Reducing health inequalities: System, scale and sustainability
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This resource identifies necessary steps to ensure a strategic approach to reduce health inequalities and to measurably improve health outcomes.
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Reducing health inequalities: System, scale and sustainability
- 1. Reducing health inequalities: System, scale and sustainability A resource to support local action to reduce health inequalities
- 2. About this resource • This resource identifies necessary steps to ensure a strategic approach to reduce health inequalities and to measurably improve health outcomes. • The slide set is an accompanying resource to ‘Reducing health inequalities: system, scale and sustainability1’, a refresh and update of the original DH Health Inequalities National Support Team (HINST) publication, ‘Systematically addressing health inequalities’2. • Audiences for this resource include local authority leaders, chief executives and other senior officers and councillors, as well as Directors of Public Health, public health specialists and practitioners and health service commissioners. 2 Reducing health inequalities: System, scale and sustainability
- 3. What are health inequalities? Health inequalities are systematic, avoidable and unjust differences in health and wellbeing between groups of people 3 Reducing health inequalities: System, scale and sustainability Around each individual are various layers of influences on health (‘determinants’), such as lifestyle, community networks, living and working conditions - including access to services - and socio- economic conditions. Health inequalities are the result of inequalities in these determinants of health. Dahlgren and Whitehead, 1991
- 4. Why intervene to reduce health inequalities? • Wide inequalities in life expectancy exist between the most and least deprived areas of England, with a difference of 9.2 years for men and 7.0 years for women3. • People living in the least deprived areas live around 20 years longer in good health than those in the most deprived areas4 • Health inequalities account for productivity losses of £31-33 billion per year, and lost taxes and higher welfare payments in the range of £20-32 billion per year. NHS healthcare costs associated with inequality are in excess of £5.5 billion per year5 4 Reducing health inequalities: System, scale and sustainability
- 5. Why intervene to reduce health inequalities? • The SoS, NHS England and CCGs have a legal duty to have regard to the need to reduce health inequalities in access to and outcomes from health services (Health and Social Care Act 2012) • Reducing the health and wellbeing gap is a key aim of the NHS Five Year Forward View; it warns that if prevention is not taken seriously, the burden of ill health will increase and health inequalities will widen • Objective 1 of the Government mandate to the NHS is, through better commissioning, to improve local and national health outcomes, and reduce health inequalities 5 Reducing health inequalities: System, scale and sustainability
- 6. Interventions to reduce health inequalities We can think about interventions to reduce health inequalities in a number of ways. For example: • Intervening at different levels of risk • Intervening for impact over time • Intervening across the life course However, to have real impact, interventions need to be at scale in order to reach large sections of the population 6 Reducing health inequalities: System, scale and sustainability
- 7. Interventions at different levels of risk 7 Reducing health inequalities: System, scale and sustainability Physiological Risks • High blood pressure, high cholesterol Behavioural Risks • Smoking, poor diet, lack of exercise, excess alcohol Psycho-social Risks • Isolation, low self esteem, poor social networks Risk Conditions (wider determinants) • Poverty, unemployment, poor educational attainment It is important that health inequalities strategies contain population level actions at each level of risk, to impact at a sufficient and sustainable scale
- 8. Interventions for impact over time 8 Reducing health inequalities: System, scale and sustainability Different types of intervention will have different impacts over different time periods 20252020 2030 2035
- 9. Interventions across the life course 9 Reducing health inequalities: System, scale and sustainability A life course approach means that action to reduce health inequalities starts before birth and continues through to old age Source: The Marmot Review (2010)
- 10. Interventions should be: • Evidence based – concentrate on interventions where research evidence and professional consensus are strongest • Outcomes orientated – with locally owned and relevant measurements • Systematically applied – not depending on exceptional circumstances or exceptional champions • Scaled-up appropriately – ‘industrial-scale’ processes require different thinking to small ‘bench experiments’ • Appropriately resourced – refocussed on core budgets and services rather than short bursts of project funding • Sustainable – continue for the long haul, capitalising on changing policy priorities where helpful 10 Reducing health inequalities: System, scale and sustainability
- 11. Population Intervention Triangle 11 Reducing health inequalities: System, scale and sustainability Civic-level interventions Service-based interventions Community-based interventions
- 12. Civic interventions • Public policy drives the social determinants of health and wellbeing e.g., transport, education, employment and the built environment • Acting to mitigate the structural obstacles to good health through civic action is a vital method of reducing health inequalities. This includes use of legislation, regulation, taxation and licensing within devolved local powers. • Action on improving this level of intervention needs to be targeted appropriately, in order to reach all relevant parts of the population • Adopting a Health in All Policies6 approach can support local public sector agencies to embed action on health inequalities across their wide ranging functions 12 Reducing health inequalities: System, scale and sustainability
- 13. Community-based interventions • The quality of community life, social support and social networks are major influences on individual and population health. • Local action on inequalities can be supported by: strengthening local communities and social networks; building capacity for people to be involved in community champion, peer support or similar roles; developing strong collaborative / partnership relationships; providing access to community resources • Civic structures and processes need to reach out to support and promote all communities and excluded groups, not just those with existing leadership, infrastructures and resources • Involving communities may also improve service reach and uptake by breaking down barriers to using services 13 Reducing health inequalities: System, scale and sustainability
- 14. Community centred approaches 14 Reducing health inequalities: System, scale and sustainability The family of approaches, adaptable to local circumstances and priorities. They are is not a set of mutually exclusive categories; many programmes will include multiple components Source: South, 2015
- 15. Service-based interventions • Quality services producing good outcomes at individual level - delivered with sufficient system and scale - can add up to population level change • Variability in the delivery and uptake of services can exacerbate health inequalities. Ensuring equitable access to (and outcomes from) service-based interventions is key. • Effective service based interventions work better with the combined input of civic and community interventions, e.g. a tobacco control strategy will include civic regulation on smoking in public spaces, and contraband sales; support to community campaigns and smoking policies in workplaces; smoking cessation services • The population outcomes through services (POTS) framework can support the planning and review of service based interventions to tackle health inequalities 15 Reducing health inequalities: System, scale and sustainability
- 16. 16 Reducing health inequalities: System, scale and sustainability Population outcomes through services framework Elements in the quality provision of services Elements in the robust planning of services Challenging, credible and measurable outcomes, agreed by key stakeholders
- 17. Place-based systems Place-based systems7 are well positioned to achieve optimal population level change where: • Strong partnerships – involving public, private and voluntary sectors – support integrated structures, governance and funding • Vision and strategy draws on shared intelligence and a bottom-up understanding of community needs and assets • Plans, programmes and services are co-produced, enhancing possibilities for multifaceted approaches to reducing health inequalities • Realistic but challenging goals are set, establishing the means, dimensions and timescales for change. 17 Reducing health inequalities: System, scale and sustainability
- 18. Tools to support local action A range of tools, data and resources are available to support a systematic approach to reducing inequalities in life expectancy and healthy life expectancy: a. assessing health inequalities – e.g. Public Health Outcomes Framework, Segment Tool, Local Health Tool b. effectiveness of actions and interventions – e.g. PHE local action on health inequalities resources, Health in All Policies c. cost effectiveness – e.g. CVD Prevention Opportunities Tool, Return on Investment Tool: Colorectal Cancer, Spend and Outcomes Tool 18 Reducing health inequalities: System, scale and sustainability
- 19. Summary • We can intervene to reduce health inequalities in a number of ways, however, to have a real impact, interventions need to be at scale in order to reach large groups of the population • Population level interventions that are multifaceted and complementary are more likely to be successful in reducing inequalities • An engaged leadership that considers reducing health inequalities as key to delivery of first level priorities is critical, as it needs to be built into local vision and strategy, and integrated with other key policy areas • Place-based systems are well positioned to achieve the population level change required to reduce inequalities. • A range of online tools and resources have been developed by PHE to support local action on health inequalities. 19 Reducing health inequalities: System, scale and sustainability
Editor's Notes
- Slide pack developed by Donna Carr, Head of Health Equity Health Equity Team Public Health England health.equity@phe.gov.uk © Crown copyright 2017 You may re-use this information (excluding logos) free of charge in any format or medium, under the terms of the Open Government Licence v3.0. To view this licence, visit OGL - https://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/ - or email psi@nationalarchives.gsi.gov.uk. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.
- This resource has been produced to support local action to tackle health inequalities, by helping local partners to identify the necessary steps to ensure a strategic approach to reduce health inequalities and to measurably improve health outcomes. It is a refresh and update of the original DH Health Inequalities National Support Team (HINST) publication, ‘Systematically addressing health inequalities’. The principles and conceptual frameworks that evolved with the HINST are still relevant and when pulled together with current tools and evidence and applied to the current system, form a resource that can be used by localities to plan their approach to reducing health inequalities effectively at scale. References: [DN: Link to main document once online] ‘Systematically addressing health inequalities is archived online at http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/%40dh/%40en/documents/digitalasset/dh_086573.pdf
- Our health is not just determined by the healthcare we receive; it is also determined by our genetics, our lifestyle, our social and community networks and the impact of wider social, economic and environmental determinants, such as education, employment and housing. This well known diagram developed by Dahlgren and Whitehead (1991) maps this relationship between the individual, their environment and health. Health inequalities – the avoidable and unfair differences in health status between groups of people or communities - arise as a result of the unequal distribution of the determinants of health. Therefore, action to reduce health inequalities requires action across the wider determinants of health. Reference: Dahlgren, G. & Whitehead, M. (1991) Policies and strategies to promote social equity in health. Stockholm: Institute for future studies Source: NHS Education for Scotland (2011) Bridging the Gap: Introducing the Wider Determinants of Health - http://www.bridgingthegap.scot.nhs.uk/understanding-health-inequalities/introducing-the-wider-determinants-of-health.aspx
- Why intervene to reduce health inequalities? Firstly, reducing health inequalities is a matter of fairness and social justice (Marmot, 2010). Health inequalities hit the most deprived communities hardest. For example: Wide inequalities in life expectancy exist between the most and least deprived areas of England, with a difference of 9.2 years for men and 7.0 years for women. People living in the least deprived areas live around 20 years longer in good health than those in the most deprived areas Reducing health inequalities can contribute to improved productivity and reduced healthcare costs. Health inequalities account for productivity losses of £31-33 billion per year and NHS healthcare costs associated with inequality are in excess of £5.5 billion per year References: 3. Source: PHOF Health Equity Report – https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/627317/PHOF_Health_Equity_Report_July_11_2017_FINAL_v2.pdf 4. Source: PHOF Health Equity Report – https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/627317/PHOF_Health_Equity_Report_July_11_2017_FINAL_v2.pdf 5. Source: Marmot M et al. (2010) Fair Society Healthy Lives (The Marmot Review) - http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review
- FOR NHS AUDIENCES – please delete slide if not required There are also healthcare legislation and policy drivers for reducing health inequalities. The Secretary of State, NHS England and clinical commissioning groups (CCGs) all have a legal duty under the Health and Social Care Act 2012 to have regard to the need to reduce health inequalities in access to health services and health outcomes. Consciously considering how to reduce health inequalities should be an integral step in planning and delivering healthcare services. The legislation also enables NHS England and CCGs to provide health and care services in an integrated way where they consider that this would improve quality, reduce inequalities in access to those services or reduce inequalities in the outcomes achieved. The NHS Five Year Forward View sets out what needs to change over the next five years if the health service is to close the widening gaps in the health of the population, quality of care and the funding of services. One of its central aims is reducing the ’health and wellbeing gap’ with a renewed focus on prevention. The government sets out its annual objectives, budget and any requirements for the NHS in its mandate for NHS England. Objective 1 of the mandate states that the NHS must, through better commissioning, improve local and national health outcomes, particularly by addressing poor outcomes and inequalities. Progress against this objective will be measured across both CCG and Sustainability and Transformation Plan (STP) areas References: Health and Social Care Act 2012 - http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted NHS Five Year Forward View (2014) - https://www.england.nhs.uk/five-year-forward-view/ NHS Mandate 2017-18 - https://www.gov.uk/government/publications/nhs-mandate-2017-to-2018
- We can think about interventions to reduce health inequalities in a number of ways. For example: Intervening at different levels of risk Intervening for impact over time Intervening across the life course However, to have real impact, interventions need to be at scale in order to reach large sections of the population
- People can experience different levels of risk of poor health: physiological risk such as high blood pressure or high cholesterol; behavioural risk such as smoking or lack of physical exercise; psycho-social risks such as poor social networks and low self-esteem. They also experience different levels of exposure to risk conditions, such as poverty, unemployment and poor educational attainment. All these levels of risk interconnect, one very often leading to the other. It is important that health inequalities’ strategies contain population level actions at each level of risk, to ensure sustained impact at sufficient scale. Labels A, B and C represents the type of actions that can be taken at each level of risk to improve health and reduce inequalities A: action to improve ‘the causes of the causes’ such as increasing access to good work, improving skills, social networks, housing and the provision and quality of green space and other public spaces B: action to improve the causes such as increasing positive health behaviours such as stopping smoking, a healthy diet and following guidelines for drinking alcohol and recommended levels of physical activity C: action to improve the provision of and access to healthcare such as ensuring NHS Health Checks are implemented at scale and targeted at those with the greatest need. Note: ‘the causes of the causes’ - those things over which people may have little control, such as public space, poor housing, unemployment, which can lead to behaviours and lifestyle that impact on their health (The Marmot Review, 2010)
- Different types of actions will have different impact over different time periods. For each substantial population level outcome, it is important to be aware of realistic timescales for measurable impact. Interventions at levels to improve ‘the causes of the causes’ and health behaviours (A and B) may take longer to impact on mortality but potentially they will have wider additional benefits such as better education outcomes, improved social networks, reduction in harmful alcohol use. However, to achieve reduction in inequalities they must be delivered systematically at sufficient scale and with long term sustainability. Interventions based on the provision and access to healthcare (C), such as medication to manage hypertension, will have a more immediate impact as well as bringing longer term health improvements.
- A life course approach means that action to reduce health inequalities should starts before birth (prenatal) and continue through to retirement and old age. In 2010, the Marmot Review identified six policy areas for action across the life course: 1. Give every child the best start in life 2. Enable all children, young people and adults to maximise their capabilities and have control over their lives 3. Create fair employment and good work for all 4. Ensure healthy standard of living for all 5. Create and develop healthy and sustainable places and communities 6. Strengthen the role and impact of ill health prevention The diagram illustrates how disadvantage (and advantage) can start at birth and accumulate throughout life. The review stressed therefore that the first policy area of giving every child the best start in life was the most critical, as this action can break the close link between early disadvantage and poor outcomes. There is also much that can be done to improve the health outcomes of children of school age, younger people in education and training, working adults and older people. Interventions that promote good health, prevent ill health and improve the wider determinants of health can reduce health inequalities at later stages of the life course. Note: Public Health England has worked with the Institute of Health Equity (authors of the Marmot Review) to develop evidence reviews and resources to support local action to reduce health inequalities at all stages of the life course. Local action on health inequalities: evidence papers – https://www.gov.uk/government/publications/local-action-on-health-inequalities-evidence-papers Local action on health inequalities: practice resources - https://www.gov.uk/government/collections/local-action-on-health-inequalities-practice-resources References: Marmot M (2010) Fair Society, Healthy Lives (The Marmot Review) - http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review
- Whether interventions are at different levels of risk, impact differently over time or intervene across different aspects of the life course, it is suggested that an intervention should meet the following criteria: Evidence based – concentrate on interventions where research evidence and professional consensus are strongest Outcomes orientated – with locally owned and relevant metrics Systematically applied – not depending on exceptional circumstances or exceptional champions Scaled-up appropriately – ‘industrial-scale’ processes require different thinking to small ‘bench experiments’ Appropriately resourced – refocussed on core budgets and services rather than short bursts of project funding Sustainable – continue for the long haul, capitalising on changing policy priorities where helpful
- Population level interventions that are multifaceted and complementary are more likely to be successful in reducing health inequalities. Three such facets are civic, community and service based interventions. These elements can have an impact in isolation, but are likely to be more effective in combination with each other. Central to successful population level intervention is engaged leadership and robust partnership arrangements, where reducing health inequalities is built into local vision and strategy, and integrated with other high-level priorities.
- Note: Health in All Policies is a collaborative approach to improving the health – and the wider determinants of health - of all people by incorporating health considerations into decision making across sectors, policy and service areas. References: 6. Public Health England and Local Government Association (2016) Local wellbeing, local growth: Adopting a Health in All Policies approach - https://www.gov.uk/government/publications/local-wellbeing-local-growth-adopting-health-in-all-policies
- Commissioners and anyone involved in local strategic planning can use the family of community centred approaches to develop a whole system way of working with communities. This means developing action across all four strands: strengthening local communities and social networks building capacity for local people to be involved as community champions/connectors, peer support workers etc involving local communities in priority setting, programme/service design and evaluation making sure there is good access for individuals and groups most at risk of poor health to connect into local activities and sources of support in their area. A first stage of developing a whole system could be mapping what is already happening and identifying community-based organisations, networks and other local assets. Using this family of approaches can help identify where there are gaps and the evidence based options for partnership work with communities. References: South J (2015) Health and well-being: a guide to community centred approaches - https://www.gov.uk/government/publications/health-and-wellbeing-a-guide-to-community-centred-approaches
- This framework can support the systematic delivery of the best health outcomes from a given set of interventions. It is based on the central assumption that the aim is to achieve optimal health outcomes at population level, while working to reduce health inequalities. The framework identifies a number of steps involved in delivering a set of interventions that contribute to a specific outcome, e.g. reducing heart disease mortality or reducing seasonal excess deaths. While it is possible to start at any point on the framework it is important to complete all the steps. The five components on the right hand side of the framework are important elements involved in the quality provision of services. The five components on the left hand side outline the planning required for the population to effectively use, and be supported to use, the available services. Equal consideration should be given to action on both sides of the framework. The two sides of the framework are brought together around a strong central core of components that influence how commissioners and their providers will balance and co-ordinate need and supply. Note: Detail on each section of the population outcomes through services (POTS) framework can be found on page X of the main document, ‘Reducing health inequalities: system, scale and sustainability’ – [DN: link to follow] Credit: Michael Heasman, Public Health Data Science, PHE for production of the POTS framework diagram. Based on the original concept created by Chris Bentley as included in ‘Systematically addressing health inequalities’ - http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/%40dh/%40en/documents/digitalasset/dh_086573.pdf
- A system for health and wellbeing demands a broader focus than healthcare services. This means that a truly joined-up agenda for health and care cannot stop at the boundaries of NHS-funded and social care-commissioned services; we need to broaden the focus of health to include the wider functions of local government, the third sector, business and social enterprise, housing providers, education and other services. By integrating these services across a geographical area, we can remodel the system to better tackle the drivers of poor health and inequality and ensure sustainability for the future. Place based systems can take a many forms, such as a local authority, sustainability and transformation partnership (STP), combined authority (e.g. Manchester). A place based system is well positioned to achieve optimal population level change where: Strong partnerships – involving public, private and voluntary sectors – support integrated structures, governance and funding Vision and strategy draws on shared intelligence and bottom-up understanding community needs and assets Plans, programmes and services are co-produced, enhancing possibilities for multifaceted approaches to reducing health inequalities Realistic but challenging goals are set, establishing the means, dimensions and timescales for change. At the heart of a place-based approach are people and communities. By working collaboratively with people, commissioners and providers of local services can develop systems ‘bottom up’ from a local perspective, rather than a ‘top down’ view that tends to focus on the deficits of a locality, rather than its assets. References: 7. The journey to place-based health - https://publichealthmatters.blog.gov.uk/2016/03/17/the-journey-to-place-based-health/
- Note: More details on specific tools, data and resources can be found on page X of the main document, ‘Reducing health inequalities: system, scale and sustainability’ – [DN: link to follow]