Friday 16th May 2003 Manchester Town Hall
Hazel Blears, Parliamentary Under Secretary of State for Public Health
Cllr Richard Leese, Leader of Manchester City Council
Edna Robinson, Chief Executive, Salford PCT
Dr Alex Scott-Samuel Director, EQUAL (Equity in Health Research and Development Unit), Department of Public Health, University of Liverpool
Geof Rayner, Chair of UKPHA
Stephen Peckham, then at Department of Sociology and Social Policy, Oxford Brookes University
Bringing People In (by Stephen Peckham and Dr Margaret Godel)
Health Inequalities – the Department of Health official page
Tackling Inequalities in Health – What is the Government Doing
Notes from the conference
Cllr Richard Leese, Leader of Manchester City Council
The objective of the City Council in health is to stop the gap between the health and life expectancy of people in Manchester and those of the rest of the country from widening. This is an important part of the community strategy. The City Council has set up a Joint Health Unit and is a member of the Mental Health Partnership – both established voluntarily. PCTs are a good thing, but it would be better if the councillors on their boards were appointed by and accountable to the Council rather than appointed by the Secretary of State or the Commissioner.
Institutional instability has made it difficult to work with the NHS on health inequalities. Institutions have fragmented and Foundation Hospitals will not improve the situation. The prioritisation of waiting lists above all else has not always encouraged partnership working. There has been no real devolution or decentralisation. Devolution is partly a question of attitude. More focus on prevention would in the long run bring waiting lists down. Health Inequalities have, up to now, not been given sufficient priority.
The council is reviewing its children’s services following the Laming report, but does not want to see Children’s Trusts imposed. Children’s problems cannot be tackled independently from their families. We should make it easier to be good parents, and we should be serving communities, not clients.
Edna Robinson: Chief Executive Salford PCT
Health Inequalities is a bit of a niche market – not really on the lists of jobs the NHS must tackle now. There have always been problems about the relationship between the NHS and the population as a whole. Poor health is largely a consequence of missed life chances. Those who most need good services are least likely to get them. GPs are still small businesses – we should encourage them to work more collectively. Too much investment goes into huge teaching hospitals which have no relationship with their local community at the expense of primary care.
Services are not welcoming to the poor so they join the waiting list late and are easily discouraged. Poverty keeps people in the sick role – they don’t want to lose their incapacity benefit. We should look more carefully at the role of the benefit system.
Guilt is a poor motivator of behavioural change. We need to be more opportunistic and imaginative in tackling health inequalities and making services accessible to deprived groups. Services for children should be available when schools are closed. Communities must grow their own solutions, which may be challenging and difficult.
PCTs should have different objectives in deprived areas. Inequality should be performance managed.
Stephen Peckham Reader in Health Policy Oxford Brookes University Bringing People In Project
Partnership project with the UK Public Health Association builds on previous work developing a public health model of primary care focusing on the relationships between primary care and local communities in public health action
Health Inequalities: the local dimension
- Access to services:
- hospital; GP; Social welfare
- Differences in health status:
- geographical; class; income ; age
- alternatives to public services
- access to complementary services
Factors affecting health inequalities:
- Location – availability transport;
- Attitudes of providers;
- Knowledge of services;
- Resources of people;
- Quality of housing
- Lay people are often marginalised – Professionals define the agenda
- Professionals emphasise the need to educate the public
- Professionals see involvement as a therapeutic process
- Lay representatives are incorporated into organisational cultures
- By exploiting voluntary effort;
- By dismissing and discounting lay people as unrepresentative or too articulate
Problems faced by communities
- Medicalised nature of the NHS;
- Emphasis on short-term projects;
- Community agenda is not taken seriously dog poo, lighting etc;
- Community research not treated seriously
- Community issues cross agency boundaries; The community is really communities
What can local organisations do?
The medical approach (reductivist):
- Identify local needs;
- design interventions for specific circumstances;
- monitor results
A community approach (creative):
- employment and income;
- improved housing;
- improved environment;
- better transport
- good educational opportunities
- Welfare benefits – A number of General Practices have established welfare benefit advice services Evaluations of these schemes suggests them to be successful in raising income
- Services provided in partnership with:
- Local authorities;
- Welfare advice services
- Housing and health Long established relationship between poor housing and poor health; the first public housing built under environmental health laws; Key concerns over damp and respiratory diseases
- Sandwell’s prescription for central heating scheme;
- Family support services for people in temporary housing
- Improving transport
- Accidents; action to reduce traffic and identify accident black spots
- Air quality
- measuring air quality in Hounslow
- mapping asthma cases to identify problem roads;
- Promoting public transport New bus routes
- Better food
- Sandwell food co-operative;
- Whole food market based in a general practice;
- Cookery classes
- Facilities for people in temporary housing;
- Northampton Healthy Living Centre – food and skills network
NHS as local employers
Wolverhampton Health Care Trust project; 30-50% unemployment rates on the most deprived estates; worked with local schools on GNVQs; community based next step shops; extended work experience programmes; developed nurse cadet scheme; total of 727 people went through the programme
Why bring people in?
The lay perspective gives insights into patterns of behaviour and lifestyles. It helps us understand factors that underpin and create health inequalities, Suggests new factors that influence people’s health and their ability to use existing resources, Helps us understand how people live and manage their lives
Encourages peoples’ interest and achieves their active involvement in maintaining their health.
Therefore we need to create continuing mechanisms for dialogue and debate
successfully implementing and monitoring programmes of health improvement with the ownership of the people they aim to help
A Community perspective
We need to think differently
- a medical approach is a reductivist approach
- micro focused looking for cause and effect
- Need an emphasis on social justice on inequalities as experienced by people in communities
Bringing People In…..
- We need to think about bringing professionals to the community not the other way round
- Need to recognise the expertise and knowledge in communities
- We need to work with communities on their agendas
- We need to engage for a the long term
Hazel Blears, Minister of Public Health, Dept of Health:
The more we say “health inequalities”, the less meaning it seems to have – gets removed from the reason why we’re doing it. So why are we doing it?
Even though we have two national targets (described as modest), the task is daunting. Health inequalities are growing and the gap between areas remains stark.
Health inequalities was never mainstream business before. Now it is – but we are only at the beginning. We are now drawing up an all-government delivery plan for the health inequalities (hope to publish it in June). The spending review settlement gives all government departments money for health inequalities. There are cross-departmental talks ongoing. The health inequalities targets are the responsibility of the government of as whole but led by the Dept of Health.
The Wanless report emphasised the importance of public health and prevention and the need to move investment into that.
Themes in the health [inequalities?] delivery plan:
- communities – working with them, involving local people in setting the agenda. Linking with Neighbourhood Renewal strategy, Single Regeneration Budget scheme etc.
- families and children [high praise for Sure Start]
- equitable access to mainstream services – the importance of equity audits, eg in coronary heart disease, cancer, renal services. Inequalities is now in the performance management framework for the NHS.
- jobs, skills, income
- particular groups – prisoners, homeless people, asylum seekers, black and ethnic minorities.
So what can each part of the system do to deliver it? Public health has a voice that it hasn’t had for some time. The PCT chief executives and Board have to sign up to health inequalities.
Local involvement – we want it, but do we show people that they’ve changed something? This is a key time. We need to do something significant around citizenship, including primary care centres owned and run by local people. We must increase the capacity of local communities to respond to needs. We need to invest in the needed social capacity-building.
Two initiatives to highlight – the Expert Patients programme, which is showing interesting results (including reduction in medication), and Skills for Health, which teaches basic skills together with knowledge of the NHS.
We should integrate the NHS, with its enormous purchasing power, into the regeneration of local economies. We should be looking to local commissioning of local providers to achieve PCT targets.
[I didn’t note the first two, which were about the predominance of short-term funding for projects rather than long-term or mainstreaming.]
Q: Training for frontline workers in health inequalities?
A. The NHS University is an exciting development – among its early courses are an introduction to the NHS and its values, and a course on customer care. There will be training for local people too.
Q: Boundary reorganisation affects measures of deprivation – we need to measure deprivation more locally.
A. We’re trying to develop local mapping. We need to understand more about why similar areas have different problems.
Q: 1) Life expectancy targets – the Netherlands have a 30-year timescale but here we only go up to 2010. Is there any longer-term look here? 2) Local targets – can we set them?
A. There is an ongoing debate about targets across government. It shouldn’t be seen as failure if targets aren’t met – we need to appreciate a rise in output/outcome even if the target isn’t fully met. “Getting from 30% to 73% is a great achievement, even if the target was 75%.”
Director, EQUAL (Equity in Health Research and Development Unit), Department of Public Health, University of Liverpool:
Health inequality means unfair or unjust differences in health determinants or outcomes within or between defined populations.
War is a health inequality issue. The problems of inequality include affluence. Equity is about distribution according to need. Capitalism is about inequality. Social democracy is regulated capitalism – on the basis that people in your own country matter slightly. Poverty is not the same as inequality. We need to consider the problem of the rich and the very narrow distribution of wealth
Workshop : Access for local communities
Facilitators : Dawn Rivers/Anna Akhtar/Bernadette Conlan
- Need to find ways to gain recognition for the work of the voluntary sector in delivering on the inclusion agenda. The Voluntary sector have a key role to play in supporting the mainstream on achieving their targets.
- Difficulty for projects/initiatives that have been set up with short term funding, difficulties in gaining ongoing core funding for established projects.
- Nationally set targets are useful for providing a framework to work within, but these need to be supplemented by locally set targets that are developed with local community involvement.
- In terms of involvement it would be useful to develop ‘Participation’ standards for all agencies to work with as part of their conditions of funding – and to be performance managed against (Including statutory org.) This would include reimbursement of travel expenses, child care costs, translation issues, and discussions/decision making to take place in more creative ways (Participatory appraisal).
- Look at the way we structure our services – Is it appropriate for so many to be run from centres with inflexible appointment systems – would it be more appropriate to offer more outreach services, making contact with more isolated people with in the community in different settings.
Workshop session on ethnicity, culture and race
(Participants from voluntary sector provider organisation, PCT, Health for All initiative)
We’d like to see equality across the board, showing itself in:
- how you are treated by frontline staff
- interactions between patients and staff
There needs to be training for frontline staff.
Prejudice isn’t only around race, it’s around class and perceived status. People express prejudice when they feel it’s safe to do so.
Racism is powerfully countered by people having personal experience of meeting other (different) people and speaking to them.
People providing care shouldn’t make assumptions but let the person (patient) lead them. “Don’t assume what my needs are. I don’t fit into categories. Take me as I am.” It’s about treating people as individuals.
There are particular needs of particular communities – these are still not sufficiently researched. Communities have to struggle to have their needs recognised (eg sickle cell anaemia and thalassemia in the 80s/90s, and the Irish community more recently).
Some people experiencing racism may find it very difficult to talk about, so it’s often hidden.
Asylum seekers (who experience a lot of racism) would never complain about it.