Health Inequalities, Population Health & Proactive Social Prescribing
What are health inequalities?
- Health inequalities, or more accurately, health inequities, are avoidable, unfair and systematic differences in health between different groups of people
- There are many kinds of health inequality, and the term is used in various ways
- When we talk about ‘health inequality’, it is useful to be clear about which measure is unequally distributed, and between which people.
- Health inequalities are widening in London and five London boroughs in top 10% most deprived boroughs in UK.
- With the cost-of-living crisis, health inequalities are likely to get worse.
Examples of health inequalities can be found in this government report.
Ethnic minority communities experience some of the worse health inequalities and they are also under-reached in social prescribing.
There are multiple ways the 3 roles can be used to reduce ethnic health inequalities:
- Care coordinators proactively calling and recalling patients for health checks, annual reviews and screening to reduce inequalities in outcomes from cardiovascular disease, diabetes, cancer and other long-term conditions.
- Specialist social prescribing link workers to support ethnic minority women during pregnancy and in the postnatal period to reduce maternal health inequalities.
- Mental health specialist social prescribing link workers to increase trust, engagement, compliance and reduce inequalities in access, outcomes and experience of mental health services patients.
- Health and wellbeing coaching using culturally and linguistically relevant resources and tools.
- Recruitment of the 3 roles from ethnic minority communities as part of building trust, engagement, and a responsive personalised care workforce.
- NHSE has produced an e-learning module to support culturally responsive social prescribing which can be accessed here.
- Wider factors (the social determinants of health) are critical in shaping the health of patients and populations, even more so than the biomedical factors that healthcare systems, education and training conventionally focus on
- Research shows that the social determinants of health (SDoH) can be more important than health care or lifestyle choices in influencing health
- Numerous studies suggest that SDH account for between 30-55% of health outcomes. However, in areas of deprivation and for patients with mental health disorders and/or multimorbidity, this statistic is likely to be much higher. Some sources determine the contribution as higher, for example up to 80-90%
- Estimates also show that the contribution of sectors outside health to population health outcomes exceeds the contribution from the health sector, which emphasises the importance of multi-agency partnership working and community development.
The 3 personalised care roles form an important part of a PCN’s strategy to address health inequalities, but they must be effectively embedded.
|Five key principles for using the 3 personalised care roles to reduce health inequalities
|1.Address the social determinants of health
|1 in 5 GP appointments focus on wider social needs with a higher proportion in more deprived practices that are also most likely to be under-doctored.
The personalised care roles link patients with these wider social determinants of health e.g.
|2. Build community intelligence
|Personalised care roles can take the time required to understand the local population, their needs and priorities in order to shape and provide care that is relevant, responsive, appropriate and acceptable.
|3. Work with specific groups who are experiencing inequality in access, experience or outcomes
|Overcome barriers and close unacceptable gaps that exist in health and care through proactive outreach and trust and relationship building with under-served patient groups.
|4. Facilitate joined up working
|Connect with community assets and resources, strengthen community development and facilitate joined-up working and whole system approaches to tackle health inequalities holistically, collaboratively and sustainably.
|5.Personalised care is an intrinsic tool for PCNs in community recovery
|There is a significant ARRS underspend in London and funding and support is available to grow these teams
Key ingredients to optimise the working environment to ensure the three roles work well with practice and PCN teams
- The roles need to feel a sense of belonging in the team.
Include them in MDT meetings and any practice and PCN wide meetings.
- Set up practice and PCN wide meetings for the personalised care ARRS roles, so they can discuss how best to work together and share best practice.
- Deliver regular training, communications, and meetings where current and new staff are educated on what the roles do, how to refer to them, what they do and not do and how they can be reached.
- Ensure the roles have access to GP IT systems and have clinic templates set up. All three roles are patient facing and should have ringfenced slots to book patients in and clinic space.
- Allocate a GP or clinical supervisor for the roles, who can provide regular ringfenced supervision and ad hoc support as well as direction regarding working with different patient cohorts.
- Give the roles time each week to spend on understanding the wider practice workings, training, connecting at an ICS and regional level, and connecting with the community, patient groups and adjacent services e.g. care homes.
- The Health Inequalities DES supplement outlines the role of PCNs in reducing health inequalities and the responsibility of a HI lead.
Top Tips for PCN Health Inequality Focus
- Get support from other organisations
- Name a lead & attract fellows
- Understand your PCN’s HI needs
- Work with your community FEEDBACK
- Make it the core of your PCN targets
- Use the resource you have and advocate for more.
From population health webinar- Aaminah Verity, Health Inequalities Lead at NLPCN.
PCN Health Inequalities Lead
- One of the requirements in the TNHI DES contract is for PCNs to appoint a Health Inequalities (HI) lead to work on priority areas including:
– Learning Disabilities (LD) register health checks
– Serious Mental Illness (SMI) physical check
– Ethnicity recording
– Identification of populations experiencing HI by PCNs.
- A named HI lead in each PCN can work with the personalised care roles to map and address local unmet needs and coordinate HI activities
- The HI lead does not have to be the PCN CD, it can be any suitable clinical or non-clinical person
- ICSs are expected to create a peer network of HI leads, provide analytics for PHM, support co-production.
Some challenges with embedding a PCN HI lead
- Many PCNs in London have not yet appointed an HI lead with a formal role and/or strategy
- We have heard PCN leaders and current HI leads reporting challenges with:
– Understanding the nature and purpose of the roles- creating job descriptions and job plans have helped with this.
– Adequately funding and resourcing these roles- a checklist and case study below may be used for ideas.
– HI leads not feeling supported- some HI leads are exploring ways of setting up a support network.
Checklist for embedding and working with a PCN health inequalities lead
- Support and commitment from PCN leadership- this is essential
- Ensure there is a named health inequalities lead who is a visible point of contact for health inequalities issues in the PCN
- Remember, an HI lead can be any suitable clinician and does not have to be a GP
- Ensure the role is funded with protected time and a clear job description and with opportunities and investment in training on health inequalities
- Use personalised care roles creatively to bridge the gap between primary care and the community and partner anchor systems to effectively address SDoH e.g. allocating time for community development and outreach work to build links and support referrals
- Adequate time to plan strategy, work with and supervise ARRS roles where needed
- Utilise asset-based approaches – with support from ARRS roles who have good local knowledge:
- Map local assets and resources
- Community engagement: join or form a stakeholder group or community forum with representation from local community groups, leaders and across agencies
- Co-produce solutions to address local health inequalities
- Outreach work: identify and reach out to underserved patient groups and communities.
- Data-driven approach; develop knowledge, data and dashboards to identify patient cohorts experiencing HI and progress national targets (e.g. ethnicity recording). See section on population health and proactive social prescribing for further information
- Support funding for local community initiatives; without investment in community development the impact of the work of a HI lead is limited. Looking for co-commissioning models such as with local authority, community grants and PCN development fund
- Training opportunities and peer support for HI leads coordinated by ICSs
- Advocacy to raise awareness of health exclusion and inequalities and approaches for tackling them.
HI lead working with the 3 PC ARRS roles
Dr C is a GP and HI lead for her PCN. She spends 2 sessions a week working and delivering on her PCN strategy to address health inequalities. As part of this, she meets with her ARRS roles for 1 hour a week. A key area of health inequality identified by her PCN is low uptake of health checks in ethnic minority communities. The care coordinator is involved in identifying patients who need health checks and books them in with a healthcare assistant. The CC also works with the SPLW to identify organisations and centres these health checks can be carried out in the community as part of outreach engagement. During the health check, if lifestyle issues are identified e.g. low activity and poor diet, these patients are referred to the HWbC who runs group consultations.
Core20PLUS5 is a national NHS England and NHS Improvement approach to support the reduction of health inequalities at both national and system level.
The approach defines a target population cohort – the ‘Core20PLUS’ – and identifies ‘5’ focus clinical areas requiring accelerated improvement.
More information can be found in the supporting document.
PLUS population groups may include:
- Ethnic minority communities
- Inclusion health groups
- People with multi-morbidities
- Protected characteristic groups
- Inclusion health groups which include:
- people experiencing homelessness
- drug and alcohol dependence
- vulnerable migrants
- Gypsy, Roma and Traveller communities
- sex workers
- people in contact with the justice system
- victims of modern slavery
- other socially excluded groups.
- Population health is an approach aimed at improving the overall health of an entire population. There is no universally accepted definition, but it is closely linked to health inequalities and addressing the social determinants of health
- The Long Term Plan sets out new commitments for action to improve prevention
- New Integrated Care Systems (ICSs) will help deliver this as the NHS moves from reactive care towards a more preventative proactive approach
- The King’s Fund has a 4-pillar framework for population health which includes action to reduce ill health, deliver integrated health and care services, work with community and partner agencies and address the wider determinants of health
- The King’s Fund has also produced an animation and written several documents below, focusing on population health, including the vision for population health and what improvement looks like: