Gloucestershire Health and Wellbeing Board
Report Title
JHWS Working Together to Address Health Inequalities
Item for
For information
decision or
information?
Sponsor
Sarah Scott
Author
Helen Flitton
Organisation GCC
Key Issues:
The draft Health Inequalities Plan is presented to the Board for comment and
discussion. There has been a very positive response from partners however
discussions are ongoing for several of the activities and meetings are planned
over the coming two months to ensure that priorities are joined up and
activities agreed across partners.
Some district level outcomes are included on the obesity, alcohol and older
people Delivery Plans and are therefore not included in this plan.
Recommendations to Board:
The Board is asked to give constructive feedback on the activities included in
the plan and the approach in general.
Financial/Resource Implications:
Joint Health and Wellbeing Strategy Delivery Plan 2016 - 2019
JHWS Delivery Plan 1
Work together to address health inequalities
GHWB Sponsor: Sarah Scott
Why is this a priority?
Commissioning Lead: Sue Weaver
Gloucestershire is one of the healthiest counties in England; overall health outcomes are better than the national average with premature death rates
from all causes falling over the last ten years.
However, the health and wellbeing of some of our communities is not improving at the same rate as others and large health inequalities exist, with some
groups having significantly shorter lives and suffering more illness and disability than others:

A man living in Kingsholm has a life expectancy from birth of 73.2 years, 13.9 years shorter than a man living in Churn Valley (Cotswolds) A
woman in St Paul’s has a life expectancy of 77.8 years, 13.3 years shorter than a woman in Wotton-under-Edge (Period: 2008 – 2012,
www.localhealth.org.uk 2015)
 The infant mortality rate in the Forest of Dean is 4.3 per 1000 live births, compared to 1.9 per 1000 in Cotswold.
Health inequalities are preventable and unjust differences in health status experienced by certain population groups. They arise from social inequalities,
themselves the result of unequal distribution of factors influencing health, such as housing, environment, social background, income, employment and
education. Around 2% of the county’s population live in areas considered to be amongst the most deprived 10% in the country (UG-JSNA 2015). These
areas fall within the urban centres of Gloucester and Cheltenham and are: Podsmead; Matson and Robinswood; St Paul’s; St Mark’s; Kingsholm and
Wotton; Westgate 1 and 3 and Hesters Way. Furthermore, 18,300 local children live in poverty (CYPPP 2014 - 2015). Residents living in our most
deprived communities are more likely to: experience crime, have a low birth weight baby, leave school with no work, education or training destination, die
prematurely, and become dependent on community health and care services.
Other factors contributing to health inequalities are: differences in individual behaviours (i.e. smoking, drinking, physical activity and eating habits), rural
isolation and poor access to and effective use of healthcare, which contributes to at least 15-20 percent of inequalities-related mortality (NHS England,
2013). There is evidence (from routine health service data) that an inverse care law exists so that those who most need health care are least likely to
receive it and those that are in least need of health care use services more (HSJ vol 111, 5760 pp37).
Among others who suffer poorer health and wellbeing outcomes are: people from black or minority ethnic communities; people living with a physical or
learning disability; the homeless; young offenders and people with mental health problems. For example, people living in England with mental illness die
on average 15-20 years earlier than those without, often from preventable causes (Chief Medical Officer, 2014).
There is a strong economic case for addressing health inequalities. Inequalities contribute to financial pressure on health and social care and to an
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estimated annual cost of between £36 billion and £40 billion through lost taxes, welfare payments and costs to the NHS (Marmot Review, 2010).
A key message from the Marmot Review (2010) was that focusing solely on the most disadvantaged will not reduce health inequalities enough – actions
must be universal, but with a scale and intensity that is proportionate to the level of disadvantage – an approach called ‘proportionate universalism’.
By adopting such an approach, and working together with individuals and communities, and with organisations across the system we can help to address
these inequalities.
What we are going to do:
Action to reduce inequalities requires focus across the causes including: the wider determinants (education, employment, financial and environmental),
the modifiable risk factors for disease (both primary and secondary prevention) and accessibility and responsiveness of health services.
Interventions to achieve short term (less than five years) impacts can have a sizable impact on life expectancy. These include actions to prevent
cardiovascular diseases, early identification of cancers and the management of long term conditions. However, these should be combined with other
interventions that aim to impact on outcomes in the medium term (from 0 to 10 years), such as lifestyle changes, and an impact on outcomes in the
longer term (from 0 to over 10 years), such as education and employment.
The actions and interventions identified within this plan are guided by the following principles:









Outcomes focused: monitoring our progress in terms of meaningful impact on local people (‘outcomes’) - not just looking at what
activities have taken place (‘outputs’)
Service user and community voice will inform all that we do and how we do it
Needs rather than demand-led: interventions will be focused where there is the greatest capacity to benefit
Proportionate Universalism: actions must be universal, but with a scale and intensity that is proportionate to the level of
disadvantage
All interventions will be informed by evidence of impact and where this is not available will be supported by a sound evaluation
Sustainability: building capacity supporting individuals and communities to help themselves and each other and to become more
resilient; fostering self-care and independence and improving levels of health literacy
Parity of esteem: ensuring we are equally focused on improving mental as well as physical health, and reducing inequalities in both
Starting early: Giving every child the best start in life through focusing on pregnancy and the first months and years of life
Long-term commitment: A commitment to ‘seeing it through’ – a long term sustained strategic approach, which includes a range of
short and medium and long term actions and interventions
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
Focusing on both communities of ‘place’ and communities of ‘interest’: (i.e. people who share common characteristics /
challenges). Our actions will include those that are applied across the whole county and others that are district or locality-led.
Key Risks and mitigating actions
Risk
Lack of engagement across the system
Mitigating Action
Communications and Engagement Strategy to enable stakeholders to stay informed
and to track progress. Provider engagement events held on a regular basis.
Involvement of partners and stakeholders in development of plans and activities.
Board level Sponsors to champion activities amongst their networks.
Diminishing resources
Maintaining a system overview (through SIG) to ensure coordination of activity and to
avoid duplication. Robust performance management to ensure where activity isn’t
effective resources are directed elsewhere.
Absence of robust data for some outcomes
Tba
Difficulties in attributing cause and effect to population level
outcomes
Tba
Interdependencies
The current and future health and social care needs of the citizens of Gloucestershire, including health inequalities, are assessed in the annually updated
‘Understanding Gloucestershire a Joint Strategic Needs Assessment’ (UG-JSNA) which can be found on the Gloucestershire Inform website:
http://www.gloucestershire.gov.uk/inform/understanding
The following strategies and plans include specific action to reduce health inequalities and these actions will not be duplicated within this delivery plan:
Building Better Lives – an all age, all disability policy which includes actions on employment, reshaping services and new ways of working with some of
the most vulnerable service users.
Mental Health and Wellbeing Strategy – objectives include: more people will have good mental health; more people with mental health problems will
recover; more people with mental health problems will have good physical health and fewer people will suffer avoidable harm.
Improving Outcomes for Children, Young People and Families in Gloucestershire: a Strategic Joint Commissioning Framework for Children,
Young People and Families - It is increasingly understood, and supported by growing bodies of evidence, that the outcomes achieved by children and
young people during their childhood and adolescence impact significantly on life-long outcomes affecting health, wellbeing, employment prospects and
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Joint Health and Wellbeing Strategy Delivery Plan 2016 - 2019
life expectancy, to name but a few. This framework takes the principles and benefits of the existing early years framework and develops them into a
broader approach across the whole of childhood, adolescence and young adulthood.
Early Help and Children and Young People Partnership Plan 2015 – 2018 – focuses on areas where partnership working will really make a difference to
the outcomes for our vulnerable children and young people including Looked After Children; children requiring safeguarding; children subject to the
effects of poverty and children living in challenging circumstances.
Youth Employment and Skills Strategy – the County Council’s commitment to help young people (14 – 24 yrs) to get the information and gain the skills,
work experience and abilities they need to make a successful transition into employment. It is also aimed at supporting economic growth by helping
businesses to access young people who can develop the skills that they need.
Gloucestershire National Dementia Strategy Local Action Plan – objectives include good quality early diagnosis and intervention for all; improving
awareness and understanding of dementia; providing training on cultural awareness for health and social care staff and providing good quality
information for those diagnosed with dementia.
Enabling Active Communities in Gloucestershire – a multi agency framework with the aim of building stronger, more sustainable communities and in turn
improving the health and wellbeing of local people, drawing upon, and stimulating the provision of, the diverse range of assets within each local
community.
Better Care Fund Plan – pooled budget arrangements between the County Council and the Clinical Commissioning Group to try to ensure that people
receive better and more integrated care and support. Objectives include flexible primary care provision over 7 days which will be accompanied by greater
integration with mental health services, and a closer relationship with pharmacy services; strengthened integrated community teams; parity of esteem;
empowering people to direct their care and support, and to receive the care they need in their homes or local community.
Growing Older In Gloucestershire Plan – includes four steps to supporting people as they age: active individuals; active communities; getting people back
to independence and being there when most needed.
Joining Up Your Care – People are provided with support to enable them to take more control of their own health and wellbeing. Those that are
particularly vulnerable will benefit from additional support.
Gloucestershire Police and Crime Plan - includes trying to ensure older and more vulnerable people are not overlooked; reducing alcohol related crime
and disorder; to deliver sensitive, relevant and effective policing to ensure our young people become law-abiding productive members of society.
Healthy Individuals Plan – aims to enable people to have the knowledge, skills and confidence to self care and take more control of their health.
Considers the social determinants of health – housing, education, employment, physical environment and inequalities.
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JHWS Delivery Plans 2016 – 2019 - Reducing Alcohol Related Harm; Improving Health and Wellbeing into Older Age and Reducing Obesity - Targeted
activity to reduce health inequalities in relation to older people’s health and wellbeing, to alcohol and to reducing obesity will be included in the separate
JHWS Delivery Plans. Improving Mental Health is covered under the Mental Health and Wellbeing Strategy.
Gloucester City Council, Cheltenham Borough Council and Tewkesbury Borough Council Joint Core Strategy – The Joint Core Strategy (JCS) is a
partnership between Gloucester City Council, Cheltenham Borough Council, and Tewkesbury Borough Council, supported by Gloucestershire County
Council. The JCS was formed to produce a co-ordinated strategic development plan to show how this area will develop during the period up to 2031.
Stroud, Cotswold and Forest of Dean Local Strategies – Strategic development plans to show how the Districts will develop during the period up to
2031.
Strategic Economic Plan for Growing Gloucestershire – gfirst LEP
Countywide Activity (targeted to need and not in other strategies and plans)
Outcome
Activity
Baseline & target
(population level
outcome)
Performance Measures
(intervention or service
level outputs and
outcomes)
Time
(completion
date)
Resource
(£ and
funding
source)
Lead
(organisation and
officer)
GCC/ GCS
/ NHS
GCC
GCC
GCC Ruth Lewis
Time to
realisation
of benefits
(1-3yrs; 3-5
yrs; 510+yrs)
Improving the wider factors that affect health and wellbeing (‘wider determinants’)
Babies and
Young Children
develop well,
are ready for,
and transition
successfully to,
school
tbc
Parents have the
confidence and
Parent Support Programme
Review is completed and
Baseline: 52% of children
are judged to have
achieved a good level of
development, measured
at the end of the
foundation stage in the
final term of the
academic year in which a
child reaches the age of
five
The percentage of
children achieving a good
level of development at
the end of reception
tbc
Tbc
Review of parent support
programmes is completed
Tbc
Sarah Hylton and
Jane Lloyd Davis to
formulate – awaiting
decision on final
outcome and activity
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skills to support
their child’s
healthy
development
provides evidence for
decision making1 Current
parent support programmes
are reviewed for efficacy and
value for money
Family Learning Programme
in Children’s Centres
and provides evidence for
decision making by
January 2016
Baseline?
Target?
Improved
employment
opportunities
and retention
for young
people2; people
with disabilities;
people with
mental health
problems and
older people
Employability Learning
using in house delivery
team and external
providers
Baseline: 2014/15?
Target?
Effectiveness of Family
Learning Programme – 3
months and 6 month
follow-up
tbc
Increase the numbers of
learners, including Adults
with Learning Difficulties
and Disabilities, who
progress to or re-enter
employment, who work for
longer, who change their
skills set, who embark on
a new career or who
progress into further
training, volunteering or
self-employment.
Tbc
GCC
Joanna Jackson;
Churchill Audi
Sally Lewis, GCC
Adult Education
Francis Gobey
Karl Gluck
Measured through the
1
Parent Support Programmes: PHE UCL Institute of Health Equity recommendation (2014). Marmot (2010). The quality of parenting that a child receives is considered the strongest
contributory factor in the development of resilient, more confident and emotionally healthy children. The importance of parents (particularly mothers) adopting a healthy lifestyle during and
after pregnancy, has a major positive influence over improving the health and life chances of their child (JHWS, 2012)
2 Employment opportunities: Comment on need insert. Employment is key area GHWB agreed to focus on. PHE UCL Institute of Health Equity recommendation (2014). Marmot (2010).
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adult education
progression survey
completed 3 months after
end of course
More homes
across the
County are
healthier and
safer to live in.
Cat 1 hazards removed
as a result of interventions
by local authorities
(grants/loans/signposting/
enforcement)
Baseline: Number of
cat 1 hazards across
the county (taken from
Housing Statistics
return for each LA)
Number and type of Cat 1
hazards removed
Savings to NHS and wider
society?
Over the
period of one
(financial)
year
District
council
private
sector
housing
teams
Gloucester City
Council
Resource
(£ and
funding
source)
Lead
organisation
(officer)
Julie Wight
Target: Need to agree
a target for Cat 1
hazards removed
Helping people to live healthy lifestyles and make healthy choices (‘health improvement’)
Outcome
Activity
Baseline & target
(population level
outcome)
Performance Measures
(intervention or service
level outputs and
outcomes)
Time
(completion
date)
Time to
realisation of
benefits (13yrs; 3-5 yrs;
5-10+yrs)
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Fewer women
will smoke at
time of delivery3
Review stop smoking
services as part of health
behaviour review and
retender stop smoking
support from January
2017
Low birthweight term
babies
Review stop smoking
services as part of health
behaviour review and
retender stop smoking
support from January
January
2017
£ tbc
GCC
(GCC. PH)
(Tracy Marshall)
£ tbc
GCC
(GCC. PH)
(Tracy Marshall)
£ tbc
GCC
(GCC. PH)
(Tracy Marshall)
tbc
Smoking status at time
of delivery
Tracy / Temi to add any
significant service
improvement activity
planned for pregnancgy
for 2016 – 2017 i.e action
plan that the service is
working towards
Fewer people
with mental
health problems
smoke4
Targets tbc
Targets tbc
Smoking rate of people
with serious mental
illness
Tracy / Temi to propose
KPI
tbc
tbc
tbc
tbc
3
Smoking in pregnancy: Pregnant women who smoke are twice as likely to have a low birth weight baby. Low birth weight is linked to survival in early infancy and health in childhood and
adult life. We also know that the numbers of low birth weight babies and sudden unexpected deaths are both higher in low income families (JHWS, 2012).
4 Smoking among people with mental health problems: Increased smoking is responsible for most of the excess mortality of people with severe mental health problems . Two out of every
five cigarettes in England are smoked by people with mental health problems.Many wish to stop smoking, and can do so with appropriate support (Department of Health, 2010).
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2017
Tracy / Temi to add any
significant improvment
activity planned for 2016 2017
Fewer children
aged 15 years
smoke
Extend delivery of
ASSIST across all
secondary schools
Smoking prevalence
age 15 years – regular
smokers* (OPS equiv
given no national data)
tbc
Fewer routine
and manual
workers smoke
Review stop smoking
services as part of health
behaviour review and
retender stop smoking
support from January
2017
Smoking prevalence
routine and manual
persons aged 18
tbc
Tracy / Temi to
propose
Tracy / Temi to propose
KPI
tbc
tbc
£ tbc
GCC
(GCC. PH)
(Tracy Marshall)
£ tbc
GCC
(GCC. PH)
(Tracy Marshall)
£ tbc
GCC
(GCC. PH)
(Tracy Marshall)
tbc
tbc
Tracy / Temi to add any
significant improvement
activity planned for 2016 2017
Fewer people
with long term
conditions
smoke
Review stop smoking
services as part of health
behaviour review and
retender stop smoking
support from January
2017
tbc
tbc
Tracy / Temi to add any
significant serivce
improvment activity
planned for 2016 - 2017
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Children in
Gloucestershire
have improved
oral health5 and
the gap for high
risk groups is
reduced
Develop a targeted multiagency oral health
promotion plan in
response to the 2015 oral
health needs assessment
Percentage of 5-yearold children with decay
Hospital admissions:
0-19 y/o for extraction
of 1+
decayed primary
/permanent teeth
Number of key oral health
information sessions to
parents in pre-schools/
schools located in areas
of high need
March 2016
£60k p.a.
(GCC, PH)
GCC
Temi Folayan
(tbc)
Number of toothbrushing
packs distributed/supplied
Percentage of looked
after children who had
their
teeth checked by a
dentist
Rates of
breastfeeding
are improved6
and gap
between
deprived and
affluent areas is
reduced
Undertake a review of
evidence for improving
breastfeeding rates
among groups least likely
to breastfeed and
develop multi-agency
improvment plan
Breastfeeding initiation
tbc once plan in place
Dec 2015
£47k p.a.
(GCC, PH)
Breastfeeding
prevalence at 6-8
weeks after birth
GCC
(David Squire)
CCG
(Helen Ford)
5 Oral Health: Significant preventible local inequalites relating to oral health with poorer outcomes among: children in care; people living in deprived communities; people with diabetes; older
people with dementia and those living in residential or nursing care; gypsy and Irish travellers and children and adults with disabilites . Significant impact on health and wellbeing including
school absence; mental health and wellbeing; quality of diet. Strong evidence for oral health promotion (PHE, 2014; NICE,2014 ). The NHS in England spending £3.4 billion per year on
dental care.
6 Breastfeeding: UG-JSNA (2015) – breastfeeding rates static and significant inequalties persist – evidence that breasfed babies are at lower risk of gastroenteritis; respiratory infections;
sudden infant death syndrome; obesity; type 1 &2 diabetes and allergies and subsequently less likely to be a cost to the NHS (Unicef UK 2015)
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Improved
nutrition among
pregnant
women and
young children
from deprived
or vulnerable
communities
Healthy Start review7
Improved health
outcomes for
people with
mental health
problems
Placeholder for action
around improving health
outcomes for people with
mental health problems.
Uptake of Healthy
Start
Review completed
Oct 2015
tbc
GCC
(Sue Weaver)
tbc
tbc
tbc
tbc
Tbc GCC
Sue Weaver
Actions to be identified
and agreed as part of
Mental Health and
Wellbeing Strategy
subgroup 3 plan.
Subgroup meets on the
8th October
Improved health
outcomes for
people with a
learning
disability
Placeholder for action
around improving health
outcomes for people with
learning disabilities.
tbc
tbc
tbc
tbc
Tbc CCG
Martin Ayres
Actions to be identified by
the HAG following
7
Healthy Start: Marmot Review (2010). Investing in giving children the best start in life and tackling child poverty is essential to reducing health inequalities and is a cost effective way of
improving longer-term health outcomes and reducing pressure on health and social care services.
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workshop on 7th Sept
Improved health
outcomes for
people with a
physical
disability
Placeholder for action
around improving health
outcomes for people with
physical disabilities.
tbc
tbc
tbc
tbc
Tbc ??
Resource
(£ and
funding
source)
Lead
(organisation and
officer)
Time to
realisation
of benefits
(1-3yrs; 3-5
yrs; 510+yrs)
GCC Public Health:
Teresa SalamiAdeti
1-3 years
To be discussed with
Lead Commissioner
(?Chris Haynes)
Protecting the population’s health from major incidents and other threat (‘health protection’)
Outcome
Improved
uptake of
Childhood
immunisations
Activity
Targeted action in the five
lowest performing GP
practices in each Locality
Focus MMR 2nd Dose &
Hib/Men C
Baseline & target
(population level
outcome)
Performance Measures
(intervention or service
level outputs and
outcomes)
Q4 14/15
MMR uptake 95%<
Hib/MenC Uptake
95%<
Time
(completion
date)
Elizabeth Luckett,
NHS England
South
Birthday Card scheme
with 5 worst performing
practices
Text messaging reminder
service focus on 5 worst
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performing practices
Targeted support for
worst performing
practices through
facilitator practice visits.
Improved
cervical
screening
coverage
Cervical Screening Pilot
targeting Polish women
under 30ys.
Q4 14/15
Cervical screening 80%<
Targeted work with
practises (GP list
cleansing for specific
population)
Improved
sexual health
outcomes in
vulnerable
communities
(as identified in
SHNA)
GCC Public Health:
Teresa SalamiAdeti
1-3 years
Elizabeth Luckett,
NHS England
South
Breast Screening
Campaign targeting
women under 60
commencing in October
Q4 14/15
Breast screening
coverage <75%
Health Equity Assessment
(Sexual Health)
Tbc
Tbc
GCC Public Health:
Teresa SalamiAdeti
Participatory Needs
Assessment
Reducing the numbers of people living with preventible ill-health and dying prematurely (‘healthcare’)
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Outcome
Reduce
differences in
under 75
mortality rate
from all
cardiovascular
diseases
Activity
Review performance of
new NHS HealthChecks
at end of Q1 2015-16
Pilot outreach NHS Health
Checks
Review commissioning of
NHS HealthChecks
Baseline & target
(population level
outcome)
Performance Measures
(intervention or service
level outputs and
outcomes)
Time
Take up of the NHS
Health Check
programme
(cumulative
percentage of those
offered)
Tbc – PHE ambition is
66% uptake
Take up of the NHS
Health Check
programme
(cumulative
percentage of those
eligible)
Resource
(£ and
funding
source)
Lead
(organisation and
officer)
Mar 2016
£ (GCC,
PH)
GCC, PH (Sue
Weaver), CCG
(Matt Pearce)
Mar 2017
Via Primary
Care Offer
2016/17
Hannah Layton
(CCG)
(completion
date)
Time to
realisation
of benefits
(1-3yrs; 3-5
yrs; 510+yrs)
Set local targets by age,
gender, deprivation and
ethnicity??
Uptake by age,
gender, deprivation
and ethnicity)
Improving the
management of
high blood
pressure in the
community

Case finding for patients
with hypertension via
opportunistic checks, or
NHS Health Checks or
methodical review of
caseload
People from the
most deprived
areas are 30%
more likely than
the least-
Implement a GP
education programme
improving skills of HCP’s
in effective management
of difficult hypertension in
a.
Estimated total
prevalence (diagnosed
and undiagnosed)
2011 25.8%
Number of recorded
patients with hypertension
against expected
prevalence by practice
2-3 years
b.
Recorded
prevalence
(diagnosed)13.8%
2012/13
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deprived to
have high blood
pressure, and
the condition
disproportionate
ly affects some
ethnic groups
including black
Africans and
Caribbean’s
primary care
Improving the
management of
Atrial Fibrillation
in the
community to
prevent stroke
Improved anticoagulant
therapy for individuals
with Atrial
Fibrillation
Number of recorded
patients with
Atrial Fibrillation
11,688 (1.9%)
c.
Number of recorded
patients with Atrial
Fibrilation against
expected prevalence by
practice
Mar 2016
Via Primary
Care Offer
2015/16
and joint
education
project with
the
Academic
Health
Science
Network
Hannah Layton
(CCG)
1-5 years
with ongoing
benefits
Mar 2017
Current
investment
in Expert
Patient
Programme
£60k
CCG Matt Pearce
1-3 years
Incidence of Ischaemic
Stroke
Promoting
effective self
management
(of condition)
People with
long-term
conditions
disproportionate
ly live in
deprived areas
and have
access to fewer
resources of all
Ensure self management
services are sufficently
targetting areas of high
heallth needs
Take-up of Expert
Patient Programme
and specialist self
management services
70% of EEP participants
are from IMD deciles 1-4
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kinds.
Reduction in the
number of
people in
Gloucestershire
with nondiabetic
hyperglycaemia
Implement an evidencebased diabetes
prevention programme as
part of NHS England’s
National Diabetes
Prevention Programme
(subject to successful bid)
Number of participants
taking up intervention
Mar 2017
Funded by
NHSE
Sue Weaver (GCC)
/Matt Pearce
(CCG)
1-3 years
Number of homeless
people admitted to
GHT
Referrrals to Time to Heal
March 2016
CCG
funded
CCG
1-3 years
Reduced length of stay
Baseline data 13/14
125 individuals seen
by Homeless
Healthcare team
Reduced readmissions
Seeking to
establish 3+2
year contract
with closer
alignment to
GCC housing
strategy
Recorded pre diabetes
59,111 (estimated via
HSE data)
People are at
increased risk
of developing
Type 2
diabetes. They
are also at
increased risk
of other
cardiovascular
conditions
Improve
outcomes for
patient groups
who have
trouble
accessing the
health service in
a traditional
manner i.e.
homeless
people admitted
to hospital
Estimated number of
people aged 16 and
over who have nondiabetic
hyperglycaemia by
local authority.
Establish a clear pathway
from hospital to safe
discharge supported by
community services
Reduced self-discharge
Referrals to other services
Debbie Clark
£££’s
Helen Vaughan
Referrals to Time to
Heal 14/15 of 155
individuals
The life
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expectancy of a
street homeless
person is 42
years compared
with 74 for men
and 79 for
women
Health care
services are
accessible to all
individuals
irrespective of
gender, race,
disability, age,
sexual
orientation,
religion or belief
Equality is embedded
throughout health care
commissioning through
the implementation of the
CCG’s Equality and
Valuing Diversity Strategy
and associated action
plan
Assessment and
grading of
performance will be
undertaken against the
eighteen goals and
outcomes of EDS2.
Action plan and ongoing
monitoring in place
Mar 2018
Utilising
existing
resources
Caroline Smith
(CCG)
1-3 years
Improve equity
of access to
health care
services
Undertake analysis to
establish the number of
unregistered patients in
Gloucestershire and
explore
TBC
Number of unregistered
patients presenting at
A&E
Mar 2016
Utilising
existing
resources
Maria Metherall
(CCG)??
1-3 years
Develop a patient facing
platform (reiteration of Gcare) that provides clear,
evidence based and
understandable patient
Number of website hits
Awareness of the web
based platform amongst
the community particularly
in areas of need
Mar 2017
TBC
Ruth Hallett (CCG)
/ Matt Pearce
(CCG)
1-3years
Access to
healthcare is a
known
determinant of
health
Increase access
to services by
providing
information,
advice and
guidance on
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available
services
information
Low health
literacy is
associated with
poorer health
outcomes
Reduction in
avoidable
variation in care
The existence
of persistent
unwarranted
variations in
health care
contribute to
health
inequalities
Use the principles of
system leadership to
understand the needs of a
local community (i.e.
Westgate corridor) and
coordinate action around
a particular health
inequalities issue.
Development of a
community based
approach to
understand local
variation in an area of
high health need
TBC
Mar 2016
TBC
Matt Pearce Becky
Parish. Andrew
Hughes (CCG) ???
(TBC)
1-3 years
Shifting focus from the
patients that present most
frequently in practices to
the wider population that
they serve
District Level Activity (targeted to need and aligned to priorities identified in the Locality Development Plans 2015 - 2017)
Cheltenham – being updated following Locality meeting on 7th September
Outcome
Activity
Baseline & target
(population level
outcome)
Performance Measures
(intervention or service
level outputs and
outcomes)
Time
(completion
date)
Resource
(£ and
funding
source)
Lead
(organisation and
officer)
Time to
realisation
of benefits
(1-3yrs; 3-5
yrs; 510+yrs)
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Joint Health and Wellbeing Strategy Delivery Plan 2016 - 2019
e.g. Families
are prevented
from needing
high level
support
Cheltenham Inspiring
Families Project.
Cheltenham
Borough Council
e.g. the harm
that alcohol
causes
individuals and
communities in
Cheltenham is
reduced
Cotswolds
Outcome
Ensure people
with health
conditions or
disabilities can
access
tailored
specialist
exercise,
helping to
manage
conditions and
Activity
Baseline & target
(population level
outcome)
Performance Measures
(intervention or service
level outputs and
outcomes)
Time
(completion
date)
Develop and deliver the
Active Lifestyles
exercise on prescription
scheme, including the
gym programme and
specialist exercise
classes (Cardiac
Rehab, etc.)
Ongoing
Explore potential to roll
March 2016
Resource (£
and funding
source)
Lead
(organisation
and officer)
Time to
realisation
of benefits
(1-3yrs; 3-5
yrs; 510+yrs)
Part of the
CDC leisure
contract
Will require
contribution
by schools
or external
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reduce obesity
out to school sites
(Tetbury and Fairford)
funding
Provide
support to
those whose
mental health
is negatively
affected by
financial
worries
Support the continued
presence of the
Citizen’s Advice Bureau
in Cirencester,
telephone and online
support and the roll out
of outreach support
across the district
Ongoing
SLA in
place
between
Stroud CAB
and CDC
Address local
health
inequalities
through
communitybased projects
Deliver the Health
Inequalities Fund
supported projects and
monitor their impact
Ongoing
Funded by
GCC HIF
Performance Measures
(intervention or service
level outputs and
outcomes)
Time
Resource (£
and funding
source)
Lead
(organisation
and officer)
New participants through
GP referral scheme
Dependant
on future
funding
sources
£31K health
inequalities
grants GCC
PH
FODDC
Forest of Dean
Outcome
Healthier and
more active
communities in
general and
targeted to
Activity
Delivery of GP referral
schemes to include;
Weight management,
cardiac rehabilitation,
respiratory rehabilitation,
Baseline & target
(population level
outcome)
(completion
date)
Time to
realisation
of benefits
(1-3yrs; 3-5
yrs; 510+yrs)
Tess Tremlett
Gary Deighton
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areas of
greatest need.
(Use of Maiden
and JSNA info)
falls prevention, back
care, Parkrun, health
walks, health classes,
buddy scheme and health
promotion
New management of 5
leisure centres across the
FoD district
Volunteers
Baseline and target
data needed
Consessionary rates
available for leisure
members on a means
tested benefit
Freedom Leisure
(Andy Barge –
FODDC)
Free swimming for the
over 75s and the under 8s
Measured by uptake?
To improve the
health and
wellbeing
outcomes for
people for
whom
"wellbeing"
services are
most likely to
address their
needs
Social Prescription
Pathway
To keep GP
surgeries and
patients
informed about
healthy living
options
Healthy living project
94 in year 2014/15
Numbers referred and the
difference/impact made
Will you set a target for
this? How will you
measure
difference/impact made?
Sept 2016
£47K
FODDC
CCG (Prime
Ministers
Challenge
funding)
Tess Tremlett
Gary Deighton
£5K Locality
Exec group
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To provide
advice, support
and advocacy
for those of
greatest need
To reduce
social isolation
and support
people in their
own homes for
as long as
possible
Service level agreements
with VCS orgs:
CAB
Each contract has
performance indicators
that are reported against
in their quarterly
monitoring report.
Age Concern FoD (to
deliver a hot meal service
at home and provide
befriending support)
31 March
2016
FODDC
budgets;
FODDC
Tess Tremlett
£86,275K p/a
All SLAs are
reviewed
annually and
are subject to
budget
approval in
February
£7,641 p/a
Artspace
To support
people of all
ages and
abilities to
access ‘arts’
activities
especially for
those on low
income
To support
young people
especially those
in most need of
support
To provide
transport for
those who do
not have their
own access to
£9,731 p/a
Provision of youth
cafes/drop-in centres at
Cinderford, Lydney and
Newent
£13,592 p/a
FODDC Malcolm
Vine
Work with G3 – supported
housing for young people
The Community Transport
project
Lottery targets and set
milestones
October
2018
£310K
FODDC
Big Lottery
Lena Maller
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transport
Communities in
the Forest of
Dean are
dementia
friendly.
Community information
and awareness raising
sessions
Facilities, public
spaces and
houses are
‘dementia’
friendly
New affordable housing
developments and
housing with care
Prevention of
homelessness
FoDDC has a statutory
duty to assist those who
find themselves homeless
Reducing the
number of
deaths during
winter
Good quality
affordable
Housing to
those on low
incomes
Enabling older
people to
Baseline: 2014/15
delivery
Number of attendees:
Target: To at least
match previous years
performance
Warm and well
partnership
Number of sessions:
Reviewed
annually
against
FODDC
corporate
priorities and
budget
FODDC
budgets
FODDC
Lena Maller
FODDC Malcom
Vine
FODDC
Budgets
FODDC
Malcom Vine
FODDC
Malcom Vine
Ensure that alternative
accommodation is
available for families and
young people so that B&B
is avoided
Safe at Home scheme
and the disabled facilities
grants
Community Alarm service;
Linkline service in the
Forest and Careline
FODDC Deb
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Joint Health and Wellbeing Strategy Delivery Plan 2016 - 2019
remain living
safely in their
own homes and
to enable older
and frail people
to leave hospital
and return to
their own
homes.
service in the Cotswolds.
Hughes
Gloucester City
Outcome
e.g. Residents
of Westgate
Ward have
improved
quality of life
Activity
Baseline & target
(population level
outcome)
Performance Measures
(intervention or service
level outputs and
outcomes)
Time
(completion
date)
Resource
(£ and
funding
source)
Gloucester City ‘Our
Place’ project
Lead
(organisation and
officer)
Time to
realisation
of benefits
(1-3yrs; 3-5
yrs; 510+yrs)
Gloucester City
Community
Partnership
Stroud
Outcome
Improved
Physical and
Mental
Activity
Cardiac Rehab Classes
Baseline & target
(population level
outcome)
Performance Measures
(intervention or service
level outputs and
outcomes)
Time
Take up of Classes
Number of clients
attending the classes
March 2016
Needs refining +
(completion
date)
Resource
(£ and
funding
source)
Lead
(organisation and
officer)
Internal
Funding &
Stroud District
Council
Time to
realisation
of benefits
(1-3yrs; 3-5
yrs; 510+yrs)
What is the
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Joint Health and Wellbeing Strategy Delivery Plan 2016 - 2019
figures for baseline
and targets
Wellbeing
Promoting the
Health &
Wellbeing of our
community
Improved
Physical and
Mental
Wellbeing
Respiratory Rehab
Classes
Take up of Classes
Number of clients
attending the classes
period for
which this is
being
measured –
the plan
doesn’t start
until April
2016?
class fees
Hannah Drew
March 2016
Internal
Funding &
class fees
Stroud District
Council
Hannah Drew
Promoting the
Health &
Wellbeing of our
community
Residents in
Stroud District
on low incomes
can improve
their housing
conditions and
as a result
prevent ill
health and
improve their
wellbeing
Healthy Homes Loan for
low income households
where a category one
hazard* exisits.
33% of owner
occupiers live in a
property with a
category one hazard
* defects in a home that
threaten the health and
safety of the occupants
may be eligible
Uptake of loan by
individual home
owners
Ensuring
occupants are
living in safe,
Mandatory Licensing
Number of Mobile
Homes, Caravan Sites,
Houses in Multiple
Occupation (HMO)
Number of essential
repairs* to homeowner’s
properties in the Stroud
District.
Budget
timescale???
???
SDC
£15,000
per
property
Stroud DC
Jon Beckett
£200,000??
Number of homes
inspected by an
Environmental Health
Officer to ensure
SDC
Stroud DC
Jon Beckett
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Joint Health and Wellbeing Strategy Delivery Plan 2016 - 2019
healthy homes
Promote and
Improve
Energy
Efficiency in
the Home to
reduce cold
related illness
which can lead
to excess winter
death
Ensuring
occupants are
living in safe,
healthy homes
through
improving
housing
conditions in the
private rented
sector
Advice on saving energy,
renewable technologies
and financial
assistance via the Severn
Wye energy advice line
Target 2050 loans of up to
a maximum of £10,000 for
energy efficiency
improvements in the
home.
Advice to landlords,
tenants and agents on
property letting standards
especially overcrowding
and housing conditions
and fire safety.
licensed and inspected
standards are met and the
home is safe with
adequate facilites
15.7% of households
in Stroud living in fuel
poverty
Number of households in
fuel poverty reduced
Reduction in the
Excess Winter Death
rate
Number of properties
solid wall properties
insulated
SDC
Stroud DC
NHS
Jon Beckett
GCC
SWEA
Number of properties
connected to the gas
main.
42% of occupiers in
the private rented
sector live in a home
with a category one
hazard
.
Number of properties with
energy efficiency
improvements made
Number of category one
hazards removed from
private rented properties
SDC
Stroud DC
Jon Beckett
Number of properties
accredited on Fit to Rent
scheme
Landlord training days
Fit to Rent Property
Accrediation Scheme
Enforcement or poor
housing condtions to
ensure property
improvements are made
where category one
hazards are found
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Joint Health and Wellbeing Strategy Delivery Plan 2016 - 2019
Tewkesbury
Outcome
Improving
knowledge of,
and links to
VCS for all
public sector
partners
To support,
encourage and
enable the
voluntary
sector to
increase
participation in
healthy
lifestyles
Activity
Baseline & target
(population level
outcome)
Performance Measures
(intervention or service
level outputs and
outcomes)
Time
Resource (£
and funding
source)
Lead
(organisation
and officer)
Developing Social
Prescribing as core
business
For Tewkesbury CCG:
people accessing
support via SP
Number of cases
managed, reduction in
visits to GP
December
2016
Tewkesbury:
£5kpa
Tewkesbury CCG
(Jeremy Welch)
Local Area/Asset Coordination
Roll out LAC to all
areas of the borough
to support Place
Programme
Mapping/directory of
services and assets
October
2016
Core ASC
budget
ASC: Margy
Fowler
Increase number of
volunteer sports/activity
coaches
New groups
established and
increase in
participation
Numbers
trained/qualified
March 2017
HIF budget
to be agreed
TBC (Neil
Meynell)
(completion
date)
Time to
realisation
of benefits
(1-3yrs; 3-5
yrs; 510+yrs)
Active People Survey
Operational Oversight for Delivery Plan:
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GHWB Strategy Implementation Group (SIG):
The Strategy Implementation Group (SIG) will oversee the delivery of the Health Inequalities Plan. The group meets once or
twice between each Health and Wellbeing Board meeting and membership consists of:

Director of Public Health (Chair)

CCG representative x2

Adult Social Services representative

Children’s and Families representative

Public Health representative x 2

Healthwatch representative

VCS Alliance representative

Districts’ representative x 2

PCC representative

Head of Performance and Need, GCC

Delivery Plan Commissioning Leads x4

Others by invitation
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