nf0269: so part two tackling inequalities in health and we're going to look at the national and local policy context are there any questions from the earlier two sessions before we start okay well if you do think of any then ask them to your small group tutors okay so the key question then is which policies and strategies are being employed to tackle health inequalities and how effective are they likely to be and i will say although this is s-, some of looking at some of this policy stuff is quite dry and requires quite a lot of concentration it is something that you can be examined on and that we have ex-, er er asked exam questions on in the past in the overarching IMPSA and qualifying papers so it's worth paying attention to okay so what i'm going to begin with is just er a very brief thumbnail sketch of the health policy framework from nineteen-forty-five this isn't something you will be examined on but it will just provide you with er a thumbnail sketch of health policy er until up to the current date okay so from nineteen-forty-five to about nineteen-seventy-eight er we had er a health policy framework which really didn't concern itself with health inequalities really until the nineteen- seventy it wasn't an issue of political concern partly because in the er immediate post-war period health inequalities were er were at their lowest and there was much more equality in health after the p-, the war years er but inequalities in health er started to increase er with the gap health gap between those who were better off and those who were poorer er starting to increase er until it was really becoming quite wide in the nineteen-seventies and of course it was in the nineteen-seventies that the Black Report was commissioned because of this concern about this er these ineq-, these inequalities in health experience between social groups from nineteen-seventy- nine onwards er we had quite a a long almost twenty years er a long period when there was er a really failure to acknowledge er or in in government policy to acknowledge that health inequalities existed and in fact the term health inequalities wasn't used in any policy documents or any policy speak during this period er and health ineq-, equalities were referred to as health variations we had er in the early nineties the first ever national health strategy for England and there was also a health s-, er strategy put in place at that time for Scotland and Wales as well and er some of you may recall that this first health strategy was called The Health of the Nation and its overarching theme and concern was with er individual health and strategies aimed to encourage individuals to s-, to take responsibility for their own health so there was no action to tackle inequalities since nineteen-seventy- nine we've had a shift in emphasis in er the health policy framework er we've talked about the Acheson Report er the Acheson Report was used to inform er the new health strategy which we currently have in place and this strategy is called Saving Lives Our Healthier Nation Saving Lives Our Healthier Nation represents the government's health strategy and this strategy aims to improve the health of everyone but particularly to improve the health of the worst off so it does acknowledge that er there are groups er who are experience health inequality and this is near-, this is where efforts need to be put to improve the health er of those who are in the the the in the poorest health and this er health strategy seeks to tackle the four main killers and you'll if you refer back to namex's lecture on lifespan he looked at er the incidence er and the patterns for er th-, these four main killers so we currently have a health policy framework which er aims to reduce coronary heart disease accidents mental health and cancer et cetera so it's important to recognize er what Saving Lives Our Healthier Nation aims to do because it does provide direction for health work so it does acknowledge the existence of health inequalities again this as i said this is a substantial change er it accepts the evidence that health is determined by social and economic factors and it states that health inequalities need to be tackled and it sees the way forward as people communities and government working together in partnership if it can be criticized er or certainly when it was published the criticisms were that no funding no specific funding was attached to reducing health inequalities it actually itself as a policy document doesn't address poor living standards or inadequacy of of benefits but having said that these are addressed in er in in other government documents and we'll be looking and these and other government policies we'll be looking at some of the social policies that aim to address issues such as poor living standards and it didn't when it was published identify any national targets er to reduce inequalities but s-, these targets er since have been identified and since February two-thousand-and- one we've had two health inequalities targets to work towards and these are targets relating to infant mortality and life expectancy the first target is to reduce by at least ten per cent by the year two-thousand-and-ten the gap in infant deaths between manual groups and the population as a whole and for life expectancy to reduce by again by at least ten per cent er by two-thousand-and- ten the gap in life expectancy between the fifth of health authorities with the lowest life expectancy at birth and the population as a whole so we now have got some targets to work towards the government works to er s-, reduce health inequalities or sees itself as reduc ing health inequalities by a number of overarching strategies and these three strategies which are White Papers er i'm not sure if the N-H-S plan was a White Paper but these three documents all refer to in some shape or form er the existence of health inequalities and the way in which health inequalities er should be tackled we've talked about er the N-H-S plan er in the first week that we were here but then it delivers these plans if you like through a number of mechanisms through Primary Care Trusts and N-H-S Trusts where you'll all be working er through health improvement and modernization programmes which i'll be talking a little bit about and through national programmes and initiatives and again i'm going to talk about those in a minute but Primary Care Trusts er has anyone not heard of a Primary Care Trust you may do if you er if you do-, if you haven't lived here very long or if you've studied in another country and just come here to do medicine has anybody sf0270: nf0269: Primary hair ca-, Trusts er G-Ps are all part of a Primary hair crust in Ireland what are they do you have health boards sf0270: yeah the health board nf0269: yeah sf0270: nf0269: yeah Primary Care Trusts okay they were they have replaced Primary Care Groups so they are relatively new so if you haven't heard them er i'm n-, i'm not too surprised they're part of the new framework for delivering the new N-H- S so they're key they're key to government's way of delivering health they've evolved from Primary Care Groups so you may still and some Primary Care Groups still exist so you may peop-, hear people talking about Primary Care Groups er but it's hoped that by two-thousand-and-four all groups will have transformed themselves into Primary c-, Care Trusts which are much much bigger on the whole and they're seen as pivotal in terms of improving health and tackling health inequalities and that by two-thousand-and-four pi-, Primary Care Trusts will be res-, responsible for at least seventy-five per cent of the N-H-S budget so er you know they'll huge hu-, they'll hold huge budgets so for example for Coventry there's just one Primary Care Trust now there were three Primary Care Groups and there's and they've reorganized into one Primary Care Trust i think in Warwickshire there are three trusts is that right how many tu-, tutors are nodding yeah there are three trusts which are north south and Rugby is that right yeah okay er and some of you may have had speakers from the trusts has anybody had speakers from the trusts yet su0272: nf0269: yeah yeah good good so Primary Care Trusts are free- standing N-H-S bodies accountable to their strategic health authority and Primary Care Trusts er are responsible for commissioning care for their local population so they're able to commission care from hospital trusts so they will be commissioning er care from secondary care and from other organizations as well so they can can commission flexibly er and innovatively so they can commission aspects of care from er local authorities from voluntary and other statutory agencies and they also provide primary and they can also commission other primary care but they also provide primary care themselves and the primary care boards are made up of all the local stakeholders in that locality so there er there are elected family doctors there are elected nurses community nurses er midwives professions allied to medicine social services for example you might have a so-, some social workers on there and also er representatives of the wider community and it's the b-, the boards that decide the priorities for the trust and ensure that er services are commissioned to meet the needs of the local population the trusts unlike Primary Care Groups they have a much stronger public health role and the public health duties that were once until recently were held by er the health authorities have now been passed on to the Primary Care Trusts so public health is now the r-, the role of the Primary Care Trusts er so they're responsible for example for publishing er the annual public health reports er and for monitoring public health in localities er and they're also responsible trusts are responsible for to er facilitate better access to services and to provide better integrated services so these are the roles that have been allocated by government to Primary Care Trusts so the trusts will be af-, er er affe-, the trusts will determine who comes to you in hospital and a ki-, and the kinds of services that you're required to pr-, er to er provide er and if you're a doctor in a community trust a community based doctor you will you may be er part of the board or you may become part of the board that's if there isn't s-, any substantial er reorganization of the health service by the time you qualify so Primary Care Trusts then have the potential to respond to local health needs because they're er they're responsible for a local geographical area er so the potential is they could be quite responsive they're required to work in partnership one of their strengths are that they're required to work in partnership with other organizations like social services they can commission very flexibly and they can target er prevention and care and work towards equity in access to care but what they can't do is reduce poverty or income inequalities because it requires er wider social policy to do that the second mechanism i identified were HIMPs which is the Health Improvement and Modernization Programme has anyone when they've been out in the community localities had a sp-, a HIMP lec-, speaker yet no it may well be you have have you yeah may well be that some of you will have er someone from the trust coming to talk about the HIMP plan the Health Improvement and moder-, Modernization Programme for your particular locality so as i said earlier they've become the responsibility of the trust and they set out the local strategic plan for improving health and importantly for tackling health inequalities okay so the HIMP will set out er the plan and it will look at er with oth-, other organizations how it can er work to tackle the broader determinants of illness with other local er with other local groups and minimize the impact of hill ill health through providing integrated services so let's turn to look at national programmes rolling out policy well it's clear if we're going to reduce health inequalities that we need to have the kinds of policy in place at national level that er will both improve er cash in kind and improve cash in income because we've seen that those those are the main ways that we're going to reduce health inequalities the government has put in place since nineteen-ninety-seven a number of programmes that aim to improve cash in kind and these are initiatives like which i'm sure you've all heard of even if you don't know what they are things like Health Action Zones Education Action Zones Sure Start and regeneration programmes as well as having er some cash in income programmes again er regeneration programmes Welfare to Work programmes and changes to benefits and pensions er are likely or are aimed to increase cash in income and i'm just going to look at some of these not all of them now so that you have at least some understanding of of what they're about so the first one i'm going to look at is er a cash in kind programme which is Health Action Zones Health Action Zones were launched er and first of all drawn attention to when the N-H- S plan was er launched they're seen by the government as blazing the trail for modernizing the N-H-S and Health Action Zones are an area based approach for improving health and reducing health equali-, health inequalities so it's a local area based approach the key objectives of Health Action Zones are t-, that the zone will identify and address local needs increase the effectiveness and responsiveness of local services and develop partnerships with other agencies and these er these programmes or initiatives are coordinated usually by the National Health Service now the government has made substantial amounts of money available for Health Action Zones er and the latest figures suggest that about two-hundred-and-seventy-four- million pounds have been made available for Health Action Zones and this two- hundred-and-seventy-four-million pounds is going to twenty-six Health Action Zones that have been established and they cover about thirteen-million people and will run for about seven years we haven't got any Health Action Zones in Coventry or Warwickshire er i don't know if any bids were made but people er groups local groups had to put together bids so it would have been local health authorities er bidding with with partners in education social services et cetera er to put a proposal forward for funding twenty-six proposals have been er successful and there's some and and i don't think there's any any more er Health Action Zones going to be funded but Leicester has one is that right but you can see that substantial amounts of money have been put into them er they're currently being evaluated but it's early days the evidence so far suggests that innovative projects have been put into place er but there has been er a flexible and i-, innova-, innovative er commissioning of services and developments of services but there's no evidence yet er on whether they have brought about any health improvements within those local areas although they were seen as blazing the trail for modernizing the N-H-S they seem to have when you er hear government ministers talking about health policy they seem to be less on the agenda than they were er sort of two years ago but if we look at the strengths of Health Action Zones er and the strengths and weaknesses really of any area based approach to tackling health inequalities and because they're they're the same er then the strengths are that they could potentially seek to address locality based needs they can build or could have the potential to build local solutions and there's some evidence that that's being done and that they can strengthen and provide money for existing and new partnerships working together to improve health in local areas and you can see the substantial among amounts of money gone into these projects but the weaknesses if you like are that they can only ever reach a small number of of people whom whose whose health is poor you can see they were only actually covering although it was two- hundred-and-fifty-four-million they were only actually covering thirteen- million people er and they're not necessarily in areas with the greatest needs so we know that there are for example there are areas of Birmingham for example and other areas of the country er which have very very high levels of disadvantage and very very and very very large numbers of people in very poor health that don't have Health Action Zones so they're not necessarily in areas with the greatest need historically there's little or no evidence that area based approaches have ever been effective area based approaches were tried in er i think the sixties and early seventies when er the government put money into community development in health schemes but the evidence from that was that er over time er er they've been shown to not produce any any lasting effects in terms of health improvement in local areas and of course it's difficult to see how they can really impact on the root causes of health inequality such as poverty and poor living standards the second programme i'm going to talk about is Sure Start because er Sure Starts are operating in several of the areas that you're you're you're based in er Nuneaton has got a Sure Start programme and also er Wood Wood End got one yeah er anywhere else anywhere in South Warwickshire no but if you listen to the news read the local newspapers you'll of-, often hear references to Sure Start schemes Sure Start is a programme a government funded programme er which is aimed at impr-, improving children's life chances so it's aimed at families with young children and is a response to the Acheson Report that we need to target parents and young children it's a cross-departmental strategy involving the Department of Health and the Department of Education and it aims to improve children's health to reduce inequalities in children's health to raise educational standards to promote opportunities in local areas and to encourage good parenting the government again has set set aside huge amounts of money for Sure Start programmes er it's set aside f-, er five-hundred-million to deliver it er and i- , it's er it's projected that by the end of two-thousand-and-four there'll be five-hundred Sure Start programmes and it's estimated that these programmes will cover or encompass one- third of all children in poverty all programmes are multiagency er agencies working together such as education social services er together with health services and often er many voluntary organizations within local areas if we're looking at what the strengths of Sure Start might be they're that they're er can be non-stigmatizing because Sure Start programmes aim to deliver the Sure Start programme to universally within an area so all families with children under under five will be er offered the Sure Start programme so it doesn't stigmatize people by only offering it to selected groups and it has been shown that er o-, offering services universally er to young families reduces stigma and therefore ensures better uptake of services to those groups who most need care it's multifaceted inte-, it's different agencies working together again like er h-, er the Health Action Zones er they're locally driven programmes and they're programmes that er are designed to address local needs specifically Sure Start programmes are required to acknowledge er er the the the fact that er different groups have different needs and they're required to deliver culturally appropriate services and that they will increase support to families with young children living in those particular areas the weaknesses of Sure Start are the same as i've i've referred to in relation to er Health Action Zones er because it's an area based approach it's got the same inherent problems although there's a there's now there's going to be about five-hundred programmes they're still only likely to reach a small proportion of of children who are poor there's two-thirds of poor children who are not being er er covered by Sure Start programmes who would benefit from more intensive support in their early lives like HAZs there are no there's no learn-, long term in funding for Sure Start er local er Sure Start programmes have got to if they want to continue er they've got to look at finding alternative funding to carry on the initiative and also they're not tag- , tackling the root cause of prob-, of poverty which are things which are l-, related to er overall social policies in the area of things like er employment wages policies et cetera okay so we've looked at HAZs and Sure Start which are er very much health service er i-, initiatives we also need to look at the w-, the broader policies that the government's put into place it's at it's at this point i wish we'd still got the camera on you because several of you are starting to look sleepy again okay remember you might get an exam question on this [laughter] what time are we only another fifteen minutes okay let's look then at what the government's got in place in terms of regeneration programmes the government is seeking to through er regeneration programmes to regenerate local areas to put more life and money and economic activity into local areas to boost the er you know the er economic climate within areas in the hope that by regenerating very poor areas there will be economic spin-offs for those who are are the poorest we've got things like New Deal for communities er this is a a government programme that targets money to most deprived areas and i think Wood End's got er and Henley in the north of Coventry have got a New Deal programme er so it it targets money on the most deprived areas and has it aims to er to build initiatives within local areas which reduce social exclusion and improve health so it has a very clear health focus and in fact next week when we're in we've got a s-, got a speaker i think haven't we from New Deal er who will be talking about er the New Deal programme in Coventry nf0271: yeah nf0269: namex's c-, namex's looking worried here we have haven't we namex nf0271: nf0269: yes [laugh] yeah we hope to have a New Deal speaker as also we hope to have a Sure Start speaker who will be talking about how sir-, Sure Start is being being implemented again in one of the local areas in Coventry and Warwickshire so regeneration programmes are aiming to tackle the local infrastructure improve en-, employment there's large amounts of money er being invested in them and they're covering er about thirty-nine neighbourhoods that are typically of between one and four-thousand households so these money are these these programmes are trying to tackle some of the root causes of poverty within local areas but again they've got er they are putting money cash into areas and trying to improve employment opportunities et cetera but they have got many of the same problems that i've described in relation to HAZ and to Sure Start in that they're short term funded er er et cetera now you also need to just bear in mind that there are things like Welfare to Work programmes that the government has in place confusingly one of them is also called New New Deal but it's different to New Deal for communities New Deal er is a Welfare to Work programme which is designed to get specific groups of the population er back into employment so it combines training and employer incenti-, incentives er er together with making it very difficult for some groups er together in one programme so it aims er New Deal is particularly aiming at getting lone parents back into employment it's aimed at getting people off welfare back into the work programme so off welfare benefits it's aimed at lone parents young adults er eighteen to twenty- four adults who are twenty-five-plus who are long term unemployed and also looking at trying to get people with disabilities back into work for some groups there where i've said coercion what i mean is there are some groups er if they h-, who if they do not er move into a New Deal programme or move into sort er a training programme then there are er it will affect their benefit so there's little opportunities for some groups to er not to g-, to take part in this scheme one of the problems with these kinds of programmes is they're only going to be effective if there are well paid jobs for people to move into so for example er if if these particular groups lone parents et cetera er are to move into e-, employment then er they need to wo-, to move into employment which has er a healthy wage in terms of a wage that provides them with access to a healthy living style we're not going to reduce in-, er inequalities if health inequalities if the people are just moving from benefits to work er without having an income that provides them access to a healthy lifestyle er and the evidence we have at the moment is that er the New Deal programme isn't move-, necessarily moving people into well paid jobs that people are moving into jobs that have poverty level incomes or minimum wages finally er we need to look at benefits and pensions and the benefits and pensions programme that the government has in place it's important because the majority of the poorest fifth of the population are dependent on welfare benefits so for example ten-million people claim income support in England the evidence that we have is that er welfare benefits particularly income support fall short of the level independent experts er say is needed to be a modern minimum so that would be the modern minimum if you like for er t-, to er support good health in these groups there is evidence that the current government has increased benefits er er for younger children er er and for families and there've been er above inflation increases in things like er er child benefit and other initiatives er have been put in place like the childcare tax credit and the working family tax credits er which aim to provide additional er resources through through income t-, the income tax system to those families who are the poorest and they're particularly aimed at providing er people with additional income that will enable them to be slightly better off in work than they were on welfare benefits and that er these are likely to to narrow some of the discrepancies between social groups but not eradicate them the government has aimed to er lift er about f-, er four-point-five-million children out of poverty in the next ten years or i think it claimed it had lifted four-point-five-million over the last Parliament but the latest figures suggested that they'd only actually er lifted about half a million children out of poverty through their welfare and tax benefits okay if we look at er older adults er 'cause again these are we saw that about twenty-five per cent of er pensioner couples live in poverty so there's high rates of poverty amongst older adults we have seen some increases in benefits to these small to these groups but they're small er and they've resulted in in single pensioner households for example being about eight pounds better off so we haven't seen substantial increases in in welfare benefits and pensions we've seen shifts at the margins so let's sum up then okay we've looked at er the evidence on er how health inequalities can be tackled it suggests it can only really be tackled effectively through national programmes we have got a government that is who has acknowledged that health inequalities exist and that health inequalities need to be tackled and has er indicated that it has er er it sees it as part of its work to tackle them we've got evidence of of some income in cash initiatives and some er cash in kind initiatives er but also the evidence is suggesting that er benefits increases are are insignifi-, insufficient to lift people out of poverty or to significantly improve people's material conditions what we're going to talk about er oops wrong one this afternoon is we're going to talk about we've looked at how the government is setting about tackling health inequalities we're going to look at what it means for you at the level of health care practice both generally and specifically as a doctor that reminder is that er your for-, your first formative assignment's due in on Friday the first if you need any help than see your small gue-, group tutor today or you can just e-mail me if if you don't do that if you are struggling just a minute if you are struggling or you need additional support because of a learning need such as dyslexia then see us early enough it's very difficult particularly when it comes to the summer term if you're only seeing us a few w-, a few days before your assignment's due in so see us early enough so we can provide you with some real support okay you've got about five minutes before we do some small group work