Jessica Allen: Narrowing the health and wellbeing gap

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  • Posted:Thursday 12 May 2016

Jessica Allen, Deputy Director, UCL Institute of Health Equity, discusses how local health bodies can use the Social Value Act to reduce health inequalities through action on the social determinants of health.

This presentation was recorded at our event, Maximising the impact of the NHS in tackling health inequalities, on 12 May 2016.


Good morning, I work at the Institute of Health Equity, which is Michael Marmot’s outfit at UCL and we produced the Marmot Review, published in 2010 and since then we’ve been working to really embed the recommendations we hope in practical, useful ways for local areas and for organisations to really have an impact and reduce health inequalities, including as you’ve heard, NHS England and Public Health England. But I’m just going to quickly mention this because this frames a lot of the work that we do and I hope it’s familiar to many of you.  It’s what we call figure one in the Marmot Review, and we’ve updated it, so this is the updated version, to show the most recent data.  So the smudgy lines below is the data from 1999 to 2003 and the harder dots are from 2009 to 2013, the most recent sets of data.  The bottom set of dots, that’s disability through life expectancy and the top set of dots, the grey ones, that’s life expectancy.

So it shows similarly to what Marie was showing, that there’s some very significant inequalities and that they’re persisting. What this graph also very clearly shows is that there’s a gradient, so we’re not just talking about the very bottom having this much worse health, although they do indeed have much worse health and lower life expectancy, we’re talking about all of us really, all of us in this room, suffer from some degree of unnecessary and avoidable health inequality.  We’re likely to live less long than we might biologically and so on and suffer from a degree of life limiting illness earlier than we might if we were right at the very … some of you might be right at the very top and making assumptions.  If you’re at the very top, you’re going to live a much shorter period in ill health, die a lot later and have a greater level of life in good health.  As you see down the bottom, that gap between ill health, disability through life expectancy and life expectancy is wider, so you live far longer in ill health, die earlier.

So these are really, really systematic and persistent health inequalities on a range of measures and we can see that since the earlier period there have been improvements as Anne Marie said, in both life expectancy and the measure of healthy life expectancy, but the inequalities haven’t diminished, in fact they may have got worse if you really start to interrogate the data, but not significantly worse. So that’s where we start, we’re all getting healthier, a little bit, and living longer, but we really, really need to close that gap for all of us across this gradient.  There is the Marmot Review.  I am just putting this up to show that these are the areas of the recommendation, there’s six areas along the right hand side and none of them covered anything about the NHS.  So we talked about the early years, education, training, good employment, having a decent standard of living and a healthy income, healthy places, and we talked about the role and impact of public health and health prevention more broadly.

Of course that’s the social determinants for health approach, which Michael has been advocating for a number of years. We said very clearly, the NHS doesn’t have much of a role in this, it’s certainly not responsible for all those systematic and very persistent and deep health inequalities that I’ve just shown you.  However, we have now begun work with the NHS and I think as has been discussed by Ruth and colleagues, there’s a huge opportunity here for the NHS to do far more, and the focus that we take is on looking at what the NHS can do to influence those social determinants of health.  So we know there’s a big workforce, we know that the health professionals and the health workforce generally have a lot of contact with people, they’re in places, they’re in communities, they can argue and advocate and I’ll come on to some of these issues.  I will come on to social value but I’m going to talk about some of the other work we’ve been doing with the NHS as well.

So we’ve been looking at the potential role of the health workforce in influencing social determinants of health. We’ve done some around healthcare organisations, but other places including the King’s Fund, have done quite a lot on that and we’ve been looking at NHS spending as Dave has mentioned, the Social Value Act and spending on prevention and I’ll come onto that towards the end.  We got into this really because Michael was appointed President of the British Medical Association which was quite a surprise considering he never talks about healthcare or medics, but he was appointed it and he said right I’m going to try and change things and we’re going to think about health inequalities and social determinants of health.  So we produced some work in collaboration with 19 royal colleges and the BMA, to think about what health professionals can do in their day to day practise, with their organisation, in their communities and at a national level, to start reducing health inequalities and influencing social determinants.  That work by the way is still ongoing.

Michael’s then surprisingly again, made President of the World Medical Association which he is this year, so we’ve been trying to do this on a global scale. He doesn’t lack ambition, Michael.  So we’ve been talking about the role of doctors across the world and really there’s an awful lot to be learnt coming from lower middle income countries where doctors … I’m talking about doctors here because we’re talking about the medical association, doctors are far more aware I think than many in England about the role of poverty in people’s lives and what impact that has on health because it’s so apparent.  We’ve all got a bit rarefied here.  We teach on a medical course, undergraduate and postgraduate, at UCL and we are the only time that they’re exposed to this kind of work in evidence around the impact of social and economic conditions and they’re only really doing it because we jumped up and down and said we must.

So it’s not in the medical courses, it’s not in medical practise, it’s not really in healthcare organisations, but as we’ve begun to see there’s work going on that has opportunity. We’ve mentioned the five year forward view, very helpful, focusing more on prevention and there’s a lot of frameworks and strategies around reducing inequalities as we’ve said and how to shift the NHS to be more focused on health and prevention.  So we’ve been commissioned by NHS England to really try and embed some practical approaches in vanguard, so we’re working with three vanguards and I’ll come on to that.  What we’re doing is some population needs analysis, so we’ve got data thanks to Richard Cookson about the outcomes at small area level in relation to the utilisation of the NHS, avoidable hospitalisation stuff, which has been really important, because it helps the NHS to focus on the differences related to deprivation and to see that the burden of healthcare use falls differently and that’s related to deprivation.

In relation to the population needs analysis, we’ve looked at a whole range of indicators and basically what we’re trying to do is show that those small areas within a CCG patch have poor outcomes in relation to housing, normal deprived areas have worse outcomes in relation to housing, education, early years measures, a whole range of different outcomes. You also have worse health outcomes and they have worse outcomes on this NHS data and that Richard and a colleague have produced.  So that’s really helpful we think for getting NHS commissioners and those planning services to really focus on what’s driving healthcare use and demand.  So we come on to how that can influence NHS commissioning and contractings, and we talk about social value approaches which I’ll come back to in a minute.

We’re also looking at weighted capitation and weighted payment models because payment by results we know, rewards at levels of activity rather than results in outcomes. It certainly doesn’t reward prevention, it does the opposite and incentivises activity and it also takes an average cost and we know that some people have higher needs because of their circumstances and where they’re living and so on, so how about weighting some of those payment models.  I’ll just briefly … an example, smoking cessation services, everybody knows working in the smoking cessation services, it’s far higher for people further down the social class gradient to make those changes and to give up smoking for all the reasons around living in difficult circumstances and poor housing and so on, it’s much more difficult to make difficult health behaviour changes than it is at the top.  But the payment, the reward for smoking cessation services to get people to quit is the same across that whole social class gradient, so they’re just looking at an average cost.  So of course the incentive is to get people up here to change.

But what we really need is to incentivise further action and greater intensity of action further down the social class gradient so we can weight the payment. We’re also looking similarly at incentives like weighting QUAFFS potentially, incentivising prevention through the equality outcomes framework and sequins.  Then finally, with the vanguards we’re looking at interventions, how the NHS can commission or support or collaborate with other services around interventions to drive improvements, housing.  The King’s Fund has done quite a lot of work in this area, housing, education, so really incentivising the NHS to work much more closely, because with the best will in the world, when we talk about integration in the NHS, at the moment, due to all the pressures, it’s mainly social care and healthcare which is great, but it’s not going right out into those drivers of ill health at the moment I think.  In some areas it is, so we do have some best practice examples.

So we’ve been working with the Isle of Wight, West Cheshire and Tower Hamlets, and they’ve got very different populations, this was the point of working in three very different areas and in all of those areas we’ve been doing as I said, looking at population health, using a range of indicators which are unfamiliar to the NHS I think and social determinants of health data sources, the NHS equity indicators, NHS outcome indicators of course that’s more familiar. So really mapping these all on in a kind of geographical sense into the small areas so you can see how those outcomes map onto each other.  As I’ve mentioned, we’ve thought about weighted capitation budgets, weighted incentives and social value commissioning.  So the Social Value Act 2012 and Ruth’s talked about the health inequalities duties also in 2012, so I won’t talk about them, but they are beginning to have an impact and the CCGs will be forced to be accountable for what they’re doing to reduce inequalities in health, so that is great.

As Anne-Marie said, we’ve published how the Social Value Act can be used to reduce health inequalities through action on the social determinants of health. So the Social Value Act says that public sector commissioners have to consider how to improve the economic, environmental and social wellbeing of their local area through their procurement.  So not just the lowest cost, not just what the service is actually going to deliver, but the economic, environmental and social wellbeing of the local area.  It’s a really quite radical way to approach commissioning, particularly for the NHS I think.  It applies to all public sector commissioners, local authorities, Acute Trusts, CCGs, other NHS organisations, three’s a list there, local authorities and so on, and government departments, national government departments who have really been the slowest adopters, if at all, of this legislation.

So there is in place a very strong new lever for reducing health inequalities and I’ll give you an example of where it’s been taken up. I’ll give you a few, but this one really struck me, about Blackburn and Darwin and the public health director there looked at his budget and how it was spent and where it was spent.  So not on services, but all the ancillary things where the money was going, so you know, sharpeners and stationery, I don’t know, computers.  Most of it was flowing straight out of Blackburn and Darwin and down to the south because that was where the lowest costs were because of the distributions etc., etc.  He thought, this is ridiculous, I’m in one of the most deprived areas in England, I have this resource which I can spend locally, improve employment, improve the conditions of people’s lives and reduce health inequalities.  So he brought all the spend back to Blackburn and Darwin.

So it wasn’t a lowest cost decision, it was based on social economic considerations. So that was a very good way … a very good example of applying it.  The Liverpool CCG, they’ve really gone far with this, embedding it in all their business case processes and we’ve got plenty more examples.  This is in Halton, who’ve also gone very far with it, they’re doing fantastic things out there around the Social Value Act and really pushing forward on this they’ve embedded it in all their procurement because the procurement and commissioning teams are trained to look at lowest cost.  It’s quite a challenge and a massive cultural shift and a technical shift actually to embed social value weighting into contracts to get those providers to respond.  So there’s lots of challenges, but there were some really good examples of where it’s happening.

There’s national support for this, there’s Social Enterprise UK are trying to support providers, the community and voluntary sector providers, to really build in social value provisions into their bids and for commissioners and procurement to build it into their contracts. It makes good economic sense.  Measuring and monitoring is another barrier because it’s quite difficult to show impact and everybody has to be able to show impact.  But there are ways of measuring impact which is helpful, which has been embedded in some of these contracts and they can show returns and satisfy the requirement to show value to the leadership.  So, social value.  If we think about the NHS budget, I think it’s about £130 billion a year, and Dave’s written very well about this.

How is it spent? It that having any impact on health apart from in the treatment of health?  Is it having any impact on health prevention and on health inequalities?  We don’t know.  That is a massive opportunity to really consider how that can be spent more effectively to begin to improve health and reduce health inequalities in the areas and from those people who need it most.  If you think about all of public procurement, so £230 billion spent on public procurement.  So it’s a real lever that’s in the system, it’s in place, it’s a legal obligation, we have to do it and I think it’s really a very good time now to really begin to embed social value approaches into all public sector procurement and actually by the way, some private providers are responding very quickly to this because they can see a big commercial advantage, so we need the public sector community and voluntary sector to get on board with this as well.  Thank you.


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