Three leaders who are tackling inequalities in deprived areas explain why their initiatives are working
Director of public health, Sheffield primary care trust and Sheffield city council
Jeremy Wright's area is not a "spearhead" although, as he points out, parts of Sheffield are just as deprived as many spearhead areas. He says: "Our city is balanced with more privileged areas, so our overall level of disadvantage looks average, but we do have very wide health and social inequalities across the city."
Sheffield's starting point was from a strong history of joint working between health and the local authority and long-term recognition of startling inequalities going back 20 years. Mr Wright feels the city's latest successes in coronary heart disease started in the late 1990s in the days of the old Sheffield health authority's big emphasis on life expectancy and CHD mortality differences between the city's wards. Health action zones were set up aimed at improving identification and management of those at risk of CHD in deprived parts.
He says: "Using our own local health data, based on death certification data and identified GP practices with high patient-CHD burdens which were not accessing secondary care, cardiology and medication, we employed specialist nurses to help practices identify at-risk patients and put them on appropriate medication.
"As a consequence, we saw substantially faster decline in CHD mortality in deprived areas than in the rest of the city; about a 50 per cent fall in CHD mortality in the worst-off quintile, as opposed to 30 per cent decline in the best-off. CHD is our biggest killer, so this impacted on overall mortality and life expectancy and narrowed the gap between lowest and average quintiles much faster than elsewhere, mainly thanks to the Citywide Initiative to Reduce Cardiovascular Disease which Chris Bentley was instrumental in setting up when he was director of public health here."
Mr Wright says initiative joint working was central and involved shared information sources and analysis between the health authority and subsequently the PCT and city council. "Sheffield has a long history of closer co-operation in this regard, which was a vital building block, as was the city's strong history of joint commissioning and planning." He says the next stage lies in "our advanced public health programmes, targeted at the worst-off third of the city. It's very partnership based, working with the local authority, voluntary sector and the local community developing public health programmes to address root causes of ill-health, access to services and community development and capacity".
The big lesson from Sheffield, adds Mr Wright, "is to scale intervention to the right level. There is a long track record in public health of neat little pilot projects funded on 'short-term money' and the odd non-recurring grant here and there - some of these can be very exciting and effective but they're not at the right scale to make a difference".
He says the city-wide initiative worked because of its "industrial scale". Nurses were sent to the relevant GP practices and they helped get prescribed statins to people who would not have got them otherwise. "It was not cheap - statins cost a lot back then, but without that scale, we would have lacked impact at population level."
Chief executive, Tower Hamlets PCT
Tower Hamlets has one of the highest deprivation ratings in London, yet has made strong progress on health inequalities. Chief executive Alwen Williams thinks this is due to "a number of key issues and characteristics that assist success, not to any single solution". She first points to prioritisation: "Tower Hamlets PCT has taken health inequalities very seriously for years; in a sense, it's our top priority and it's a chief executive responsibility - not something to be delegated to the public health director. You have to make it important and let the organisation know it really matters."
Partnership is also crucial. "In our 2006 joint health and well-being strategy with the local authority, we set our sights on health improvements and addressing inequalities. Key to that was ensuring high-quality primary and community care - with a focus on staying healthy, screening, support to stop smoking. So our services have been increasingly geared to improving health as well as serving the ill.
"The key for me was in developing our local strategic partnership work across local stakeholders and lots of engagement with local communities. We used our local area agreement to underpin delivery of strategy. Doing this well is not just about having a good strategy; it's about very clear performance and outcome objectives that we relentlessly pursued to ensure delivery."
She stresses that increasingly this work needs joint direction across the PCT and the council, supported by joint appointments. "In our area, this led to a joint tobacco control team on cessation, which fed into broader tobacco control and stop-smoking legislation."
Ms Williams also emphasises their "real critical focus on quality of and access to primary care services, which helps us ensure that we're delivering on diabetes management or blood pressure control. Good medical management is critical to people staying healthy and increasing life expectancy".
The PCT is also working inventively with local communities on access, taking services to communities where they know of various barriers. She cites the example of dentistry: "We've known for a long time that uptake in dental services is poor and so there are poor oral health outcomes and high levels of decay, yet we also know we have enough NHS dentists.
"Our community dental service worked [with] local communities to understand barriers to access - some financial, some cultural, some plain fear of going to the dentist. This led to our establishment of a mobile dental service. Four vans go to housing estates and supermarket car parks: a designed solution created with local people. These are staffed by regular general dental practitioners. As people come into the van, the plan is to treat them but at the same time encourage them to go and register." So it encourages access and then puts the patients in touch with local practice.
Ms Williams concludes that genuine localism is the strength: "We talk about being 'up close and personal' to our local community and do a lot with ethnic media (Channel F, Bangla TV). We also work with faith groups and community organisations, finding ways to contact local communities and using new techniques like social marketing to help inform what we need to do. It's about working with local communities to deliver behaviour change. Reports on smoking, child obesity and so on, help us design and provide appropriate services in ways that are proving to be much more effective."
Director, Manchester Joint Health Unit
The Manchester Joint Health Unit, which David Regan leads, was established in 2002 "mainly because in Manchester, it was clear that health inequalities were going the wrong way. The life expectancy gap between the better off and the worse off was widening". Mr Regan emphasises that the project was "not just about the NHS alone, it had to be joint working between the city council and [what were then] the three PCTs". The PCTs merged in 2006.
The unit was given funding over three years. Mr Regan emphasises that although positive results of its work are now showing, "there's no overnight fix. These things take time. It's about the council working collaboratively with the NHS over the medium term to deliver progress".
In December 2007, the 70 spearhead areas were rated on their progress. The report rated Manchester "green - on track" for the national life-expectancy-increasing target for men but Mr Regan points out that although Manchester was rated "amber" for women, "with sufficient effort, we could hit that by 2010. At the start of the decade the gap was predicted to continue to widen, so for us to steady the ship is very positive. But Manchester still has the lowest life expectancy in the country for men and fourth lowest for women."
The next stage, he says, is about "concentrating on public health high-impact changes: long-term wider determinants of health, such as employment and housing. In the short term, we can do better managing cardiovascular disease and seeking early diagnosis of cancer, so we're upping investment in programmes to find people with heart disease risks, get them into services and provide lifestyle advice - and statins".
"In this area," he says, "cancer can be a great taboo because of fatalism and fear. Our push is saying, 'if you have symptoms or even just concerns, go to your GP'. In this area, early diagnosis should save 35 men and 59 women from premature death each year."
In what looks like an economic downturn, is Mr Regan concerned about the effects on social determinants of health inequalities?
He says: "We work with colleagues in the city's economic development unit. Employment for health has created 45,000 jobs in the last six years and the overall local economy has grown. But we know those jobs are not all for residents, because of the skills gap in local residents unable to access jobs.
"The economy may slow, but we see new jobs in health and social care, having done our workforce plans. The problem is to skill people up for work. There are 38,000 people on incapacity benefit in Manchester alone. We know that good-quality work remains the best route out of health inequalities."
Mr Regan's concluding thought is that "you've got to commit resources to this. Leaders in the city council and NHS pooled resources to invest in early intervention and prevention, enabling us to invest in prevention programmes. It's got to be mainstream investment, not 'short-term money'. Get resources and partners' commitment or you'll struggle to improve".