An NHS Grampian Framework for Reducing Health Inequalities 2004-2007

An NHS Grampian framework for reducing health inequalities 2004-2007

Appendices

Appendix A: NHSG Healthy Inequalities Steering Group

Appendix B: Key findings on successful interventions to tackle health inequalities

Appendix C: Common cause: Social justice milestones and targets alongside PAF targets

Appendix D :Constituencies –map

Appendix E: National themes and existing local priorities & Priorities for

healthy living

Appendix F: Health scenarios (Wanless, 2004)

Appendix G - Data framing

Developing a simple system

Developing a template: ‘Four pillars’ and potential data sources

Populating the template

Selective examples

Constituency data analysis: template and example

Appendix A

Health Inequalities Steering Group Membership

• Director of Public Health (Chair)

•NHSG lead for Social Inclusion

NHSG General Manager or nominee from each of the Joint Health Improvement Planning Groups within City, Aberdeenshire and Moray collectives
Local Authority lead director for Social Inclusion and/or Health Improvement, or nominee, from each of the Community Planning Partnerships of City, Aberdeenshire and Moray
Lead officer for Social Justice from Communities Scotland (Grampian)
CEO or nominee from Grampian Local Health Council
Health Improvement Lead Director from Acute Sector
NHSG lead for Children and Young People
NHSG lead nominated by Director of Corporate Finance
NHSG Head of Health Intelligence
NHSG Head of Performance
NHSG Director of Strategic Change and Innovation
NHSG representative of Director of Nursing (Primary Care)
NHSG Director of Planning or nominee
NHSG Head of Corporate Communications ( to ensure effective connection with PFPI)
Administrator/project support

Appendix B

Key findings on successful interventions to tackle health inequalities

Scotland’s population reached a peak in 1974 and since then has been on a gradually declining trend, although with some fluctuations.
Local assessment of needs, especially involving local people in the research process itself.
Mechanisms that enable organisations to work together – ensuring dialogue, contact and commitment.
Representation of local people within planning and management arrangements – the greater the level of involvement, the larger the impact.
Design of specific initiatives with target groups to ensure that they are acceptable – that is, culturally and educationally appropriate – and that they work through settings that are accessible and appropriate.
Training and support for volunteers, peer educators and local networks, thus ensuring maximum benefit from community-based initiatives.
Visibility of political support and commitment.
Re-orientation of resource allocation to enable systematic investment in community based programmes.
Policy development and implementation that brings about wider changes in organisational priorities and policies, driven by community-based approaches.
Increased flexibility of organisations, so supporting increased delegation and a more responsive approach

Source: Tackling Health Inequalities

Appendix C

A SCOTLAND WHERE EVERYBODY MATTERS: A Social Justice Strategy for Scotland

Targets & Milestones (Appendix`2)

The Social Justice Strategy is a key policy driver for the public sector in Scotland in which the Scottish Executive has established its commitment to social justice and its principal aim of defeating child poverty.

It presents 10 long-term targets for 2020 and 29 milestones to ensure, over progress towards these over the short term. Milestones cover reserved and devolved areas. Milestones reflecting UK wide indicators in the areas of income, pensions, employment, and drugs misuse are 1,2,14,15,19.20 and 25. The lifecycle has been used as a way of framing these. The document provides the data sources that will be the basis of the Annual Scottish Justice Report. It is intended to present breakdown data wherever sources allow for: age gender, ethnicity, disability.

Health has some bearing on most, if not all, of the milestones but arguably those with greatest direct connection to health are 5,11,18, 22 and 25.

Targets

Every child matters

Defeat child poverty within generation
All leave primary able to read write and count

Every young person matters

Leave school with maximum skills and qualifications posible
All 19 year olds in education, training or work

Every family matters

Full employment
Everyone taking some form of learning to widen knowledge and skills

Every older person

Financially secure

Increase the numbers with active, independent, and healthylives

Every community matters

Reduce inequalities between communities
Increase residents’ satisfaction with their neighbourhoods and communities

Summary of milestones NHS PAF: Health Improvement and Reducing Inequalities Improving Health: The Challenge

Every child matters /

1.04 Infant Health

1.04.01 Low Birth Weight Babies

1.04.02 Breast Feeding

1.05.01 Dental Disease - Preschool

1.06 Immunisation Programmes

1.06.01 Childhood Immunisations Excluding MMR

1.06.02 MMR

1.06.03 Influenza

1.12 Physical Activity

1.13 Diet

1.14 Inequalities

1.14.01 Pregnant Women Smoking

1.14.02 Dental Disease - Children under 5 Years

Indicators of Inequalities

Children
Reduce proportion of children in workless households
2Reduce proportion of children in low income
households
3Increase proportions of children attaining appropriate levels in reading, writing and maths at end of P2 and P7
4All children to have access to quality care and early learning before entering school
5Reducing the proportion of women smoking in pregnancy, percentage of low birth-weight babies, dental decay among 5 year olds and increase the proportion of women breastfeeding. / 1 Smoking during pregnancy
2 Breastfeeding
3 Dental health

4 Low birthweight babies

5 Emergency admissions
6 Infant mortality
6 Reducing the number of households,
especially families with children, living in
temporary accommodation
Every young person matters / 1.03 Mental Health – Promotion

1.07 Sexual Health

1.07.01 Pregnancy Rate among 13-15 year olds
Halving the proportion of 16-19s not in education, training or work.
8 All young people leaving LA care with at least English and Maths Standard grades and with access to appropriate housing options
9 Improving poorest performing 20% of pupils, in terms of Standard Grades, closer to the performance of all pupils.
10 Reducing by a third days lost through exclusion from school and truancy.
11 Improving the health of young people through reductions in 12-15s who smoke, recucing teenage pregnancies among 13-15s and rates of suicides among young people. / 7 Emergency admissions
Teenage pregnancies 13-15
Teenage pregnancies 13-19

Suicides among 10-24

12 No-one has to sleep rough
Every family matters
13 Reducing the proportion of working age unemployed
14 Reducing the proportion of working age with low incomes
15 Increasing the employment rates of groups, such as lone parents and ethnic minorities, that bare relatively disadvantaged in the labour market
16 Increasing the proportion of students from under-represented, disadvantaged groups and areas in higher education, compared with the overall student population in higher education.
17 Increasing the proportion with learning disabilities able to\live at home or in a ‘homily’ environment
18 Improving the health of families by reducing smoking, alcohol misues, poor diet and mortality rates from coronary heart disease. /

1.03.01 GHQ12 scores

1.07.02 Incidence of STIs

1.08 Smoking

1.08.01 Pregnant Women Smoking

1.08.02 Adult Smokers

1.09 Alcohol Problems

1.09.01 Persons Exceeding Weekly Alcohol Limits

1.10 Drugs Misuse Assessment

1.10.01 DAT action plans progress

1.11 Drugs Misuse

1.11.01 DrugMisusers in Contact with Services

1.11.02 Drug Misusers Injecting

1.11.03 Drug Misusers Sharing Needles and Syringes

1.12.01 Physical Activity

1.13.01 Persons Eating Fruit and Veg

1.14.03 Adult Smokers

1.14.04 Mortality - Coronary Heart Disease

1.14.05 Life Expectancy /

Diet

Adult smoking

Self-reported general health

14 Self-reported limiting long-standing illness

15 Obesity

16Mental health (GHQ12 scores)

All cause mortality rate among under 75s

Mortality from CHD among under 75s

19 Mortality rates from cancer among people under 75
20 Life expectancy at birth
Every older person
19 Reducing the proportion of older people with low incomes
20 Increasing the proportion of working age people contributing to a non-state pension
21 Increasing the proportion of older people living independently by doubling the proportion of older people receiving respite care at home and increasing home care opportunities
22 Increasing the number of older people taking exercise and reducing the rates of mortality from coronary heart disease and the prevalence of respiratory diseases / 21 All cause mortality rate among people over 75
22 Mortality rates from CHD among 75 and over
23 Mortality rates from cancer among 75 and over
23 Reducing the fear of crime among older people
Every community matters /

1.01 Assessment of actions

1.01.01 NHS Board development as Public Health Org

1.02 Deaths from Various Causes

1.02.01 CoronaryHeart Disease

1.02.02 Cancer

Stroke
1.05 Dental Health

2 Fair Access to Healthcare Services

5.02 Vulnerable Groups

5.02.01 Meeting Disabled Peoples Needs

5.02.02 Health and Homelessness Action
24 Reducing the gap in unemployment rates between the worst areas and the average rate for Scotland
25 Reducing the incidence of drugs misuse in general and of injections and sharing of needles in particular
26 Reducing crime rates in disadvantaged areas
27 Increasing the quality and variety of homes in our most disadvantaged communities
28 Increasing the numbers from all communities taking part if voluntary activities
29 Accelerating the number of households in disadvantaged areas with access to the internet

** Addressing Rural Health Inequalities

The task of assessing health need in rural and semi rural areas such as Grampian can be difficult. Rural areas by definition tend to have low populations that can be dispersed or clustered into small communities. Aggregated data even at electoral ward level, can relate only to a small number of people. Very small numbers are often rounded down to zero to protect confidentiality. Statistical significance for inequalities in health either within rural areas or between rural and more urban areas can therefore be difficult to achieve.

An additional feature of the rural areas is the heterogeneity of the population. Whilst in more urban areas social groups are often clustered together, data for a geographical unit in rural areas are likely to contain information on a range of social groups and any health inequalities will be averaged. From a rural perspective on deprivation, indices often define an area rather than people as deprived. An additional difficulty, particularly for routine data such as census data is that certain variables can have different interpretations in urban and rural settings. For example, data on employment status is often used in assessing health need. Unemployment statistics are a key component in indices of deprivation (cf the Townsend index). However the pattern of employment is different in rural areas A greater proportion of the labour force is either part time or self employed on very low wages. Analysis of unemployment statistics, taken in isolation from rural market factors, can be affected.

Data on the use of services may also be biased towards urban areas as increasing distance from a service has been shown to have a negative impact in uptake. The distance decay does not necessarily, mean decreasing need with distance from the service, but may suggest unmet need. Research suggests that rural residents not only present less with health concerns (Bentham and Haynes 1985) but also delay consultation (Campbell et al 2000). Existing use of services is not a reliable indicator of health need. Most data suggest that rural communities are relatively healthy and indeed this may be largely true. However it is also likely that health inequalities are hidden. (Deaville et al 2002).

Bentham CG and Haynes RM (1985) Health, personal mobility and the use of health services in rural Norfolk. Journal of rural studies 1 (3) 231-239.

Campbell NC, Elliot AM, Sharp L et al (2000) Rural factors and survival from cancer: Analysis of Scottish Cancer registration. British Journal of Cancer 82 (11) 1863-1866.

Deaville J, Mitchinson K and Wilson L (2002) ‘Think Rural Health’. The Institute of Rural Health.

Appendix E

National themes - Local Health Plan Priorities

Appendix E (cont’d)

Local Health Plan Priorities for Healthy Living

Tobacco / Reduce in priority groups: pregnant women and partners
Young people
Low income
Healthy Eating /

Fruit & veg to 5 a day esp among poor

Reduce obesity

Physical Activity / Promote active tasks,transport and living
Physical activity most days for 30 mins adult, every day for 60 mins children
Alcohol / Reduce harmful drinking esp children and young.
Promote culture of sensible drinking

Appendix F

Source Wanless, D (2004) Securing Good Health for the Whole Population. Crown Copyright.

Appendix G

Data framing

Developing a simple system

Developing a template: ‘Four pillars’ and potential data sources

Populating the template

Selective examples

Constituency data analysis: template and example

Health Inequalities Data Framing

Introduction

Our strategic framework sets out the basis for developing a systematic, a system-wide programme of sustained action to improve health by reducing health inequalities in Grampian: ensuring that each sector implements the NHSG vision and the vision of community planning partners to increase heath and well-being in Grampian.

To ensure that we are working to a common understanding, we need to have a shared evidence base which is coherent across the system, and is sufficiently flexible to allow us to add new information, to add different levels of information, or to draw in different data sets which inform a particular issue, problem or topic.

‘Givens’

Agreeing a systematic framework

We have agreed that the Scottish Executive’s ‘four pillars’ are ones around which we should be gathering data on health inequalities viz Early Years; Teenage Transition; Communities and Workplace.

We have also acknowledged that there are communities of interest such as the homeless; those suffering domestic abuse; communities disadvantaged by rurality and so on.

These categories are not mutually exclusive but we require some means of pulling together relevant data on key areas.

What follows is the outline of a simple framework.

Developing a template

The first template illustrates, by way of example only, how we can pull together existing data which will provide both evidence, triangulation, and analysis on health inequalities around the four pillars.

Populating the template

The second set of data illustrates the kinds of comparisons we can make to gain a clearer understanding of relative inequalities in relation to particular topics or health problems, such as a comparison of the three local authorities on, for example, mortality rates for coronary heart disease in the under 75s. It too is indicative.

The third set of data illustrates how we might utilise the Constituency Profiles to sharpen our focus around issues of concern. We believe that we have the basis of a tool which we will use to offer a similar sharpening of focus around the Community Profiles which are likely to be released by NHS Health Scotland to NHS Boards in May/June 2004. Similarly, we believe the ‘ tool’ has the potential to help sharpen the focus of other data sets we hold and we flag this in our action plan. (separate file)

Our action plan, towards the end of the introductory document, indicates how we plan to build on our initial work on health inequalities to develop, sustain and share our understandings across the system and with partners, many of whom hold data which will provide the breadth, depth and triangulation to form a robust contribution to decision making to create a step change in the health outcomes of the people we serve.

HI Framework 22 march Annex

Selective examples

The first templateillustratesInequalities in health outcomes, by way of example only, how we can pull together existing data which will provide both evidence, triangulation, and analysis on health inequalities around the four pillars.

Summary of data sources – work in progress – examples.

Four pillars / Grampian V Scotland / LA V Scotland / LA V LA / LA communities V communities / Health outcomes
Health behaviour / Evidenced interventions
Early years /

Dental data

/ *Breast feeding-City
(HCH) /

Smoking during pregnancy

Dental health

Sure Start?

Teenage transition /

PAF- teenage pregnancy; use of alcohol-smoking young people

*Hospitalisation attributed to alcohol / * Teenage delivery Rates 02/03 City (HCH) /

Hospitalisation attributed to alcohol

Give Kids a Chance

Communities /

Blood Borne Viruses DPH

-IHD 75-
Neoplasms 75-
Cerebrovascular 75-
-PAF Smoking in pregnancy
-smoking adults / * Scottish Health Index of Multiple Deprivation ISIMD) 2003
City. -
Health and disability deprivation 2003
*Limiting Long Term Illness City, 2001
*Perception of general health
Premature mortality IHD
*Health Summary
(All Tribal/HCH) /

Adult smoking

Mortality rates from CHD uder 75

Life expectancy at birth

Breastfeeding
Towards a healthier LGBT

Scotland (2003) /

Workplace / DPH-SHAW
Rural communities / Mc Minn health profiles of small communities data
Aberdeenshire sexual health needs assessment
Communities of Interest:
Homeless / Small numbers issue
Action Plan data/DPH / HHAP
DAAP

** Addressing Rural Health Inequalities