This document provides an overview of place-based approaches for reducing health inequalities. It discusses what health inequalities are and their key dimensions and causes. It introduces the Population Intervention Triangle (PIT) framework, which shows how civic, community, and service interventions can independently and jointly impact population health outcomes. Examples are provided of interventions across these three areas for issues like early years education, employment, access to services, housing, and air pollution. Additional resources are referenced that can help local areas implement place-based strategies to reduce health inequalities using the PIT framework.

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

11. 11

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

14. 14

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

17. 24

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

20. 20

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

24. 24

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 health.equity@phe.gov.uk 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 https://wellbeing.bitc.org.uk/tools-impact-stories/toolkits
●https://www.aomrc.org.uk/wp-content/uploads/2019/04/Health-Work_Consensus_Statement_090419.pdf
●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:
health.equity@phe.gov.uk