Circulatory Shock, types and stages, compensatory mechanisms
Health inequalities reduxv3
1. Health inequalities redux
Greg Fell
Director of Public Health Sheffield
Greg.fell@sheffield.gov.uk
@felly500
Thanks to Dave Buck and Mark Gamsu from whom slides are used.
2. Aim of this deck
set out the key points of a series of
HWBB on health inequalities
summary of 5 long blogs
recent history of this in Sheffield
issues highlighted in run up, the
workshops and the follow up
All 5 blogs linked here
https://twitter.com/felly500/status/1014257191933698049
3. 1. Context
2. How do we “do”
3. Current plan and recent HWBB discussions
4. What should we do, evidence led
intervention suggestions
5. Where next, following HWBB discussions
5. The most important pictures in health
policy
https://www.bmj.com/content/360/bmj.k1090/rr-2
https://www.dropbox.com/s/ro703io2d9h6qth/IMR_2016_NSSEC.pdf?dl=0
7. Inequalities in health
Why is there a gap in 2018
access to health care, esp primary care. Focus on
services, not risks and populations
tobacco, alcohol, obesity etc
exposure to environmental and social issues – aka
“the determinants
Belief in an economic system based on
trickledown economics.
https://gregfellpublichealth.wordpress.com/2018/06/26/why-is-there-a-20-year-gap-in-healthy-life-
expectancy-between-best-and-worst-in-2018/
https://twitter.com/felly500/status/1014257191933698049
8. Health inequality is therefore about
• unequal distribution of clinical and lifestyle
risk factors (a small part of which is about
NHS)
• The unequal distribution of social and
environmental risk factors (the determinants)
• The determinants of the determinants
(power, concentration of wealth, dominant
economic model etc.)
9. Strands around equality, poverty,
inequality. Rethink?
• We may have strategies that are partial and disconnected - financial security, community
stability, community coherence - need all to be pulling together.
– HI, Equality, Poverty, inclusive growth. Cover similar space? Inclusicve growth is one
means of talking HI but in a different way and with a different lens.
– Are we conflating and confusing agendas??
– Poverty is not inequality and vice versa.
• Poverty = Where people’s resources are below their minimum needs, and where they
experience material deprivation.
– Can be used as a relative measure of income, it typically refers to families that have less
than 60 percent of national median income.
– Or absolute – income below xxxxxx
• Economic insecurity = harmful volatility in people’s economic circumstances.
– This includes their exposure to objective and perceived risks to their economic well-
being, and their capacity to prepare for, respond to and recover from shocks or adverse
events.
• Inequality examines the relative distribution of resources (in this context often income or
wealth), among social identifiers (such as ethnic groups) or between places (such as regions
or neighbourhoods).
• Can equally apply to crime, education, health, other….
10. Starting point for health inequalities -
this working backward?
Health ≠ the NHS …………
11. Or this forward
The inequitable distribution of these
things is as important as IAPT and EIP…….
12. Well being in a slide
Basically don’t have a crap life
13. Everything is “in”
How far upstream?
Causes of health
inequitable spread of risk
Causes of causes
Inequitable spread of power
Austerity.
Neoliberalism. Global crisis caused by public debt
vs reckless action of financial markets?
Political origins of health inequities: trade and investment agreements
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31013-3/fulltext?rss=yes
Joseph Stiglitz Says Standard Economics Is Wrong. Inequality and Unearned Income Kills the Economy
http://evonomics.com/joseph-stiglitz-inequality-unearned-income/
Ha-Joon Chang | The economic argument against neoliberalism -
https://m.youtube.com/watch?feature=youtu.be&v=ti3rjogF_VU
14. View of a GP working in the “deep
end” on role of GPs
• Holistic care. Continuity and teamwork. Wide
team. Everything is “in”
– HV, DN, H Trainers, wider social infrastructure. Ability
to call on wide range of resources to manage risk, help
people solve problems ensure people don’t fall
through nets
– Trauma informed skills
– Families and Children:- HVs in practices.
– Multimorbidity & Complexity. Ability to call on wide
range of resources to help solve “specialist” generalist
problems
– persistent pain and addiction to prescription drugs
https://gregfellpublichealth.wordpress.com/2018/02/24/view-of-a-gp-working-in-the-deep-
end-on-role-of-gps-addressing-health-inequalities/
15. it remains important
• Social cohesion
• Important factor in the slowing down of improvements in
Life Expectancy & Healthy Life Expectancy;
• This is NOT a side issue, its a population issue.
Inequalities are bad for ALL– we’re ALL worse off as a
consequence.
• From an NHS perspective, inequity in morbidity (and
multi morbidity) is driving demand
• Not addressing demand will lead to costs to the state
that are unfunded & storing up future problems
• It is not only a public funding issue but public funding is
an important social protection and source of investment
in things the market won’t provide.
16. Why is it in a cities interest
• “health” (or lack of) linked to service demand.
(And economic productivity / social justice)
• Not addressing upstream risks sets up
demand for our own services
• Addressing AQ, building bike lanes reduces
demand for social care
• A long run business case for investment (or
cuts? What outcomes are we prepared to
give up to make ends meet now)
https://gregfellpublichealth.wordpress.com/2018/08/03/why-is-it-in-the-interests-of-a-city-to-improve-health-and-well-being/
17. Why is it so hard? Why has there been
limited to no progress?
1. No burning platform for the issue that everyone
aligns around (hint = the money).
2. Differential resourcing is easy to say but very
difficult, politically and operationally;
3. the resource allocation formula itself has created
inequality (wrong assumptions in NHS formula, OBR
etc)
4. The wider context is exceptionally challenging.
– Austerity - 50% smaller LG spending power (will affect
“the determinants”), welfare reform - significant &
disproportionate impact on those most vulnerable.
– Brexit,
– minority government.
18. The impact of a deliberate strategy
is it worth the effort?
• Barr et al - positive impact of a deliberate
strategy at national level. The reductions in
the gap between best and worst were circa 1
year,
• hugely significant given the population nature
of life expectancy.
19. We cant do it, there aren’t simple
answers
• There is a tendency to search for simple answers, but
no such single pithy answer exists. However -
1) 30 years ago, survival from leukaemia in childhood was 5% at 5
years; it is now closer to 95%;
2) reducing teenage pregnancies
3) cardio vascular reduction in mortality over the last 25 years
4) smoking prevalence used to be 50%; it is now closer to 15%
• All of these were once seen as intractable, but great
progress made through the accumulation of small
steps over time, and commitment over time.
• Inequalities are arguably more complex, but the same
principles can apply
21. What does our data tell us
• Not getting worse (not getting better)
• Given the backdrop (8 years of austerity) the
no change may be a good thing. Hard to
celebrate though.
• HLE and LE. Slowdown / halt of improvement.
Signs are that disadvantaged faring worst
• Infant Mortality
https://www.bmj.com/content/360/bmj.k1090/rr-2
https://www.dropbox.com/s/ro703io2d9h6qth/IMR_2016_NS
SEC.pdf?dl=0
23. People say - nothing going on (not true)
Currently extant plan is still right
• Sheffield has a Sheffield Health Inequalities Plan agreed
in 2014.
– Says all right things. Capacity to programme manage? Nothing in
it is “wrong”. That mix of ingredients still stands
• 2016 HWBB discussion - five areas of focus
• Some high priority population groups also ID
– Beyond protected groups, 0-5, BME, LD, mental
health, multiple and layered disadvantage
• 2017 workshops of HWBB developed further.
24. 10 things of current focus
1. Continued commitment to an asset based community development based
approach to health and wellbeing.
2. Continued investment in and commitment to primary care and within this GP
services, especially in the most disadvantaged parts of the city
3. Refocused effort on the link between employment and health
4. When looking at “healthy lifestyles” focus on the environment and make the
healthy choice the easiest and default choice.
5. emphasis be given to unequal offer (unequal need and outcomes) . Not just
about deprivation and geography
6. Re-look at the economic impact of inequality: GVA vs broader social benefits.
Inclusive growth vs sustainable economy
7. Inequality and poverty are obviously inextricably linked. Arguably povert is
underplayed in the health inequality agenda - debt advice, cheap credit &
welfare rights for those most financially vulnerable, in the context of welfare
reform
8. Participation in education and generating aspiration is importat . Investment in
children's outcomes is a long term infrastructure investment for economic
prosperity. "That's not for kids from round here”,
9. focused effort on CVD risk factors.
10. investment in primary care esp in poorest parts of town, Shift of hospital to
primary care £.
25. 4 What should we “do”
What interventions does the
evidence suggest
26. Take care re medicalising, even if it is
tempting
• Lynch –
– attractive to medicalise. Alluring. Doable. Countable.
– But gives impressing of doing something, makes the
case of the danger of “medicalising” or individualising:
smoking cessation for the poor vs income inequality
and poverty.
• Marmot –
– “downstream” interventions have been covered, for
the most part, in the scientific literature.
– There has been much less focus on structural
interventions. Poverty and poor housing vs treating
those who misuse drugs
• That said, there ARE individual level & downstream
interventions that must be in the mix. Bentley / HI NST
27. Taking Action- Three Levels
system influencing and working with
our partners
our role as commissioners
What our delivery services do
28. A full vision all pillars, all connections, inequality core
At the centre:
A system that understands and is able
to make all the connections > with a
stronger shared narrative, supported
by incentives, information and
leadership for population health with a
focus on inequality reduction
Dave Buck
Kings Fund
29. Evidence base / policy prescriptions
• We all want a “list”.
– Avoid “lists”. People understand this, but it is astounding how
quick they came back to 1) but tell us what to do, the three big
things etc and 2) individual focused and medical model thinking
– We cant cope with a list of 500 projects. Nobody can
coordinate that.
• No single intervention – policy or service wise – that will crack this
issue.
– Splitting the agenda into actionable chunks my help – but not letting go of
slight of the whole is important (interconnected system).
– ask to our services and policy areas, and what cuts across many services or
portfolios
• Some interventions are within SCC control, some are within the
cities control, some are NOT within immediate control.
30. General principles, framework and
evidence
• General framework
– Marmot, Due North, PHE (Bentley)
– plenty of others
• Lots of evidence reviews re detailed
interventions
– Picket, Marmot , Smith et al, British Academy,
Public Accounts Committee 2010, NAO, McAuley,
Baum, Luchenski, NHS Scotland, Glasgow / Deep
end,
Summarised here - https://gregfellpublichealth.wordpress.com/2018/02/24/health-
inequalities-what-to-do-what-actions-or-interventions/
31. Due North
• Recommendations
1 Tackle poverty and economic inequality within the
North and between the North and the rest of England
2 Promote healthy development in early childhood
3 Share power over resources and increase the influence
that the public has on how resources are used to improve
the determinants of health
4 Strengthen the role of the NHS in promoting health
equity
https://www.gov.uk/government/publications/due-north-report-phe-response
32. Marmot 2013 remains the most valid
and comprehensive guide
• Reminder of key messages
– Gradient matters AS WELL as the most vulnerable.
Proportionate universalism
– Injustice itself is a risk.
– Economic benefits of addressing – productivity
loss, tax receipts, welfare payments, treatment
costs
• 6 policy objectives
33. The Marmot 6 areas of recommended
policy focus
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 a 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.
34. reducing health inequalities: system,
scale and sustainability
Chris Bentley’s advice of 15 years ago - summary slides. Revision of the DH Health
Inequalities National Support team work
1. a combination of doing different stuff better (transformation) AND sustained effort
to do the right things, at scale, over a long time (aggregation of marginal gains).
2. intervening at different levels of risk – physiology through to eco system.
3. All interconnect. Don’t neglect one at the expense of others
4. intervening for impact over time
5. intervening across the life course
6. population level impact – reach and depth of coverage in those at risk
7. in biomedical terms most of the gap is made up of CVD, respiratory, Cancer
8. Not just service level – also civic & community level.
9. healthy public policy, including legislation, taxation, welfare & Health in All Policies
10. community level interventions. What communities want wont look like what
funders think communities need (or want). Deal with it
36. The Buck eight (focused on NHS
responsibilities)
1. Get out of your disease and coalition silos. multi-morbidity strikes
10-15 years earlier in disadvantaged populations,
2. Refocus integration. The 2012 Act says that its purpose is quality
improvement and inequality reduction.
3. Work with, and if necessary, fund your partners.
4. Re-discover, implement and scale-up what has worked in the
recent past (HINST – see Barr et al made a difference up to 2010).
5. Recognise and react to the NHS being a wider determinant of
health. Economic Anchor model
6. allocation and payment systems to support inequality reduction.
7. Segment and stratify with the goal of inequality reduction. Most
population health management, at its heart, is about cost control,
turn it on its head
8. Set goals, ambitions, targets with consequences. Inequalities is
such a critical issue and a cross-cutting one that without strong
incentives,
https://www.kingsfund.org.uk/blog/2018/09/health-inequalities-nhs-plan-needs-take-more-responsibility
37. Most agree that it is important to
1) resist a temptation towards single silver bullet
answers;
2) resist single sector answers; and
3) focus on the aggregation and amplification of
big and small changes.
39. (at least) two-fold challenge for the
city :
1) To set a clear focus on a small number (no more
than five or six) of big ideas that aim to deliver
major structural change at the city level.
(Different stakeholders have (very) different
ideas of what that small number of things are)
2) Ensuring that broader conditions are right for
others to follow and build on these with smaller
scale activity at many different levels – defined
by geography and by population cohorts.
40. If we only do 4 things…..
• Shift of hospital to primary care £.
• Disproportionate distribution of resources,
services and assets to meet disproportionate
need (and inequitable outcomes). All service
areas across the city. Proportionate universal
approach needed.
• Relook at the economic impact of inequality.
GVA vs broader social benefits. Inclusive
Growth & sustainable economy.
• Community capacity and approach.
Primary care https://gregfellpublichealth.wordpress.com/2017/01/01/the-gp-5-year-
forward-view-the-importance-of-inequality-and-the-deep-end/
41. Other important
considerations
• Short, medium or long term is not a choice:
– all three but not defer starting on long term because there
are no near term wins;
• develop a method for prioritising actions, considering
what stakeholders think we should focus on
• balance between
– interventions that open up space to change now (e.g.
financial security),
– interventions that change things now and lay foundations
for the future (e.g. employment & skills),
– interventions that are focused entirely/mostly on future
gains (e.g. Best Start);
42. recurrent themes in a discussion on
general principles (1):
• Resist single silver bullet answers: all domains need
answers and solutions.
• Most are unconvinced that “writing plans” will solve
or make much progress.
• Influence by proposition:
– splitting the agenda into actionable chunks might help but
not letting sight of the whole is equally important.
• Measuring remains an issue.
– Macro and micro programme and project level measures.
– Linking measures to investment plans
43. recurrent themes in a discussion on
general principles (2)
• There was agreement that a focus on Early Years is vital
• Creating aspiration is important
• think differently about localities and communities – assets, people
and building. Remember ABCD? Person centred approaches at
individual, community and city level
• There is a link here to the role of ward councillors – hold great
intelligence. Also jobbing GPs.
• There is a balance between supporting and empowering people,
and setting the context straight. Even empowered people are still
not going to be optimally healthy if they live with poor quality air,
or in poverty with little prospect of getting skills or a job
• What does the relationship between the state and VCS need to
look like? Level playig field?
44. The HWB Strategy focused on HI
• are those who are doing well prepared to reduce what they get in
the name of reducing inequalities?
• a conversation per neighbourhood focused on “What does health
mean to you?”, or “What would conditions would make it easiest
for you and your family to be healthiest?”.
• role of Ward Councillors in leading this, the role of Local Area
Partnerships;
• Consider how, when all boards and governance mechanisms
consider any development, this is done so with the lens of
inequality and in particular ensuring this is not a tick box exercise,
and consciously focused on the social model and the upstream
context;
• visible and emblematic to do list, to ensure tangibles and
deliverables are not lost.
• the “letter” construct as means of setting challenge to other sectors
45. Themes within Sheffield HWBS
• Life course
• Recognise everything is “in” but needs
some focus
• First 1001 days, school readiness, ACEs,
school inclusion, post 16 destination
• Homes and housing, employment and
work, transport
• Multi morbidity, loneliness, end of life
46. Economic power of big anchors
• underplayed.
• reconsider this in context of inequality.
• aspiration into work and learning – what are
the streams into employment and learning.
• What role can anchor institutions play in this?
• Anchor – role to connect aspiration to
opportunity
• Create a single approach as a city.
47. Resources
• Don’t expect significant new resource
• Figure out how to bend existing resources to
the goal
• We have had new resources in the past, often
they have added and done some incredibly
useful things
• they havent bent the mainstream
48. Maximising our touchpoints and networks
• SCR and Combined Authorities – officer /
member level. What is our ask.
• Central government – similarly wrt to central
government what is our ask, within existing
powers or future devolved arrangements.
• SOLACE
• Networks of DASS, DCS
• Obviously the importance of elected members in
this cant be expressed strongly enough. Many
elements of health inequalities debate transcend
party politics.
Overall aim. Suggestion…..
Land
the notion that MM is a big thing (will be news to some, but not most)
matters well beyond NHS. also matters in social care, econ productivity etc etc
notion that we already have a response in place. Right ingredients in place. How to push harder on it. Any things we really want to get into air. Give people faith in that.
further cement the idea that the analysis John has done is a decent chunk of the business case for “being more preventive”
embed the notion that the number of bike lanes we build, the number of parks we maintain, and further upstream housing, income etc all have a bearing on the endpoint - MM – which has impact on NHS social care and other
whats next in this area
covering
background
Air time to the analytic work done on MM
What & why it matters - NHS demand, social care demand, productive economy, social justics. Put in the inequality context. Onset = 45 in some parts of town 65 in others etc.
Link MM to burden of disease. Chris Bentley has some good slides on this. Treating populations not patient by patient
Why it matters to local govt. Social care demand resulting from MM / Economic stuff - Also land in context of healthy people / economy - onset of MM is 45 in some parts of town. 18,000 people in Sheffield on ESA, weighted massively in poorest parts of town.
Approach to managing multiple morbidity, across the board
Upstream approach , prevent reduce delay. Upstream in locus of intervention (structural policy for population vs treatment for individuals, emptying ocean with teaspoon). Upstream in terms of age - earlier start the better.
Approach in NHS & social care - describe And inequalities. Neighbourhoods , risk strat
Outcome fund. Why doing, what point, where heading
Person centred stuff. Give bit of airtime
https://www.gov.uk/government/publications/health-profile-for-england-2018/chapter-1-population-change-and-trends-in-life-expectancy
https://www.gov.uk/government/publications/health-profile-for-england-2018/chapter-4-health-of-children-in-the-early-years
Despite the fact that the term health inequalities is used a great deal in NHS meetings and strategies there is a surprising lack of clarity about what we actually mean. Recently the NHS England Board considered this issue. In discussions Professor John Newton (Director of Health Improvement, PHE) suggested that it is important to be clear about three separate issues;
Inequality - there are groups of people who experience significant inequality for long periods or for the whole of their lives. A characteristic is financial insecurity - NHS England uses the term economic deprivation. For a range of reasons - one of which is availability of cheap housing there are parts of any city where there are a high proportion of people who are on low incomes, working in impermanent jobs that can often involve anti-social hours.
There is a growing body of evidence on the impact that long term economic deprivation has on people and communities. We know that the experience of financial and social exclusion can lead to a lack of “sense of coherence” a feeling of alienation and a greater likelihood of poor mental health.
Inclusion Health - there are small populations of people who may be more likely to experience inequality. One of the characteristics of this group is impermanence and transience. It includes populations such as Street Sex workers, Substance misusers, Homeless People, People in Prison and Gipsy and Traveller communities.
Equality - there are a range of legislative requirements to ensure that particular groups of people are not discriminated against. These groups of people with ‘protected characteristics’ are those who have often experienced some form of discrimination because of their age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation
We suggest that while there is a legislative requirement to take account of the needs and interests of people with protected characteristics, the legislative focus on those who experience socio-economic disadvantage or those in Inclusion Health groups is much weaker.
This is the area where Sheffield CCG needs to and can take a greater focus; inequality and inclusion health.
https://gregfellpublichealth.wordpress.com/2018/06/26/why-is-there-a-20-year-gap-in-healthy-life-expectancy-between-best-and-worst-in-2018/
more“Health” ≠ or better NHS
See Burns on Salutogenesis vs pathogenesis
Determinants ≠ inequalities
Health inequality is therefore about:
The unequal distribution of clinical and lifestyle risk factors (a small part of which is about the NHS)
The unequal distribution of social and environmental risk factors (the determinants)
The determinants of the determinants (power, concentration of wealth, dominant economic model etc.)
Health inequalities ≠ “health” thing, or indeed a “public health” thing.
Is your starting premise something about an aspect of medical science, social policy or something about ethics and values
"Austerity was based on an analysis that what had caused the global recession was the high level of public debt rather than the reckless action of the financial sector"......
How far upstream
Individualisation of social issues
Dominance of market mechanism
Misplaced belief in trickledown economics
Privatisation of profit, socialisation of risk
Concentration of wealth
Neo liberalism
I was thinking about how some of the public health issues have changed since the Ottowa charter and hoping they can be incorporated into whatever we all come up with.
Since 1986 the rise of Neo-liberalism and its effects on inequalities are much better known and of course the effects of Climate Change.
However one of the issues I want to highlight is the growing evidence of the effects on health of abuse and neglect particularly in childhood. I am particularly struck by the evidence from the Adverse Childhood Experiences (ACE) trials.
On line paper from Journal of Public Health (Oxford)
10.1093/pubmed/fdu065
Even though I have retired as a GP I continue to work in the regional CFS/ME (Chronic fatigue / Fibromyalgia) service and come across these issues frequently.
I would like to see them brought to the fore and have cc'd The Director of Public Health, Greg Fell to highlight this as a public health issue
Why is it in the interests of a city to improve health and well being
LG is at bottom funding wise, now demand pressures.
Summary points
“Health” and “well being” are flip sides of the same coin. There is a whole philosophical debate about the definition of “health” and of “well being”, salotogenesis theory. One for another time
We have an approach to this in the city where we have “health” or “well being” as a theme running through all policies.
Not addressing well being or health simply sets up demand for services. Demand for NHS and social care is a response to failure to optimise this further upstream and is buying back health that we've already lost via policy choices in other spaces.
Social care demand will be the bit that bankrupts any local authority. Thus considering the upstream causes of that demand is a highly legitimate goal. Upstream includes the built environment, green space, transport policy. Thus the role of the Sheffield Plan is critical
"We should have a health in all policies approach", or "we should be more preventive". Both are easy to say and the right aspiration to have.
How we build our environment and city - built places, social neighbourhoods, the services we provide, what the economy looks like and how it develops and includes all. All of this, and much more, matters and matters a lot for how healthy we are.
We underweight the importance and relevance to "health" of changes we make in landing service and policy discussions, we underweight health (by which I don’t mean health care) and inequalities in outcomes in the trade offs we make.
We still aren’t landing the rationale for why PH folk hassle others to build bike lanes, parks, not advertise junk, do progressive licencing etc. Here are some thoughts on linking "how healthy we are" it back to demand for our services.
Defining "health" and why is matters to service demand
Healthy Life Expectancy (HLE) is the standard proxy used for describing years in wellness or illness, or lack of it.
Other metrics are available (activities of daily living, functional ability), there are some distinguishing features but they are all sides of the same coin. All have tricky methodological issues with calculation.
We have broadly accepted that HLE is the measure.
It can be readily linked to NHS demand.
More people with more years of less than good health.
That demand is inequitably spread - affluent / poor, mental illness / not etc.
This leads to demand for NHS and social care (and arguably is THE point of the NHS's newfound enthusiasm for "population health".)
Social care demand is related directly to how poorly people are (that’s a medical model construct) or loss of independence (often related to consequence of decline related to illness or broader social factors)
It is easy to track that back to interventions to reduce or manage risk, and thus delay complications (and thus loss of functional ability, illness etc). This is easy to do re NHS services, easy to track back (or forward) to social care.
These risks are due to well known risk factors. Downstream and upstream risk factors matter. Upstream always matters a lot more.
Not addressing risks sets up demand for our own services.
Thus it IS important to set up an environment where people can be healthy, it is an investment in preventing future demand.
To use an over simplistic example, if we build a city like Amsterdam more people will walk and cycle, there will be less obesity, less downstream complications of obesity - diabetes, cancer, heart disease, joint pain. And all the NHS demand, and loss of function thus social care demand that ensues. The city will be more connected, likely mental health will improve. Some if this is near impossible to prove in modelling terms, though plenty have done this - see here (Pop benefits of Dutch levels of cycling) for an example directly linking active travel, health status and economic productivity via GDP .
Having a healthier set of folk than you would otherwise is probably the biggest, and seemingly as yet untapped by those that "do" the economy, economic lever you can pull at a city level. I’ve written a little on that before – the link between “health” and economy is two way..
Im not only picking on bike lanes here, though there are a neat simple example. The same can be said in almost any area of policy.
Thus it IS in the cities interests that we DO use the various levers available to us to get a healthier set of folk than would otherwise be the case.
Why don’t we do better.
Many obvious reasons.
Austerity has led to us stripping out lots of service to maintain statutory.
Even before austerity, however, this was an issue. “health (or “prevention”) isn’t my job, its done by someone else, somewhere else, leave me alone I’ve got other stuff to do”.
There is something in here about business planning/budget/accountancy
We didn’t want to make severe cuts to any of our preventive services. Circumstance dictated that result – we need to balance this budget NOW, we have these stat services we must deliver, something has to go somewhere, etc. We can’t fix the problem of the amount of money available – so will need to affect that decision process in other ways.
This is the classic Public Service Reform problem of where returns on investment go – and how long they take to accrue.
Given that we cant make the challenge go away, there IS a case to add more information to the frame so it is not just a financial calculation – or can we design a budgeting/business planning approach that exposes the dependencies across the system (so we can model “make this cut now and you will add 5x the pressure to future budgets”).
We probably don’t have the data for this sort of approach, or peraps the capacity (and maybe the capability) for the modelling
A “business case for cuts” process might be an interesting exercise.
Makes it more complex, admittedly. The mechanism/what would need to be in place for someone (cabinet? EMT?) to be able to say “the long-term implications of change x in service y for service z is not something we can ignore – go away and think again” and possibly then look to move some money around the system in response? This might make budget setting even more terrifyingly complex than it is already.
More broadly and away from narrow budget view: application of COM-B to this might be useful
what is the behaviour we want from colleagues on this – need to define this clearly, something like “decision making with full view of the long term outcomes and implications”? Then from this, do they have capability, opportunity, motivation? Suspect capability and motivation might be a problem, haven’t really thought through opportunity.
Knowledge is important but values too.
Who are we delivering for? Eg think the evidence on active travel etc is well understood but we are continually under ambitious.
Ultimately it needs to be a performance issue for Directors/HoS etc?
Obviously be aware of the backdrop – 50% smaller LG spending power (will affect “the determinants”), welfare reform that has had / continutes to have massive and disproportionate impact on those most vulnerable.
Differential resourcing: this is the disproportionate distribution of resources, services and assets to meet disproportionate need (and inequitable outcomes). Disproportionate distribution of resources, services and assets to meet disproportionate need (and inequitable outcomes). Esp primary care resourcing
There are three levels of action:
System [influencing our partners, e.g. Universal Credit and MoveMore (Rob Copeland joining our deepend practices to adapt movemore to suit their population]
CCG [what we commission e.g. neighbourhoods, person centred care, diabetes]
Practice Level [e.g. practices choosing different workforce models that recognise their population needs])
The Health and Social Care Act 2012 introduced a new duty on the Secretary of State, NHS England and clinical commissioning groups to ‘have regard to the need to reduce inequalities’ in access to care and outcomes of care.
As a CCG we can undertake specific activities as described above, as well as recognise our role as an anchor organisation in employing a diverse workforce and supporting stable employment. But we also have an influencing role with our partners and with MPs. We need to use our significant system influence and the voices of our members to ensure the wider determinants of health are prioritised, with an immediate example being Air Quality. We need to describe and coordinate our approach to this.
Dave Buck
Kings Fund
Ultimately the ask on many different parts of the organisation is what is their contribution, in service delivery or policy terms, to redressing inequalities; and determining what “good” or “better” looks like in that area.
Multiple authors and commissions have published many detailed specific and generic recommendations and policy prescriptions. These may be worth considering as we move forward, but should be done in a local context and not followed unthinkingly. The reports include Due North, the British Academy, Marmot, Smith (JPH), McAuley (PLOS) and others. Each of these prescriptions has merit, there is some overlap between different publications, many of the recommendations are of relevance to national agencies, some to regional agencies, some to local agencies. Some of the national recommendations may be localisable (either directly or through devolution).
It may also be framed around life course (starting well, living well, ageing well) and in terms of services for people and places where people live.
There is also merit in bringing together the various strands around equality, poverty, inequality and similar as many of them cover similar space
Key messages from Kings Fund Blog for the NHS and responsibility for inequalities
https://www.kingsfund.org.uk/blog/2018/09/health-inequalities-nhs-plan-needs-take-more-responsibility
Get out of disease and condition silos.
Refocus integrated care.
Work with and, if necessary, fund your partners.
Rediscover, implement and scale up what has worked in the recent past.
Harness the power of the NHS as a wider determinant of health.
Change payment systems to strengthen support for inequality reduction. Use the power of data and analysis to tackle inequalities in health in populations.
Set goals, ambitions and targets with consequences.
Addressing inequality is NECESSARY for econ growth. There will be merit in relooking at the public sector supply chain in this and how well we really enact social value in our commissioning, inclusive growth & sustainable economy, living wage and our role as employer around skills and jobs. In this area the wealth gap is (by far) the most important, however not easily resolvable quickly.
(some may call it community development). Some have suggested that the various strategies for community capacity building (PKW, Neighbourhoods and others) are too small, marginal, insecurely funded and not well enough connected. There may be merit in relooking at how we commission volcom organisations, and what our expectations are of them both in terms of service delivery and in terms of voice and capacity development. Linked to this, but not just in this domain is the focus on a needs (the needs of the marginalised) vs asset (scope of opportunity) approach, and a greater sense of coherence across areas. Some of the key issues here are financial insecurity, anxiety about not being in control of where they live (‘social cohesion’) and a cynicism about local services. Our strategies are a mixture of responding to crisis and jam tomorrow (employment) we often miss out the bit in the middle - addressing current insecurities and vulnerabilities.
It is unknown whether the distribution of resources (wrapped into service delivery or otherwise) and assets reflects the patterns of need. In NHS delivery there IS a mismatch, and the challenge is to disproportionately invest in generalist offer matched to need levels. We don’t know the extent to which this story is reflected across sectors within the economy. This may not ONLY be a debate about “resources” defined narrowly or broadly, but also about the right policy framework and coverage of effective interventions.
What should we do?
Most agree that it is important to:
1) resist a temptation towards single silver bullet answers;
2) resist single sector answers; and
3) focus on the aggregation and amplification of big and small changes.
Setting in train a vast range of projects in response to the challenge will mean that none of them are done well and that much effort is wasted. Our capacity to orchestrate and execute a set of interventions and programmes that make up any complex system approach is limited (extremely) we need to be realistic on that.
In this space we do know what some of the “right stuff” is, but need to set the conditions for this to be the default; if the conditions are right then the smaller scale activity will follow.
There was agreement that a focus on Early Years is vital
A common theme throughout the discussions was that Best Start and the need to ensure that all children in Sheffield get the best possible start in life, and a commitment to maximising our implementation of this approach, are vital in addressing health inequalities.
Creating aspiration is important
This links to the above point, in that a part and consequence of giving young people a good start in life is ensuring they have aspirations for their futures. However, it goes beyond this as what underpins inequalities is not just lifestyle “choices”, nor poverty of finance, but also poverty of aspiration. This is associated with lack of control (for example over employment or housing); if you lack control then aspiration is gradually and permanently knocked out of you. There is a need to shift blame away from perceived lifestyle “choices” and place it back on society, and argue that in an society with a norm of inequality, aspiration will be impacted.
In response to this we should be building aspiration, and in so doing we will reduce inequality, or vice versa; this could be seen as a deliberate strategy of creating pushy individuals.
There is a need to think differently about localities and communities
All seem to agree that there is a need to do more to empower communities; however what is meant by this and whether there is definitely agreement is less clear. However it is clear that this view should have implications for use of resources; it also lines up with other work that is already underway, such as around the Person-Centred City.
There is a link here to the role of ward councillors, who it was suggested are an underutilised asset in their communities, and represent an untapped asset, source of strength and intelligence that might not otherwise be used.
Linked to this there was agreement that there is a need to engage fully and at length with communities and citizens, – both in terms of what people want (not just now but for the future) and in terms of appetite for rebalancing the way resources are used.
There is a balance between supporting and empowering people, and setting the context straight
The point was made that even empowered people are still not going to be optimally healthy if they live with poor quality air, or in poverty with little prospect of getting skills or a job. From this point of view empowerment is context specific, with structure and broader context still important: in Sheffield 25% of children are in poverty.
There was some discussion of this in terms of shifting the locus of control to the individual or to communities; but also concerns that this could also lead to a shift of the locus of responsibility to the individual, which should be avoided.
What does the relationship between the state and VCS need to look like?
It was suggested that there needs to be a level playing field in this space, and further suggested that there isn’t currently. In response, there was a desire to expose the asymmetrical nature openly and debate it. The VCS will not, by itself, solve the Health Inequalities problem, but it is critically important.
, agencies or partnerships (such as housing, welfare, economic development) at the local, county and national level, using this as a proposition to focus on achieving health in all policies across many sectors
Social value and how we use our institutions/assets – link to inclusive growth, procurement work – but need to think wider than this – eg can employment practices be more supportive?
We cannot expect significant new resource – so we need to figure out how to bend existing resources to the goal
An easy answer to the challenge could be “we just need to invest in x”, but we need to recognise that significant new investment is unlikely to arrive in the short-term. Instead we should focus on the whole resource envelope already at our disposal – the whole economy – and aim to bend it to do the right thing to achieve our goals.
This involves building in the externalities most often excluded from conversations about “the economy”, such as around healthy ageing through the whole life course, and talking about services in terms of investments rather than cost drains.
Further to this, we tend to focus on the money, and the short term. This is understandable, but if we only focus on the money we will do the wrong things. There should be no conversation about money until there has been a conversation about outcomes, and no conversation about outcomes till there has been a conversation about inequality.
Marmot’s message on proportionate universalism is still relevant and still resonates
As noted above, the Marmot report remains the gold standard in this space, but we need to think about this for all of our services, not just the NHS. We need to ask questions like: what does proportionate universalism mean in housing, schools, or early years (to pick just three areas)? What does resource allocation look like now across totality of city – does it mirror the NHS experience of those who need it least receiving the most?
All in the room seemed committed to differential funding. It is clear there is no reverse gear, but if new resource becomes available, or we are reviewing services, we should use a principle of differential gearing to ensure we increase focus on a preventive model and a greater rate of growth in those areas most likely to achieve our stated goals
Creating aspiration is important
This links to the above point, in that a part and consequence of giving young people a good start in life is ensuring they have aspirations for their futures. However, it goes beyond this as what underpins inequalities is not just lifestyle “choices”, nor poverty of finance, but also poverty of aspiration. This is associated with lack of control (for example over employment or housing); if you lack control then aspiration is gradually and permanently knocked out of you. There is a need to shift blame away from perceived lifestyle “choices” and place it back on society, and argue that in an society with a norm of inequality, aspiration will be impacted.
In response to this we should be building aspiration, and in so doing we will reduce inequality, or vice versa; this could be seen as a deliberate strategy of creating pushy individuals.
There is a need to think differently about localities and communities
All seem to agree that there is a need to do more to empower communities; however what is meant by this and whether there is definitely agreement is less clear. However it is clear that this view should have implications for use of resources; it also lines up with other work that is already underway, such as around the Person-Centred City.
There is a link here to the role of ward councillors, who it was suggested are an underutilised asset in their communities, and represent an untapped asset, source of strength and intelligence that might not otherwise be used.
Linked to this there was agreement that there is a need to engage fully and at length with communities and citizens, – both in terms of what people want (not just now but for the future) and in terms of appetite for rebalancing the way resources are used.
There is a balance between supporting and empowering people, and setting the context straight
The point was made that even empowered people are still not going to be optimally healthy if they live with poor quality air, or in poverty with little prospect of getting skills or a job. From this point of view empowerment is context specific, with structure and broader context still important: in Sheffield 25% of children are in poverty.
There was some discussion of this in terms of shifting the locus of control to the individual or to communities; but also concerns that this could also lead to a shift of the locus of responsibility to the individual, which should be avoided.
What does the relationship between the state and VCS need to look like?
It was suggested that there needs to be a level playing field in this space, and further suggested that there isn’t currently. In response, there was a desire to expose the asymmetrical nature openly and debate it. The VCS will not, by itself, solve the Health Inequalities problem, but it is critically important.
