www.hertsdirect.orgTaking on Public Health in 2013:key equality issues for HCCJim McManus, CPsychol, CSci, AFBPsS,FFPH, FRSPH, MIHMDirector of Public Health, Hertfordshire
www.hertsdirect.orgThe ChallengeThe Challenge:Creating conditions in whichindividuals andcommunities have controlover their health and livesand participate fully insociety.New Levers:• Healthwatch – full engagement• Health and Wellbeing structures– local democratic engagement• Public health transfer• Health scrutiny function• Duty to tackle health inequality• NHS Outcomes Framework• Public Health OutcomesFramework• EDS
www.hertsdirect.orgSo what’s the Link between equality dutyand health inequalities?Equalities• Ensuring people are treatedand can access services on thebasis of their health need whichHealth Inequalities• A worse health outcome,access or experiencecompared with a chosen“standard” population ormeasure, usually across asocial gradient but can work byethnicity or gender or sexualityor faith
www.hertsdirect.orgKey Points• Most health inequalities express themselvesthrough social or other inequalities, and mostsocial or other inequalities can be associatedwith health inequalities• These are expressed cumulatively across theLifecourse– Disabled people, employment and stressfrom hate crime– Lower education, earlier death?
www.hertsdirect.orgWhat does Lifecourse mean?• From conception to grave, things influence ourhealth all the time– Lower birth weight – disease in later life– South Asian – genetic risk for diabetes– Readiness for school
www.hertsdirect.orgLife course perspective• A way of looking at life not as disconnected stages, but asan integrated continuum• Suggests that a complex interplay of– biological,– behavioral,– psychological,– and social protective and risk factorscontributes to health outcomes across the span of aperson’s life.• The life course perspective conceptualizes birth outcomes as theend product of not only the nine months of pregnancy, but theentire life course of the mother leading up to the pregnancy.
www.hertsdirect.orgThe Lifecourse impact of health
www.hertsdirect.orgExample: Gaps in school readiness at 3 and 5years by family income: UKAveragepercentilescoreWaldfogel & Washbrook 2008
www.hertsdirect.orgKey Issues• Largely well population in Hertfordshire• Inequalities masked by wellness• Worst off die 7 years earlier than best off• Inequalities expressed across lifecourse• Protected characteristics can worsen lifeexperience and thus health, or access to healthservices
www.hertsdirect.orgA reflection from self harm studies• ALL the evidence suggests strongly it is NOTintra-individual factors but societal factors toowhich are important to address• Healthy public policy and services plus accessto services plus skills and motivation are key• It’s the same with equality – look at LGBT hatecrime• The individual is neither the whole problemnor the whole answer
www.hertsdirect.orgSelf-harm case postcodes with Indices of Multiple Deprivation score inHertfordshire, by Middle Layer Super Output AreaKey IMD 20103 to 8.99 to 14.915 to 20.921 to 26.927 and over
www.hertsdirect.orgSmoking 10%Diet/Exercise 10%Alcohol use 5%Poor sexual health5%HealthBehaviours30%Education 10%Employment10%Income 10%Family/SocialSupport 5%CommunitySafety 5%Socioeconomic Factors 40%Access to care10%Quality of care10%Clinical Care20%EnvironmentalQuality 5%Built Environment5%BuiltEnvironment 10%Source: Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute.Used in US to rank counties by health statusWhile this is from a US context it does have significant resonance with UK Evidence, though I wouldwant to increase the contribution of housing to health outcomes from a UK perspective.
www.hertsdirect.org• Best start in life – conception, weight, vaccs,imms• Readiness for school• Good Housing• Resilient Childhood, Resilient Adulthood• Into employment and education• Lifestyle in working age• Self management in older ageWork for us all here!
www.hertsdirect.orgIncreasing deprivationTarget health outcomeAmount ofintervention neededto get everyone totarget levelCurrent level ofhealth outcomeHigh level ofdeprivationLow level of healthLow level ofdeprivationHigh level of health
www.hertsdirect.orgYears0 1 5 10 15PlanningEducationVitaminSupplementsAir PollutionDecentHomesJobsPrimaryCare20CVDEventsSelf CareVitamin D and TBRicketsCVD EventsAcute Bronchitis AdmissionsRespiratoryMental Health overcrowding educational attainmentLife ExpectancyHealthier space use Changing culture of activityLife ExpectancyMental Health
www.hertsdirect.org• A strong role for every agency• A need to rethink what the specialists bits ofpublic health have done and what they do infuture• A need to rethink how we transform ourselvesinto public health agencies• Everyone has a PH role
www.hertsdirect.orgExamplesEqualities• Systematic review in WestMidlands of LGBT populationfound• New migrant populations arenot always good at accessinghealth care servicesHealth Inequalities• Young gay men self-harm atten times the rate of the rest ofthe population• Late maternity booking andperinatal mortality among somenew migrant populations
www.hertsdirect.orgPerverse outcomes...• Interventions designed to reduce HealthInequalities but cause them– Uptake of cancer screening varies by class,so does smoking. Those most at risk accessscreening least!• Uptake of cancer screening• Uptake of diabetic retinopathy screening• Call and Recall for treatment
www.hertsdirect.orgThe upshot of this unless we do something is that2/3 of people will be in chronic ill health or disabilitybefore age 68, the new retirement age
www.hertsdirect.orgAnd Hertfordshire shows the same pattern!
www.hertsdirect.orgWhy lifestyle alone will not eliminate healthinequalities 1• Lifestyle is not sufficient – environment, genetic, lifecourseinfluences• It’s too late for some people – those who have disease already –while lifestyle will help manage disease and health they will needtreatment• It will be ten to fifteen years before lifestyle effects sustainedpopulation change. Meanwhile people will still need treatment• Lifestyle is not enough for some people at high risk – othertreatments are needed to• Some risks are not amenable to lifestyle interventions for (e.g.immunosuppresion; infectious diseases which make up 16% ofBirmingham’s deaths)Healthy lifestyle is necessary but not sufficient of itself for significantReduction of health inequalities
www.hertsdirect.orgWhat should HCC and HWBB do?1. Understand the populations of identity andgeography and work to ensure their healthoutcomes are understood2. Commission and provide with knowledge of whatthose populations seek for optimal care3. Audit programmes for equity and inequality andmake adjustments4. Consider whether any populations need specificclinics/interventions
www.hertsdirect.orgThe Big Tasks – a 15 year agenda• Short term challenge of tertiary prevention• Medium term problem of keeping the ill well• Short term problem of stopping avoidableevents• Long term problem of changing determinants ofhealth, health expectations, behaviour andculture
www.hertsdirect.org2011 Census – Hertfordshire Projected Population Change