Working for Health Equity: The Role of Health Professionals 5 th Feb 2014 Matilda Allen – UCL Institute of Health Equity

Today… 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

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 communities F.Strengthen the role and impact of ill-health prevention 6 Policy Objectives

1.Workforce Education and Training 2.Working with Individuals and Communities 3.NHS Organisations 4.Working in Partnership 5.Workforce as Advocates 6.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 Therapists Chartered Society of Physiotherapy Dental Schools Council Royal College of Obstetricians and Gynaecologists British Association of Occupational Therapists and College of Occupational Therapists Royal College of Psychiatrists Royal College of Nursing Allied Health Professionals Federation Medsin 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 level. Providing information : referral and social prescribing

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 engagement

Royal Free Cont. 1.SUPPORTING HEALTHIER LIVES –Well at the Free –Comprehensive Stop Smoking Service 2.BETTER HEALTH FOR ALL –Homelessness Pathway –A&E assault-related violence data sharing –Domestic Violence Screening: Pilots in key areas: Gynaecology, Maternity and Sexual Health. 3.CREATING A HEALTHIER WORKFORCE –Fit at the Free 4. TAKING A POPULATION PERSPECTIVE –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* *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 % children with four or more negative outcomes* Number of previous 5 years child has lived in these conditions

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 Income 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 High Low 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: equity.org