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
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
Commissioning
NHS England: Delivering equalities and
health inequalities in a new
commissioning landscape.
Where are we and what do we
know?
Update on Midlands and East
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
on Midlands and East
•Update
specialised
services.
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
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
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.
What is Known
Focusing on Premature Mortality &
Health Life Expectancy
2
Average Life Expectancies
• England (ONS, 2008-10)
• Men
• Women
78.6 years
82.6 years
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
Local Authority
Cambridgeshire
Derbyshire
Leicestershire
Lincolnshire
Northamptonshire
Nottinghamshire
Staffordshire
Worcestershire
Birmingham
Coventry
Dudley
Sandwell
Solihull
Walsall
Wolverhampton
Derby UA
Leicester UA
Rutland UA
Nottingham UA
Herefordshire, County of UA
Telford and Wrekin UA
Shropshire UA
Stoke-on-Trent UA
Male inequality in life
expectancy (years)
7.2
7.7
6.2
7.3
9.4
9.0
8.0
7.8
10.8
11.7
9.9
9.6
10.8
10.8
9.7
12.6
9.4
5.7
10.0
Female inequality in life
expectancy (years)
5.3
5.6
5.7
4.9
5.8
7.6
6.2
5.4
5.9
7.9
5.7
6.4
10.3
6.9
5.8
8.9
5.0
7.3
9.1
4.8
7.0
6.7
8.2
4.1
2.8
4.3
4.7
Healthy Life Expectancy
Authority
HLE Inequality Men HLE Inequality Women
Derby UA
16.6
13.9
Leicester UA
11.1
9.7
Rutland UA
1.8
1.3
13.3
11.1
Herefordshire, County of UA
6.1
5.0
Telford and Wrekin UA
9.9
7.9
Shropshire UA
4.6
3.7
11.9
9.2
Nottingham UA
Stoke-on-Trent UA
Marmot – Life Expectancy and Healthy LE
Basis of Health Inequalities
• Gender and deprivation
• Educational attainment
• Status
• Occupation
Basis
• Think through interactions - between / previous
• Disabilities
• Age
• Sexual orientation
• Ethnicity
• Religion
• “Inclusion” groups
• Trans people
What Can We Do?
3
Across Diseases – by Occupational Group
Rate per 1,000 reporting long-standing condition by socio-economic group of household
Source: General Household Survey (2006)
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
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.
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.
Equality & Health Inequalities Strategic
Priorities and Deliverables
• NHS England as system leader • Resource allocation supports
and supports the NHS EDC
duties on inequalities
• Supports NHS organisations to • Incentives and prioritise
improve equality performance
improvements in primary care
& meet the public sector
towards communities &
Equality Duty
groups who experience
inequalities in healthcare &
• Robust data available to
outcomes
measure equality and health
inequalities, determine
• Embed equality and tackling
priorities and drive
health inequalities in CCG
improvement
assurance regime
• Create an NHS workforce &
•
leadership that is reflective of •
communities we serve and free
from discrimination
Remove derogations
Support reduction of mental
illness inequalities through
Parity of Esteem Programme.
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
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
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
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
The 1st 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.
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
Reducing health inequalities
Inclusion Health - Improving care
pathways for homeless people: what is
working well!
London Pathways – case study
Stan Burridge – Service user
Lead
The NHS belongs to the people……
that includes homeless people
We need integrated commissioning leading to
integrated provision for homeless services
Barriers to GPs registering homeless patients
must be removed
General Practice–must improve access for homeless patients
Or new primary care services should be commissioned
There are great examples of care provided outside
general practice–they should be replicated across the country
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
Select the people who care for homeless people for their
values then support them and help them develop skills
throughout their career.
Discussion
•Any Questions
Contact
• Ranjit Senghera
• Senior Manager: Equalities & Health Inequalities,
• National Lead on Inclusion Health
• NHS England
• Ranjit.senghera@nhs.net