Systematically Addressing Inequalities in Health and Wellbeing

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Systematically Addressing Inequalities in Health
and Wellbeing

• Professor Chris Bentley
• National Support Team
• Health Inequalities

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Personal Well being
Physical
Vitality, energy
Ability to do things one enjoys
Good social relations
Well being
Meaning and purpose
Connectedness to community
Control over life
Mental
Social
Labonte 1998
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Physiological risks High blood pressure High
cholesterol Stress hormones Anxiety/Depression
Well being
Behavioural risks Smoking Poor diet Lack of
activity Substance abuse
Risk conditions e.g. Poverty Low social
status Dangerous environments Discrimination Steep
power hierarchy Gaps/weaknesses in services
and support Unsafe environments
Psycho-social risks Isolation Lack of social
support Poor social networks Low self-esteem High
self-blame Low perceived power Loss of
meaning/purpose of life
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Physiological risks High blood pressure High
cholesterol Stress hormones Anxiety/Depression
Well being
Health Seeking Behaviour
Behavioural risks Smoking Poor diet Lack of
activity Substance abuse
Risk conditions e.g. Poverty Low social
status Dangerous environments Discrimination Steep
power heirarchy Gaps/weaknesses in services
and support Unsafe environments
Psycho-social risks Isolation Lack of social
support Poor social networks Low self-esteem High
self-blame Low perceived power Loss of
meeting/purpose of life
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Gestation from Input to Outcome
A
B
C
2005
2010
2015
2020
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GOBI Strategy

• G rowth Monitoring
• O ral Rehydration Therapy
• B reast Feeding
• I mmunisation

UNICEF 1980s
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Public Health

• The science and art of preventing disease,
  prolonging life and promoting health (of whole
  populations) through the organised efforts of
  society
• Acheson 1998

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Population Health
Public Health
Community Health
Personal Health
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Direct Population Measures
Partnership Vision and Strategy Leadership and
Engagement
Community Engagement
Frontline Services
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Making best use of effective interventions
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Commissioning Healthcare for Best Outcomes
Optimal Population Outcome

• Population Focus

Challenge to Providers
5.Supported self-management
10. Engaging the public
13.Networks,leadership and coordination
4. Responsive Services
9. Accessibility
7. Local Service Effectiveness
2. Expressed Demand
6.Known Intervention Efficacy
1.Known Population Health Needs
12. Balanced Service Portfolio
3. Equitable Resourcing
8.Cost Effectiveness
11.Adequate Service Volumes
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Identifying patients not yet registered with
target diseases

• Studies have identified reasons why patients do
  not present eg with angina
• Geographical eg distance from practice complex
  journey
• User unfriendly service access frosty,
  bureaucratic reception cultural/interpreter
  problems appointment systems access delays
  unlinked out-of-hours
• Community knowledge, understanding, beliefs and
  expectation about condition about services
  about life
• Personal beliefs and skills demotivation low
  expectations low self-confidence poor literacy
  low-IQ etc.
• Supportive strategies need to explore each of
  these elements systematically

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Social Marketing

• When reaching out to residents not yet
  benefiting, or defaulting from, service
• Segment your population into groupings meaningful
  locally eg bespoke Mosaic (Hammersmith and
  Fulham, Doncaster)
• Segment your services to attract and receive
  different groups differently eg Customer Access
  Strategy (Hammersmith and Fulham, Hull)
• Target groups differently according to risks and
  preferences ( eg Slough diabetes screening )
• Explore segmentation of registers as well as maps
  (Rotherham pilot with CVD patients still smoking)

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CVD
Seasonal excess deaths
Diabetes
COPD
Cancer
Infant Mortality
Alcohol
Tobacco
Obesity
Income and Debt
Employment and Skills
Housing
Community Safety
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Systematic Community Engagement

• It is not so much deprivation that is the issue
  for us these days. It is demotivation
• Voluntary Action Chair

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Policy drivers on Community Development

• The Sustainable Community Strategy in each local
  authority area should include a strategic
  approach to Community Development across the
  locality, linking input from all providers, both
  statutory, independent and VCS and forming a
  strong theme in LAA and the LSP DCLG
  December 2006
• .. The development of the LAA should be based on
  strong local involvement. This should be part of
  a comprehensive approach to community engagement
  rather than consultation in isolation
  Operational Guidance Nov 2007
• Community development is about building active
  and sustainable communities .. It involves
  changing power structures to remove the barriers
  that prevent people from participating in the
  issues that affect their lives. NICE
  guidelines on Community Development 2008

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Agreed definition of natural communities

• The NST has seen a full spectrum of approaches to
  defining geographical communities
• Featureless map

Prioritised (NRA) neighbourhoods only
Comprehensive division into natural communities
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Community profiling

• Providing understandable information about, and
  for, communities is an important support for
  change
• Ward based information often has limited
  ownership, and can hide pockets of difference
  e.g. deprivation
• Too much focus on target neighbourhoods, e.g.
  NRAs, can also lead to neglect of pockets of
  deprivation
• Division of whole borough/city into agreed
  natural communities, and subsequent profiling,
  allows balanced view of need, and monitoring of
  progress in whole system (Doncaster, Sheffield)
• Top- down provision of information e.g. health
  data, should be augmented by bottom-up
  intelligence about perceived needs through
  engagement of communities and front-line staff
  (Hartlepool)

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Tiers of Community Engagement

• Systematic engagement needs to address 3 levels
• Themed engagement at borough/city level
  organised structures to draw in meaningful input
  to strategy, planning and evaluation of services
  eg from BEM groups, the elderly, Voluntary,
  Community and Faith (VCF) sector. LINks and OSC
  important
• Sub-district organisational divisions e.g.
  Locality co-terminosity of partnership
  structures, including PBC, important, drawing
  inputs from VCF in coordinated way
• Neighbourhood level neighbourhood management
  connecting with community groups and structures
• Such structures are necessary to support
  meaningful bottom-up engagement in planning and
  consultation (Wolverhampton)

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Forms of Community Engagement

• Consultation Asking service users and
  residents opinions before making decisions about
  services and facilities. Includes distant
  (opinion surveys) to the more direct (eg focus
  groups, citizens juries, workshops)
• The NST sees lots of innovative and energetic
  practice (eg Bolton)
• Partnership Involving the community directly in
  addressing local problems, through community
  organisations and local planning
• This is less usual and patchy within areas (but
  eg Hartlepool)
• Empowerment Supporting individuals and
  communities to make their own contribution to the
  local community or run their own services and
  projects and to make their own choices about the
  services they receive
• This is very unusual, and very unsystematic (but
  eg Bolsover)

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Behaviour and Action
Developed
Infrastructure
Un-developed
High
Low
Motivation
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Infrastructure

• Necessary for
• Establishing the ongoing dialogue necessary to
  foster the desire to change behaviour or to act
  positively
• Supporting individuals motivated to act/change to
  capture the moment, making healthy choices
  easier choices
• Systematic delivery requires strategies for
• Cultural change in statutory agencies
• Community Development

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Changing statutory sector culture

• This requires a coherent approach to adjusting
  the focus of the whole organisation, but
  preferably as a whole LSP. There are five main
  elements
• Overview and coordination
• Organisational development
• Professional infrastructure
• Community infrastructure
• Grass-roots community work
• Jan Smithies

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Voluntary, Community and Faith Sector

• Great potential as bridge between statutory
  sector and individuals
• Only fulfil potential for population health if
  systematically connected in, well supported and
  quality assured
• Best where overarching body, e.g. CVS, provides
  infrastructure support such as financial
  services, training and HR (Bolton)
• Better still where also supported to input
  strongly and cohesively at LSP level (Rotherham)
• When moving towards a commissioning arrangement,
  joint learning sets with commissioners and
  providers offer best chance of mutual
  understanding of needs (North East Lincs)
• For persistent action, 3-5 year contracts
  beneficial

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Social exclusion

• Systems for community engagement usually rely on
  connectivity with groups, leaders and motivated
  individuals
• Individuals not in contact with services will
  often exclude themselves, or be excluded from
  such contact
• Where strategies for outreach focus on peer
  training e.g. health trainers, health advocates,
  community ambassadors, they need to be targeted,
  and scaled up appropriately rather than being
  tokenistic (Birmingham)
• Whole communities with low social capital can
  also be excluded if lacking capability and
  capacity to engage with outside structures, and
  to compete for developmental resources. Community
  engagement strategies need to actively seek out
  and support such communities (Sheffield, Bolsover)

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Engagement strategy/ies extended into stakeholder
engagement involving front line staff across
partnerships (statutory and VCF sector) with
feedback on action taken. We asked, you said, we
did, this is the difference you made.
Respect and trust between partners backed by
mechanisms for shared learning between partners
e.g. learning sets. Community based organisations
delivering local services with an asset base for
future sustainability
Community level partnerships contributing and
being influential at strategic level i.e. across
City / Borough / District
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Devolution of assets from statutory sector to
community organisation/s in support of developing
community self-determination.
A range of innovative methods for reaching seldom
seen and heard groups. Elicited views
demonstrably impacting on action.
Effective partnership framework (or TOR)
providing protocols and safeguards to ensure
collaborative decision making and conflict
resolution
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Range of reach a strategy involving a menu of
methods of engagement other than large meetings
e.g. citizens panels, patient liaison/user
groups, household surveys. Elicited views
demonstrably impacting on action.
Community representatives feel that they
influence decisions being taken about their
community.
Community organisations sustained by a mixture of
income from trading and/or commissioned
activities, and/or grant aid.
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Community planning and implementation groups have
representative membership with systems of support
back to their constituency.
Consultation based on large meetings /events and
the usual suspects, with feedback on results.
Community organisations surviving mainly through
voluntary effort
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Membership of community planning and
implementation forums may be tokenistic with
unequal power relationships
No /few community organisations with limited
lifespan
Minimal consultation
Community Partnership
Community Empowerment
Community Consultation
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CNE Local Profile
Structures
CNE Staff
Neighbourhood Coverage
Neighbourhood Action Planning
Community Empowerment
Development of Social Capital
CNE Service Organisation
Neighbourhood Management
Community Consultation
Community Partnership
CNE Service Delivery
Development of Human Capital
Neighbourhood and Community Profiling
Stock-take of Neighbourhood Infrastructure
Development of Social and Community Cohesion