Two senior executives discuss putting healthcare at the centre of local policy.
Addressing health inequalities is the polar opposite of tinkering at the margins. It is a strategic priority for primary care trusts and strategic health authorities, as Nick Hicks, chief executive of Milton Keynes PCT and Ruth Hussey, regional director of public health and SHA medical director at NHS North West explain.
Regional director of public health, NHS North West
In her Manchester office, Ms Hussey says that from the creation of the SHA, the North West team "were clear we wanted to see improvements in health as well as in healthcare. Health inequalities underpin this, making them important to address. Many organisations in our health economy emphasised the importance of health inequalities".
North West published Our Life in the NW, a public health report dedicated to health inequalities, making recommendations aimed at regional organisations, offering context for local delivery of health initiatives.
Targets for men
Hussey adds that North West "picked up on the space for a regional vision statement in the Darzi review: in our case, the ambition to reduce the gap in life expectancy. The vast majority of people working in our health economy recognise the need for focus, context and direction setting."
Ms Hussey has also been encouraged by the use of the range of tools available to support delivery: the health inequalities intervention tool by the public health observatories, the national support teams and, for local government, the Improvement and Development Agency to help teams look at what they're doing, and what they can do differently to move forward.
Ms Hussey adds: "If you look at the key drivers of health inequalities (coronary heart disease, chronic respiratory disease, etc), it's so often the ones you'd most expect. In the North West, we've seen substantial improvement on cardiovascular mortality and good progress in the right direction to hit our 2010 targets for men.
Legacy of tobacco
"For women, it's not quite so good. There is a legacy of later take-up of tobacco among women and the consequent knock-on is what we're seeing now as we focus on cardiovascular disease and cancer. It's a big lesson to understand what is happening and looking at local data, to focus on the right things."
North West has launched what it has called The Big Drink Debate. Ms Hussey says: "We know that our region is showing a health pattern from alcohol substantially different from the rest of the country. Knowing about this difference helps us target strategies for delivery that will be relevant locally."
Does she think the region is up to the task of tackling the health inequalities facing the North West? "It's fair to say the public sector here is fully on board with the need to address health inequalities: it's one of the four cross-cutting priorities of the Government Office and is also strong in our local area agreements. Health has also been picked up in Merseyside's health and wealth commission. For the Greater Manchester Commission, the focus is on health and workforce.
"The area in need of more attention is delivery: people in general understand now and broadly know what they need to do; there's enough evidence to get to work. The NHS issue is systematically scaling up and delivering interventions that work to whole populations; not to just a part of the population. It will take time to scale to the level of need we have in this region. Pilots are not useful when there are thousands in need of a service."
Engaging the public
Ms Hussey adds that she and colleagues are mindful of the important role of mental health and well-being in underpinning lifestyle choices. "Our mental health commission will be reporting later this year and I hope this will steer support for more attention to issues around mental health and well-being."
She concludes that "engaging the public is key - in the real sense that we must question both professional and popular involvement in really understanding changes in lifestyle.
"The 'Our Life' coalition in our region is about wanting to create broadly socially healthy environments, and more opportunities for healthy behaviours, so we can promote behaviour change in people - but it's also about community action, supporting debate on issues like alcohol.
"In this region, the work we did around protection from secondhand smoke proved highly effective in traditionally heavy-smoking communities and we want to build on that success".
Chief executive, Milton Keynes primary care trust
Nick Hicks, Milton Keynes PCT's chief executive since January 2008, was appointed joint PCT director of public health and council lead for public health five years ago.
He points out that the PCT has totally separated its commissioning and provision functions, with the former now sitting under the directorate of contracting and planning.
"On the commissioning side, my deputy chief executive is also the director of finance and performance." He notes the importance of having a leadership team with backgrounds in public health: "myself as a director of public health, colleagues from similar backgrounds - it sends a signal that the issue is at the centre of the organisation".
Mr Hicks emphasises that the PCT's strong public health approach is rooted in the culture of their SHA, South Central, which led the way on what is now called world-class commissioning. This is unsurprising, since DH director general of commissioning Mark Britnell was formerly chief executive of South Central.
"Mark was building world class commissioning in his two years running the SHA and the vocabulary has barely changed on the national WCC programme from what was being implemented in that period."
Over those two years, Milton Keynes PCT was transformed from a very challenged health economy in financial turnaround and recovery, with a mediocre Fitness For Purpose review. Mr Hicks says: "We used the world-class commissioning process as a lever. The products were a very clear strategy derived from analysis of the director of public health's annual report, and this year's joint strategic needs assessment is grounded in health issues and population needs.
"From that, we then produced robust operating plans and much more rigorous programme management and delivery to address inequalities. The changes allowed us to continue improving health and health services while getting back into financial balance on a sound footing and keeping an eye on our sense of direction.
"We're continuing to reduce death rates from the major killers. These are stubborn problems, though - life expectancy at birth in the poorest wards of our city is six years less than the whole city average. This has not really changed. Ward-based inequalities are not moving yet. We don't pretend we've cracked it."
Mr Hicks emphasises that his time as public health director across both PCT and council "got me good access to the council and helped form a local strategic partnership. Using health inequalities data, we really put the issues onto the city's agenda".
He identifies two significant achievements to date: "First, the second generation of the local public service agreement is focused on inequalities and social inclusion and second, we agreed a political consensus for action to target on poor estates. This was tricky: some councillors worried what their constituents would or wouldn't get out of the plans.
"Our public health team have tried to identify interventions that matter (like education, over time) and trying to address inequalities in achievement. But this hasn't been done by going to the council education department saying: 'You're a public health worker now and have to do this for health'.
"It's about letting teachers identify themselves as teachers and about us supporting them in what they do well. In fact, the Audit Commission criticised us for not bringing activities together under a health banner. But we're not trying to claim that health is the only societal value. Health is often people's secondary motivation: people will cycle or walk if it's cheaper or easier. We want to try to work with existing structures, rather than bringing things together under a health banner."
Flattened and rebuilt
For Mr Hicks, having a strong public health team at the centre has proved a powerful means of organising the PCT.
"We're now putting more focus on primary and secondary care prevention, and will be putting more focus on the quality of primary care in poorer areas - lots of mortality differences are from CHD, stroke, COPD, where general practice isn't doing enough high-risk preventative work. Medical effort can offer a quick return, whereas social and economic efforts take longer to impact. But you need both at the same time."
Mr Hicks is obviously excited about the work: "These are difficult issues and there are questions for us about how if you support people in poorer areas and they become enabled, they tend to move out and the poor areas get backfilled with people with even more needs. Yet people in those areas don't want the buildings flattened and rebuilt as in London's Docklands. Another challenge is how to do regeneration well". l
The Improvement and Development Agency supports local authorities working alongside PCTs and leads local action on tackling health inequalities through the Healthy Communities programme.
The main strands of this work are:
Healthy Communities peer review, where a team of trained peers from health and local government provide feedback to individual local authorities on their work on health inequalities and health improvement, using tailored benchmarks.
Leadership academies for elected members who lead on health and social care. Core programmes are delivered nationally and tailored programmes are delivered for individual councils and groups of authorities. Programmes also involve PCT non-executive directors.
idea.gov.uk/health is a popular area on the IDeA knowledge website for local authorities, health organisations and others, with an emphasis on health inequalities, health improvement and health and well-being.