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Place-based approaches for reducing health inequalities

  1. Place Based Approaches for Reducing Health Inequalities: Summary and examples of how to use a place-based approach to reduce health inequalities
  2. Part 1 Executive Summary of Place-Based Approaches for Reducing Health Inequalities 2
  3. What are health inequalities? 3 Health inequalities are unfair and avoidable differences in health across the population, and between different groups within society. Health inequalities arise because of the conditions in which we are born, grow, live, work and age. These conditions influence our opportunities for good health, and how we think, feel and act, and this shapes our mental health, physical health and wellbeing. Health inequalities have been documented between population groups across at least four dimensions, as illustrated to the right. Action on health inequalities requires improving the lives of those with the worst health outcomes, fastest. Socio- economic/ Deprivation e.g. unemployed, low income, deprived areas Equality and diversity e.g. age, sex, race Inclusion health e.g. homeless people; Gypsy, Roma and Travellers; Sex Workers; vulnerable migrants Geography e.g. urban, rural. Dimensions of health inequalities
  4. The causes of health inequalities This adapted Labonte model1 simplifies the complex system that causes health inequalities. • It shows the different factors that impact our health; where they stem from; and how – both in sequence and simultaneously – they interact, multiply and re-enforce each other. 4 Health and Wellbeing Wider determinants of health • Income and debt • Employment / quality of work • Education and skills • Housing • Natural and built environment • Access to goods / services • Power and discrimination Psycho-social factors • Isolation • Social support • Social networks • Self-esteem and self-worth • Perceived level of control • Meaning/purpose of life Physiological impacts • High blood pressure • High cholesterol • Anxiety/depression Health behaviours • Smoking • Diet • Alcohol
  5. 5 Why we must act to reduce health inequalities Moral reason: • 9.4 year (males) and 7.4 year (females) gap in life expectancy between most/least deprived areas3. This gap is growing. • • People in the most deprived areas spend nearly 1/3 of their lives in poor health, compared to 1/6 in the least deprived areas4 Economic burden: • Marmot Review estimated that health inequalities cost society £31bn in lost production pa to localand national economies1 • • Higher burden of disease in most deprived neighbourhoods costs NHS 22% more per woman and 16% per man2, than in least deprived areas Legal and institutional requirements: • CCGs and Local Authorities face legal duties to have regard to reduce health inequalities5   • • The NHS Long Term Plan requires every local area to develop targets and plans for health inequalities6 •
  6. Part 2 Population Intervention Triangle: A Framework to Support Place-Based Action on Health Inequalities 6
  7. Place-based guidance for health inequalities: Population Intervention Triangle (PIT) 7 • PIT1 shows the main components of place-based interventions: civic, community and service interventions • Each have the potential to independently make a quantifiable change to population-level measures Place-based planning Civic-led interventions Service-based interventions Community-centered interventions
  8. The three apices of PIT 8 Deliberate joint working between the civic, service and community sectors can help the whole be more than the sum of its parts. Community-centred interventions focus on place and shared identity. They centre on community life, social connections, and ensuring people have a voice in local decision- making. Service-based interventions focus on services, in particular addressing unwarranted variability in quality, delivery and use. Civic-level interventions focus on the wide-ranging policy functions that impact populations. Place-based planning Civic-led interventions Service-based interventions Community-centered interventions
  9. Contents of next section to bring PIT to life 9 The issue Why it matters The cost Example of intervention across PIT
  10. 1. Early Years and Education 10 Educational attainment is the most important predictor of poverty in adulthood. It has a strong socio-economic gradient. THE ISSUE Pupils eligible for free school meals had an average Attainment 81 score of 34, lower than the average of 48 for pupils not eligible for free school meals2 42% of working-age adults have limited health literacy (rising to up to 6 in 10 adults when numeracy skills are required) and cannot understand and make use of everyday health information3
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  12. 12 Examples of place-based interventions CIVIC SERV COM Local Authorities can support schools – particularly in deprived areas – to deliver appropriate Relationship and Sex Education/Personal, Social Health and Economic Education to support reduction of risky environments and behaviours Public services can take a public health approach to support children and young people, known to the criminal justice system, to continue in education Health visitors, early years and speech and language practitioners in deprived areas can help strengthen development of speech, language and communication skills during early years2 Local Authorities and VCSE organisations can raise educational aspirations through mentoring schemes for vulnerable and under achieving pupils, and support parents to provide a positive home learning environment. Local Authority Public Health teams and school nurses can support teachers to take a whole school approach1 to health and wellbeing, to provide a positive and inclusive learning environment for vulnerable pupils • Health and Wellbeing Boards to support children and young people to fulfil their educational potential
  13. 2. Employment and Income 13 People with lower socio-economic status are at higher risk of unemployment and poor quality work – including insufficient pay – which can negatively affect physical and mental health THE ISSUE 60% of people of all ages living in poverty are living in working households1. Insufficient pay, limited hours of work, and a low number of workers in a household can contribute to in-work poverty
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  15. 15 CIVIC SERV COM Local Authorities and NHS can lead by example by paying staff a living wage. They can promote good quality work through advice, enforcing employer legal obligations, partnership working, incentivisation and use of contractual levels using the Social Value Act 20121 Local Authorities can ensure employment service providers are members of Health & Wellbeing Boards and participate in Joint Strategic Needs Assessments2 Unemployment services e.g. JobCentre Plus, can provide personalised tailored support to help people with long-term conditions and disabilities into work or training VCSE sector and business organisations can help employers to understand employee rights, empower vulnerable individuals and build resilience • Businesses and employers can use tools e.g. Health Impact Assessment3, Health Needs Assessment4 to gather information about the health of their workforce, and set a baseline to track progress against Expanded provision of childcare, with potential support from the VCSE sector, to help enable people to work additional hours Examples of place-based interventions
  16. 3. Access to services 23 • The lower access and use of primary care and subsequent higher use of emergency care is more likely in deprived areas, leading to poorer health outcomes and high costs for the NHS. • • The current model of healthcare, including provision, does not match the greater burden of need in deprived areas Distribution of elective and emergency care by deprivation1 Distribution of screening take up and detection of aneurysms by deprivation2 THE ISSUE
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  18. 18 CIVIC COM Primary care providers can support self-management services, such as health coaching and peer support groups. Embed social prescribing pathways into ambulatory care and community health care services to help tackle the wider determinants of health. Primary Care Networks, Population Health Management programmes and MECC approaches can help identify, and support, people who need targeted support. Closer integration and collaboration with VCSE sector providers and communities themselves may help to design better services for vulnerable groups Community services and primary care providers can explore different approaches to access such as online and telephone consultations, and use of workplace, community centres, gyms Post Offices2, and supermarkets for opportunistic detection SERV Examples of place-based interventions Local Authorities, GPs, pharmacists and CCGs can increase access to and uptake of early detection; offer population lifestyle programmes; enhance health literacy; and improve uptake of the NHS Health Check in deprived areas1
  19. 4. Housing 26 • Households with relative low income are more likely than other households to live in poor housing (34% compared with 25%)1 • • Poor housing includes: • Unhealthy homes (damp, cold, hazardous) • Unsuitable homes (overcrowded, inaccessible) • Unstable housing (precarious living circumstances) • • 11% of households are fuel poor in England3. • Housing-related ill-health is particularly high in people living in private rented homes. 19% of all homes are classified as non-decent; and 25% in the private rented sector4. THE ISSUE
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  21. 21 CIVIC SERV COM Health & Wellbeing Boards to commission or set up a single-point- of-contact health and housing referral service to resolve problems that are affecting people’s health, as per NG61 NHS, Local Authorities, and other organisations can build capacity among front line workers (e.g. faith, voluntary and social care) and Allied Health Professionals3 to identify people at risk of unhealthy, unstable and unsuitable housing; and refer them to local services designed to address these problems Local Authorities can use selective licensing and the HHSRS4 to address housing problems in the private rented sector, including defining renting conditions for houses in multiple occupation. • Primary health and home care service providers can work with relevant local authority partners to identify people who live in cold or hard-to-heat homes, including through the Make Every Contact Count (MECC) and MECC Plus Approach2. • Building control officers, housing officers, environmental health officers and trading standards officers can maximise effort to ensure current, and future, buildings meet ventilation and other building and trading standards. Examples of place-based interventions
  22. 22 5. Air Pollution • Air pollution affects everyone, but there are inequalities in exposure, with the greatest impact in the most deprived areas. • 433 of London’s 1,777 primary schools were in areas which breached European Union limits for NO2. 83% were considered deprived schools, with over 40% of pupils on free school meals1 THE ISSUE
  23. 23 CIVIC SERV COM Local Authorities1 can set low emission or clean air zones, boost investment in clean public transport, and encourage uptake of low emission vehicles by setting higher targets for electric car charging points. Local Authorities can redesign cities so people do not live close to highly polluting roads, and develop foot and cycle paths. All major organisation in any place, including the private sector, NHS and Local Authorities, can minimise the air pollution they create through their operations e.g. using low emission vehicles. All professionals play a key-role in increasing understanding among patients/public about the health effects of air pollution, and how to reduce exposure and manage conditions2. Primary care practitioners can understand the health impacts of air pollution, identify and support vulnerable individuals who might be affected.3 CCGs can champion action on air pollution by public health and local government through Joint Health and Wellbeing Strategy.3 Community organisations can support car sharing schemes. Industry can work together to reduce the impact of air pollution created by economic development.3 Examples of Place-based interventions
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  25. Part 3 Summary and Links to Additional Resources 25
  26. Summary 26 • Tackling health inequalities requires a joined-up, place-based response which co- ordinates and capitalises on different institutions’ actions across the system. • • The Population Intervention Triangle (PIT) provides a framework for co-ordinating this action, and enabling it to reach large scale populations that face the greatest burden of disease • • This action will not only improve people’s lives, but can save the NHS, social care, and the national and local economy billions of pounds • • PHE, ADPH and the LGA have developed guidance and tools to support local areas implement a place based approach to health inequalities using the PIT as a framework. Further resources can be found here. • • PHE has supported NHS-E to develop the Menu of Evidence Based Interventions for Health Inequalities to assist local areas implement the NHS Long Term Plan. This includes recommendations for interventions that can support local areas reduce inequalities which is informed by this approach. • • Please contact for further information on this suite of products, including how we can work with your team to support their use
  27. Links to Additional Resources 27 4. Data pack for ICSs on inequalities 3. Live repository of case-studies 2. Self- assessment guides for place-based action on inequalities 1. Main Document – ‘Place Based Approaches for Health Inequalities’ 5. NHS-E’s Menu of Evidence Based Interventions for Health Inequalities
  28. Local NHS and PHE data resources to prioritise action on health inequalities: 28 Examine the key factors driving inequalities across the full causal pathway including conditions, behaviours and wider determinants Consider care pathways relevant to care priorities. Look to other systems with similar populations but better outcomes Identify priorities for local area using measure of burden/ risk factors Consider comparators, national standards or local targets to estimate relative size of gaps Examine within-area inequalities e.g. GBD burdens or local information on health or social care service use e.g. other similar local authorities or CCGs e.g. LKIS slide sets, NHS RightCare Inequalities Packs and the Health Equity Dashboard e.g. Segment Tool, Atlases of Variation, Health Equity Dashboard, Wider Determinants Tool e.g. RightCare Inequalities Packs and LKIS slide sets
  29. 29 Table of Further Resources on Evidence and Action on Inequalities ●Physi cal and mental health conditi ons ●Health condition ●Improving access for all: reducing inequalities in access to general practice services (NHS, 2017) ●Reducing Health Inequalities Through New Models of Care (UCL, 2018) ●Improving Health Literacy (PHE, 2015) ●Local Health and Care Planning: Menu of Preventative Interventions (PHE, 2016) Health Matters: Reducing health inequalities in mental illness (PHE, 2018) Cardiovascular Disease: Identifying and supporting people most at risk of dying early (NICE, 2008) ●Population health framework for healthcare providers (Provider Public Health Network, 2019)
  30. 30 ●C aus es ●Smoking ●Smokeless Tobacco: South Asian Communities(NICE, 2012) ●Behaviour Change: Individual Approaches (NICE, 2014) Towards asmokefreegeneration: a tobacco control plan for England (PHE, 2017) ●CLeaRlocal tobacco control assessment(PHE, 2014) ● ●Poor Diet/Lack of activity ●Health Equity Pilot Project (HEPP) Scientific report on evidence based interventions to reduce socio-econom (European Commission, 2017) ●Health Inequalities: dietary and physical activity-related determinants (European Commission Science Hub) ●Obesity and inequities. Guidance for addressing inequities in overweight and obesity (WHO, 2014) ●BMI: Preventing ill health and premature death in black, Asian and other minority ethnic groups (NICE, 2013) ●Obesity: Working with local communities(NICE, 2017) ●Substance misuse ●Alcohol and inequities. Guidance for addressing inequities in alcohol-related harm (WHO, 2014) ● ●Alcohol, drugs and tobacco commissioning support: principles and indicators (PHE, 2018) ● ●Local alcohol services and systems improvement tool (PHE, 2017 ● ●Drug misuse prevention: targeted interventions [NG64] (NICE, 2017) ● ●Coexisting severe mental illness and substance misuse: community health and social care services [NG58] (NICE, 2016) ●
  31. 31 ●C a us es of th e C a us es ●Psychosocial risks: ●Health and wellbeing: a guide to community-centred approaches (PHE, 2015) ●Health matters: community-centred approaches for health and wellbeing (PHE, 2015) Psychosocial Pathways and Health Outcomes (PHE & UCL, 2017) ●Community Engagement: Improving health and wellbeing and reducing inequalities (NICE, 2014) ●Wider determinants: ●Local wellbeing, local growth: adopting Health in All Policies (PHE, 2016) ●Health in All Policies a manual for local government (LGA, 2016) ●Reducing health inequalities: system, scale and sustainability (PHE, 2017) ●Tackling health inequalities through action on the social determinants of health: lessons from experie (PHE & UCL, 2014) ●Poverty ●Health inequalities and the living wage (PHE & UCL, 2014) ●Law ● ●Using the Social Value Act (PHE & UCL, 2015) ●
  32. 32 ●Educational attainment ●Improving Resilience in Schools (PHE & UCL, 2014) ●Reducing the number of young people not in employment, education or training (NEET) (PHE & UCL, 2014) ●Social and emotional wellbeing in primary education(NICE, 2008) ●Social and emotional wellbeing in secondary education (NICE, 2009) ●Work Promoting good quality jobs (PHE & UCL, 2015) ●Increasing employment opportunities and retention for older people (PHE & UCL, 2014) ●PHE/BITC Toolkits ● ●Environment ●Fuel poverty and cold home related health problems (PHE & UCL, 2014) ●Improving Access to Green Spaces (PHE & UCL, 2014) ●Excess winter deaths and illness and the health risks associated with cold homes (NICE, 2015) ●Reducing Inequities in Early Childhood Mental Health: How Might the Neighbourhood Built Environment He , International Journal of Environmental Research and Public Health, 2019 ●C a us es of th e C a us es
  33. 33 For further information please contact the PHE Health Inequalities team at:

Editor's Notes

  1. (1) Marmot M. Fair society, healthy lives: the Marmot Review: strategic review of health inequalities in England post-2010. 2010.
  2. (1) Adapted from the health promotion model in Labonte, ‘Heart health inequalities in Canada: Models, theory and planning’,Health PromotionInternational, vol. 7, no. 2, pp.121
  3. (1) Marmot M. Fair society, healthy lives: the Marmot Review: strategic review of health inequalities in England post-2010, 2010. (2) Asaria M, Doran T, Cookson R. The costs of inequality: whole-population modelling study of lifetime inpatient hospital costs in the English National Health Service by level of neighbourhood deprivation. Journal of Epidemiology and Community Health. 2016;70(10):990. (3) Public Health England. What’s new in the February 2019 PHOF update? 2019 [Available from:]. (4)Public Health England. Health Profile for England. 2018. (5) These legal duties stem from the 2012 Health and Social Care Act and terms associated with the Public Health Grant. UK Parliament. Health and Social Care Act [Legislation]. 2012: (6)The NHS Long Term Plan, NHS, January 2019,
  4. (1) This updated version builds on the Population Intervention Triangle outlined by Chris Bentley in ’Reducing health inequalities: system, scale and sustainability, PHE, August 2017
  5. (1) Attainment 8 measures the achievement of a pupil across 8 qualifications including mathematics (double weighted) and English (double weighted), 3 further qualifications that count in the English Baccalaureate (EBacc) measure and 3 further qualifications that can be GCSE qualifications (including EBacc subjects) or any other non-GCSE qualifications on the DfE approved list. Each individual grade a pupil achieves is assigned a point score, which is then used to calculate a pupil’s Attainment 8 score. (2) (3), p4
  6. (1) Lamb P, Berry J. Health Literacy – the agenda we cannot afford to ignore: Community Health & Learning Foundation (2014) (2)
  7. An example of a whole school approach to mental wellbeing (2) Law, J., Charlton, J. and Asmussen, K. (2017). Language as a child wellbeing indicator. London: The Early Intervention Foundation. wellbeing-indicator/
  8. ‘In Work Poverty in the UK: Problem, policy analysis and platform for action’, Rod Hick and Alba Lanau, Cardiff University, 2017
  9. (1) (2) (3) (4), (5), (6) (7), Joseph Rowntree Foundation, 2016
  10. Social Value Act 2012 Joint Strategic Needs Assessment (3) Health Impact Assessment (4) Health Needs Assessment
  11. Hospital Admitted Patient Care Activity 2017/18, NHS Digital (September 2018) PHE: Percentage uptake of AAA screening in men and the percentage of aneurysms detected in screened men by IMD 2010 decile: England, 2013/14 to 2014/15. 
  12. (1) Emergency Hospital Admissions in England: which may be avoidable and how?’,The Health Foundation, (2018) p18 (2) (3)Asaria M, Doran T, Cookson R. The costs of inequality: whole-population modelling study of lifetime inpatient hospital costs in the English National Health Service by level of neighbourhood deprivation. Journal of Epidemiology and Community Health. 2016;70(10):990. (4) Kossarova et al., ‘Admissions of inequality: emergency hospital use for children and young people’, 2017 Nuffield Trust
  13. BI pilot project led to improvements of uptake to 12% And PHEBI team produced case studies about the use of weighted remuneration to NHS Health Check providers, to encourage take-up by target groups. Ireland has launched an online GP service from local post offices This is run by a private company called VideoDoc. Aim is to save the local Post Office and increase GP access in remote communities. Patients can access a private medical booth from the Post Office.
  14. (2), (3), Department for Business, Energy and Industrial Strategy, ‘Annual Fuel Poverty Statistics Report, 2018 (2016 Data), England, June 2018. (4) English Housing Survey, Headline Report 2017-18, MHCLG
  15. The Marmot Review Team: The Health Impacts of Cold Homes and Fuel Poverty. Available here: BRE (2015).The cost of poor housing to the NHS[online]. Briefing paper. BRE website. Available at: (accessed on 27 February 2018). ‘The real cost of poor housing’, Building Research Establishment, 2014
  16. Nice Guidance 6: ‘Excess winter deaths and illness and the health risks associated with cold homes’, 2015. Useful tool to help implement NG6: (2) (3) Allied Health Professionals (AHPs) include 12 professions regulated by the Health and Care Professions Council (HCPC) who collectively make up the third largest workforce in the NHS. They work across a range of sectors including health, social care, education, academia, voluntary and private sectors; covering the whole life course. AHPs deliver services to individuals, groups and in some cases specific populations of children and older adults. They work across sectors providing integrated care in health, social care, education, voluntary sector and private settings. (4) HHSRS – Housing Health and Safety Rating System
  17. (1) ‘Analysing Air Pollution Exposure in London: Report to Greater London Authority’, Katie King, Sean Healy, 2013
  18. (1) (2) (3)
  19. ‘Estimation of costs to the NHS and social care due to the health impacts of air pollution’, 2018, p6. ‘Valuing the Impacts of Air Quality on Productivity’, DEFRA, 2014, p2. To estimate the NHS and social care costs for treating health effects, PHE developed a modelling framework to quantify present and future morbidity. PHE’s report, Estimation of costs to the NHS and social care due to the health impacts of air pollution, provides the methods and results of the modelling exercise to quantify: the future incidence and cumulative incidence cases of air pollution related diseases the NHS and social care costs; specifically primary care, prescription, secondary care, and social care, associated with air pollution