing levels of obesity and depression.
The effect of the accumulation of health issues in early adulthood is that BbBC GPs report they see people in their 40s who present health conditions one would expect to see in their 60s.

11. Behaviour: the 4 healthy lifestyle factors in Tower Hamlets
Clustering within individuals, aggregation within communities
For those living in social housing
In Tower Hamlets 40% of residents live in social housing, in Bromley by Bow, almost 60%.
Chance of being a current
smoker is 1½ times higher
Chance of having a BMI of
30+ is 1.4 times higher
Chance of being physically
active 3 times a week is
20% lower
Chance of drinking 2+ units
a day is 40% higher
Healthy
eating
10% of adults eat
5 portions of vegetables and fruit a day
Exercise
30% of adults exercise 5 times a week
Smoking
27% of adults smoke, higher than the London average
Alcohol
50% of adults drink alcohol, 43% of them excessively
THESE are the same notes as previous slide
The social determinants of health, including behaviour, are considered to be a stronger influence on health outcomes than genetics and healthcare combined.
The social determinants of health have a cumulative effect on people’s health outcomes over the life course.
The effects of the social determinants are magnified by concentration and aggregation.
The four healthy lifestyles factors (clustering effect in individuals):
Exercise, healthy eating, not smoking, moderate drinking
25% of the population do not adopt any of these and less than 10% adopt all four.
Low levels of people doing physical activity 5 times a week
Only 10% of the population eat 5 a day, with a considerable percentage reporting regularly eating almost no fruit or vegetables
Above average levels of smoking and the highest level of smoking related mortality in London
Of the 50% of the population who drink, 43% had alcohol consumption patterns that were hazardous or harmful to health
For those in social housing (aggregation effect within the community)
In Bromley by Bow almost 60% of residents live in social housing, (Tower Hamlets is 40%).
Chance of being a current smoker is 1½ times higher
Chance of having a BMI of 30+ is 1.4 times higher
Chance of being physically active 3 times a week is 20% lower
Chance of drinking 2+ units a day is 40% higher

12. The effects of the social determinants of health…..on health
Map shows high risk of diabetes,
15-17% (darker shaded areas)
2nd highest rates of premature death in the UK from circulatory disease, cancer and respiratory disease (conditions which constitute 75% of all premature deaths)
10% of adults diagnosed with depression (4th highest in London), 7th highest level of mental health hospital admissions in London
13% of children in reception year are obese (6th highest UK), 25% of year olds are obese (9th highest UK)
1 year survival rate for cancer amongst the lowest 10% in the UK
Notes on the effect that deprivation and the social determinants has in terms of prevalence of disease, some headlines:
Higher than average low weight babies and higher than average baby deaths under one year old (7 deaths per 1,000 live births in Tower Hamlets, compared to 4.1 per 1,000 in Newham and Hackney)
Below average child development at 5 years old
High rates of tooth decay in children
High rates of obesity (malnutrition?) in children: 13% of children in reception year are obese (6th highest in UK), 25% of year olds are obese (9th highest in UK)
Significant, over-representation of long term conditions, including; diabetes, cardio vascular conditions, respiratory conditions, asthma and late presentations of cancer
2nd highest rates of premature death in the UK from circulatory disease, cancer and respiratory disease (these conditions typically constitute 75% of all premature deaths)
Higher than average levels of diabetes affecting 6% of the adult population and up to 10% of the Bangladeshi population. In 2010 there were 12,000 people known to have diabetes, a further 2,000 undiagnosed and the total is set to increase by a further 25% to 17,000 by 2020.
10% of adults with diagnosed depression, 7th highest level of mental health hospital admissions in London
1 year survival rate for cancer amongst the lowest 10% in the UK
High rates of consultation, prescribing and admission including the highest secondary care admission rate for circulatory conditions in London

13. where have we landed?
Note the effect of deprivation on consultation rates at General Practice
From 0 – 30 years consultation rates are broadly the same across the five socio-economic quintiles
From 30 onwards the diverge with those in the lowest socio-economic quintile attending general practice most frequently and those in the highest socio-economic quintile least frequently. The divergence is greatest between where the rates of consultation are double between the lowest and the highest socio-economic quintiles. From 75 years onwards the rates begin to converge again with those in the second most deprived beginning to be the ones with the highest consultation rates.

14. Socio-economic status is a major determinant of life expectancy and disability-free life expectancy
20% of households in Tower Hamlets living on less than £15,000, and 50% on less than £30,000, almost 50% of children in poverty, 70% of the borough’s residents located in the most disadvantaged quintile.
That gives one an idea of the health impact across the population of the social determinants of health in our community. That impact is demonstrated by an 10 year life expectancy difference and a 17 year disability-free life expectancy difference in Tower Hamlets between the most and least deprived men in our community.
Effectively 70% of Tower Hamlets residents are in the quintile that is at risk of developing Long Term Conditions from their 50s onwards, compared to those at the opposite end who develop them around 65 years old. That implies a huge reduction in quality of life, and a huge cost to the health service. More than half the inequality of life expectancy is due to the different rates of smoking between social economic groups.
The impact has huge implications, not least for our health services that are ever more stretched by the increasing level of demand. Whilst some of that increase in demand is the result of increases in longevity, much of it is the result of the effects social inequality and health inequalities, for example the growing levels of obesity and depression.
The effect of the accumulation of health issues in early adulthood is that BbBC GPs report they see people in their 40s who present health conditions one would expect to see in their 60s.
70% of the Tower Hamlets population are located in the most deprived quintile of this diagram

15. Welcome to the Bromley by Bow Centre

16. so what’s at the Centre?
Bromley by Bow Centre independent charity c£4m turnover, c150 staff, operating on 23 sites around 2,000 clients per week learning centre – daycare centre – social welfare provider creative arts centre - integrated health programmes – employment programmes – debt advice Plus ‘Beyond Business’ - incubated 57 social businesses in 10 years, 42 still trading. Turnover in excess of £4 million and created over 320 jobs
GP Partnership – Primary Care 4 sites with 37,000 patients and turnover c£6m – including a 7 day per week 8am – 8pm Walk-in Centre. 110 staff.
Plus Bow Childcare and Poplar Harca and FoodCycle and Bromley by Bow Church on site

18. Connection Zone
A warm welcome with engagement staff, tea and coffee. A place to meet, make friends and build social networks. Group activities, internet café with digital inclusion support, homework club, informal learning and family learning. Time Banking, Community Grants for small projects.
Social Care and arts space
Social care, inclusive arts space and programmes, including for elders and carers. Artists’ studios.
Café
Provides training and volunteering opportunities
Church / Nursery
Childcare provision, community celebration space
Welfare, Debt, Legal Advice, Financial Capability
Social welfare and legal advice on benefits, housing, debt. Money management and fuel poverty programmes. Promotion of Credit Union.
Vocational Learning
A range of learning options for young people and adults, including traineeships and apprenticeships
Social Enterprise
Supports establishment of new social enterprises, creates service provision and employment.
Employment Service
Careers advice. Extensive employer relationships, work experience placements, and support in applying for jobs.
Bromley by Bow Centre as a campus – re-creating community – integrated services and why this is so important to the Health Service
The role and importance of design in creating spaces that are empowering and support integrated services (integration, not colocation)
Shared and devolved leadership
Why this model is so effective in deprived communities and so important for the health service
The social determinants of health are precisely that, they are social. They need addressing through social programmes, however Primary Care is in an unparalleled position to work in an integrated manner with agencies that address the social determinants of health
The role primary care and volume of consultations of in deprived communities, we can see this two ways, as a level of un-meetable, and sometimes inappropriate demand, or as an unrivalled opportunity with levels of contact and potential engagement that cannot be found anywhere else in our communities
The synergies are that precisely that those who most frequently attend Primary Care are those with the lowest social determinants of health and who would most benefit from access to other services
Core elements and integrated services
Community Centre and space – green space, café, connection zone
Services that improve the social determinants of health, e.g. healthy lifestyles, welfare advice, skills, employability, social enterprises etc
Specifically – Health and Social Care e.g. support with long term conditions, mental health, social care etc
Primary Care
How these work together, including Social Prescribing
Integrated services
Social Prescribing
Initial mention of working with wider partnerships
Growing spaces
Social and therapeutic horticulture, food growing
Health Centre
General Practice, Community Health Services
Social Prescribing
Supports access to all Centre services
Health and social care
Healthy lifestyles promotion, weight management, mental health projects, social care brokerage, carers support, disability sports.
Social Prescribing
Receives referrals and supports those referred
Children’s Centre activities Activities for parents and children
Park and playground
Managed by the Centre. Recreational space, children’s playground, sporting events, summer fairs

19. elders’ programme

20. Referral Referral Referral
Integrated service model
and social prescribing
Service provider networks
Housing providers
Down to Earth
Service Providers
Partnerships, networks and policy
Home Store
Public
Services
Digital Inclusion
Literacy numeracy
Credit Union
English courses
Family Learning
Ministries
Services to improve the social determinants of health
Expert Patients & Self Care
Corporate
Partners
Traineeships
Health Trainers
Activity groups
Carers support
Weight Management
Commission -ers
Apprentice-ships
Time Bank
Employers
Social Care
General Practice
Health and Wellbeing Boards
Mental Health Projects
Social Welfare Advice
Youth Training
Services that directly support health and social care, often Public Health Programmes
Social Enterprises
Care brokerage
Social Enterprise incubation
Legal Advice
Local Authorities
Inclusive Sport
Food Bank
Domiciliary Care
THESE are the same notes as previous slide
Bromley by Bow Centre services across Tower Hamlets and East London
We currently provide services in over 25 venues across Tower Hamlets and the Olympic Growth boroughs
Our social prescribing programme works with 6 Health Centres with a combined patient list of 35,000, with up to 100 referrals a month
Our health and wellbeing programmes see over 3,000 people a year, with a substantial focus on those with Long Term Conditions.
Our services integrate with those of a wide range of partners and stakeholders, including:
housing providers,
children's centres,
primary schools,
credit union, etc
Services to improve socio-economic determinants in our community
Good quality parenting programmes and the home to school transition
High quality early education
High quality educational and skills development provision, including adult learning services
Building children and young people's resilience in school
Reducing the number of young people not in employment, education or training (NEET)
Having control over one’s life
Secure employment with a fair wage
Being in a workplace that supports health and wellbeing
Having income that is sufficient for healthy living
Living in a physical environment that supports health (housing, public space etc)
Fuel poverty and cold home-related health problems
Improving access to green spaces
Having social and community support networks
Programmes to promote behavioural risk factors for health
Access to high quality health and social care services throughout life
Youth Employment
Financial Capability
Social Prescribing
Regeneration
agencies
Referral Referral Referral
Energy Advice
Schools
Resident
groups
Primary care and community health services
Employment
Children’s Centres
Faith organisations
Safer Neighbour- hood Team

21. Social determinants of health also act through
the doctor-patient relationship
Doctor: ‘Listen……’
‘your patient…..’
Empathy, attention, time, responsibility, ownership
Patient: ‘telling…..’
Education, communication, advocacy, confidence
“Listen to your patient, he is telling you the diagnosis”
The relevance and importance of this model in the current context
The challenge facing the health services are considerable. Rising demand and health costs come from a number of quarters, including:
increased longevity
better, but more expensive treatments
the growing burden of ill health, driven by our lifestyles, patterned by deprivation and other social and economic influences, leading to significant health inequalities, particularly in relation to Long Term Conditions. LTCs account for 75% of the health spend. Those at the lowest end of the determinants scale develop LTCs 20 years earlier than those at the highest end. Reducing health inequalities would improve people’s quality of life and dramatically reduce health care expenditure. E.g. The 3 million diagnosed with diabetes already cost £10million a year to treat (almost 10% of the NHS budget) and with 2/3 of adults obese or overweight, there are a further 7 million at risk of developing the disease.
The opportunity for a fresh approach to health and wellbeing , we need to re- orientate our health service to developing healthy communities
Health and Wellbeing Boards, Public Health, CCGs, - the opportunity to tackle the fragmentation of the past
Also the opportunity to work with the community and partners to develop a community based approach to improving health behaviours and the other social determinants of health.
Socially determined health inequalities, by their nature, require action on the social inequalities, not health.
The resources and levers to improve the social determinants of health lie, to a considerable extent, outside the health system
However the health service can play a critical role in encouraging and facilitating access to such support
Turning problems into opportunities. The volume of contact that primary care has gives an unequalled opportunity for engagement, particularly as frequency of attendance will be in proportion to social disadvantage, giving most contact with those we most need in order to support them to improve the social determinants of health
Social Prescribing within the health sector
About primary prevention, e.g. working with all patients, and also those patients identified as having a higher risk of developing a condition, e.g. ‘pre diabetic patients’
About primary secondary prevention, e.g. working with patients who have a diagnosed condition, supporting healthy lifestyles and condition specific self care
About improving the social determinants of health
The power of bringing out three elements together
Primary Care
Public Health
Programmes that support the social determinants
And wider partnerships, with housing, children’s centres and others. Building a shared understanding of the social determinants of health, is a way in to considering ‘holistic approaches’ to working with, and supporting, people, across a wide range of fields, not just health. Essentially sharing and reinforcing each other’s agendas This involves cultural change across a wide range of sectors e.g. housing providers, children’s centres, schools etc
The importance of our empowering model
Working with local communities
Innovating
Leadership culture

22. timebank coffee afternoons

23. planet asthma

25. arts and health programme

26. be focused our mission is to enable people to be well and live life to the full in a vibrant community

27. Dan Hopewell
Director of Knowledge and Innovation - Bromley by Bow Centre
Website
@bromley_by_bow