Transcript Document

Alcohol misuse, obesity and smoking:
a social determinants approach to
public health interventions
Wednesday 10th April 2013
The need for a SDH approach
•
Practitioners’ feedback that, often because they have to show how they are meeting a
health target or achieving a health related outcome, they are often drawn back to
intervening downstream and in lifestyle behaviours – lifestyle drift - rather than taking
action on ‘the causes of the causes’.
•
There has been a dominance of lifestyle interventions with an emphasis on either
downstream interventions or on approaches that have a socially neutral impact (Hunter
et al. 2009). Evidence has shown that life style approaches will not make significant
impact on health inequalities because they do not tackle the causes of health
inequalities, which lie in the SDH.
•
Responsibility for public health and processes for commissioning are currently
changing in England with a view to come into effect in April 2013. Priorities for health
improvement will be set within the local authority (Health & Wellbeing Boards) rather
than by the NHS or at national level. It is envisaged that this system will enable
commissioning and work outside the strict remit of health in the areas of the social
determinants of health.
Approach
The Health and Social Care 2012 Act also contains duties to integrate health services…
“Each clinical commissioning group must exercise its functions with a view to securing that
health services are provided in an integrated way where it considers that this would (a) [improve quality];
(b) reduce inequalities between persons with respect to their ability to access those
services; or
(c) reduce inequalities between persons with respect to the outcomes achieved for them by
the provision of those services.”
…duties to integrate health with health-related or social care services…
“Each clinical commissioning group must exercise its functions with a view to securing that
the provision of health services is integrated with the provision of health-related services or
social care services where it considers that this would (a) [improve quality];
(b) reduce inequalities between persons with respect to their ability to access those services;
or
(c) reduce inequalities between persons with respect to the outcomes achieved for them by
the provision of those services.”
“Health related services” are broadly defined and can include services related to the wider
determinants of health such as housing, fuel poverty, debt, education, employment etc.
The practical effect should be that services are integrated around the needs of the
individual.
… and duties around planning, reporting and assessment
Planning
The Act requires the NHSCB and CCGs to include, in their business plan and commissioning plans
respectively, an explanation of how each proposes to discharge their duties as to reducing inequalities.
Reporting
The SofS, NHSCB and CCGs are required to include, in their respective annual reports, an assessment of how
effectively they have discharged their duties as to reducing inequalities.
Assessment
The SofS, having considered the NHSCB’s annual report, is required to make an assessment of how well the
Board has discharged its duty as to reducing inequalities.The NHSCB is required to undertake a similar
annual assessment of how well CCGs have discharged their duty as to reducing inequalities
•
The Health and Social Care Act 2012 contains the first ever specific legal duties on health inequalities.
•
NHSCB and CCGs have duties to have regard to the need to reduce inequalities in access to health
services and the outcomes achieved for patients.
•
Secretary of State has a duty to have regard to the need to reduce inequalities covering his NHS and public
health functions for the whole population.
•
NHSCB, CCGs and Monitor have further duties around integration of health services, health-related
services or social care services where they consider this would reduce inequalities.
•
The Act also contains duties around health inequalities on, variously, SofS, NHSCB and CCGs concerning
planning, reporting and assessment.
Approach
Prevention
and
Regulation
E.g. Smoking
ban in public
places.
Employment
and Work
E.g. Address
stress at work.
Delivery
system
E.g. BLT
Strategy
Education and
Skill
Development
E.g. Reduce
the number of
NEETs.
Early Years
E.g. Increase
children and
family services.
Approach
Delivery
system
E.g.
Swansea
and
Wrexham
Delivery
system
E.g.
Birmingham
Brighter
Futures
E.g. Free
NRT
E.g. 5-a-day
campaign
E.g. Stop
smoking
programmes
Standard of
Living
E.g. Tackling
debt problems.
E.g. Advertising
campaigns
E.g. Weight
management
programmes
Delivery
system
E.g. Feeling
good about
where you
live
Communities
and Places
E.g. Reducing
environmental
inequalities.
E.g. School
educational
programmes
Equity
E.g. Reducing
population
groups’
differences in
PPHCs
Process for developing interventions
• Describe health inequalities from the JSNA the socio economic
gradient – inequalities in the distribution of alcohol misuse,
obesity and smoking.
• Identify and analyse key social determinants affecting
inequalities and health outcomes: the causes of the causes.
• Assess evidence and propose actions and interventions:
evidence, feasibility, synergy, cost efficacy.
• Set metrics, targets and responsibility: timescales and indicators.
Approach
Social Determinants Approach to PPHCs
PPHC
Alcohol Misuse
Obesity
Smoking
E.g. Universal free school meals.
E.g. improved access to early years
education.
SDH
Early Years
Education and
Skill Development
E.g. Reducing the number of NEETs.
Employment and
Work
E.g. Managing stress at work.
Communities and
Places
E.g. Reducing environmental
inequalities.
Standard of living
Prevention and
Regulation
Equality and
Health equity
Matrix 1
E.g. Reducing crime and fear of crime.
E.g. Develop pathways to work.
E.g. Planning walkable neighbourhoods.
E.g. Increase exposure to green space.
E.g. Minimum income for healthy diet.
E.g. Tackle debt issues.
E.g. Reducing salt and fat content in
processed foods.
E.g. Fire fighters in the community.
Birmingham Brighter Futures
Percentage of 5-year-olds achieving a good development
score increased from 40% in 2007 to 55% in 2010.
• Strategic focus (strategy has been prepared by a multi-disciplinary
leadership team of 35 people, supported by over 200 practitioners from
across the city’s children's organisations).
• Identifying target groups and needs (in-depth analysis of need to
secure the services people really need; a robust outcomes and planningdriven approach to improvement).
• Partnership working and information sharing (Local Authority, Careers
Wales, JobCentre Plus, head teachers, teachers, Learning Coaches,
Youth Workers, and Education Welfare Officers).
• Provision & support (radical changes to the way they organise,
commission and deliver services, especially in how people from
different organisations work together at the front-line).
Early Years
Percentage
Percentage of 5-year-olds achieving good
development score* in Birmingham Local Authority,
the West Midlands region and England.
* in personal, social and emotional development and communication, language and literacy. Source: Department of Education.
Early Years
• Educational attainment is a
predictor of health outcomes.
• Higher educational attainment is
associated with healthier
behaviour.
• There is a gradient in limiting
illness by level of educational
attainment.
• There is a gradient in mortality by
educational attainment.
Education and Skills
Swansea and Wrexham NEETs
NEETs reduced by 68% over 5 years, in Swansea from 12.2% in
2004 to 4.2% in 2010 – well below the Welsh average.
• Strategic focus (priority at strategic level; clear targets set; resources
shifted; work intensified; earlier intervention)
• Identifying target groups within the population of young people
(Careers Wales advisers and school staff working together to identify
pupils in Year 11 at risk of becoming NEETs)
• Partnership working and information sharing (Local Authority, Careers
Wales, JobCentre Plus, head teachers, teachers, Learning Coaches, Youth
Workers, and Education Welfare Officers)
• Provision & support (change in core service provision, greater emphasis
on summer months, skills building provision, flexible start dates for
training, work placement through project partners)
• People (enthusiastic and committed staff)
Employment
Proportion of Year 11 school leavers known to
be NEET in 2004 - 2010
Employment
Young people offending in Swansea
Employment
• EWDs are almost three times higher in the coldest
quarter of housing than in the warmest quarter (21.5%
of all EWDs are attributable to the coldest quarter of
housing, because of it being colder than other housing).
• Children living in cold homes are more than twice as
likely to suffer from a variety of respiratory problems
than children living in warm homes.
• Mental health is negatively affected by fuel poverty and
cold housing for any age group.
• More than 1 in 4 adolescents living in cold housing are at
risk of multiple mental health problems compared to 1
in 20 adolescents who have always lived in warm
housing.
• Cold housing increases the level of minor illnesses such
as colds and flu and exacerbates existing conditions such
as arthritis and rheumatism.
Communities and Places
Feeling good about where you live
• Run by Greenwich Council and NHS Greenwich.
• Aims to understand the causality between built environment, social networks and
mental well-being through providing a number of interventions in the
environment.
• 3-years study which include a case control group.
• Based on postal survey to 1,600 households in 9 areas in Greenwich; response
rate 38% (n=608).
• Focused on two estates - Baseline survey has been completed on two estates 810 responses (from 1500 households); the ‘control’ estate will receive
improvements at the end of the project.
• Delivery partnerships with NHS Greenwich, Metropolitan Police, Greenwich
Council, local schools established.
Communities and Places
• The is a gradient in environmental
disadvantage.
• Strong link between environmental factors
and health (e.g. Pollution).
• Strong evidence that access to good quality
green spaces improves mental health.
Income group 4 is most deprived
Communities and Places
• Traffic accidents concentrated at the
bottom of the gradient.
Alcohol
Communities
and Places
E.g. Increase
exposure to
green space.
Employment
and Work
E.g. Address
stress at work.
Standard of
Living
E.g. Tackling
debt problems.
Delivery
system
E.g. BLT
Strategy
E.g. Advertising
campaigns
Education and
Skill
Development
E.g. Reduce
the number of
NEETs.
Early Years
E.g. Increase
children and
family services.
Alcohol
Delivery
system
E.g.
Swansea
and
Wrexham
Delivery
system
E.g.
Birmingham
Brighter
Futures
E.g. Expand
access to
alcohol
services.
E.g. units and
calories
labelling
E.g. School
educational
programmes
Prevention
E.g. Fire
fighters in the
community
Equity
E.g. Reducing
ethnic
difference in
alcohol
consumption
Social Determinants Approach to Alcohol Misuse
Areas of action
General Influential Factors
Mental well-being – control and confidence
Early Years
Education and
Skill Development
Employment and
Work
E.g. Address stress at work.
Communities and
Places
E.g. Increase exposure to green space.
Standard of living
Prevention and
Regulation
Equality and
Health equity
Alcohol
E.g. Reducing ethnic difference in alcohol
consumption
Obesity
Prevention and
Regulation
E.g. Reducing
salt and fat
content in
processed foods
Employment
and Work
E.g. Address
stress at work.
Delivery
system
E.g. BLT
Strategy
E.g. School
educational
programmes
Education and
Skill
Development
E.g. Reduce
the number of
NEETs.
Early Years
E.g. Increase
children and
family services.
Obesity
Delivery
system
E.g.
Swansea
and
Wrexham
Delivery
system
E.g.
Birmingham
Brighter
Futures
E.g. Weight
management
programmes
E.g. 5-a-day
campaign
Communities
and Places
E.g. Planning for
walkable
neighbourhoods
Delivery
system
E.g.
Gloucesters
hire Active
Planning
Toolkit
Delivery
system
E.g.
Islington
Pilot
Delivery
system
E.g. Luton
Nourishing
Neighbourh
oods
objective
Standard of
Living
E.g. Universal
free school
meals
Equity
E.g. Reducing
ethnic
difference in
obesity levels
Social Determinants Approach to Obesity
Areas of action
General Influential Factors
Early Years
E.g. Universal Free School Meals.
Mental well-being – control and confidence
Education and
Skill Development
E.g. Address stress at work.
Employment and
Work
Communities and
Places
E.g. Planning Walkable Neighbourhoods.
Standard of living
E.g. Improving energy efficiency of homes.
Prevention and
Regulation
Equality and
Health equity
Obesity
E.g. Reducing crime and fear of crime.
Smoking
Communities
and Places
E.g. Reducing
crime and
fear of crime.
Employment
and Work
E.g. Address
stress at work.
Standard of
Living
E.g. Tackling
debt issues.
Delivery
system
E.g. BBBC
Welfare and
Benefits
Advice
Delivery
system
E.g. BLT
Strategy
E.g. Advertising
campaigns
Education and
Skill
Development
E.g. Reduce
the number of
NEETs.
Early Years
E.g. Increase
children and
family services.
Smoking
Delivery
system
E.g.
Swansea
and
Wrexham
Delivery
system
E.g.
Birmingham
Brighter
Futures
E.g. Free NRT
E.g. Stop
smoking
programmes
E.g. School
educational
programmes
Prevention
E.g. Fire
fighters in the
community
Equity
E.g. Reducing
ethnic
difference in
smoking
Social Determinants Approach to Smoking
Areas of action
General Influential Factors
Mental well-being – control and confidence
Early Years
Education and
Skill Development
Employment and
Work
E.g. Reducing crime and fear of crime.
Communities and
Places
Standard of living
E.g. Reducing fuel bills
Prevention and
Regulation
Equality and
Health equity
Smoking
E.g. Reducing ethnic difference in smoking
Principles for
Selection and
Prioritisation
Address the area’s needs:
Intervention likely to impact on the greatest needs of the population as identified in the JSNA, regardless of what sphere the
intervention takes place in and allowing for the fact that the timescale needed for an impact on health outcomes might be long
Is universal and addresses the social gradient in health
Intervention likely to impact on the whole population, but provides more intense support to those in greater need, with less
socio-economic resources, or living in areas of greater economic or environmental deprivation
Is aligned with other local and national policies
Intervention does not interfere with other policy objectives, e.g. sustainability, and is likely to have positive impact on other
social outcomes and performance indicators
Is backed-up by evidence of efficacy
Intervention considered because there is strong evidence base that it is likely to have an impact on the SDH and on health
inequalities
Is cost-beneficial
Intervention likely to positively impact on long term costs to health and social services, and to provide significant social gains
for its cost
Takes advantage of existing assets and resources
Intervention makes efficient use of existing service infrastructure and enhances the availability and quality of community
resources
Provides the population with control over their lives
Interventions devised on the basis of clear community priorities as stated by consulted stakeholders and users; intervention
engages the public in decision-making and delivery
Falls within one of the following unifying themes:
•The importance of improving the physical, social and economic environment of deprived areas.
Early intervention and the long term public health benefits of intervening early in the life course particularly for
prevention.
Looking at the close interplay between physical and mental health when designing strategies to reduce health
inequalities.
The use of fiscal and financial policy instruments to enable deprived populations to live healthier lives.