1. Reducing Health Inequalities, Inclusion & Promoting Human Rights Focus: National Inclusion Health Programme Ranjit Senghera Senior Manager Equalities and Health Inequalities; Regional Link Midlands and East & National Lead for Inclusion Health. NHS England

2. What I aim to cover? Part 1 - NHS England – The commissioning landscape What do we know: Promoting Equalities & Tackling Health Inequalities: Marmot Review & Social determinants of health Equalities & health inequalities approaches Strategic priorities and deliverables Part 2 - Inclusion health programme Background & context – key facts & figures Homeless hospital discharge Fund and updates Case Studies – Pathways London & primary care models Part 3 - Questions to NHS Employers Equality & Diversity strategic partners

3. Update on Midlands and East Commissioning NHS England: Delivering equalities and health inequalities in a new commissioning landscape. Where are we and what do we know?

4. The role of NHS England Patient-focused, clinically-led organisation that has the culture, style and leadership to truly improve outcomes for patients To allocate resources to clinical commissioning groups (CCGs) CCGs to commission providers To support CCGs to commission services on behalf of their patients (according to evidence-based quality standards) To have direct responsibility for commissioning services: primary care; & public health military and prison health services; high secure psychiatric services; and specialised services. Update on Midlands and East

5. Aims of NHS England Improved health outcomes as defined by the NHS Outcomes Framework People’s rights under the NHS Constitution are met NHS bodies operate within resource limits These will enable: patients and the public to have more choice and control over their care and services; clinicians to have greater freedom to innovate to shape services around the needs and choices of patients; and the promotion of equality and the reduction of inequality in access to healthcare. Update on Midlands and East

6. Health Inequalities Health Inequalities have been defined as: “Differences in health status or in the distribution of health determinants between different population groups” Addressing Health inequalities forms a key part of NHS England’s vision and values and are in line with those of the NHS Constitution. Addressing Health inequalities is also crucial to tackling the key challenges across the domains, including preventing premature mortality, improving recovery from illness and enhancing quality of life for people with long-term conditions. We should work to ensure that NHS services are resourced, planned and commissioned, based on robust evidence, to address both barriers to healthcare and health inequalities. 6

7. Legal Duties – First Ever Health and Social care Act 2012 NHS England 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. NHS England, 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. Monitor can set licence conditions and may appoint a special administrator. The Act also contains duties around health inequalities on, variously, SofS, NHS England and CCGs concerning planning, reporting and assessment.

8. What is Known Focusing on Premature Mortality & Health Life Expectancy 2

9. Average Life Expectancies England (ONS, 2008-10) Men78.6 years Women82.6 years

10. Life expectancy Life expectancy from birth: For men in the 10% most deprived areas of Coventry For women living in the most affluent areas of Rutland Rough sleepers experience stark health inequalities – rough sleepers life expectancy is 30 years shorter than average population; at 47 for men and 43 for women (Crisis, 2012) In 2004 life expectancy was estimated 12 year less for gypsy traveller women and 10 years less for men than in other populations

11. Local Authority Male inequality in life expectancy (years) Female inequality in life expectancy (years) Cambridgeshire7.25.3 Derbyshire7.75.6 Leicestershire6.25.7 Lincolnshire7.34.9 Northamptonshire9.45.8 Nottinghamshire9.07.6 Staffordshire8.06.2 Worcestershire7.85.4 Birmingham10.85.9 Coventry11.77.9 Dudley9.95.7 Sandwell9.66.4 Solihull10.810.3 Walsall10.86.9 Wolverhampton9.75.8 Derby UA12.68.9 Leicester UA9.45.0 Rutland UA5.77.3 Nottingham UA10.09.1 Herefordshire, County of UA4.84.1 Telford and Wrekin UA7.02.8 Shropshire UA6.74.3 Stoke-on-Trent UA8.24.7

12. Healthy Life Expectancy Authority HLE Inequality MenHLE Inequality Women Derby UA16.613.9 Leicester UA11.19.7 Rutland UA1.81.3 Nottingham UA13.311.1 Herefordshire, County of UA6.15.0 Telford and Wrekin UA9.97.9 Shropshire UA4.63.7 Stoke-on-Trent UA11.99.2

13. Marmot – Life Expectancy and Healthy LE

14. Basis of Health Inequalities Gender and deprivation Educational attainment Status Occupation

15. Basis Think through interactions - between / previous Disabilities Age Sexual orientation Ethnicity Religion “Inclusion” groups Trans people

16. What Can We Do? 3

17. Across Diseases – by Occupational Group Source: General Household Survey (2006) Rate per 1,000 reporting long-standing condition by socio-economic group of household

18. What Can We Do? 15-20% Know them Wider social determinants - HWBB Primary and secondary prevention – 15-20% clinical and quality of care; Health behaviours account for 30% of influences (public health messages/screening) Commission – across population and knowing physical environment (10%) Socio-economic factors account for 30% of all influences – where you live, employment. Plan according to need – proportionate universalism (shifting the mean) Services that match need Community engagement & Co-production

19. Current Priorities for the National Equalities & Health Inequalities Team Assurance within NHS England - governance, active awareness and application within decision making, capability of staff including a positive awareness of legal duties, reporting mechanisms, Equality & Diversity Council (EDC); 9 Strategic priorities and Deliverables (NHS England Board Paper – Annex B); CCG development and assessment process including annual assessment against these duties Working with national commissioners (specialised and primary care) to promote equalities & reduce health inequalities Embedding in business of NHS England including Resource Allocation, Incentive Reviews, Quality Accounts etc.

20. Delivery mechanisms & Tools include: The Equality and Diversity Council provides visual leadership on equality and health inequality across the NHS. The Equality Delivery System (EDS 2) is a facilitative tool that helps NHS organisations to promote equality and reduce health inequalities. Health inequalities subgroup of the commissioning assembly will work with CCGs on health inequalities and NHS England commissioners and will have a wide-ranging in its role as an ‘expert reference group’. The NHS England Equality and Diversity Strategy Group design, implement and evaluate effectiveness of NHS England’s internal strategy for equality, diversity in the workplace. NHS Values Summits bring together diverse range of people and perspectives to understand how people’s differences can affect experiences of health and care.

21. Equality & Health Inequalities Strategic Priorities and Deliverables NHS England as system leader and supports the NHS EDC Supports NHS organisations to improve equality performance & meet the public sector Equality Duty Robust data available to measure equality and health inequalities, determine priorities and drive improvement Create an NHS workforce & leadership that is reflective of communities we serve and free from discrimination Resource allocation supports duties on inequalities Incentives and prioritise improvements in primary care towards communities & groups who experience inequalities in healthcare & outcomes Embed equality and tackling health inequalities in CCG assurance regime Remove derogations Support reduction of mental illness inequalities through Parity of Esteem Programme.

22. Reducing Health Inequalities, Inclusion & Promoting Human Rights National Inclusion Health Programme & Board 4 Working groups: Workforce & Leadership; Data & Research; Provn, Prevention & promotion & Assurance & Accountability Inclusion Health Board & Working Groups Key facts and concerns Key issues What works well? Case studies

23. Marmot – Fairer society – how ? Marmot review highlighted, “reduce the steepness of the social gradient in health, [with] action [that is] universal, but with a scale and intensity that is proportionate to the level of disadvantage”. This is called “proportionate universalism”, which means that closing the gap in health inequalities requires outcomes for the most disadvantaged to improve faster than the most advantaged

24. The living reality of ‘Tri-morbidity’ Long term homelessness is characterised by ‘tri-morbidity’ (combination of mental ill-health, physical ill-health and drugs and alcohol misuse) complex health needs and premature death Rough sleepers experience stark health inequalities – rough sleepers life expectancy is 30 years shorter than average population; at 47 for men and 43 for women (Crisis, 2012) Costs to the NHS – Homeless people attended A&E 5 times as often as house population, are admitted 3.2 times as often and stay 3 times as long because they are 3 times as sick. Resulting in secondary care costs 8 times higher than average; costing estimated £330 million a year Source: McCormick, B, 2010

25. Theme of the day – human rights based approaches ‘ tackling health inequalities through connecting communities, inclusion, participation and common purpose – & co-production & co-design.. Five key reasons for putting human rights at the heart of healthcare Better services and outcomes – help drive quality and improve outcomes Helping oil the wheel, not reinventing it – providing coherent and practical framework Familiar shared values – FREDA – Fairness, respect, Equality, dignity and autonomy/choice Power not pity –use a powerful language Its about day to day practice (not theory) – Human rights as a practical tool

26. The 1 st Principle of the Constitution The NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status. The service is designed to diagnose, treat and improve both physical and mental health. It has a duty to each and every individual that it serves and must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population.

27. Inclusion Health Groups Life expectancy is lower than national average Healthy life expectancy is poorer than national average, with poorer outcomes, that are within the gift of the NHS. Data on inclusion health groups is poor Very little evidence on cost benefit of current models, place care services and providers at risk’ Need better integrated and co-ordinated services for inclusion health groups Barriers to access GP services for all inclusion health groups Inappropriate discharges pathways and outcomes for inclusion health groups

28. Reducing health inequalities Inclusion Health - Improving care pathways for homeless people: what is working well! London Pathways – case study Stan Burridge – Service user Lead

29. The NHS belongs to the people…… that includes homeless people

30. We need integrated commissioning leading to integrated provision for homeless services

31. Barriers to GPs registering homeless patients must be remove d

32. General Practice–must improve access for homeless patients Or new primary care services should be commissioned

33. There are great examples of care provided outside general practice–they should be replicated across the country

34. Where it works - London Pathway  Holistic approach  Lead GP in hospital  Specialist homeless nurse specialist  Ex-homeless care navigators  Cost – effective  Ave length of stay reduced by 3.2 days (12.7 – 9.5)  Reduction of 800 bed days (average 250 admissions per year)  Cost savings per stay (£500 / day = £4,750 / stay)  Annual savings £100,000 after costs of service

35. Select the people who care for homeless people for their values then support them and help them develop skills throughout their career.

37. Discussion Any Questions

38. Contact Ranjit Senghera Senior Manager: Equalities & Health Inequalities, National Lead on Inclusion Health NHS England Ranjit.senghera@nhs.net