An NHS Grampian Framework for Reducing Health Inequalities 2004-2007

An NHS Grampian framework for reducing health inequalities: 2004-2007

30 April 2004

Summary

A pivotal task signalled in our Local Health Plan is the need to action a system-wide approach to tackle health inequalities, to increase penetration on addressing health inequalities, throughout our business and in conjunction with our partners.

In the first phase of this work, NHS Grampian, with Local Authority and Communities Scotland colleagues, have jointly developed initial guidance on a Grampian-wide framework to build the basis for creating a step change to reduce health inequalities.

The policy direction and the weight of national and international evidence on health inequalities are remarkably consistent. At the same time, there has been extensive organisational re-shaping both in the NHS and among partners. Political reality, public involvement, organisational development and performance management are creating the relevant structures and processes to support us in tackling health inequalities, increasing the potential for local involvement and ownership in both healthcare and health.

Our aim in taking account of these complexities has been to produce an initial local framework with the following features. A framework which:

Builds on and supports existing work, particularly within JHIPs and Community Plans

Is systematic and system-wide

Is evidence based and intelligence driven

Is conceptually simple, but sound

Uses the ‘four pillars’ of the Health Challenge

Focuses policy, practice and performance management on accelerating change to reduce the health gap

Builds towards use of postcodes to measure the gap

Begins to focus, as a first step, on the five core, pan-Scotland, indicators of inequality

Supports the process of prioritisation by refining understanding of health inequalities in Grampian

Offers a tool to promote the development of shared intelligence

Provides an initial resource from which to work towards ‘full engagement’

Includes seven system-wide actions to focus our work

Creates the basis for more systematic collaboration to reduce health inequalities

We illustrate key policy and evidence which has influenced us in constructing the framework. We recognise, however, that more important than any framework will be its contribution to the sustained, concerted, systematic assault on health inequalities.

By ‘fully engaging’, we are affirming the long term sustained partnership commitment to change hearts and minds, and to support priority groups and areas to aspire to and achieve good health for themselves, their families and their communities.

Interdependence, however, needs to be managed with clearly identified responsibilities to lead and or support, and account for delivery. The next phase of our work will address these key issues, informed by the current review of performance management systems within NHSG.

We will have come full circle, when we identify the health outcomes we agree to benchmark, to allow us to say with strong evidence, as well as conviction, not only is Grampian’s health improving but we have all but eliminated health inequalities within our communities within a generation.

To help accelerate our work on health inequalities we are recommending the following action.

Agree and implement a framework for systematic data collection, including benchmarking, on health inequalities across NHSG.

Mainstream NHSG health inequalities data and guidance progressively informing the policy context across NHSG.

Review regularly the health inequalities framework.

Support each sector of NHSG in its role to reduce health inequalities through the JHIPs.

Support partners as Public Health Organisations in agreeing, delivering, monitoring and mainstreaming evidence-based interventions to make a step change in the health of vulnerable communities.

Engage fully on health inequalities, as described overleaf, through existing planning and prioritisation processes within NHSG and Community Planning Partners.

Collaborate with Community Planning Partners in progressing complementary initiatives.

Page

Summary2

INTRODUCTION5

Purpose5

Guide to framework5

Aims7

Principles7

Health Inequalities-what we mean8

Health Inequalities and Health Improvement8

Focus of framework8

Health Inequalities-how we measure the gap8

Mainstreaming Health Inequalities9

THE EVIDENCE BASE10

National context10

Is Scotland’s health improving?10

Local context11

Is Grampian’s health improving?11

Constituency Profiles12

Grampian constituencies at a glance12

Doing better (than the Scottish average)?12

Doing worse?13

Grampian wards at a glance13

Health and Health Inequalities14

The data raises questions14

THE POLICY CONTEXT15

National context15

Working within existing and emergent policy and planning frameworks15

‘Significant’ policy18

Local context18

Unifying visions18

FULLY ENGAGING IN GRAMPIAN19

Actions for NHSG20

INTRODUCTION

Purpose

This strategic framework sets out the basis for developing a systematic, system-wide programme of action to improve health by reducing health inequalities in Grampian to ensure that each sector implements the NHSG vision and the vision of community planning partners to increase heath and well-being in Grampian.

NHSG, in the context of the national priorities set by the Scottish Executive, identified in the Grampian Health Plan an initial pivotal task: to develop a system-wide strategy to tackle health inequalities, to ensure increased penetration on addressing health inequalities throughout our business, and in conjunction with our partners.

The social causes of ill-health and inequalities are now widely acknowledged, ‘that tackling inequalities generally, is the best means of tackling inequalities in particular.’ Two sets of policies, therefore, are vital: general policies to tackle social exclusion and inequality, and specific health service policies aimed at reducing health inequalities.

More important, however, than the production of a framework, will be its impact in maximising concerted effort to reduce inequalities in health, placing these at the centre of policy, planning and delivery of services. To achieve this, NHSG is dependent on the goodwill and commitment of all its partners, including the private sector, to unite behind current ‘best evidence’, to agree the strategic priorities for NHSG for the next three years.

Guide to framework

Our framework emerges from national and local evidence of, and policy on, health inequalities. This first phase of work has focused on health outcomes and is indicative rather than comprehensive. We envisage subsequent phases tackling our evidence base, issues of access, professional as well as community capacity building, performance monitoring and management through the development of effective benchmarking of outcomes.

Initially, we set out our aims and the principles which have underpinned our work. We have defined ‘health inequalities’, following the Scottish Executive’s guidance.

We have identified the key characteristics of social inclusion, illustrating how fundamental partnership is to the mobilisation of effort, the inescapable corollory being that because addressing these issues is ‘everybody’s business’, it becomes ‘nobody’s particular business.

Our system wide group is determined to ensure that collectively we build the necessary shared evidence and understandings to identify collective action and leadership to deliver. We recognise that, whilst our focus is necessarily on an NHSG contribution to reduce health inequalities, our Community Planning Partners bring equal opportunity to realise our shared ambitions.

In reviewing the policy base we have deliberately highlighted the changes in organisational structure and culture within the NHS and Local Authorities. We recognise that we are in a different place from the position from which previous attempts to address some of the issues of (health) inequality took place.

Never before has there been such a compelling and realisable goal as the reduction of health inequalities. The principles driving the shape of our infrastructure are clearly signalled. Consequently, as the changes take root, we move closer to the vision of involving and supporting patients and the public in taking responsibility for their own health, and ensuring equal access where interventions are required.

Our approach to framework development has been pragmatic. We illustrate how, taking account of the format of most local evidence, a number of approaches can help us to identify health inequalities in Grampian. We have, of necessity, been selective. As we tackle subsequent stages of our work, we believe we have the basis from which to achieve an increasingly systematic and comprehensive approach to health inequalities which will better inform our decision making. Gaps have emerged in the form in which some of our data is held. Our actions will include reviewing the ways in which our data are currently collected and structured, in order to address different questions which arise from a significant focus on reducing health inequalities.

We illustrate the influence of national and international data in exposing the relative consistency, over a sustained period, of a gap in health outcomes between different ‘communities’: between Scotland and other European countries, between Scotland and England, within Scotland, and within Grampian.

Grampian is widely regarded as a prosperous part of Scotland, facing fewer health challenges than many other areas. A number of points need to be made.

First, where the unit of analysis is large, for example, data at regional or constituency level Grampian emerges relatively favourably. Yet even with such broad brush treatment, we can identify issues of considerable concern at constituency level, as we demonstrate both here and in the appendix, with the aid of a simple tool which helps us focus on issues of apparent concern .

Second, large units of analysis are particularly unhelpful when we grapple with the health issues affecting dispersed rural populations such as predominate in Aberdeenshire and Moray, an issue which we give more attention to in our data framing (Appendix G).

Third, we have taken the view that the Scottish average, tends to produce an unchallenging benchmark when we consider our health performance in relation to England and other European countries. We illustrate in our section on local evidence, how we have tackled interpretation of the data, consistent with our NHSG vision of achieving the best possible health for the people of Grampian.

Fourth,our action plans are based on our collective experience and concerns, cognisant of national and local data, and reflect multi-professional consensus locally on how we can make most effective progress in a Grampian context. Evidence is important in informing policy, but does not, in itself make, policy. Locally, examining the evidence base has provided a context and basis for decision-making, tempered as always by professional experience and resource availability.

Fifth, this strategic framework represents a beginning, not an end. Consequently, we have agreed actions incorporating two significant strands: one working with partners to tackle the underlying causes of inequality and focusing on life circumstance and the range of processes which will build capacity; the other, tackling specific health inequalities such as breastfeeding, self harm, drink related hospitalisation among teenagers.

For ease of reading we have produced an appendix which comprises the ‘evidence’ we have used to illustrate the framework, and how we might begin to structure an effective evidence base. Successive phases of our work will generate deeper and more comprehensive intelligence within NHSG, and between NHSG and our partners, to ensure the most appropriate decisions are made on investing and disinvesting to enable us to close the health gap.

In our appendix on data framing, we also include a simple ‘traffic lights’ tool to make a range of existing data more accessible to a wider audience and to assist planning and policy by flagging apparent inequalities. The tool can be further refined and employed across a wider range of data if it proves helpful, in the ways we have suggested.

Aims

We agreed a set of key aims to focus more effectively our efforts and actions to reduce health inequalities:

Develop initial system wide guidance in the form of a strategic framework to facilitate continuous improvement in NHSG’s approach to tackling health inequalities locally, to close ‘the gap’;

Ensure long-term sustainable change, making health inequalities an integral part of policy development and implementation by feeding into existing planning processes;
Establish a phased programme of action to inform local implementation, under the aegis of the respective Community Planning Partnerships;
Ensure (public health) governance, as part of the planning process, through an agreed system of performance monitoring, as a second phase of work.

Principles

Early on in our deliberations, we agreed the key principles which should guide the development of the strategic framework to reflect the nature of our corporate task to reduce health inequalities by influencing the factors which create and destroy health:

Working in partnership to address the underlying determinants of health;

Working through the mainstream to respond to the diversity of need, especially among disadvantaged groups;

Targeting specific interventions by complementing mainstream services, offering different ways to meet need, and improving mainstream services through lessons learned;

Integrating policies into mainstream service planning, performance monitoring and performance management;

Delivering close to the customer, creating regional and pan-Grampian standards and local diversity.

Health Inequalities-what we mean

We recognise that some variances in inequalities in health are unavoidable. Genetic inheritance may predispose individuals to particular diseases. Exposure to certain environments undoubtedly influences heath outcome, as do individual choices and the play of chance. Where variations are distributed unequally - across gender, ethnic or socio-economic groups or associated with levels of education, income, occupation or access to services - these variations are unethical and unacceptable. When we refer to health inequalities, it is to these non-random, unacceptable variations in health (outcome).

Health Inequalities and Health Improvement

In Scotland, and locally in Grampian, we need to build on the existing improvements in decreasing deaths from heart disease and increasing life expectancy for example, by accelerating the rate of improvement.

Accelerating the rate of improvement means improving the health of our most disadvantaged communities at a faster rate, reducing health inequalities between advantaged and disadvantaged communities to develop a healthy, inclusive society. In focussing our action, we regard health inequalities as a subset of health improvement, requiring positive discrimination to accelerate change.

The focus of framework

The focus is to identify, agree and tackle the differences in health between those who are best and worst off in Grampian, taking account of socio-economic circumstances such as employment, income, housing and social support. In so doing, we set Grampian in a national and international context. Fundamentally, this framework is about assessing the gap and closing the gap.

Health inequalities – how we measure the gap?

We are keen to embrace Scottish Executive guidance. Inequalities will be measured, ultimately, as the ratio between the 20 % in the most deprived postcode sectors and the 20% in the most affluent postcode sectors as determined by the Carstairs deprivation index[1]. The Executive has identified five core Performance Assessment Framework (PAF) indicators (2003:5) for the measurement of health inequalities nationally across the 15 NHS Boards[2]. These are:

Smoking during pregnancy

Dental health of children

Adult smoking

Mortality rates from coronary heart disease among people under 75

Life expectancy at birth.

In most instances we are not yet at the point of being able to provide data on a wide range of health outcomes on the basis of postcode. The anticipated release in June of the Community Profiles (NHS Health Scotland) will begin to help us address this.

For the purposes of illustrating the importance and range of data capture in Grampian, and in the absence of specific postcode information, we have drawn more heavily onnational, regional and local authority level data to enable us to build an initial picture of health inequalities, and more specifically health inequalities.

Part of our function or our framework has been to identify weaknesses in our evidence base and, in conjunction with our partners to address these. In this way, we can establish pan-Grampian, as well as local ‘markers’, effectively benchmarking these to enable us to monitor progress in reducing inequalities within and between communities in Grampian, at the same time contributing to similar benchmarking at regional and national levels. We illustrate our thinking on this in our Appendix on data framing.

Mainstreaming Health Inequalities

The NHS plays a key role nationally and in Grampian, delivering services to the community. It is a major employer, facilitator and partner along with community planning colleagues. Historically public health and, more recently with the concept of the public health organisations, Local Authorities have focused increasingly on inequalities in health.

Arguably, for this experience to be consolidated, health (in)equalities should be built into all aspects of the policy process effectively mainstreaming health (in)equalities, integrating them into all policy development, implementation, evaluation and review (EOC, 1997). To give us the penetration we need to make a step change, we need to ensure that our strategic guidance systematically influences each of the pivotal planning documents in the NHS - JHIPs and the Local Health Plan – and through these, the Community Plans and service plans.

Our framework has been developed to facilitate that process: in order to sustain progress, tackle areas of inequality, balance the needs of target groups, mobilise resource, and influence partners to work from a common platform to ‘close the gap’. We recognise that tackling inequalities is not new. Doing so systematically, in a concerted partnership of agencies within communities, is.

We have the benefit of, and evidence from, a range of interventions conducted within particular communities, such as those comprising geographic or thematic Social Inclusion Partnerships (SIPs). We have health information from the National Demonstration Projects.

We have some evidence on the features implicit in successful interventions to tackle health Inequalities (Appendix B). We need to become smarter at targeting our interventions to those whose health will benefit from them. We also need to become smarter at adjusting existing programmes to take account of the learning from evaluated interventions so that we mainstream that learning, and change our delivery to meet the needs of particular client groups more effectively.

An NHS Grampian Framework for Reducing Health Inequalities 2004-2007