Addressing Health Inequalities

1. Lancashire Public Health Report 2011 Addressing Health Inequalities

2. Background • Purpose of the report: • To set out the main causes of health inequalities in Lancashire • To make recommendations to partners about the action needed for health equity

3. Health inequalities in Lancashire • Lancashire Joint Strategic Needs Assessment analysis of health inequalities (2009) • People who live in the most deprived parts of Lancashire are: • 7 times more likely to die early from chronic liver disease • twice as likely to smoke • 6 times more likely to say that anti social behaviour is a problem in their neighbourhood • 5 times more likely to have symptoms of extreme anxiety and depression • Than those that live in the least deprived neighbourhoods in the county

4. Financial cost of health inequalities in Lancashire • If the death rates in the most deprived 40% of areas in Lancashire were improved to the Lancashire average: • 16,224 years of life would be saved with an economic value of £661 million • Estimated lost production costs due to health inequalities are £900 million per year • Increased benefit payments and lost taxes due to health inequalities cost the Lancashire economy £800 million per year. • Health inequalities are estimated to cost the NHS in Lancashire around £300 million per year.

5. What do we mean by health inequalities? •  Health inequalities - differences in health status or in the distribution of health determinants between different population groups. Examples include differences in death rates between people from different social classes. • Health equity - the distribution of disease, disability and death in such a way as to not create a disproportionate burden on one population. It is the absence of persistent health differences over time, between different groups of the population.

6. Why do health inequalities matter? • Poor health and wellbeing prevents too many citizens from: • working • learning • being involved in their community • enjoying their leisure time • Reduced productivity due to poor health has a negative impact on Lancashire's economy • Health inequalities are fundamentally unfair • It is possible to reduce health inequalities • Health reforms provide new opportunities for health equity

7. Setting priorities for addressing health inequalities • Stakeholders keen to address the causes of the causes of health inequalities • Identified 6 priorities for health equity: • Reduce unemployment and worklessness • Increase income and reduce poverty • Strengthen communities • Increase opportunities for life long learning and skills development • Reduce tobacco and alcohol consumption • Increase social support

8. Focus on wellbeing • New Economic Foundation Five ways to wellbeing: • Connect • Be active • Take Notice • Keep learning • Give

9. Reduce unemployment and worklessness • Work protects mental and physical health through : • income • psychological benefits • social interaction • Poor working conditions, including: • uncertainty and job insecurity • high work demands and low rewards, • low control and autonomy in relation to work • low social support within the workplace • contribute to increased risk of heart disease, stroke, poor mental health and unhealthy behaviours

10. Unemployment and worklessness – recommendations • Undertake analysis of health needs of unemployed and workless people • Employers should: • Encourage those facing redundancy to develop alternative social networks • adopt healthy recruitment and working practices and encourage suppliers to do the same • GPs recognise role they play as potential gateway to employment support services • Train front line health staff to provide support to unemployed patients and those at risk of worklessness • Align health services to the ‘work programme’

11. Unemployment and worklessness – recommendations 6. Mental health programmes reviewed to ensure they address timely identification of mental health problems in workplace and meet needs of those not in employment 7. Develop multi agency strategy to optimise healthy working practices 8. Existing healthy workplace schemes should be retained during the reform and should be targeted at employers within sectors with the highest risk of redundancies and worklessness 9. Existing work and health initiatives should be reviewed and a common approach to delivery should be agreed and commissioned across the county

12. Increase income and reduce poverty • Low income: • Reduces access to goods and services that maintain/ improve health • Prevents participation in social, cultural and leisure activities that protect mental health and wellbeing • Action needs to both reduce poverty and address its impacts • Child poverty – perpetuates health inequalities across the generations • Poverty in the working age population – minimum income for healthy living • Poverty in later life – older people vulnerable to effects of fuel poverty

13. What is already happening to reduce poverty and its effects? • Developing child poverty strategy • Total Family • Welfare rights in health settings (through GPs and Macmillan nurses and for those with asbestos related illness (Partnership between LCC and PCTs) • Fuel poverty referral project (LCC, PCTs and 12 district councils) • Fire and rescue service integrated identification of fuel poverty into home safety checks)

14. Poverty and income – recommendations • All partners identify how they will contribute to the Lancashire Child Poverty Strategy • Partners identify families in poverty and work together to provide co-ordinated services • Focus resources towards pregnancy and early years • Expand Total Family Programme across Lancashire • Integrate Fuel Poverty Referral Project into the NHS QIPP programme and promote it to GP commissioning consortia • Undertake equity audit of welfare rights provision to ensure services are reaching and benefiting those that need them most • Investigate provision of welfare rights services in primary care settings • Integrate income maximisation into social prescribing programmes and link to case management approaches

15. Strengthen communities • Strong communities increase resilience to the affects of poverty • Good health and wellbeing is associated with access to good social and community networks • Characteristics of strong communities not equally distributed

16. What is already happening to strengthen communities? • The Voluntary, community and faith sector contributes to strengthening communities by: • Providing opportunities people to connect with others through volunteering, social network, involvement in community associations • Providing 'wellness services’ • Contributing to assessment of health and wellbeing needs • Providing a public and service user voice into commissioning and provision of services • Advocating for the needs and involvement of specific communities and promoting equality and diversity

17. What is already happening to strengthen communities? • Asset based approaches to strengthening communities (Preston, West Lancashire, Ribble Valley) • Advocate for the needs and involvement of specific communities (e.g. Preston work with travellers) • Voluntary, Community and Faith Sector • Provide opportunities for people to connect with others • Provide 'wellness services’ • Provide public / service user voice

18. Strengthening communities – recommendations • Asset based approaches to community development should be used by local authorities at both county and district levels • Extend the Central Lancashire framework for action for asset based community development across the county • Develop capacity and capability for asset based approaches within the voluntary, community and faith sector (VCFS) • As far as possible, protect public investment in the VCFS • Implement the Healthy Streets initiative (includes 20 mph speed limits, improved quality of the public realm, promotion of street based physical activity • Where possible provide public sector services at local venues and share public sector assets across agencies

19. Increase Opportunities for Life Long Learning and Skills Development • Lifelong learning impacts on health inequalities: • Indirectly, provides skills and qualifications for employment and progression in work • Directly, participation in learning impacts on health behaviours and outcomes • Learning for its own sake is one of the five ways to wellbeing

20. What is already happening to increase life long learning and skills development? • Programmes to widen participation from d deprived areas in education for those 14-19 • Healthy schools • Adult learning services • Employment training for those not in work • Library services • Cultural and arts opportunities • Voluntary, community and faith sector provision (e.g. University of the Third Age co-operative approach to learning)

21. Life long learning and skills development – recommendations • Increase access to lifelong learning across the social gradient by: • providing 16 – 25 year olds with life skills training and employment opportunities • providing work based learning and work experience for those not in employment • Local authorities take account of the impact learning has on wellbeing in spending decisions • Identify and develop opportunities to increase the availability of non vocational learning across the life course • Support VCFS to provide learning opportunities using asset approaches

22. Life long learning and skills development – recommendations 5. Learning, culture and arts opportunities should be integrated into social prescribing schemes and extended across the county 6. Develop and implement a youth employment and employability strategy for Lancashire 7. Social landlords should include training as part of resident involvement in decision making 8. Community growing schemes should be extended across the county to encourage the development of new skills 9. Schools should integrate the Five Ways to Wellbeing into the curriculum 10. Employers should recognise skills gained by informal opportunities

23. Reduce alcohol and tobacco consumption Alcohol • Alcohol consumption has an inverse social gradient • Alcohol harm has a strong social gradient • Those in the most deprived areas of Lancashire are 8.2 times more likely to die prematurely from chronic liver disease, than those in the least deprived Tobacco • Strong social gradient in tobacco use • Smoking impacts across the whole life course, with children particularly vulnerable to the effects of tobacco • Smoking contributes to inequalities in many health outcomes

24. Reduce alcohol and tobacco consumption

25. What is already happening to reduce tobacco and alcohol consumption? • Community alcohol project (Hyndburn - Trading Standards, Constabulary, School and Community Partnership Team, Young Peoples Service) • Youth tobacco prevention (Smoke and Mirrors) • Lancashire Alcohol Network Strategic Framework • Responsible alcohol retailing (Pendle and Rossendale) • Chorley Alcohol Intervention (Chorley partnership) • Tackling illicit tobacco (Smoke Free North West) • Reducing exposure to second hand smoke (Take 7 steps out)

26. Tobacco and alcohol – recommendations • Resources should be allocated from the planned ring-fenced public health budget for tobacco control and alcohol misuse • A strategic needs assessment on substance misuse (including tobacco and alcohol) should be undertaken JSNA to inform the development of strategies to address substance misuse • QIPP programme should include preventative action to reduce alcohol and tobacco consumption • Use of regulatory powers in relation to alcohol and tobacco should be maximised • Frontline staff and volunteers should be trained to deliver identification and brief advice on alcohol and tobacco • Support should be given to employers to develop workplace alcohol and tobacco policies • Partnership approach to alcohol and tobacco should continue and develop within Public Health Lancashire

27. Tobacco and alcohol – recommendations • Resources should be allocated from the planned ring-fenced public health budget for tobacco control and alcohol misuse • A strategic needs assessment on substance misuse (including tobacco and alcohol) should be undertaken JSNA to inform the development of strategies to address substance misuse • QIPP programme should include preventative action to reduce alcohol and tobacco consumption • Use of regulatory powers in relation to alcohol and tobacco should be maximised • Frontline staff and volunteers should be trained to deliver identification and brief advice on alcohol and tobacco • Support should be given to employers to develop workplace alcohol and tobacco policies • Partnership approach to alcohol and tobacco should continue and develop within Public Health Lancashire

28. Tobacco and alcohol – recommendations 8. Screening for tobacco and alcohol use should be integrated into health service delivery and targets re completeness of data included in contracts 9. Service evaluation/ monitoring should include information to assess acceptability and effectiveness 10. Intelligence-led social marketing approaches should be undertaken 11. Media campaigns re tobacco and alcohol should be evaluated for their effectiveness and sustained or scaled up as appropriate 12. Partners should contribute to the delivery of alcohol and tobacco elements of Children and Young People’s Plan (2011-2014) 13. Local partnerships should maintain and strengthen advocacy and lobbying in relation to minimum unit pricing for alcohol and increasing taxation on tobacco 14. North of England 'Tackling Illicit Tobacco for Better Health Programme' should be sustained and supported locally.

29. Increase social support • Social support provides emotional and practical resources needed to live a fulfilled life and be resilient to challenges • Belonging to a social network makes people feel cared for, loved and valued • Supportive relationships also encourage healthier behaviour patterns • The influence of social relationships on risk of mortality is comparable with well-established risk factors such as smoking, alcohol consumption, obesity and lack of physical activity • We estimate that there are more than 130,000 people in Lancashire who experience a severe lack of social support

30. What is already happening to increase social support? VCFS in Lancashire offers wide range of social support for children and young people: • 153 voluntary youth organisations • offer opportunities to over 94,000 young people • E.g. West Lancashire young carers Councils and VCFS provide social support for adults: • Opportunities to volunteer time through Timebanks • Befriending services to support people who are lonely and at risk of becoming vulnerable • luncheon clubs • Handy person schemes • Help Direct

31. Social support – recommendations • Undertake equity audits of supporting people and support services for carers • Scale up social prescribing schemes • Undertake strategic needs assessment of older people to inform commissioning of social support services • Monitor the impact of the recession on excluded groups • Screen budget reduction decisions for their health impact to ensure vulnerable and isolated people are protected • Improve local data collection in relation to social support • Use asset approaches to enable assets of residents to be realised and gaps to be filled by public services • Support the VCFS to engage in public sector procurement and to develop the VCFS social support market

32. Setting health equity targets • Liver disease – those in the most deprived areas are 8.2 times more likely to die prematurely than those in the least deprived areas. This gap should be narrowed to a ratio of 6.5. • Mental health and wellbeing – those in the most deprived areas are 6.1 times more likely to experience extreme anxiety and depression as those in the least deprived areas. This gap should be narrowed to a ratio of 4.9. • Diabetes – those in the most deprived areas are 4.1 times more likely to die prematurely than those in the least deprived areas. This gap should be narrowed to a ratio of 3.2. • Quality of life – those in the most deprived areas are 3.4 times more likely to be experiencing extreme pain and discomfort than those in the least deprived areas. This gap should be narrowed to a ratio of 2.72 • Infant mortality – babies in the most deprived areas are 2.9 times more likely to die than those in the least deprived areas. This gap should be narrowed to a ratio of 2.3.

33. Setting health equity targets • Coronary heart disease – those in the most deprived areas are 2.8 times more likely to die prematurely than those in the least deprived areas. This gap should be narrowed to a ratio of 2.2 •  Lung cancer – those in the most deprived areas are 2.7 times more likely to die prematurely than those in the least deprived areas. This gap should be narrowed to a ratio of 2.2. •  Stroke - those in the most deprived areas are 2.7 times more likely to die prematurely than those in the least deprived areas. This gap should be narrowed to a ratio of 2.2. •  Child health and wellbeing – those in the most deprived areas are 2.5 times more likely to die than those in the least deprived areas. This gap should be narrowed to a ratio of 2. •  Accidents – those in the most deprived areas are 2.2 times as likely to die as those in the least deprived areas. This gap should be narrowed to a ratio of 1.8.