Addressing Health Inequalities

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Lancashire Public Health Report 2011

• Addressing Health Inequalities

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Background

• Independent report of the three Directors of
  Public Health for Lancashire
• Purpose of the report
• To set out the main causes of health inequalities
  in Lancashire
• To make recommendations to partners about the
  action needed for health equity

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Health inequalities in Lancashire

• Lancashire Joint Strategic Needs Assessment
  analysis of health inequalities (2009)
• People who live in the most deprived parts of
  Lancashire are
• 7 times more likely to die early from chronic
  liver disease
• twice as likely to smoke
• 6 times more likely to say that anti social
  behaviour is a problem in their neighbourhood
• 5 times more likely to have symptoms of extreme
  anxiety and depression
• Than those that live in the least deprived
  neighbourhoods in the county

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Financial cost of health inequalities in
Lancashire

• If the death rates in the most deprived 40 of
  areas in Lancashire were improved to the
  Lancashire average
• 16,224 years of life would be saved with an
  economic value of 661 million
• Estimated lost production costs due to health
  inequalities are 900 million per year
• Increased benefit payments and lost taxes due to
  health inequalities cost the Lancashire economy
  800 million per year.
• Health inequalities are estimated to cost the NHS
  in Lancashire around 300 million per year.

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What do we mean by health inequalities?

•  Health inequalities - differences in health
  status or in the distribution of health
  determinants between different population groups.
  Examples include differences in death rates
  between people from different social classes.
•  Health equity - the distribution of disease,
  disability and death in such a way as to not
  create a disproportionate burden on one
  population. It is the absence of persistent
  health differences over time, between different
  groups of the population.

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Why do health inequalities matter?

• Poor health and wellbeing prevents too many
  citizens from
• working
• learning
• being involved in their community
• enjoying their leisure time
• Reduced productivity due to poor health has a
  negative impact on Lancashire's economy
• Health inequalities are fundamentally unfair
• It is possible to reduce health inequalities
• Health reforms provide new opportunities for
  health equity

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Setting priorities for addressing health
inequalities

• Stakeholders keen to address the causes of the
  causes of health inequalities
• Identified 6 priorities for health equity
• Reduce unemployment and worklessness
• Increase income and reduce poverty
• Strengthen communities
• Increase opportunities for life long learning and
  skills development
• Reduce tobacco and alcohol consumption
• Increase social support

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Focus on wellbeing

• New Economic Foundation Five ways to wellbeing

• Connect
• Be active
• Take Notice
• Keep learning
• Give

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Reduce unemployment and worklessness

• Work protects mental and physical health through
  
• income
• psychological benefits
• social interaction
• Poor working conditions, including
• uncertainty and job insecurity
• high work demands and low rewards,
• low control and autonomy in relation to work
• low social support within the workplace
• contribute to increased risk of heart disease,
  stroke, poor mental health and unhealthy
  behaviours

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Unemployment and worklessness recommendations

• Undertake analysis of health needs of unemployed
  and workless people
• Employers should
• Encourage those facing redundancy to develop
  alternative social networks
• adopt healthy recruitment and working practices
  and encourage suppliers to do the same
• GPs recognise role they play as potential gateway
  to employment support services
• Train front line health staff to provide support
  to unemployed patients and those at risk of
  worklessness
• Align health services to the work programme

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Unemployment and worklessness recommendations

• 6. Mental health programmes reviewed to ensure
  they address timely identification of mental
  health problems in workplace and meet needs of
  those not in employment
• 7. Develop multi agency strategy to optimise
  healthy working practices
• 8. Existing healthy workplace schemes should be
  retained during the reform and should be targeted
  at employers within sectors with the highest risk
  of redundancies and worklessness
• 9. Existing work and health initiatives should be
  reviewed and a common approach to delivery should
  be agreed and commissioned across the county

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Increase income and reduce poverty

• Low income
• Reduces access to goods and services that
  maintain/ improve health
• Prevents participation in social, cultural and
  leisure activities that protect mental health and
  wellbeing
• Action needs to both reduce poverty and address
  its impacts
• Child poverty perpetuates health inequalities
  across the generations
• Poverty in the working age population minimum
  income for healthy living
• Poverty in later life older people vulnerable
  to effects of fuel poverty

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What is already happening to reduce poverty and
its effects?

• Developing child poverty strategy
• Total Family
• Welfare rights in health settings (through GPs
  and Macmillan nurses and for those with asbestos
  related illness (Partnership between LCC and
  PCTs)
• Fuel poverty referral project (LCC, PCTs and 12
  district councils)
• Fire and rescue service integrated identification
  of fuel poverty into home safety checks)

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Poverty and income recommendations

• All partners identify how they will contribute to
  the Lancashire Child Poverty Strategy
• Partners identify families in poverty and work
  together to provide co-ordinated services
• Focus resources towards pregnancy and early years
• Expand Total Family Programme across Lancashire
• Integrate Fuel Poverty Referral Project into the
  NHS QIPP programme and promote it to GP
  commissioning consortia
• Undertake equity audit of welfare rights
  provision to ensure services are reaching and
  benefiting those that need them most
• Investigate provision of welfare rights services
  in primary care settings
• Integrate income maximisation into social
  prescribing programmes and link to case
  management approaches

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Strengthen communities

• Strong communities increase resilience to the
  affects of poverty
• Good health and wellbeing is associated with
  access to good social and community networks
• Characteristics of strong communities not equally
  distributed

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What is already happening to strengthen
communities?

• The Voluntary, community and faith sector
  contributes to strengthening communities by
• Providing opportunities people to connect with
  others through volunteering, social network,
  involvement in community associations
• Providing 'wellness services
• Contributing to assessment of health and
  wellbeing needs
• Providing a public and service user voice into
  commissioning and provision of services
• Advocating for the needs and involvement of
  specific communities and promoting equality and
  diversity

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What is already happening to strengthen
communities?

• Asset based approaches to strengthening
  communities (Preston, West Lancashire, Ribble
  Valley)
• Advocate for the needs and involvement of
  specific communities (e.g. Preston work with
  travellers)
• Voluntary, Community and Faith Sector
• Provide opportunities for people to connect with
  others
• Provide 'wellness services
• Provide public / service user voice

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Strengthening communities recommendations

1. Asset based approaches to community development
   should be used by local authorities at both
   county and district levels
2. Extend the Central Lancashire framework for
   action for asset based community development
   across the county
3. Develop capacity and capability for asset based
   approaches within the voluntary, community and
   faith sector (VCFS)
4. As far as possible, protect public investment in
   the VCFS
5. Implement the Healthy Streets initiative
   (includes 20 mph speed limits, improved quality
   of the public realm, promotion of street based
   physical activity
6. Where possible provide public sector services at
   local venues and share public sector assets
   across agencies

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Increase Opportunities for Life Long Learning and
Skills Development

• Lifelong learning impacts on health inequalities
• Indirectly, provides skills and qualifications
  for employment and progression in work

• Directly, participation in learning impacts on
  health behaviours and outcomes
• Learning for its own sake is one of the five
  ways to wellbeing

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What is already happening to increase life long
learning and skills development?

• Programmes to widen participation from d deprived
  areas in education for those 14-19
• Healthy schools
• Adult learning services
• Employment training for those not in work
• Library services
• Cultural and arts opportunities
• Voluntary, community and faith sector provision
  (e.g. University of the Third Age co-operative
  approach to learning)

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Life long learning and skills development
recommendations

• Increase access to lifelong learning across the
  social gradient by
• providing 16 25 year olds with life skills
  training and employment opportunities
• providing work based learning and work experience
  for those not in employment
• Local authorities take account of the impact
  learning has on wellbeing in spending decisions
• Identify and develop opportunities to increase
  the availability of non vocational learning
  across the life course
• Support VCFS to provide learning opportunities
  using asset approaches

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Life long learning and skills development
recommendations

• 5. Learning, culture and arts opportunities
  should be integrated into social prescribing
  schemes and extended across the county
• 6. Develop and implement a youth employment and
  employability strategy for Lancashire
• 7. Social landlords should include training as
  part of resident involvement in decision making
• 8. Community growing schemes should be extended
  across the county to encourage the development of
  new skills
• 9. Schools should integrate the Five Ways to
  Wellbeing into the curriculum
• 10. Employers should recognise skills gained by
  informal opportunities

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Reduce alcohol and tobacco consumption

• Alcohol
• Alcohol consumption has an inverse social
  gradient
• Alcohol harm has a strong social gradient
• Those in the most deprived areas of Lancashire
  are 8.2 times more likely to die prematurely from
  chronic liver disease, than those in the least
  deprived

• Tobacco
• Strong social gradient in tobacco use
• Smoking impacts across the whole life course,
  with children particularly vulnerable to the
  effects of tobacco
• Smoking contributes to inequalities in many
  health outcomes

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Reduce alcohol and tobacco consumption
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What is already happening to reduce tobacco and
alcohol consumption?

• Community alcohol project (Hyndburn - Trading
  Standards, Constabulary, School and Community
  Partnership Team, Young Peoples Service)
• Youth tobacco prevention (Smoke and Mirrors)
• Lancashire Alcohol Network Strategic Framework
• Responsible alcohol retailing (Pendle and
  Rossendale)
• Chorley Alcohol Intervention (Chorley
  partnership)
• Tackling illicit tobacco (Smoke Free North West)
• Reducing exposure to second hand smoke (Take 7
  steps out)

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Tobacco and alcohol recommendations

1. Resources should be allocated from the planned
   ring-fenced public health budget for tobacco
   control and alcohol misuse
2. A strategic needs assessment on substance misuse
   (including tobacco and alcohol) should be
   undertaken JSNA to inform the development of
   strategies to address substance misuse
3. QIPP programme should include preventative action
   to reduce alcohol and tobacco consumption
4. Use of regulatory powers in relation to alcohol
   and tobacco should be maximised
5. Frontline staff and volunteers should be trained
   to deliver identification and brief advice on
   alcohol and tobacco
6. Support should be given to employers to develop
   workplace alcohol and tobacco policies
7. Partnership approach to alcohol and tobacco
   should continue and develop within Public Health
   Lancashire

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Tobacco and alcohol recommendations

1. Resources should be allocated from the planned
   ring-fenced public health budget for tobacco
   control and alcohol misuse
2. A strategic needs assessment on substance misuse
   (including tobacco and alcohol) should be
   undertaken JSNA to inform the development of
   strategies to address substance misuse
3. QIPP programme should include preventative action
   to reduce alcohol and tobacco consumption
4. Use of regulatory powers in relation to alcohol
   and tobacco should be maximised
5. Frontline staff and volunteers should be trained
   to deliver identification and brief advice on
   alcohol and tobacco
6. Support should be given to employers to develop
   workplace alcohol and tobacco policies
7. Partnership approach to alcohol and tobacco
   should continue and develop within Public Health
   Lancashire

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Tobacco and alcohol recommendations

• 8. Screening for tobacco and alcohol use should
  be integrated into health service delivery and
  targets re completeness of data included in
  contracts
• 9. Service evaluation/ monitoring should include
  information to assess acceptability and
  effectiveness
• 10. Intelligence-led social marketing approaches
  should be undertaken
• 11. Media campaigns re tobacco and alcohol should
  be evaluated for their effectiveness and
  sustained or scaled up as appropriate
• 12. Partners should contribute to the delivery of
  alcohol and tobacco elements of Children and
  Young Peoples Plan (2011-2014)
• 13. Local partnerships should maintain and
  strengthen advocacy and lobbying in relation to
  minimum unit pricing for alcohol and increasing
  taxation on tobacco
• 14. North of England 'Tackling Illicit Tobacco
  for Better Health Programme' should be sustained
  and supported locally.

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Increase social support

• Social support provides emotional and practical
  resources needed to live a fulfilled life and be
  resilient to challenges
• Belonging to a social network makes people feel
  cared for, loved and valued
• Supportive relationships also encourage healthier
  behaviour patterns
• The influence of social relationships on risk of
  mortality is comparable with well-established
  risk factors such as smoking, alcohol
  consumption, obesity and lack of physical
  activity
• We estimate that there are more than 130,000
  people in Lancashire who experience a severe lack
  of social support

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What is already happening to increase social
support?

• VCFS in Lancashire offers wide range of social
  support for children and young people
• 153 voluntary youth organisations
• offer opportunities to over 94,000 young people
• E.g. West Lancashire young carers
• Councils and VCFS provide social support for
  adults
• Opportunities to volunteer time through Timebanks
• Befriending services to support people who are
  lonely
• and at risk of becoming vulnerable
• luncheon clubs
• Handy person schemes
• Help Direct

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Social support recommendations

1. Undertake equity audits of supporting people and
   support services for carers
2. Scale up social prescribing schemes
3. Undertake strategic needs assessment of older
   people to inform commissioning of social support
   services
4. Monitor the impact of the recession on excluded
   groups
5. Screen budget reduction decisions for their
   health impact to ensure vulnerable and isolated
   people are protected
6. Improve local data collection in relation to
   social support
7. Use asset approaches to enable assets of
   residents to be realised and gaps to be filled by
   public services
8. Support the VCFS to engage in public sector
   procurement and to develop the VCFS social
   support market

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Setting health equity targets

• Liver disease those in the most deprived areas
  are 8.2 times more likely to die prematurely than
  those in the least deprived areas. This gap
  should be narrowed to a ratio of 6.5.
•  Mental health and wellbeing those in the most
  deprived areas are 6.1 times more likely to
  experience extreme anxiety and depression as
  those in the least deprived areas. This gap
  should be narrowed to a ratio of 4.9.
•  Diabetes those in the most deprived areas are
  4.1 times more likely to die prematurely than
  those in the least deprived areas. This gap
  should be narrowed to a ratio of 3.2.
•  Quality of life those in the most deprived
  areas are 3.4 times more likely to be
  experiencing extreme pain and discomfort than
  those in the least deprived areas. This gap
  should be narrowed to a ratio of 2.72
•  Infant mortality babies in the most deprived
  areas are 2.9 times more likely to die than those
  in the least deprived areas. This gap should be
  narrowed to a ratio of 2.3.
•  

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Setting health equity targets

• Coronary heart disease those in the most
  deprived areas are 2.8 times more likely to die
  prematurely than those in the least deprived
  areas. This gap should be narrowed to a ratio of
  2.2
•  Lung cancer those in the most deprived areas
  are 2.7 times more likely to die prematurely than
  those in the least deprived areas. This gap
  should be narrowed to a ratio of 2.2.
•  Stroke - those in the most deprived areas are
  2.7 times more likely to die prematurely than
  those in the least deprived areas. This gap
  should be narrowed to a ratio of 2.2.
•  Child health and wellbeing those in the most
  deprived areas are 2.5 times more likely to die
  than those in the least deprived areas. This gap
  should be narrowed to a ratio of 2.
•  Accidents those in the most deprived areas are
  2.2 times as likely to die as those in the least
  deprived areas. This gap should be narrowed to a
  ratio of 1.8.