Addressing Health Inequalities
– From Mystery and Imagination
to Practical Action
Professor Chris Bentley
Health Inequalities National Support Team
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
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, Stokeon-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
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
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
Risk conditions – e.g.:
Poverty
Low social status
Dangerous environments
Discrimination
Steep power heirarchy
Gaps/weaknesses in
services and support
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
Gestation from Input to Outcome
A
B
C
2005
2010
2015
2020
CVD
Seasonal
excess
deaths
Diabetes
Cancer
COPD
Infant
Mortality
Alcohol
Income and
Debt
Tobacco
Employment
Obesity
Housing
Community
Safety
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
Population Health
Personal Health
Community Health
Producing Percentage Change at Population Level
C. Bentley
2007
Population Health
Partnership,
Vision and Strategy,
Leadership and
Engagement
Personal Health
Community Health
Producing Percentage Change at Population Level
C. Bentley
2007
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?
Population Health
Systematic and scaled
interventions through
services
Personal Health
Community Health
Producing Percentage Change at Population Level
C. Bentley
2007
Commissioning Services to Achieve Best Population Outcomes
Population Focus
10. Supported selfmanagement
9. Responsive Services
Optimal
Population
Outcome
Challenge to Providers
13.Networks,leadership
and coordination
12. Balanced Service Portfolio
8. Equitable Resourcing
C Bentley
2007
4. Accessibility
2. Local Service
Effectiveness
7. Expressed Demand
6.Known
Population Needs
5. Engaging the public
11.Adequate Service Volumes
1.Known
Intervention
Efficacy
3.Cost Effectiveness
Commissioning Services to Achieve Best Population Outcomes
Optimal
Population
Outcome
Challenge to Providers
5. Engaging the public
4. Accessibility
2. Local Service
Effectiveness
1.Known
Intervention
Efficacy
3.Cost Effectiveness
C Bentley
2007
Commissioning Services to Achieve Best Population Outcomes
Population Focus
10. Supported selfmanagement
9. Responsive Services
7. Expressed Demand
6.Known
Population Needs
8. Equitable Resourcing
C Bentley
2007
Optimal
Population
Outcome
Commissioning Services to Achieve Best Population Outcomes
Population Focus
10. Supported selfmanagement
Optimal
Population
Outcome
Challenge to Providers
9. Responsive Services
4. Accessibility
2. Local Service
Effectiveness
7. Expressed Demand
6.Known
Population Needs
12. Balanced Service Portfolio
8. Equitable Resourcing
C Bentley
2007
5. Engaging the public
11.Adequate Service Volumes
1.Known
Intervention
Efficacy
3.Cost Effectiveness
Commissioning Services to Achieve Best Population Outcomes
Population Focus
Optimal
Population
Outcome
13.Networks,leadership
and coordination
C Bentley
2007
Challenge to Providers
Commissioning Services to Achieve Best Population Outcomes
Population Focus
10. Supported selfmanagement
9. Responsive Services
Optimal
Population
Outcome
Challenge to Providers
13.Networks,leadership
and coordination
12. Balanced Service Portfolio
8. Equitable Resourcing
C Bentley
2007
4. Accessibility
2. Local Service
Effectiveness
7. Expressed Demand
6.Known
Population Needs
5. Engaging the public
11.Adequate Service Volumes
1.Known
Intervention
Efficacy
3.Cost Effectiveness
F820
01
F820
03
F820
04
F820
05
F820
12
F820
15
F820
17
F820
18
F820
23
F820
25
F820
27
F820
34
F820
35
F820
36
F820
38
F820
40
F820
42
F820
51
F820
54
F826
04
F826
12
F826
21
F826
25
F826
29
F826
34
F826
42
F826
45
F826
47
F826
50
F826
60
F826
61
F826
65
F826
67
F826
68
F826
76
F826
77
F826
78
F826
79
F826
80
F826
87
F860
40
F866
60
Y01 2
80
Y01 7
19
Y01 7
95
Number of GPs
National Support Teams
B87 0
01
B87 0
02
B87 0
03
B87 0
04
B87 0
05
B87 0
06
B87 0
07
B87 0
08
B87 0
09
B87 0
11
B87 0
12
B87 0
13
B87 0
15
B87 0
16
B87 0
17
B87 0
18
B87 0
19
B87 0
20
B87 0
21
B87 0
22
B87 0
23
B87 0
24
B87 0
25
B87 0
26
B87 0
27
B87 0
28
B87 0
29
B87 0
30
B87 0
31
B87 0
32
B87 0
33
B87 0
36
B87 0
39
B87 0
40
B87 0
41
B87 0
42
B87 0
44
B87 6
00
B87 6
02
B87 6
04
Number of GPs
Number of GPs per Practice
Number of GPs by Practice
14
12
10
Wakefield PCT
8
6
4
2
0
Number of GPs by Practice
12
Practice Code
10
8
6
Barking and
Dagenham PCT
4
2
0
Practice Code
NHS Bolton 2006/07
Expected v Registered Prevalence of major QOF conditions
25%
22.9%
20%
15%
PCT Registered
PCT Expected
10%
5.2%
4.5%
11.9%
5%
4.2%
3.7%
0%
Coronary Heart
Disease
Hypertension
Diabetes
NHS Bolton
Dr.S.Liversedge
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
>40
14
79.4
30-39
18
73.7
20-29
12
75.2
<20
11
74.3
It
NHS Bolton 2008/09
Expected v Registered Prevalence of major QOF conditions
35%
PCT Registered 16+
31.0%
PCT Expected
30%
25%
20%
16.4%
15%
10%
5%
4.6%
6.1%
4.8% 4.7%
4.8%
2.5%
0%
Coronary Heart
Disease
Hypertension
Diabetes*
COPD
N820
N82001
N82002
N82003
N82004
N82009
N82011
N82014
N82018
N82019
N82021
N82022
N82024
N82026
N82033
N82034
N82035
N82036
N82037
N82039
N82041
N82046
N82048
N82049
N82050
N82051
N82052
N82053
N82054
N82058
N82059
N82060
N82062
N82065
N82066
N82067
N82070
N82073
N82074
N82076
N82077
N82078
N82079
N82081
N82082
N82083
N82084
N82086
N82087
N82089
N82090
N82091
N82092
N82093
N82094
N82095
N82097
N82199
N82100
N82101
N82103
N82104
N82105
N82106
N82107
N82108
N82109
N82110
N82113
N82115
N82116
N82617
N82617
N82619
N82621
N82623
N82633
N82641
N82642
N82645
N82646
N82647
N82648
N82649
N82650
N82651
N82655
N82657
N82659
N82662
N82663
N82664
N82665
N82668
N82669
N82670
N82671
N82676
78
N
Y08021679
10
National Support Teams
Another Spearhead PCT - QOF Scores by Practice
Analysis of QOF Non-Clinical Points earned by GP Practice
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Practice Code
Points Earned
Points Missed
Bradford
Analysis of QOF Non-Clinical Points earned by GP Practice
100%
90%
80%
70%
National Support Teams
60%
50%
40%
30%
20%
10%
0%
Airedale
Bradford
City
North
Bradford
PCT Area
Points Earned
Points missed
South &
West
Liverpool
QOF % non-clinical points
achieved
National Support Teams
QOF non-clinical score by GP practice and deprivation
100.0
95.0
90.0
85.0
80.0
75.0
70.0
65.0
60.0
55.0
50.0
0.0
20.0
40.0
60.0
Ward deprivation score (2004)
80.0
F840
F84004
0
F840 6
0
F840 9
F84010
1
F840 4
F84017
2
F840 2
F84032
4
F840 7
5
F840 0
F84052
5
F840 3
F84070
7
F840 4
7
F840 7
F84086
8
F840 8
F84089
9
F840 0
F84091
9
F840 2
9
F840 3
F84197
2
F841 1
F84624
3
F846 1
4
F846 1
F84642
5
F846 4
F84657
5
F846 8
6
F846 0
F84661
6
F846 2
F84666
6
F846 9
F84670
7
F846 1
7
F846 2
F84673
7
F846 7
F84679
8
F846 1
9
F847 9
F84700
0
F847 6
F84707
0
F847 8
F84713
1
F847 7
2
F847 2
F84724
2
F847 7
F84728
2
F847 9
3
F847 0
F84734
3
F847 5
F84736
3
F847 9
F84740
4
F847 1
4
F847 2
Y00 2 49
25
Quality of delivery
CHD 6 - % patients whose last BP reading <= 150/90 (measured in last 15 months)
100%
80%
60%
40%
20%
0%
Practice code
Target Met
Target Missed
Exception Coded
C860
01
C860
02
C860
03
C860
05
C860
06
C860
07
C860
09
C860
11
C860
12
C860
13
C860
14
C860
15
C860
16
C860
17
C860
18
C860
19
C860
20
C860
21
C860
22
C860
23
C860
24
C860
25
C860
26
C860
29
C860
30
C860
32
C860
33
C860
34
C860
37
C860
38
C860
39
C866
03
C866
04
C866
05
C866
06
C866
09
C866
11
C866
12
C866
13
C866
14
C866
16
C866
21
C866
23
C866
25
C866
26
C866
29
Wakefield
CHD 6 - % patients whose last BP reading <= 150/90 (measured in last 15 months)
100%
80%
60%
40%
20%
0%
Practice code
Target Met
Target Missed
Exception Coded
F840
F84004
F84006
F84009
F84010
F84014
F84017
F84022
F84032
F84047
F84050
F84052
F84053
F84070
F84074
F84077
F84086
F84088
F84089
F84090
F84091
F84092
F84093
F84197
F84121
F84624
F84631
F84641
F84642
F84654
F84657
F84658
F84660
F84661
F84662
F84666
F84669
F84670
F84671
F84672
F84673
F84677
F84679
F84681
F84799
F84700
F84706
F84707
F84708
F84713
F84717
F84722
F84724
F84727
F84728
F84729
F84730
F84734
F84735
F84736
F84739
F84740
F84741
F84742
Y00 2 49
25
National Support Teams
A PCT with problems
DM 6 - % patients whose HbA1C <= 7.4 (measured in last 15 months)
100%
80%
60%
40%
20%
0%
Practice code
Target Met
Target Missed
Exception coded
Target Met
Target Missed
Practice code
Exception coded
A88 0
18
A88 6
15
A88 6
14
A88 6
13
A88 6
11
A88 6
08
A88 6
03
A88 6
01
A88 0
25
A88 0
24
A88 0
23
A88 0
22
A88 0
20
A88 0
16
A88 0
15
A88 0
14
A88 0
13
A88 0
12
A88 0
11
A88 0
10
A88 0
09
A88 0
08
A88 0
07
A88 0
06
A88 0
05
A88 0
04
A88 0
03
A88 0
02
A88 0
01
National Support Teams
South
Tyneside
DM 20 - % patients whose HbA1C <= 7.4 (measured in last 15 months)
100%
80%
60%
40%
20%
0%
Fig 7a - Prescribing Costs per Diabetic Pt (Apr 06-Mar 07) v Percentage of diabetic patients whose HbA1C
has been 7.4 or less in the last 15 months (Apr 06-Mar 07)
80
75
Higher % pts at target - Low prescribing
25
Higher % pts at target - High prescribing
70
% target met
21
17
65
13
1
14306
60
28
5
26
22
55
32
33
50
4
20
15 8
45
23
29
19
16
107
2
24
27
12
31
40
11
9
3
18
35
Low er % pts at target - Low prescribing
30
£150
£200
Low er % pts at target - High prescribing
£250
£300
NIC (£) per diabetic patient
£350
£400
£450
Cardiac Rehabilitation Programme
Patients remaining through the programme
100%
80%
55%
25%
Phase 1
Phase 2
Phase 3
Phase 4
(Hospital)
(Leisure
services)
Islington CVD Mortality Audit
Population Health
Systematic community
engagement
Personal Health
Community Health
Producing Percentage Change at Population Level
C. Bentley
2007
Industrial Scale
-
“Small is beautiful”
Piecemeal Project Based Approach
Industrial Scale
-
“Small is beautiful”
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
•4
•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 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.
•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 selfdetermination.
•Effective partnership framework (or TOR)
providing protocols and safeguards to
ensure collaborative decision making and
conflict resolution
•Devolution of assets from statutory
sector to community organisation/s in
support of developing community selfdetermination.
•3
•A range of innovative methods for
reaching seldom seen and heard
groups. Elicited views demonstrably
impacting on action.
•2
•‘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.
•Community representatives feel that
they influence decisions being taken
about their community.
•Consultation based on large meetings
/events and the ‘usual suspects’, with
feedback on results.
•Community planning and
implementation groups have
representative membership with
systems of support back to their
constituency.
•Community organisations surviving
mainly through voluntary effort
•Minimal consultation
•Membership of community planning
and implementation forums may be
tokenistic with unequal power
relationships
•No /few community organisations –with
limited lifespan
•1
•0
Community
Consultation
Community
Partnership
•Community organisations sustained by a
mixture of income from trading and/or
commissioned activities, and/or grant aid.
Community
Empowerment
Community and Neighbourhood Engagement
Warrington Local Profile
Structures and Profiling
Engagement and
Capital Building
•
Organising for Delivery
Population Health
Personal Health
Community Health
Service engagement with
the community
Producing Percentage Change at Population Level
C. Bentley
2007
Strategic Framework for Community Engagement
Grass-roots
Community Work
Professional
infrastructure
Overview
& Co-ordination
Organisation
Development
Community
Infrastructure
Addressing Diabetes Inequalities through Community Engagement
Support patient selfmanagement and
empowerment, targeting
those not achieving treatment
goals. Facilitating links to
other supports where
necessary
Raising community awareness
of key health messages about
prevention/early identification.
Case finding and linking to
life-style and primary care
services
Coordination of inputs and
output with strategic
approach to Community
Engagement
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
Outreach to identify reasons
for non-engagement with
services. Advocacy to improve
accessibility of clinical care
and ongoing quality of
services
WHO Commission
on the
Social Determinants of Health
2008 Report
“Bridging the Gap in a Generation”
Bridging the Gap in a Generation
Commission on the Social Determinants of Health
Overarching Recommendations
National Support Teams
• Improve Daily Living Conditions
• Tackle the Inequitable Distribution of Power, Money
and Resources
• Measure and Understand the Problem and Assess
the Impact of Action
Improve Daily Living Conditions
• Equity from the start
Comprehensive approach to early child development, including:
 Physical
 Social/emotional
 Language/cognitive
National Support Teams
• 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
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
National Support Teams
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
Tackle the Inequitable Distribution of
Power, Money, and Resources
• Health equity in all policies, systems and programmes
National Support Teams
 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:
o Establish mechanisms to finance cross-government action on social determinants
o Allocate finance fairly according to need between geographical areas and social
groups
 Market responsibility:
o Vital social goods (health; education) governed by public sector, not left to markets
o Public sector leadership of regulation of harmful products and activities
o Institutionalisation 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 :
o Guarantee a comprehensive set of rights
o Ensure fair distribution of essential material and social goods
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
National Support Teams
• 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
Mike Grady
University College London
Life expectancy and disability free life expectancy at birth, persons
by neighbourhood income level, England, 1999-2003
Age
85
80
75
70
65
60
Life expectancy
55
DFLE
50
Pension age in 2024
Poly. (DFLE)
45
0
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75
Poly. (Life
80 85 90
expectancy)
95 100
Neighbourhood Income Deprivation - Population Percentile
Source: ONS …………………………………………………………………………..
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
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.
Policy objectives
Give
every
child
the
best
start in
life.
Enable all
children,
young
people &
adults to
maximise
their
capabilities
& control
their lives.
Create
fair
employm
ent &
decent
work for
all.
Ensure
healthy
standard
of living
for all.
Create and
develop
healthy and
environmenta
lly
sustainable
places &
communities.
Policy mechanisms
Equality & health equity in all policies.
Effective evidence-based delivery systems.
Strengthen
the role and
impact of illhealth
prevention.