Greater Manchester Health Inequalities Review

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Greater Manchester Health Inequalities Review

• March 2006

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Why did we set out to do this review?

• Greater Manchester has one of the lowest life
  expectancies in the country. Despite progress in
  recent years Greater Manchester is not projected
  to achieve the 2010 life expectancy target.
• Poor health and inequalities results in increased
  costs, lower economic output as part of the cycle
  of multiple deprivation.
• Partnership working is increasingly critical to
  effective public services

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Structure of the review

• Phase 1 interviews and documentary review to
  establish the main issues facing Greater
  Manchester
• Phase 2 a workshop approach to explore possible
  solutions to issues arising from Phase 1
• Phase 3 developing and agreeing action plans

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Purpose of today

• To share with you our initial findings and get
  your views
• Agree a process to share the findings more widely
• To agree a broad outline for Phase 2 workshops
• To share a new tool for looking at NHS spend
• Agree ongoing ERG requirements

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Audit Approach Phase 1

• 110 interviews with 41 organisations across GM
• Review of key documents/papers and good practice
  initiatives from those organisations as well as a
  number of networks and cross-GM alliances
• Consultation with some voluntary sector groups

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Findings Key topic areas

• Strategic fit
• Partnership and Accountability
• Information and Intelligence
• Workforce
• Performance Monitoring
• Diversity
• and
• Finding Good practice

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The overall picture

• Collaboration - moving in the right direction
• Greater Manchester knows what the health
  inequalities issues are
• BUT
• There is no health vision for Greater Manchester
  and a lack of champions
• Concerted, radical action is required to make a
  difference and reduce the health inequalities gap

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• Strategic Fit

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GM has a number of collaborative structures to
support the implementation of Health Inequalities
action and develop policy

• AGMA
• AGMPCTs
• Health Leadership Group
• Alliances and taskforces
• Networks e.g. Mental Health
• Greater Manchester Forum
• Acute Chief Executives Forum

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GM knows what its health issues are and
undertakes significant information analysis

• All organisations were able to tell us what the
  health inequalities issues are in their area
• There is growing and in some cases sophisticated
  understanding of health inequalities in local
  areas

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GM has intent to address the issues facing the
population

• Most organisations demonstrated intent to engage
  in the HI agenda
• The move towards collaboration is critical to
  success and is an excellent foundation for the
  future
• The use of NRF, engagement in LAAs and the health
  partnerships are driving some new initiatives.

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But there is no clear leadership of the Health
Inequalities agenda

• There is no overall leadership for addressing
  health inequalities across Greater Manchester
• Local strategic partnerships provide a focus but
  this is not necessarily aligned with health
  partners agendas.
• Inconsistent engagement in local partnerships and
  this is exacerbated in Mental Health where
  providers work with a number of different
  district partnerships.
• Leadership of the health inequalities agenda is
  often via the Director of Public Health.

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And

• Often acute service change is driven by new build
  and clinical services but without an explicit
  expectation that change will lead to improved
  health
• The potential for the corporate citizen approach
  is not well understood or embedded
• The public health delivery framework is a good
  move forward but does not include local
  government.
• There are different approaches to health
  inequalities issues

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GM does not put the mental health of its
population as a priority.

• Concentration on physical health and secondary
  care
• Lack of information about mental health
• Mental health organisations have particular
  difficulties in engaging with LSPs
• Pockets of excellence exists showing good
  outcomes

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Constant reconfiguration prevents progress

• A characteristic of the more successful
  partnerships appears to be stability
• Reconfiguration in the NHS in particular is
  damaging the potential for more successful joint
  developments
• Creates difficulties for some partners in
  engaging fully with the NHS on joint agendas

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• Partnership and Accountability

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There is some excellent partnership working

• Some partnerships show success in taking action
• These partnerships engage their acute trust
  colleagues
• Some DPHs have excellent relations across all
  sectors regardless of whether there is joint
  funding
• This creates a climate where action can be taken
• Smoke Free Manchester is one such example

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But

• Partnerships take different approaches to Health
  Inequalities
• Some local partnerships are focusing on wider
  determinants such as skills, employment, housing
  and crime
• Others focus on the agenda defined by Choosing
  Health
• Action arising from partnerships varies
• Not all partners are engaged
• Not engaging a wider range of partners fully will
  prevent meaningful dialogue

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The impact of non-executives and members makes a
difference

• This appears to be a key characteristic in
  excellence
• Robust challenge of board decisions is evident
• Support provided by those who represent their
  local communities is influential in getting a
  mandate for action

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But this impact could be greater..

• Health and overview scrutiny committees need
  better skills to challenge effectively
• Strengthen the role of scrutiny and challenge
  through HOS committees and support of NEDs in
  ensuring robust challenge.

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Clear variance in spend between organisations

• Variance in spend between PCTs is not well
  understood
• Great deal of management time exerted on planning
  for and spending relatively small amounts of money

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Lack of engagement with the voluntary sector

• Inconsistent involvement of the voluntary sector
• There is insufficient voice for the hard to
  reach groups
• Meaningful management support of the voluntary
  sector will add greater insight into practical
  solutions and ensure quality provision to target
  groups

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• Information and Intelligence

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The information is available

• GMAS GIS, PHO portal, Tactical Information
  System, Stats and Maps
• There are data analysts positioned across GM
• A great deal of analysis happens

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Intelligent use of information?

• Minimal use of information provided by the Public
  Health Observatory
• Limited use of TIS is made by DPHs and
  organisations
• The GMAS GIS has potential for highlighting hot
  spots
• Data skills and capacity is unco-ordinated and
  often not accessible
• Information is not effectively used to identify
  targeted actions or inform commissioning
• Action plans are oriented towards monitoring and
  data collection
• Lack of common agreement about where the data
  gaps lie

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GM not confident in applying HI evidence to
commissioning decisions

• Lack of evidence that concerted action is being
  taken
• Needs to have a clear vision of what has to
  change to make a difference and commission
  accordingly
• Excessive analysis may prevent decisive action

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Making the most of research and research funds

• Do research funds inform changes locally?
• Research establishments not tied into the local
  health inequalities agenda
• Teaching, secondary and tertiary centres have a
  wealth of untapped information
• 5 star research facilities in mental health yet
  little local impact
• The public health practice unit proposal is
  emerging but must be widely available to all
  organisations

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• Workforce

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Workforce planning is beginning

• Strategic arrangements are in place to ensure a
  range of skills available to senior public health
  staff
• Some good analysis of the current workforce
  available in direct public health provision
• No evidence of workforce implications of
  addressing health inequalities in local
  government

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Has GM got the workforce capacity to address
health inequalities?

• Little evidence that the potential of existing
  staff to address health inequalities in all
  organisations is being harnessed
• Management time is spent on gaining small numbers
  of extra staff
• With management support for small service
  providers in the voluntary sector an untapped
  resource can be enhanced

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Impact and role of Directors of Public Health

• Embracing joint appointments has resulted in real
  engagement
• DPHs have too wide a range of responsibilities to
  be able to provide suitable and sufficient advice
  and guidance
• The collective role of Directors of Public Health
  to all sectors is unclear
• The role and focus of the PH network is unclear
  to many organisations

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• Performance Monitoring

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There are some good examples of performance
monitoring

• Some organisations and partnerships have
  sophisticated monitoring systems
• Nationally prescribed targets are generally well
  monitored
• Local Area Agreements has strengthened some
  performance monitoring

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Performance is not monitored on a GM wide basis

• No readily owned GM wide performance measures
• No readily available comparative information
  between partnerships
• Many partnerships struggle to agree common
  priorities and set appropriate targets.
• Focus still on individual organisational targets.

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• Diversity

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Diversity is managed by exception

• Where there is a high ethnic minority population
  - diversity is high on the agenda
• Where there is a low ethnic minority population -
  in some cases therefore more diverse, diversity
  is not on the agenda
• GM appears to identify diverse communities as
  problematic
• needing special treatment rather than dealing
  with the barriers to access

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Diversity

• Some clear indications of the impact that diverse
  populations are having on the provision of
  services
• These are not widely shared
• information from acute trusts about take up by
  diverse communities
• Inequality of access
• examples of late presentation which are not
  informing commissioning

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• Sharing of good practice
• Its your problem when your neighbours wall is on
  fire

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Good practice

• There is a wealth of notable practice across
  Greater Manchester
• Good practice across the board including joint
  working, learning disability, ethnic minorities,
  use of information, public health reports,
  corporate citizen, member engagement, teenage
  counselling
• Significant time and effort is invested in
  getting new initiatives off the ground

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But

• Need to think outside the box
• Tertiary centre has designed hard hitting posters
  on prevention but why arent these up in
  secondary schools
• Some organisations do not know their neighbour
  has a solution
• An example of a PCT struggling to engage a
  particular group but a neighbouring authority had
  this addressed
• A PCT understands what corporate citizen means
  and can demonstrate real actions but a neighbour
  doesnt know where to start
• Acute trust has insight into real inequity of
  access but there is no obvious forum to share
  this and the wider lessons
• Acute trust wants to get involved but never
  approached or asked

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Summary of what needs to happen

• Develop a health inequalities vision for Greater
  Manchester
• Clarify the role of DPHs and the focus of the
  Public Health network
• Ensure health and overview scrutiny committees
  develop their skills to challenge more
  effectively
• Improve the use and co-ordination of information
• Ensure that existing groups of staff are utilised
  in addressing health inequalities
• Develop pan-GM performance measures that support
  regular monitoring, comparison and evaluation.
• Engage more widely to understand the barriers to
  access facing the population of more diverse
  groups
• Develop arrangements to share good practice as a
  matter of course across GM

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Food for thought

• The following slides give an insight into the
  high level data available to all organisations
  and the insights it can provide.
• They are intended to raise questions at this
  stage.

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NHS spend in Greater Manchester total spend for
the population
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Admissions by PCT across GM
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Endocrine, nutritional and metabolic admissions
(not diabetes)
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Cancer and tumour admissions
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Circulation problemsis the excess spend around
28m?
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Respiratory admissions
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Dental admissions compared with a fluoridated SHA
area
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Phase 2 Creating the environment for change
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Visioning

• A workshop to explore what needs to happen to
  create a vision for Greater Manchester
• To identify key players and stakeholders
• To understand what existing structures and
  organisations could help
• Representation from across sectors

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How to make scrutiny and Non-Executive
Director/Member challenge a greater strength?

• New non-executives to the NHS in coming months
• Strengthening Board/cabinet/executive challenge
• Councillors encouraged into health scrutiny
• Making health scrutiny more effective

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Resource allocation

• Overall cost Is the spend of the right amount
  in the right areas and are variances understood
  and justifiable?
• Explore outliers in spend by programme budget
  categories
• Explore the effects of ill-health in GM on NHS
  spend in particular
• Can this type of use of data inform GM wide
  performance monitoring?
• Is something similar possible for LG funds?

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Information and intelligence

• What systems are available and what has to happen
  to information systems to support joint
  performance monitoring?
• How to get ownership of collective information
  systems??
• What support do public health and data analysts
  require and how to access their skills and
  capacity better?
• What public health/health inequalities
  information does commissioning need to inform
  decisions?
• How does HEA inform commissioning?
• What insights can secondary and local government
  providers give to increase understanding and
  inform the right commissioning for GM?

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Application of research and intelligence

• How does the research capacity available in GM
  get locally applied?
• What role would a public health practice unit
  play across all sectors?
• What engagement needs to happen to secure
  research funds? Influence university research?

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What role can the Directors of Public Health play
to have best effect in supporting the HI agenda
for Greater Manchester across all sectors?

• Strategic? Enabling? Operational?
• What do local government and primary care
  commissioners need from these roles?
• What resource needs to be dedicated to a
  commissioning function?

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Mental health where does this really sit in the
priorities of Greater Manchester?

• What has to happen to engage all partners in
  addressing the real inequalities that exist for
  the people of Greater Manchester in their mental
  health? And consequently their physical health
  and the health of those around them?

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How can the existing workforce be galvanised into
the Health Inequalities agenda?

• For example
• Explore the role and use of the health visiting
  resource
• Delivering a school health service
• Engaging local authority staff
• Making health improvement everyones business

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Would a Greater Manchester good practice database
help? Who could own and facilitate this?

• Web-based? Excel based?
• What organisations have the skills to do this?
• What categories might be best to focus on?
• Will organisations contribute to populating this?

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(No Transcript)
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Some other options to support those tasked with
leading the Health Inequalities agenda ?

• Corporate Citizen?
• Engaging with the voluntary sector?
• Facilitated self-assessment workshops with
  individual health partnerships?