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By Dr Sohail Abbas, director – Reducing Inequalities Alliance, Bradford District and Craven Health and Care Partnership.

It feels like yesterday when we were talking about developing a programme of work to tackle health inequalities in Bradford city clinical commissioning group (CCG) following an uplift in funding from NHSE. Five years have passed and looking back, we have done some amazing work.

The Reducing Inequalities in Communities programme, commonly known as RIC, has been the flagship health inequalities programme in Bradford. RIC and its associated projects have allowed us to develop and learn from our local approach to tackling health inequalities in the most deprived, inner-city areas of Bradford District and Craven.

RIC was formed from an increased funding in 2019 from NHS England to tackle the stark health inequalities and poor life expectancy in inner city Bradford.  This funding came from the recognition that health inequalities for much of the population of England are deep and entrenched, and that existing ways of delivering services were not having the desired impact on population outcomes. It recognised that equal was not fair, and to improve outcomes for some of our most deprived communities we needed, and continue to need, to embed the principle of equity and proportionate universalism, rather than equality, to our service planning and delivery.

It is this principle, to provide additional capacity and resources to facilitate equal access and outcomes, which underpinned the prioritisation of the RIC projects. Our work follows our partnership’s Act as One ethos and our partnership’s vision of helping people live ‘happy, healthy at home.’

Acting As One

Over the years since RIC programme launch, more than 50 partner organisations have worked together as part of a collaborative to initiate and deliver 21 different projects. The projects reached a significant number of people with over 16,000 people benefiting from the RIC programme. This includes service users, new volunteers and people working across our place who have received training. The projects have employed around 100 whole time equivalent staff, some of which are in completely new roles.

RIC has instigated new and collaborative ways of working to tackle health inequalities. The decision to ring-fence the additional funding for health inequalities, and the creation of a distinct programme of work created clear focus and intent on improving outcomes for the people of central Bradford.

Creating RIC as a standalone health inequalities programme allowed for better collaboration between system partners through the different projects, as there was a common goal for organisations to work together to achieve.

A population health management approach

In RIC we adopted a population health management approach. We used data and local knowledge to develop intelligence about our population needs, identified population segments at risk of ill health and co-developed interventions with our statutory and community provider colleagues to manage those conditions.

Having a framework for prioritisation, which was co-produced by public health and research colleagues, provided real rigour to decision making, particularly when combined with the Delphi prioritisation process. It provided a clear rationale for how decisions were taken, and resultant recommendations were reached.

Having a combination of intervention types that have included testing new approaches as well as building on previous successes and expanding previous work, has meant we have been able to gain momentum in certain areas quickly as we have not needed to create new infrastructure and skill sets throughout.

A test bed of innovation

Working with the voluntary, community and social enterprise (VCSE) sector as a part of the pathway of care has been a distinct feature of all RIC projects. Highlighting human stories and sharing learning across projects has been effective and contributes to the RIC story. Showing the real-life impact for individuals lives helps to show the real value of the work the projects are achieving to reduce health inequalities.

The RIC programme brought together two distinct worlds that traditionally worked in silos, the worlds of commissioning and academia. Through the RIC programme we developed the Bradford Inequalities Research Unit. The academic expertise and access to big data brought a unique element to the RIC programme, providing the opportunity to deliver the most relevant, feasible and evidence informed interventions to reduce health inequalities in central Bradford population. As a result of this, Bradford District and Craven is seen, regionally and nationally, as an exemplar in its leadership approach to tackling health inequalities with Dr Bola Owolabi, the Director of the National Healthcare Inequalities Improvement Programme at NHS England, travelling to Bradford to visit our projects.

There are elements of the RIC programme’s success that are evident now with the evaluations done by the Inequalities Research Unit and there are elements of RIC whose impact will not be seen for years, if not decades. We have sown the seeds and our generations will reap the benefits. We have learnt in RIC that greater consideration of the wider economic benefits of a programme should be undertaken at the start of the programme. This should include employment and positive impacts on the criminal justice system, as well as the impact that a service has on the wider family and community of an individual. This is a learning that we shall incorporate in future programmes of population health and inequalities and look at wider health economics to show benefit realisation.

I would like to take this opportunity to thank each one of my colleagues for their support, passion, enthusiasm, sincerity, expertise, and hard work. It is a testament to the dedication of all the people involved in delivering the RIC programme that we fully mobilised 21 projects in an unprecedented set of delivery challenges triggered by the COVID-19 pandemic, and the subsequent financial and wider workforce pressures.  Despite these challenges the RIC projects have shown significant impact on health inequalities.

Whilst the RIC as a standalone programme is reaching its end, we are living in the post COVID world where our population and the heath and care system are facing huge challenges; cost of living crisis, increasing pressure on services and budget constraints in the NHS and local government. This means evidence of what works to reduce health inequalities and provides value for money becomes more important.

So, what next?

How are we going to keep the momentum and tackle inequalities in these increasingly difficult times? There is a present reality where people in the most deprived areas are dying 10 years younger and spending 20 more years of their life in ill health as compared to people living in the most affluent areas. There is also a future that we want to create where our chances of living a long, happy and healthy life will not be determined by who we are, where we live and how much we earn.

This is going to require some magic, and WE are that magic, We, the people who are working in Bradford district and Craven system. We have this responsibility to keep the flame burning and act as the conscience of our system. COVID-19 showed us the mirror and we saw the inequalities right in front of us, killing our people, our friends, and our loved ones. COVID-19 taught us a lesson and we must not forget that lesson. We must work together and the time to do that is now.

And how can we not do it? Are we willing to accept that it is ok for a child to die because of mould in his house and an elderly person to become ill because he does not have the means to keep his house warm? Can we accept that a mother will have different experience because of the colour of her skin and a child born in Manningham or Keighley is not able to reach his or her full potential because of poverty, trauma, lack of education and safe environment? And that continues from generation to generation. And our people in deprived, multi-ethnic, multi-lingual neighbourhoods of inner-city Bradford and Keighley and people in rural areas of Craven have different experience when it comes to access, and outcomes of healthcare?

This is not just about ethics and morality. There is as much financial case to reduce inequalities as there is ethical and moral case. Michael Marmot’s work calculated the treatment costs of health inequalities to be in the region of £5.5 bn a year. Productivity losses in the economy due to health inequalities amount to £33bn, while a further £32bn a year is spent on higher welfare payments. Billions of ££s are spent on late cancer diagnosis, cost of prescribing to treat long term conditions that are more prevalent in deprived areas and unplanned admissions and A&E attendances as a result of complications of these long-term conditions stemming from the wider health and social inequalities. If we want to balance our books and stop the system getting into financial deficits year after year, we must tackle these health inequalities.

What can we do?

First and most important thing is to have hope and firm belief in our abilities. Difficult times create strong leaders and true leadership blossoms when times are tough. We are not some insignificant parts in a big system, WE are the System. We can and we will make a difference.

Then there is the power of I. What can I do in my role to tackle inequalities? We need to reflect and develop ourselves, develop our awareness of inequalities and take action that is within our sphere of control so we can embed this in our day-to-day work. To have meaningful impact on health inequalities, we need to work on many fronts. We need to bring more people to this cause by using our circles of influence, develop networks and relationships and support each other. We need to continue to advocate for equity-based funding and more resources into areas of deprivation and we need to review and improve our prioritise and our pathways of care. We shall make the biggest difference when we shall start to think about inequalities at every stage of service development and delivery, making it business as usual and not an optional extra.

We need to come together and take collective, coordinated action to tackle inequalities across Bradford district and Craven. We must align all our efforts, totality of our resources and our accountability and governance mechanisms to improve population health and reduce inequalities, so we can truly plan, design, and deliver our services based on our population needs and we invest in frontline workforce, in prevention and in our communities. For that purpose, we developed Reducing Inequalities Alliance in Bradford district and Craven in 2022. The vision of this alliance is to harness the passion and equip every one of the 30,000 people working in this system with the skills and abilities to tackle inequalities, and to create a movement that will transform the way we plan, design, and deliver our services.

I shall finish this blog by once again thanking all colleagues who worked tirelessly for this programme and for the people of Bradford. When we launched RIC few years ago, I finished the event with the words of Shams Tabriz, a Sufi mystic, who said:

“Fret not, where the way will take you. Just take your first step and the rest will follow. Don’t go with the flow, Be the flow.”

RIC was a milestone in this journey, and the journey goes on. Thank you very much.

View more inequalities blogs below or on our Reducing Inequalities Alliance webpage. To write a blog about inequalities work you’re involved in, please email ria@bradford.nhs.uk

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