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Some of the equality and diversity issues from taking on public health in local government in 2013
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Taking on Public Health in 2013: key equality issues for HCC
Jim McManus, CPsychol, CSci, AFBPsS,
FFPH, FRSPH, MIHM
Director of Public Health, Hertfordshire
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The Challenge
The Challenge:
Creating conditions in which individuals and
communities have control over their health and lives
and participate fully in society.
New Levers:
• Healthwatch – full engagement
• Health and Wellbeing structures – local democratic engagement
• Public health transfer
• Health scrutiny function
• Duty to tackle health inequality
• NHS Outcomes Framework
• Public Health Outcomes Framework
• EDS
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So what’s the Link between equality duty and health inequalities?
Equalities
• Ensuring people are treated and can access services on the basis of their health need which
Health Inequalities
• A worse health outcome, access or experience compared with a chosen “standard” population or measure, usually across a social gradient but can work by ethnicity or gender or sexuality or faith
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Key Points
• Most health inequalities express themselves through social or other inequalities, and most social or other inequalities can be associated with health inequalities
• These are expressed cumulatively across the Lifecourse
– Disabled people, employment and stress from hate crime
– Lower education, earlier death?
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What does Lifecourse mean?
• From conception to grave, things influence our health all the time
– Lower birth weight – disease in later life
– South Asian – genetic risk for diabetes
– Readiness for school
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Life course perspective• A way of looking at life not as disconnected stages, but as
an integrated continuum
• Suggests that a complex interplay of
– biological,
– behavioral,
– psychological,
– and social protective and risk factors
contributes to health outcomes across the span of a person’s life.
• The life course perspective conceptualizes birth outcomes as the end product of not only the nine months of pregnancy, but the entire life course of the mother leading up to the pregnancy.
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The Lifecourse impact of health
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Example: Gaps in school readiness at 3 and 5 years by family income: UK
Ave
rage
per
cent
ile
scor
e
Waldfogel & Washbrook 2008
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Key Issues
• Largely well population in Hertfordshire
• Inequalities masked by wellness
• Worst off die 7 years earlier than best off
• Inequalities expressed across lifecourse
• Protected characteristics can worsen life experience and thus health, or access to health services
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A reflection from self harm studies
• ALL the evidence suggests strongly it is NOT intra-individual factors but societal factors too which are important to address
• Healthy public policy and services plus access to services plus skills and motivation are key
• It’s the same with equality – look at LGBT hate crime
• The individual is neither the whole problem nor the whole answer
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Self-harm case postcodes with Indices of Multiple Deprivation score in Hertfordshire, by Middle Layer Super Output Area
Key IMD 2010
3 to 8.9
9 to 14.9
15 to 20.9
21 to 26.9
27 and over
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Smoking 10%
Diet/Exercise 10%
Alcohol use 5%Poor sexual health
5%
Health Behaviours
30%Education 10%
Employment 10%
Income 10%
Family/Social Support 5%
Community Safety 5%
Socioeconomic Factors
40%Access to care
10%
Quality of care 10%
Clinical Care 20%
Environmental Quality 5%
Built Environment 5%
Built Environment
10%
Source: Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute. Used in US to rank counties by health status
While this is from a US context it does have significant resonance with UK Evidence, though I would want to increase the contribution of housing to health outcomes from a UK perspective.
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• Best start in life – conception, weight, vaccs, imms
• Readiness for school
• Good Housing
• Resilient Childhood, Resilient Adulthood
• Into employment and education
• Lifestyle in working age
• Self management in older age
Work for us all here!
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Increasing deprivation
Target health outcome
Amount of intervention needed to get everyone to target level
Current level of health outcome
High level of deprivation
Low level of health
Low level of deprivation
High level of health
www.hertsdirect.orgYears
0 1 5 10 15
Planning
Education
Vitamin Supplements
Air Pollution
Decent Homes
Jobs
Primary Care
20
CVD Events
Self Care
Vitamin D and TBRickets
CVD Events
Acute Bronchitis Admissions
RespiratoryMental Health overcrowding educational attainment
Life Expectancy
Healthier space use Changing culture of activity
Life ExpectancyMental Health
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• A strong role for every agency
• A need to rethink what the specialists bits of public health have done and what they do in future
• A need to rethink how we transform ourselves into public health agencies
• Everyone has a PH role
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Examples
Equalities
• Systematic review in West Midlands of LGBT population found
• New migrant populations are not always good at accessing health care services
Health Inequalities
• Young gay men self-harm at ten times the rate of the rest of the population
• Late maternity booking and perinatal mortality among some new migrant populations
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Perverse outcomes...
• Interventions designed to reduce Health Inequalities but cause them
– Uptake of cancer screening varies by class, so does smoking. Those most at risk access screening least!• Uptake of cancer screening
• Uptake of diabetic retinopathy screening
• Call and Recall for treatment
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The upshot of this unless we do something is that 2/3 of people will be in chronic ill health or disability before age 68, the new retirement age
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And Hertfordshire shows the same pattern!
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Why lifestyle alone will not eliminate health inequalities 1
• Lifestyle is not sufficient – environment, genetic, lifecourse influences
• It’s too late for some people – those who have disease already – while lifestyle will help manage disease and health they will need treatment
• It will be ten to fifteen years before lifestyle effects sustained population change. Meanwhile people will still need treatment
• Lifestyle is not enough for some people at high risk – other treatments are needed to
• Some risks are not amenable to lifestyle interventions for (e.g. immunosuppresion; infectious diseases which make up 16% of Birmingham’s deaths)
Healthy lifestyle is necessary but not sufficient of itself for significant Reduction of health inequalities
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What should HCC and HWBB do?
1. Understand the populations of identity and geography and work to ensure their health outcomes are understood
2. Commission and provide with knowledge of what those populations seek for optimal care
3. Audit programmes for equity and inequality and make adjustments
4. Consider whether any populations need specific clinics/interventions
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The Big Tasks – a 15 year agenda
• Short term challenge of tertiary prevention
• Medium term problem of keeping the ill well
• Short term problem of stopping avoidable events
• Long term problem of changing determinants of health, health expectations, behaviour and culture
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2011 Census – Hertfordshire Projected Population Change
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Hertfordshire percentage projected population change 2010 to 2035
Age Group Percentage Change All persons - 0-4 6.89 All persons - 5-9 21.27 21.27All persons - 10-14 24.04All persons - 15-19 18.36All persons - 20-24 13.32All persons - 25-29 13.56All persons - 30-34 11.68All persons - 35-39 8.35All persons - 40-44 9.49All persons - 45-49 11.91 All persons - 50-54 20.83All persons - 55-59 25.24All persons - 60-64 20.16All persons - 65-69 59.04 All persons - 70-74 69.54 All persons - 75-79 51.01All persons - 80-84 53.82All persons - 85-89 102.96All persons - 90+ 231.33
