THE JOINT HEALTH AND WELLBEING STRATEGY

FOR HARROW 2013- 2016

FINAL

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1 INTRODUCTION

Harrow is a good place to live. People in Harrow are, in general, healthier

and live longer than the average for England and London. However, the

Joint Strategic Needs Assessment has shown that unacceptable inequalities

in health and wellbeing exist in Harrow as in the rest of the UK. People living in

different social circumstances experience differences in their health and

wellbeing and in the length of their life. People living in the poorest parts of

Harrow live on average 7 years less than those in the richest areas. These

differences are avoidable but can’t be addressed by health services alone.

Health inequalities occur because of inequalities in society – in the places

where we live, in education, access to employment and the sort of jobs we

do and the money we have to live on and the lifestyle choices we make as a

result.

The local Sustainable Communities Strategy1, has a vision that by 2020,

Harrow will be recognised for:

� Integrated and co-ordinated quality services, many of which focus on

preventing problems from arising, especially for vulnerable groups,

and all of which put users in control, offering access and choice;

� Environmental, economic and community sustainability, because we

actively manage our impact on the environment and have supported

inclusive communities which provide the jobs, homes, education,

healthcare, transport and other services all citizens need.

� Improving the quality of life, by reducing inequalities, empowering the

community voice, promoting respect and being the safest borough in

London.

1 Harrow’s Sustainable Communities Strategy 2009-2020.

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In order to achieve this vision, inequalities in health and wellbeing must be

addressed to improve the quality of life for all residents. Reducing health

inequalities and promoting wellbeing and independence for adults and older

people is a key goal in achieving the 2020 vision.

This strategy for health and wellbeing in Harrow sets out the strategic

direction for partners to work together to improve health and wellbeing,

reduce health inequalities and promote independence. The success of this

work will be guided and measured by the Health and Wellbeing Board.

2 PURPOSE

The purpose of this strategy is to improve health and well-being in Harrow by

guiding the commissioning intentions of the member organisations, primarily

the local authority and the clinical commissioning group. It is grounded on

the fundamental principles that what we do will:

• Improve the wellbeing and quality of life of the people of Harrow

• Reduce the health inequalities gap

• Have long term and sustainable impact

The Health and Wellbeing Board for Harrow was established in shadow form

late 2011. The Board has taken external advice and undergone a

development programme to establish the working relationships and role for

the Board. The Board have overseen the development of the Joint Strategic

Needs Assessment, which was then used by the Board to debate and agree

the principles underpinning this strategy and the priority areas for Harrow.

Our strategy aims to bring together the wide variety of areas that impact on

health and well-being by making those links explicit. As we enter a phase

where funding for public services is limited, partnership working and

maximising the benefits of preventing ill health will become even more

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important. To this end, we also recognise the need to build capacity to

deliver public health programmes in the voluntary/third sector and the

important contribution that front line staff working in both public and business

sectors have in delivering the health improvement vision.

This strategy is not about finding additional funding to make these

improvements. In the current financial climate, this is not possible. It is,

however, about getting the best value for the funding we have through

effective commissioning, by reducing duplication and by working closely

together to achieve more than any one agency could achieve on its own.

The London Health Improvement Board, which receives 3% of the total public

health budget for Harrow, will also be a partner in this strategy. The LHIB has

a number of priorities including childhood obesity, cancer prevention and

early detection and alcohol misuse.

As a result of this strategy we expect that future commissioning intentions and

service plans will change to meet these priorities. Our annual implementation

plans will identify what we want to achieve within the year and how we will

achieve it.

3 A SNAPSHOT OF HEALTH AND HEALTH INEQUALITIES IN HARROW

Harrow is generally a healthy place but like everywhere else, there are parts

of the borough or groups with our community who have poorer health.

Inequalities result from differences in health outcomes (i.e. mortality rates, life

expectancy, etc.) which occur as a consequence of differences in health

status (socio-economic, deprivation, life styles and behaviour). The Harrow

Joint Strategic Needs Assessment (JSNA) identifies a number of inequalities.

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Life expectancy within the Borough, at 81.2 for men and 84.6 for women, is

better than that of England as a whole. However, there are marked

geographical inequalities. Women in Pinner South can expect to live more

than 10 years longer than women in Wealdstone. Men in West Harrow can

expect to live for five and a half years longer than men in Greenhill ward. It is

clear from analysis of local data that effort needs to be made to address the

inequality gap in the more deprived parts of the borough.

The JSNA shows that the biggest impact on life expectancy could be made

by focusing on circulatory disease. If mortality rates from Coronary Heart

Disease in the most deprived parts of Harrow were to reduce to the rate seen

in the most affluent, life expectancy would increase by over a year in males

and over 9 months in females. Lung cancer in men, breast cancer in women

and COPD2 in both sexes are the other areas where significant gains in life

expectancy could be made.

The slope index of inequality (SII) is an indicator that demonstrates within-area

inequalities. This indicator shows the relative difference within an area. In an

area where there are few inequalities within the area the slope index will be

small. It is important that this indicator is not looked at in isolation as an area

where everyone is deprived or where everyone is affluent will have very

similar small SII.

The data for Harrow shows that the inequalities in women in Harrow have

decreased over the past six years but have worsened for men in Harrow over

the same period. The difference in life expectancy in women in the most

deprived deciles in Harrow was six years lower than in the most affluent areas

but this has decreased to only 4 years. In men, the gap started at less than

seven years but has widened to over 8 years.

2 Chronic obstructive pulmonary disease – lung diseases such as emphysema and chronic bronchitis which are largely caused

by smoking

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FIGURE 1 SLOPE INDEX OF INEQUALITY FOR MALES AND FEMALES IN HARROW 2001-5 TO 2006-2010

Source: Public Health Observatories of England

Smoking prevalence and teenage pregnancy are amongst the lowest in

England and mortality from heart disease and cancer are also lower than

those of England as a whole, although they remain the two highest causes of

death in Harrow. Diabetes rates and tuberculosis rates are higher than the

England average.

However, health and wellbeing is about how we live not just what we die

from and indicators of quality of life need to be taken into consideration.

Mental health is one such area. Mental Illness affects one in four people

nationally but also has an impact on the carers and families of those with

poor mental health – making them more likely to suffer from it too. Although

rates of common mental health problems as well as more severe mental

illness are lower in Harrow than they are nationally, there are still hundreds of

people at any time who are suffering from mental health problems. Other

indicators of quality of life include fear of crime, which is high in Harrow

despite the low crime rates in the borough, and the proportion of carers who

are able to have a break from caring.

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4 HEALTH IS EVERYONE’S BUSINESS Health improvement is everyone’s business. As health technologies become

more advanced and more successful so should our efforts in improving

health. A strategy for health improvement looks to engage both public

sector and private sector organisations in its task there-by making health

improvement part of mainstream systems for incentives, performance

management, regulation and inspection.

FIGURE 2 THE DETERMINANTS OF HEALTH

Source: Dahlgren G, Whitehead M. 19913.

No single person or agency determines a population’s health and well-being.

In Figure 2, we can see the multi-layered factors that determine our health

and wellbeing.

• Our age, gender and genetic makeup are something we can’t get

away from. Some diseases are more common in one gender; some

conditions increase with age; some people are genetically

predisposed to certain diseases.

3 Dahlgren G, Whitehead M. 1991. Policies and Strategies to Promote Social Equity in Health. Stockholm, Sweden: Institute for

Futures Studies.

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• The decisions we take about our lifestyle will influence our health. Do

we eat healthily, take enough exercise, smoke, drink alcohol, use

drugs, sunbathe, have unprotected sex, or engage in high risk

behaviours? All of these and more will have an impact on our health

and wellbeing

• Our family and social networks and the way we interact with society

around us also have an impact on our health. Our health habits are

shaped as children and many of our health behaviours are influenced

by our peers. Socially isolated people are more likely to have poorer

health – and people with poorer health can become socially isolated.

• Where we live, what we do, how much we earn, the quality of our

food, our water, our natural and built environment and what services

are available to us can make us more or less healthy. Health services

are only a small part of this whole picture. They are important in

responding to ill health and in promoting good health.

• Taxation policy, funding of public services, global warming, intra- or

international conflicts and economic recession are all issues that affect

health and wellbeing but which have to be dealt with at a national

and sometimes global level.

What the diagram doesn’t show is how much each of the different factors

affects our health. This is shown in Figure 3. Health care services main role is

in dealing with the consequences of ill health although the focus on disease

prevention is also important. They account for around a quarter of the

overall health status of the population. Our age and genes account for

around 15% of the overall health status of the population and the physical

environment in which we live accounts for a further 10%. The most important

factors by far are the social and economic determinants which account for

half of the overall health status of the population.

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FIGURE 3 ESTIMATED IMPACT OF DETERMINANTS ON THE HEALTH STATUS OF THE POPULATION

5 SETTING OUR PRIORITIES

The setting of priorities is based on the evidence presented in the Joint

Strategic Needs Assessment and the best available evidence4. This shows

that:

• There is a social gradient in health – the lower a person’s social position,

the worse his or her health. The focus on reducing the gradient in

health inequalities requires action across all the social determinants of

health.

• Focusing solely on the most disadvantaged will not reduce health

inequalities sufficiently. To reduce the steepness of the social gradient

4 Fair Society, Healthy Lives - Strategic Review of Health Inequalities in England post-2010. The Marmot Review, February

2010

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in health, actions must be universal, but with a scale and intensity that

is proportionate to the level of disadvantage.

• Action taken to reduce health inequalities will have economic benefits

in reducing losses from illness associated with health inequalities which

currently account for productivity losses, reduced tax revenue, higher

welfare payments and increased treatment costs.

• Effective local delivery requires empowerment of individuals and local

communities and will require a local partnership approach as well as

action by central government.

Reducing health inequalities will require action on six policy objectives:

• Give every child the best start in life

• Enable all children young people and adults to maximise their

capabilities and have control over their lives

• Create fair employment and good work for all

• Ensure healthy standard of living for all

• Create and develop healthy and sustainable places and communities

through effective planning and housing strategies

• Strengthen the role and impact of ill health prevention

The Health and Wellbeing Board has agreed that the priorities for Harrow

should reflect three important criteria:

• They affect the wellbeing and quality of life of the people of Harrow

• They will lead to a reduction in the health inequalities gap

• They will have long term impact

Bearing these in mind, seven local priority areas have been agreed.

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5.1 LONG TERM CONDITIONS (LTCS)5

Long term conditions is the umbrella term used to describe the health

conditions that have a long term or lifelong impact. For the purposes of this

strategy, we have initially agreed to focus on cardiovascular disease (heart

disease stroke and hypertension), respiratory disease and diabetes. These

were chosen because there is a significant impact on wellbeing and quality

of life of people with LTCs and their family and carers. LTCs are the major

drivers of the health inequalities gap - CVD is the highest and respiratory

disease the third highest cause of death in Harrow. Although Harrow has one

of the highest rates of diabetes in London, it is largely well managed and

many of the adverse consequences are avoided. However, action is needed

to prevent people developing diabetes in the future as the rates are

increasing and therefore the treatment costs will also increase putting

additional financial pressure on the system.

All of the LTCs chosen share some common risk factors such as smoking,

obesity, diet, physical activity and alcohol. All of these will need to be

addressed as there is clear evidence that effective prevention will have a

long term impact on the rate of LTCs.

LTCs fit with the policy objectives in that there is a significant role for ill health

prevention and early interventions are possible from pregnancy and

throughout life that affect long term outcomes. There are links to

employment issues for people with LTCs and impact of disease on local

economy. With the additional pressure on household finances, the standard

of living of people with LTCs and their carers is affected and the .

5 Long term conditions include cardiovascular disease, respiratory disease and diabetes

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5.2 CANCER

Cancer was chosen as a priority because it has a significant impact on

wellbeing and quality of life of people with cancer and their family and

carers. Although many cancers are treatable and have a good and

improving survival rate, cancer is the second highest cause of death in

Harrow. Lung cancer and breast cancer are two specific cancers that drive

the health inequalities gap. Effective prevention and early detection will

have a long term impact on incidence of some cancers and deaths from

other cancers.

As with long term conditions, there is a significant role for ill health prevention

and early detection and there are considerable employment issues for

people with LTCs and impact of disease on local economy. Standard of

living is affected impacting on the individual with the condition and their

family.

5.3 WORKLESSNESS

Employment underpins much of our wellbeing whether we consider the

standard of living and ability to make healthy choices or the impact on self-

esteem. It has a significant impact on inequalities and the impact of

unemployment can be a long term impact affecting children’s attitude and

aspirations and intergenerational umemployment.

In terms of the inequalities policy objectives, there is the obvious link to

creating fair employment and good work for all. However, there are also links

to education of children and training/retraining of young people and adults

to maximise their capabilities for future employment. Reducing worklessness

will have benefits for the local economy and will make it possible for people

to have a healthy standard of living which in turn will make them more able

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to make healthy lifestyle choices. There are obvious links between long term

worklessness and housing need.

5.4 POVERTY

Poverty has a major impact on health inequalities and affects wellbeing and

quality of life. It can have a long term impact on families. It is important to

look at poverty at the current time as the changes in the benefits system will

mean that some families in Harrow are adversely affected either by

increasing the pressure on them by reducing benefits or by a need to move

to housing that is under the benefit threshold. This could have impacts on

social cohesion and mental wellbeing as well as the increasing risk of physical

health problems associated with poverty.

Poverty has impact right through a person’s life: from a poor start as a child,

poorer educational attainment leading to lack of control over their lives,

lower paid and low grade work and a poor standard of living with poor

housing. It impacts on individuals, families and the community in which they

live. It makes it less likely that people can make healthy choices about their

lifestyle and the stress from having a lack of control over their lives impacts

considerably on mental health.

5.5 MENTAL HEALTH AND WELL-BEING

Our mental health affects our wellbeing and quality of life. It is a factor

common to many of the other priorities. People with long term conditions

can have poor mental health due to their illness but equally poor mental

health is related to poor physical health outcomes and is therefore related to

health inequalities. Has long term impact

Mental health links into a number of the inequalities policy objectives: post-

natal depression and coping can impact on a child’s start in life; bullying,

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stress and diagnosed mental health problems reduces people’s ability have

control over their lives or hold down a job. Our community and environment

impact on our mental health whether by our perceptions of crime or

reduced social cohesion and increased isolation. And of course, there is a

role for mental health promotion to reduce both the incidence and impact

of mental ill health.

5.6 SUPPORTING PARENTS AND THE COMMUNITY TO PROTECT CHILDREN AND

MAXIMISE THEIR LIFE CHANCES

Giving a child the best start in life is important to the individual child but also

to society in general. Parents and carers impact cannot be underestimated.

A child’s early life affects their wellbeing and quality of life not only during

their childhood but throughout their life – and indeed into the next

generation. It is vital that this part of the strategy picks up the

recommendations from the recent children's safeguarding and looked after

inspection.

This priority area directly impacts on the goals to give every child the best

start in life and enable all children young people and adults to maximise their

capabilities and have control over their lives It also relates to the healthy

standard of living for all and healthy and sustainable communities. As early

behaviours lay down the foundations for behaviour in later life, it is important

that we strengthen the role of primary prevention.

5.7 DEMENTIA

As our population ages and life expectancy increases, we expect that

dementia will become an increasingly pressing issue. Dementia affects the

not only the person’s wellbeing and quality of life but that of their family and

carers.

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Caring for someone with dementia, as with other long term conditions,

affects the carer’s ability to maintain their employment and their standard of

living. Keeping both physically and mentally active can prevent the onset

and the development of dementia and therefore there is a role for

promotion of healthy lifestyle choices.

6 OUR APPROACH TO ADDRESSING THE PRIORITIES

In order to address each of the priorities we will take a life course approach.

For each of the priorities we will consider the contribution of prevention, early

detection, intervention and services, reablement and end of life issues. Using

the model in Figure 4, we will look at each of the priorities and the actions

needed to improve health and reduce inequalities in each of the life course

blocks.

FIGURE 4 HARROW’S APPROACH TO DELIVERING THE HEALTH AND WELLBEING STRATEGY

6.1 PRIMARY PREVENTION: MATERNAL HEALTH AND EARLY INTERVENTION

Primary Prevention is concerned with the actions that can be taken to

reduce the likelihood of a disease starting to develop but can equally be

considered in terms of preventing poverty or unemployment. The first stage

of our delivery model is concerned with the actions that can be taken

before, during or after pregnancy and in childhood to improve health and

wellbeing.

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Examples might include reducing smoking in pregnancy; reducing teenage

pregnancy in order that we have improved maternal education which

impacts on the child’s health and life expectancy; increasing rates of breast

feeding. Child health interventions will include education, and development

of life skills and ambitions.

6.2 PRIMARY PREVENTION: LIFESTYLES AND COMMUNITY

The second element for primary prevention is around lifestyle issues and the

impact of community. The choices we make about how we live our lives has

a huge impact our future health and wellbeing. Important elements in the

lifestyles part of this section will include tobacco use, healthy eating, physical

activity, maintaining a healthy weight, alcohol use and substance (drug and

alcohol) misuse.

The community part of this section is about the social dimension of wellbeing

which encourages building relationships within the community and

contributing to the physical environment with the intention of the common

welfare of one's community. We know that socially isolated people are

more susceptible to illness and have a death rate that is higher than those

who are not socially isolated. People who maintain their social network and

support systems do better under stress and can create a good mood and

enhance self-esteem.

6.3 EARLY DETECTION

Finding a problem early means it is usually easier to deal with. This section will

cover the things we can do to identify problems early. It will include things

like cancer screening and NHS Health Checks. However, we will also look at

how we might need to target certain groups who are at higher risk or who

are particularly vulnerable e.g. young people at risk of future unemployment,

.

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6.4 SERVICES AND INTERVENTIONS

This section will involve the bulk of services that are provided by health and

the local authority. It will include what health, social care and other services

are available; how they are accessed; the pathways to follow to ensure

seamless care; and how we can use our resources effectively. It will also

include other issues affecting people accessing these services such as the

health of carers. This section will be closely linked to the service planning for

the Community Health and Wellbeing Directorate at the local authority and

to the commissioning strategy and Out of Hospital strategy of the Clinical

Commissioning Group.

6.5 SECONDARY PREVENTION: BREAKING THE CYCLE AND SUPPORTING

INDEPENDENCE

Once people have a problem, there are things that can be done to break

the cycle of poor health and help people back into independence. This will

include the different sorts of rehabilitation e.g. cardiac rehab or pulmonary

rehab; programmes that target people with early stage problems e.g

exercise on prescription for people with LTCs and interventions to stop people

being readmitted into hospital e.g. falls prevention. It will also include issues

like debt management or retraining for people who have lost their jobs.

6.6 DIGNITY AND CHOICE AT THE END OF LIFE

Overall, the consensus is that the majority of people wanted to be informed,

share their care planning and to die with dignity in their own surroundings, be

that home or nursing home. This section of the strategy will be about how we

can achieve this aim.

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7 AN EVIDENCE-BASED APPROACH

In developing this strategy we will use the best available evidence of what

works to improve health and wellbeing and reduce health inequalities. To

support our approach we will continue to use evidence of what works and

learn from others to adopt policies and interventions that will work in Harrow

and which are acceptable to our diverse population. We have a number of

policy drivers that will support us in implementing the strategy. We have

engaged with stakeholders and will continue to do so to ensure that our

understanding matches theirs and that we are working towards the same

goals without duplicating the effort unnecessarily. It is using this partnership

approach that will deliver the reduction in health inequalities that we are

seeking.

We have a range of tools and techniques that we will employ to support the

development of action and implementation plans that will support the

strategy.

7.1 EVIDENCE AND BEST PRACTICE

Using and promoting evidence based practice is key to the delivery of

effective health improving programmes. We will, wherever possible use the

best available evidence from a range of sources.

NICE provides a wide range of reviews of effectiveness of public health

programmes. However, not all of the topics we want to focus on or the

groups where we know there are health inequalities are covered by NICE

guidance. In these cases, we will use other evidence based reviews such as

those from the Cochrane Collaboration, the national Library for Public Health

and in published reviews in peer reviewed journals.

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Where evidence is not available we will use best practice guidelines to

develop programmes to address our priorities and ensure that there are

measures of effectiveness embedded in each programme as well as robust

evaluation.

7.2 NATIONAL POLICY DRIVERS

There is a wealth of evidence that shows that we need to shift the focus of

health and wellbeing. Our current model relies on providing services to

respond to health needs. The shift needs to move towards providing services

to reduce the likelihood of future ill health through prevention and early

intervention targeted at those with the greatest need as this will be the most

cost effective way forward.

7.3 TOOLS AND TECHNIQUES

There are a number of tools and techniques that will be used to deliver the

strategy and monitor its impact. These tools are considered best practice in

public health.

7.3.1 EQUITY AUDIT

Equity Audit is an important method for systematically assessing the

inequitable mismatch between the need of a population for services and

interventions and those that are being provided. Fundamental to this is an

understanding of the difference between Equality (where everyone gets the

same level of health care) and Equity (where people with higher need get

more). It begins with an equity profile but does not stop there. It must

include agreed recommendations and actions to address the inequities

identified and evaluation of the impact of the actions undertaken to reduce

the inequity.

7.3.2 HEALTH IMPACT ASSESSMENT

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Health Impact Assessment (HIA) is a technique to assess the positive and

negative impact of policies, plans and proposals. HIA will recommend how

the negative impacts on health can be minimized and positive ones

maximized. It can be undertaken at a variety of levels – a rapid stakeholder

appraisal to a full health impact assessment – which have different resource

implications. It can also be undertaken prospectively and retrospectively.

We have already developed and adopted a local tool for undertaking HIAs

on partnership policies.

7.3.3 NEEDS ASSESSMENT

Needs assessment is the process by which the needs relating to a particular

population group, disease topic or determinant are analysed and actions

required. Health needs assessments (HNAs) are worthwhile only if they result

on changes that will benefit the population and it is therefore it is essential

that adequate resources are available and the outcomes that are required

to be achieved are realistic unachievable. HNAs involve epidemiological

profiling the current and future needs, opinions of stakeholders (including

patients) and a comparison with other similar areas. It is underpinned by

robust evince of what works to address the needs that are identified. It will

include action plans and risk management or risk minimisation plans and

measuring the impact and reviewing the plan.

We will undertake a minimum of four health needs assessments per year on

the topics identified by health and wellbeing board.

7.3.4 SOCIAL MARKETING

As we have shown, there are many differences in the population across

Harrow. Targeting the right messages and delivering the right services to the

right population in a way that is acceptable to them and addresses their

needs is vital to achieving an effective and efficient health and well being

programme. The way to do this is to look at the population in greater detail

and rather than simply use geography or age or ethnicity, we look at

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characteristics and the preferences of different groups, their attitudes and

beliefs about health and other services and how best to communicate with

them. This is known as population segmentation. Harrow has a group of

locally specific Mosaic profiles or segments which are already being used

across the local authority, health and police services though the Joint

Analytical Group. This targeting of segments within the community is known

as social marketing and this approach will underpin the delivery of the

strategy.

8 CONSULTATION AND DEVELOPMENT OF IMPLEMENTATION PLANS

Consultation workshops and meetings will be held with stakeholders to discuss

the priorities; identify the main outcomes we want to achieve on each of the

priorities and develop the action plans for the priorities.

8.1 THE PRIORITIES

Stakeholders will be consulted on whether they agree with the priority topics

identified by the health and wellbeing board. If they don’t, they will be

asked which priority should be replaced.

8.2 OUTCOMES

Our strategy is outcome focussed. Stakeholders will be asked what outcomes

we should be striving for. It is important that we focus on the outcome for the

whole workstream although different elements may have process indicators

8.3 IMPLEMENTATION PLANS

In our implementation plans, we will identify:

• What we need to do

• What we have already do well and plan to continue

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• What we already have planned that will support the outcomes of the

strategy

• How we will address any inequalities issues

• Who is responsible for delivery

• How we will monitor the outcomes

These implementation plans will be monitored and reviewed annually. Each

priority area will be championed by at least one member of the Health and

Wellbeing Board.