By Duncan Cooper, Public Health Consultant and Associate Director of the Reducing Inequalities Alliance (Bradford District and Craven)
Earlier this year I was lucky enough to attend the national ‘Tackling Inequalities’ conference in London, hosted by the Royal Society of Medicine. This covered NHS England’s Core20PLUS5 approach to reducing healthcare inequalities. This is the latest major policy in the long history of tackling inequalities in this country.
There were some important lessons to take home to our work to reduce inequalities in Bradford District and Craven. This includes the role each person and organisation can play, as well as lessons that can be applied through our Reducing Inequalities Alliance. The conference was opened by Dr Bola Owolabi (NHS England’s health inequalities director) with her overall vision of:
Addressing equitable access, with excellent patient experience, leads to optimal outcomes.
She talked about the rationale for the inclusion of five Core20PLUS5 clinical priorities. Bola stressed that these priorities should certainly not be our only priorities for reducing inequalities (as there are locally defined areas of focus and for health and care), but Core20PLUS5 is a good place to start with “health” inequalities.
The reasons why the 5 clinical areas plus smoking are important are:
- Maternity: Black women are four times more likely to die giving birth than white women (Asian women two times more likely).
- Severe mental illness (SMI): People with severe mental illness such as schizophrenia or bipolar disorder die on average 15-20 years sooner than the general population.
- Chronic respiratory disease: COPD patients from more deprived areas are more likely to be admitted to hospital and die earlier from the disease.
- Early cancer diagnosis: People living in more deprived communities are more likely to have lower recognition of cancer symptoms, not take up cancer screening and have cancer diagnosed at a later stage.
- Hypertension (high blood pressure): Early deaths from heart disease were already beginning to rise again before the COVID pandemic.
The importance of preventing people from smoking and helping them to quit. This positively impacts on all five clinical areas above.
Key themes that the conference often returned to were:
The COVID-19 pandemic
There was a reminder that although the worst of the COVID pandemic is hopefully behind us, inequalities persist on many fronts. For example, cardiovascular disease (CVD) or “COVID without the vowels” continues to kill more people than COVID did, but every year. Thinking more upstream, 90,000 people continue to die in poverty in the UK each year.
A lot of prevention work was disrupted during the COVID-19 pandemic: half a million people with high blood pressure in the UK were missed during the pandemic, so there is some catching up to do.
The importance of prevention and early interventions
Prevention is important as it allows us to intervene during the first stages of disease, or better still before disease even occurs. A conference session on prevention gave three main reasons to increase prevention services:
- to tackle causes of illness that we can change and reduce (e.g. identified during health checks or through vaccination),
- to reduce the number of lives cut short by disease (premature mortality), and
- to reduce preventable hospital admissions, as this obviously isn’t good for patients, and we have an urgent care and NHS workforce shortage.
The role of the NHS
Michael Marmot delivered a passionate address about how we are falling behind other parts of Europe in tackling inequalities (and failing our poorest communities). However, his message was that we can do something about this. By focussing our greatest effort on those most in need, by prioritising the health of children, and by tackling the social determinants of health.
The social determinants of health (employment, education, income, housing etc…) may at first seem outside the direct influence of health services. However, there’s plenty that the NHS and community services can do: as employers, as contractors, as community venues and as care planners. There’s some useful guides on this about the cost of living crisis, fuel poverty and food insecurity (NHS Confederation), a West Yorkshire approach for Hospitals, and a useful summary of the whole topic and practical ideas for the NHS in this blog from Greg Fell.
We are not alone
It was useful to have national organisations at the conference. This reminded me that we are not alone in tackling inequalities (as individuals, organisations or as communities). Others are grappling with the same issues. We can draw on their experience and evidence base for inspiration, or simply just a few ideas.
Information on reducing inequalities are available from the Health and Race Observatory, Kings Fund, Health Foundation building blocks of health, and NICE guidelines.
Leadership – What do I focus on?
There was a fair bit of discussion at the conference that Core20PLUS5 focusses too much on healthcare. Healthcare quality and access to healthcare are responsible for about 20-30% of our health, as opposed to socio-economic and environmental factors that account for a greater proportion (about 50% of our health outcomes).
Conference leaders stressed however that 20-30% is still a big chunk, and that with a large health, social care and VCS workforce we must take this challenge on. We just need to focus on what we can personally influence and achieve.
In Bradford District and Craven, the Reducing Inequalities Alliance is using a 3A’s model to start conversations about our personal role – what is our Awareness, Action, Advocacy to reduce inequalities. This framework can help you work out your own role in reducing inequalities and prompt a discussion in your team.
Thinking more widely about the role of a whole organisation or healthcare ‘system’, speakers pointed out the need to “chunk things up” (or don’t let inequalities overwhelm you). The Labonte model which you can view on the GOV.UK website, can help us decide which chunk of inequalities we’re working in. Whether this is working directly on health inequalities (or Core20PLUS5 priorities), behavioural influences on health or the social determinants of health.
Something that also resonated with me was a call for us, as leaders, to create the conditions for staff to reduce inequalities by:
- “setting the vision” (for the team, service, or organisation)
- “connecting people up with each other” (to take action)
- “helping people find their bite sized chunk to work on”
- “being courageous, collaborative and building trust”
Data or narrative?
There was clear and important message to use data to identify inequalities; and a lot of data was presented! For Bradford District and Craven see our local data profile and JSNA. Personally, I love data but it’s pretty useless without the story behind it and why its important – this is something we have been keen to demonstrate with the human stories from our Reducing Inequalities in Communities programme. The best speakers were the ones that told a story about what the data showed, what we could do about and what it meant for peoples real lives.
Simply put: Data + narrative = change
Our local approach
Locally in Bradford District and Craven we are working with our Community Partnerships and clinical programmes to develop a Core20PLUS5 approach for our place. This is at an early stage but the partnership working, funding streams and approach to evaluating the impact has begun. One thing we do all agree on locally is that reducing inequalities is everyone’s business. We just need to chunk it up and crack on.
Note: The conference and this blog covers the adult focussed approach. Since Nov 2023, we have had the Core20PLUS5 for reducing inequalities in Children and Young People which we will be addressing during 2023.
If you’d like to learn more about the alliance, visit the Reducing Inequalities Alliance webpage. To write a blog about inequalities work you’re involved in, please email ria@bradford.nhs.uk