NHS Grampian. Reducing Inequalities The Role of the NHS

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1 NHS Grampian Board Meeting Item 7.2 Reducing Inequalities The Role of the NHS 1. Actions Recommended Board members are asked to: Note the strategic context for NHS Grampian s role in Tackling Health Inequalities. Approve the proposal to set up a short-life working group to review and make recommendations on how NHS Grampian can maximise its contribution to tackling health inequalities within the context of Community Planning. 2. Strategic Context Tackling inequalities is one of the most complex and important tasks facing the healthcare system. Health inequalities are potentially preventable differences in health status across the population. They manifest as variation in risk exposures, disease prevalence, access to services and in people s experiences and outcomes of care. The 2015 Health Inequalities Policy Review for the Scottish Ministerial Task Force on Health Inequalities (1) confirmed the continued presence of significant inequalities by social position. Director of Public Health Annual Reports have indicated that health is improving for everyone in Grampian. But, while life expectancy rates are increasing overall, they are rising faster for the affluent than the most deprived so the gap is getting wider. In Grampian, people living in the poorest neighbourhoods, will, on average, die 10 years earlier than people living in the richest neighbourhoods. The difference in disability free life expectancy is 22 years. So, people living in poorer areas not only die sooner, but will also spend more of their shorter lives with a disability. There are differences in health behaviours and lifestyles between communities as highlighted in the Local Delivery Plan Board paper. These differences are also evident in the use of health services for example, emergency hospital admission rates rise as deprivation increases across Grampian and this gap has not narrowed over the past decade. Clearly there is potential to reduce emergency hospital admissions from poorer populations, which would significantly reduce the overall impact on emergency health care. 1

2 The NHS, as an organisation and as a partner in Community Planning has a key role to play in ensuring that it plans, delivers and procures services in a way that openly addresses such inequalities. Not only are the costs of treating preventable ill health avoided, but it improves quality of life for individuals and brings benefits to society. This is a complex agenda requiring a multifaceted approach. It is recommended that in light of Integration Joint Boards a short life working group is established to review the health system contribution to the agenda and make recommendations if appropriate to strengthen our response. Key matters relevant to the recommendation Policy context There have been a number of policy documents in Scotland calling for action to address inequalities. In 2008 the Equally Well report from the Ministerial Task Force on Health Inequalities (2) outlined recommendations to tackle the underlying causes of health inequalities under a range of headings: early years and young people, poverty and employment, physical environments and transport, alcohol, drugs and violence and health and wellbeing. The Commission on the Future Delivery of Public Services, known as the Christie Report called for public service organisations to prioritise prevention, reduce inequalities and promote equality. NHS Scotland Healthcare Quality Strategy has put patient experience and standards of care at the heart of the NHS. Addressing the nine national outcomes for Health and Social Care Integration including improving health and reducing health inequality, as a priority. The policy landscape sets out the important role for those working in the health system to address inequalities for staff and patients through action on the social determinants of health. The Institute of Health Equity (3) and Health Scotland (4) have identified action that the NHS can take to strengthen its efforts. 2

3 This could provide a useful framework for NHS Grampian to conduct the review - summarised under four headings: The quality of service the NHS plans and provides What the NHS does in partnership The NHS as an employer and procurer of goods and services The advocacy role of the NHS. The quality of service the NHS plans and provides Good quality care cannot be provided consistently if people from disadvantaged groups have an unequal experience of healthcare. Leadership is required to ensure services are planned, resourced and allocated to need. This means that addressing the social determinants of health is part of health professionals business, particularly in frontline practice. To fulfil this role we need to know the nature of needs within the community we serve. Health intelligence provides the foundation for tackling inequalities. As a Board and in conjunction with our partnerships there should be a shared understanding of the scale of the gap between the least and most deprived, which population groups utilise our services and whether the outcomes are equal across our population. We must ensure that all Board members understand which inequalities are being targeted and that our performance data monitors the impact on inequalities. We need to ensure that feedback influences our planning, particularly from patients and the public living in deprived areas and those known to be at risk of poor health outcomes. Acknowledging that the art and science of measuring the wider determinants of health is still emerging, we have made progress to help with service planning by illustrating differences in health status and determinants in communities through for example the health traffic lights NHS Grampian Board has also committed to using the health inequality impact assessment tool and has developed a Resource Allocation and Decision Making framework which has tackling inequalities at the centre. What the NHS does in partnership Analysis of health inequalities shows a clear social gradient in health outcomes which closely relates to social and economic factors, described by Marmot (5) as the conditions of daily life. These conditions early years experiences, education, working life, income and environmental conditions lie outwith the traditional remit of the NHS and require agencies to work together to address. NHS Grampian and the Integration Joint Boards are active partners in the three Community Planning Partnerships in Grampian. Although at different stages in development, the three Community Planning Partnerships are undertaking strategic needs assessment. This will enable partners to consider joint agendas to be delivered together or as single agencies. The Community Empowerment (Scotland) Act 2015 previously discussed by the Board aims to make the most of the talents that exist in communities, to co-design and deliver public services and to ensure high quality responsive services. NHS 3

4 Grampian has been actively involved in the development of our approach to fulfil the obligations of the Act. In the context of inequalities it is necessary to ensure that our services are reaching out to those who find it difficult to access our services or benefit from the services provided and /or to make their voices heard. The third sector is a key partner in facilitating engagement. There are many examples of partnership programmes including the Early Years Collaborative, Keep Well, Making Every Opportunity Count, Community Kitchens, Offender Health Improvement and Health Development Workers. As part of the Local Delivery Plan the Board and Integration Joint Boards are committed to monitoring the local impact that the NHS is making in community planning and the role senior leaders are playing particularly in relation to tackling health inequalities. The NHS as an employer and procurer The Marmot Review mainly focused on actions which could be taken out with the health care system to reduce health inequalities. A subsequent publication Working for Health Equity: The Role of Health Professionals sets out actions and strategies that can be developed within the health system, particularly with staff, where there is great scope. Six areas are highlighted for action: Education and training a greater focus on awareness of graded distribution of health outcomes, conditions that affect outcomes and practical actions that can be taken by health professionals to address them supplemented by practical skills to reduce inequalities within professional practice. Working with individuals two professional actions gaining and giving information. Taking a social history can supplement a medical history and enable professionals to deliver better care. Health professionals should refer patients to a range of services so that the root causes of ill-health can be tackled as well as the symptoms being medicated. Action by NHS organisations (as managers) - health professionals have opportunities in their roles as managers, commissioners and employers to ensure that workforce health and wellbeing are central to their activities. Literature has suggested at as much as 15-20% of a local communities employment and income comes from the health sector, giving significant power to affect health and wellbeing of a local population. Working in partnership in addition to the partnerships outlined above the report calls for health professionals to work in partnership with other health and non-health professionals across sectors. Workforce as advocates health professionals have great authority and expertise and should be using this to advocate for individuals and policies to reduce health inequalities. The health system challenges and opportunities the report acknowledges the extent of public sector reform identifying the opportunity to ensure that new systems are designed to tackle social determinants of health. The NHS in Scotland spends significant amounts of money each year and has recently considered ways in which this expenditure can be used to deliver wider social, environmental and economic benefits. Work has been taken forward to 4

5 explore Community Benefits in Procurement an example of which is targeted recruitment and training. There are many examples of good practice across NHS Grampian procurement policy to include community benefits, alcohol licensing, Families first. The advocacy role of the NHS Even among health professionals who have insight, there has been a sense that it is for others to respond, there is not much we can do. But the response we have had from the many organisations and individuals that have helped us with this report, is not only should we be taking action, there is ample evidence that we can Working for health equity: the role of health professionals (2013). NHS Boards have an important role in advocating for action at national and local levels to address the fundamental and environmental causes of health inequality. This sort of leadership and momentum is challenging to create and sustain, but underpins the Christie commission recommendations. Tackling health inequalities is a complex issue which requires the Board to understand, ensure appropriate action to tackle and monitor inequalities. The above framework provides a helpful tool to consider the response of the Board to tackling inequalities. There are a range of activities underway. Less clear however, is how we will in future assure ourselves that appropriate action is being undertaken and the impact that it will have. Board members are therefore asked to endorse the establishment of a short life working group to review NHS Grampian s Health Inequalities response. 3. Risk Mitigation The proposed action to establish a short-life working group to review and make recommendations to strengthen NHS Grampian s contribution to tackling health inequalities will contribute to the mitigation of risk 851 Delivery strategies to meet the future health needs of the population and risk 1784 Integration of Health and Social Care. 4. Responsible Executive Director and contact for further information If you require any further information in advance of the Board meeting please contact: Responsible Executive Director Susan Webb Interim Director of Public Health susane.webb@nhs.net Contact for further information Christopher Littlejohn Interim Deputy Director of Public Health chris.littlejohn@nhs.net 25 July 2016 Additional supporting information/ 5

6 Additional Supporting information: Health Inequalities Policy Review for the Scottish Ministerial Task Force on Health Inequalities Working for Health Equity: The Role of Health Professionals, UCL Institute of Health Equity Reducing health inequalities: What NHS Non-Executive Directors can do to make a difference, NHS Health Scotland Fair Society Health Lives (The Marmot Review), Strategic Review of Health Inequalities in England post 2010, UCL Institute of Health Equity