Working for Health Equity

Working for Health Equity: The Role of Health
5th Feb 2014
Matilda Allen – [email protected]
UCL Institute of Health Equity
• Health Inequalities and Social Determinants of
Health – brief background
• Working for Health Equity report
Workforce education and training
Working with individuals and communities
Working in partnership
Workforce as advocates
• NHS Organisations and health at work
Key themes
Reducing health inequalities is a matter of fairness and
social justice
Action is needed to tackle the social gradient in health –
proportionate universalism
Action on health inequalities requires action across all the
social determinants of health
Reducing health inequalities is vital for the economy –
cost of inaction
Beyond economic growth to well-being of society:
sustainability and the fair distribution of health
6 Policy Objectives
A. Give every child the best start in life
B. Enable all children, young people and adults to maximise
their capabilities and have control over their lives.
C. Create fair employment and good work for all
D. Ensure a healthy standard of living for all
E. Create and develop healthy and sustainable places and
F. Strengthen the role and impact of ill-health prevention
Workforce Education and
Working with Individuals and
NHS Organisations
Working in Partnership
Workforce as Advocates
The Health System – Challenges
and Opportunities
Statements for Action and Commitments
Statements for action – short,
practical and accessible guides for
particular professionals
Commitments to action – in all areas
of the report
Institute of Health Equity
Academy of Medical Royal Colleges
Royal College of Midwives
Royal College of Physicians
Barts and the London NHS Trust
British Dietetic Association
Royal College of Paediatrics and Child Health
Royal College of General Practitioners
Royal College of Speech and Language
Chartered Society of Physiotherapy
Dental Schools Council
Royal College of Obstetricians and
British Association of Occupational
Therapists and College of Occupational
Royal College of Psychiatrists
Royal College of Nursing
Allied Health Professionals Federation
British Association for Music Therapy
British Medical Association
NHS Alliance
Social Work and Health Inequalities Network
Royal College of Psychiatrists
College of Paramedics
Society and College of Radiographers
Why we did this
• NHS workforce has an underutilised role in SDH
and wider inequalities
• NHS has 1m employees and reach to wider
families, from across the social gradient
• And sees 1m people every 36 hours and nearly
whole population every year
The health system
• Legal duties to reduce health inequalities, for the
first time
• Public Health in Local Authorities
• Health and Well Being Boards in LAs
• Platform for joining up health services, social care
services and health-related services at local level
Workforce Education and Training
• Knowledge: greater focus on SDH in UG and PG.
• Skills: communication, partnership and advocacy
• Placements: More training placements in
disadvantaged areas and in a range of sectors
e.g. charities, social services
• Continuing Professional Development
• Access
Working with Individuals and Communities
• Relationships : including collaboration and
communication with communities
• Gathering information : social history, used for
referral, greater understanding, and at aggregate
• Providing information : referral and social
Royal Free London Case Study
(taken from Adrian Tookman presentation at the ‘working for health equity’ launch)
• Presented to board –
– High levels of deprivation
– High levels of smoking, drinking and obesity
– Ethnic differences – Bangladeshi, Jewish/Armenian,
Eastern European and other East Asian all over 20%
more likely to be non-elective admission
• In order to make changes, need to start with quick
wins and provide a bundle of changes
• Need senior sign up/sponsorship and front line
Royal Free Cont.
Well at the Free
Comprehensive Stop Smoking Service
Homelessness Pathway
A&E assault-related violence data sharing
Domestic Violence Screening: Pilots in key areas: Gynaecology, Maternity
and Sexual Health.
Fit at the Free
Trust strategy
Reducing Readmissions
More information available in Adrian Tookman’s presentation on IHE website
Working in Partnership
• Within health sector: consistent, broad and
focussed on SDH
• With external bodies: e.g. joint commissioning,
data sharing and joint delivery. Design and
assessment are essential.
• CCGs: should tackle HI through role as
commissioner, in partnership (e.g. HWBBs), and
as local employer and advocate
Living in cold homes: effect on adolescents
% children with four or more negative outcomes*
All children
Inadequately heated
Poor state of repair
Number of previous
5 years child has
lived in these
28 conditions
3-5 years
1-2 years
0 years
All children
% children with four or more negative outcomes*
*i)A long-standing illness or disability, ii) to go without regular physical exercise,
iii) in trouble for smoking, drinking or taking drugs,
iv) bullied in or out of school, v) expelled or suspended from school,
vi) does not see friends and does not attend organised activities, vii) has been in trouble with the police,
viii)below average in key academic subjects, ix) family cannot afford an annual holiday,
and, x) family in income poverty.
Source: Barnes et al 2008
Case Study - AWARM
Local area partnerships that link health, housing and fuel poverty.
Designed to reach most vulnerable.
Model identified key systems and processes needed to access vulnerable poor,
streamline referral and delivery systems.
Over 1000 referrals made by frontline professionals.
1,359 professionals trained.
Gain in quality-adjusted life years was estimated to range from 1.67 to 31.6,
depending on model used.
Workforce as advocates
For individuals
For changes to local policies
For changes to the health profession
For national policy change
Projected relative AHC income poverty rates under
current policies and without the coalition government’s
tax and benefits reforms: UK
IFS 2010
Neighbourhoods affordable to Housing
Benefit Recipients in 2011 and 2016
NHS Organisations
Health professionals should utilise their roles as managers and
employers to ensure that:
• Staff have good quality work that increases control, respects
and rewards effort, and provides services such as
occupational health.
• Their purchasing power is used to the advantage of the local
population, using employment and commissioning to
improve health and reduce inequalities in the local area.
• Health inequalities strategies are given status at all levels of
the organisation, so the culture of the institution is one of
equality and fairness.
Impact of working conditions on health
Physical hazards
Psychosocial working environment
Job security
Long or irregular hours or shift work
All are distributed along a social gradient.
Stress at work
• Two models
– Demand-control model: high job strain is characterised
by high job demands and low job control
– Effort/reward imbalance: efforts at work are not
adequately rewarded by pay, esteem, job security or
opportunities for career advancement
• Socially isolated
– (no supportive co-workers or supervisors)
The association of civil service grade with job
control, Whitehall II study, 1985–88
Job control
Employment Grade
Chandola et al. BMJ 2006
• Stress at work is associated with a 50% excess
risk of coronary heart disease
Kivimäki M, Virtanen M, Elovainio M, Kouvonen A, Väänänen A, Vahtera J
. Work stress in the etiology of coronary heart disease—a meta-analysis.
Scand J Work Environ Health 2006;32(6 special issue):431–442.
RCP audit: implementing public health
guidance for the workplace
73% of all hospital trusts participated
Some findings:
- 24% of trusts do not monitor the mental wellbeing of staff
- Only 31% of trusts monitor long term sickness absence by age
- Trusts had difficulty estimating how many contracted or outsourced
staff they had.
- Outsourced staff, and those working irregular or night shifts, have less
access to health promoting initiatives or healthy conditions of work
- Many trusts do not measure who participates in programmes by
characteristic (e.g. gender, age, ethnicity, job grade, etc.)
- 38% of trusts do not allow staff to attend smoking cessation services
during working hours without loss of pay.
Case study: Barts and the London NHS Trust
Developed a public health approach with 3 themes:
1. Making every contact count for patient health
2. Staff health and wellbeing
3. Community employment and procurement
On-going IHE work
• Support to implement the commitments made by royal
colleges and BMA and others
• Set up an education working group
• Will set up a CCG working group
• And explore incentives and system drivers
Thank you for listening!
Lots of information on
our website:

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