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1 EPHA response to the UCL Institute of Health Equity consultation on The Role of the Health Workforce in Tackling Health Inequalities: Action on the social determinants of health European dimension EPHA is the European Platform bringing together public health organisations representing health professionals, patients groups, health promotion and disease and injury specific NGOs, academic groupings and other health associations. Our membership includes representatives at international, European, national, regional and local level. EPHA's mission is to protect and promote public health in Europe. EPHA brings together organisations across the public health community, to share learning and information and to bring a public health perspective to European decision-making. We help build capacity in civil society participation across Europe in the health field, and work to empower the public health community in ensuring that the health of European citizens is protected and promoted by decision-makers. Our aim is to ensure health is at the heart of European policy and legislation. Please see for more information.

2 Introductory statement Health inequalities have been a problem for decades but in times of economic downturn and financial instability, the most vulnerable and disadvantaged people living in Europe experience the consequences of subsequent political choices stronger than other groups. With 23% of the European population living at risk of poverty or social exclusion, and ever more people being pushed into poverty, vulnerabilities, disadvantage and discrimination both in terms of opportunities and outcomes are on the rise. The conclusions of the 2008 final report of the World Health Organization s Commission on the Social Determinants of Health Closing the gap in a generation clearly stated that being healthy is not an individual choice but primarily a result of a toxic combination of poor social and economic policies as well as other policies that shapes the conditions that people are born into, grow up, live, and work in, and age. The report also stated that tackling health inequalities through addressing the social determinants of health should be taken outside the healthcare system. Nonetheless, as the health workforce is only too well aware of, action taken both within and outside the health sector - on the whole population and on individual level health outcomes - can be utilized to a greater benefit for all, particularly the most disadvantaged and vulnerable, taking every opportunity that health services offer to prevent diseases and promote health. Health workforce and healthcare systems have an important role to play in reducing health inequalities through systematic and effective action on the wider social context in which their customers are placed. By virtue of having unique access to the population, combined with trust and a well-recognised position in communities, health professionals are crucial points in the life course of individuals, both during illness and most importantly something that has not yet been fully explored - during the healthy stages of life as well. At the moment almost all European countries see a changing policy context in which health services and health staff are undergoing a radical reorganisation. Many social determinants of health-associated support services have either been downgraded, or else they have been changed, passed on to local authorities and their funding has been significantly cut. As witnesses of such cuts, health professionals can serve as providers of evidence on detrimental effects of the current financial situation on health inequalities. Actions taken from within the health sector would be most effective when aligned with broader and inclusive policies in all other areas that touch upon social determinants. The European Public Health Alliance (EPHA) believes that the University City London Institute of Health Equity (IHE) and the consultation on their report The role of the health workforce in tackling health inequalities: action on the social determinants of health can benefit from our expertise on the European policy-making context, its impact on crossborder, national and local level health sector work. As the biggest European Platform bringing together public health organisations including from the UK we represent a broad spectre of the public health community including health professionals, patient groups, health promotion and disease specific non-governmental organisations (NGOs), academic groupings and other stakeholders working at international, European, national,

3 regional and local level. Our diverse membership enables us to act as a change agent and to bring a public health perspective to European decision-making. We build up capacity in civil society participation across Europe in the health field, and we work to empower the public health community in ensuring that the health of all people living in Europe is protected and promoted by policy-makers so that other stakeholders are able to address the social determinants of health as their principle. In this light EPHA welcomes the opportunity to contribute to the consultation process on this report and would like to thank the UCL IHE for their interest in hearing the European perspective of health professionals role in reducing health inequalities. We will structure our response to follow the framework of the report itself, that is to say we will analyse three areas: 1. Health system, services and professionals in practice; 2. Health system, services and professionals in education; 3. Health system, services and professionals in relation to incentives, monitoring and directives. The text is to attempt to provide answers to the following questions: (Overall approach) 1. Do you agree that practice, education and incentives, monitoring and directives are the most important areas for action? 2. Can you identify any further mechanisms, not identified in the report that could be used to facilitate action on the social determinants of health by the health workforce? 3. Are there any activities or themes that feature in the report that you think should not? If so, please state. (Coverage) 4. Are there any activities or themes that do not feature in the report? If so, please could you give examples? 5. Are there specific health professional groups that do not feature adequately in the following report? 6. Do you have any examples of work that you do/are aware of on the social determinnats of health that we could share with stakeholders (via case studies in the report or our website)? If yes, please include in your consultation response. (Actions) 7. What action are you thinking of taking as a result of this report?

4 8. What would help you take action after reading this report? 9. Do you think you/professional groups would find the appendix illustrative example useful? (Dissemination and implementation) 10. How can the Report findings be most effectively disseminated and implemented? 11. What can the IHE do to improve the likelihood that its proposals will be adopted locally, nationally and internationally? 12. What do you think should be the priority actions the IHE should take following the publication of this report? 13. Any further comments?

5 The health sector s role in addressing the social determinants of health is significant, especially given the range of professions and responsibilities held in the areas of prevention and health promotion at the population level. EPHA believes that helping to create the conditions for individuals and communities at large to take control over their own lives, and enabling all children, young people and adults to make the most of their potential, as well as fostering healthy, cohesive and sustainable places that people regardless their health status are born into, grow up, live and work in, lies within the scope of practice of healthcare professionals. The extent of people s participation in community life, their involvement in service development and the special relationship between providers and users greatly contributes to people s well-being and improved health outcomes. Certainly, this cannot and should not be attempted to be achieved from a fragmented and silo approach to tackling health inequalities. On the contrary, the healthcare sector as a whole and the health workforce need to look beyond their boundaries, actively reaching out by working cross-sector and in partnership with other areas. As mentioned in the report, research has stressed a much needed shift from vertical disease-oriented initiatives and specific target groups towards a horizontal and holistic community-oriented approach, able to address multiple social determinants of health, and build social cohesion and trust. Partnership with communities especially disadvantaged ones is crucial in order to identify local needs and demands, develop solutions fitted to these local needs, i.e. locally accepted, owned and, as much as possible, also led. We would also like to emphasise the importance of advocacy and influencing policy from the healthcare sector in order to influence local, regional, national but also European and international policy and decision making, and to promote the European value of solidarity. As this can be undertaken in different ways e.g., on a patient basis, on behalf of communities and by professional bodies and associations the impact can be significant and extremely valuable. There is already a great deal of evidence showing that the health workforce can positively affect health determinants, which remain greatly out of reach for clinical actions. Importantly, the inclusion of advocacy skills at various political levels could be considered as an addition to medical courses and as part of continuous training of already practicing professionals. In the case of health professional associations active at European or national level, voicing the concerns of vulnerable groups, children, patients and all for whom maintaining health gains is at stake - should be considered written into their professional mandate. European and EU-oriented organisations members of the European Public Health Alliance such as the European Federation of Nurses (EFN), or the Royal College of Physicians (RCP) and the Royal College of Nurses (RCN) based in the UK, through their ongoing participation in public health networks and platforms (e.g., Diet Platform, Alcohol Forum, EU Health Forum) and in close collaboration with their national members deliver a great body of work of value to European policy-makers. Given the cycle of political influence across Europe, sooner or later these decisions also affect national-level policies. Therefore it is an asset for health professionals to be involved in the policy-making process at all stages of its design.

6 Through professional associations support to the social determinants of health dimension of EPHA s activities, their impact can also be seen in, e.g. social platforms and networks debating poverty, civil society and democracy. Given the breadth of public health issues, professional bodies can play a role in shaping and lending support to a variety of not traditionally health-considered subjects of European relevance, such as the Directive on Patients Rights in Cross-border Healthcare, the Audiovisual Media Directive, debates surrounding advertising to children and food intended for infants, and crucially also discussions on the EU Budget and public health spending, research and Innovation, etc. Collecting and using information is also very important in order to act on health inequalities and the social determinants of health of individual patients, as well as patients embedded in their broader community. However, there must be a proper consideration of data protection and ethical deliberations concerning sensitive and personal information. This relates to a great extent to ehealth and ICT technologies currently used or being scaled up in the health sector. Making referrals to initiatives and services of positive impact on the social determinants of health (including childcare and education, employment, housing, family support, nutrition), as well as greater utilisation of referrals to other health services in areas of particular importance for dealing with core factors of a healthy lifestyle, such as prevention and cessation of tobacco smoking and excessive alcohol consumption, physical activity and healthy diets. A fifth factor should be added here, which is a health-promoting and sustaining environment in collaboration with adequate services responsible for urban and rural settings at national, local or municipal levels. In a similar vein, as part of wider antipoverty and social exclusion action plans, primary community-based care organisations and services could offer advice about child, family and other welfare benefits or taxes, debt reliefs, food deprivation and others, from within the healthcare setting itself. Enabling and supporting people and communities to take control of their lives, promoting and reaffirming messages supporting early child development as the best start in life, promoting and working in line with the provision of fair and quality employment, as well as supporting and building up resilience of healthy, cohesive and sustainable communities and physical places should be integral to the work of health services professionals. All of these go well beyond disease management and fragmented, single lifestyle interventions. For as much as health service professionals can and do affect individuals, they have an extremely important role to play in being a change agent for the communities people live in. Apart from the mechanisms identified in the report, we believe in the added value of the following activities: - (coverage and actions) developing and implementing principles on child-friendly healthcare services that are applied by healthcare professionals, including health promotion and disease prevention activities (according to the Council of Europe s guidelines), - (coverage) participation of health professional advocates in the revision of the EU Directive on Professional Qualifications; increased harmonisation of practices across country-, regional-, national- and EU-level

7 - (coverage and actions) participation of health professionals in the proper implementation of the WHO Framework Convention for Tobacco Control, the WHO Global Code of Conduct on the Recruitment of International Health Personnel, as well as the WHO Code on Breastfeeding and Infant Foods (and baby milk formulas promoted in hospitals); - (coverage and actions) health professionals can also help promote specific public healthrelated aspects of maternity and paternal leave, advertising and marketing of food, drinks, tobacco, lifestyles, sin-taxes, poverty and social exclusion; - (coverage) healthcare services and health professionals can greatly improve people s social determinants of health by placing stronger attention to specific inequalities-driven issues of sexual and reproductive health and rights, gender-based violence, early years emotional and cognitive child development, child injuries, neglect and abuse, community-based physical, social and mental health care, parenting support and referring families to specific community initiatives; - (coverage and actions) in particular working with marginalised groups like ethnic minorities, Roma and traveller communities, the homeless and people suffering from mental illness, health professionals attitudes pertaining to the legal aspects of individuals (who may have an unregulated legal status and no health insurance coverage) can have a positive impact on the empowerment and health of individuals and communities. In this regard, cultural sensitivity and understanding of in-group values need to be included in the design and facilitation of social determinants of health-oriented activities. This requires empathy and the ability to grasp different viewpoints (e.g. religious, cultural, moral beliefs and practices) in order to protect and advance the health of vulnerable individuals like gays and lesbians, transsexuals, single mothers, etc. More should also be done with regards to advocacy for universal access to healthcare, including health promotion, disease prevention and treatment. This is particularly important for disadvantaged people with a precarious legal status, who often avoid (or are unsuccessful in consulting) health professionals for lack of financial means or out of fear of being referred to the police. The health workforce could take a proactive stand on this subject by detaching healthcare help from legal status; - (coverage) the specific role that the health workforce can play in rural, disadvantaged and remote areas should be considered. In particular, access and availability of quality healthcare services (incl. health promotion and disease prevention), but also other basic services of general interest (family and care services, education, employment, housing) could benefit from influence, involvement and support from health professionals in this specific context where needs are high but resources limited; - (coverage and actions) the health workforce can positively act on influencing policy on a number of social determinants of health resting under the ordinance of services of general interest like water, sanitation, public transport, fuel, food, climate change, chemicals and environments necessities known to be difficult to attain in sufficient quality and quantity for the most vulnerable groups. This would give a particularly powerful push, based on public health arguments, to consider changing public policy in order to mitigate the current austerity measures and budget cuts to re-shift public spending priorities. This also includes

8 advocacy on efficient public procurement processes that incorporate health, social and environmental factors for the benefit of communities and specific vulnerable groups; - (coverage) specific health professional groups that were not mentioned in the report and would certainly be of added-value to be considered as tackling health inequalities through addressing social determinants of health would be pharmacists (especially communitybased pharmacists, who are often the first health professionals to be consulted by members of the public and whose advice is therefore very influential), dietitians and nutritionists, but also professionals working in the area of complementary and alternative medicine (CAM), and school nurses. Sensitising them to the social determinants of health would enable support to be much more holistic and integrated, responsive to individuals embedded in their communities and able to catch a wider picture of peoples health problems to find the best solution for treatment or prevent them from occurring in the first place. Only through increased awareness and collaboration can hidden health problems be addressed. - (coverage cross-sector and partnership working) in addition to local government and other public sector partners, the police, fire service, third sector and private sector organisations we would like to stress the inclusion of trade unions, employers, retailers, media, teachers, farmers, church workers, local public procurement services, businesses and entrepreneurs; - (coverage education and health researchers) tackling health inequalities through addressing social determinants of health should be granted a proper place in universally recognised medical courses and aligned with a set of European public health skills. The same attention should also be given to training included in continuous professional development for a wide variety of health professionals. However, these courses must do more than merely make references; they should also consider including placements (e.g., with civil society organisations) relevant to various social determinants of health. Professions outside the health and well-being agenda should also be able to consider including teaching on health inequalities both in theoretical and practical ways. The same consideration should be given to research undertaken in the area of (public health), especially with due attention to evidence-based preventive measures on social determinates of health. Dissemination and successful implementation It is very important that the results of this review should be recognised at the three levels of practical and political action local, national and international. Too often we see examples of national or international actors attempting to control interventions that are best managed locally or even at the community level. As a European network of public health organisations operating at all levels of European and even global society, we believe any recommendations made must be differentiated into one-size-fits-all and specific or tailor-made proposals. Regardless the scope, we believe any recommendations need to encompass:

9 - Meaningful participation, negotiation and civil consultation with all relevant stakeholders, including the affected and general population, employers, consumers; - Public health capacity so that public health professionals at all levels know the value of working cross sectors, take leadership, know how to use evidence to inform decision makers; - Strategies need to be really applicable, affordable and acceptable on the ground by recipients and intervention makers; There are possibly several channels through which the results and findings of this consultation could be most effectively disseminated: - Regional authorities conferences, workshops, seminars and meetings; - Local authorities cross-department learning and information exchange meetings; - WHO collaborating centers and networks of excellence in country; WHO focal points; - National institute of public health, schools of public health associated in Association of Schools of Public Health of the European Region; - Media, health and social journalism, public information campaigns;