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