Developing a Strategy
for addressing Health
Inequalities in
Westminster
Discussion paper to explore issues and options
for the strategy
Issued: September 2008
Deadline for responses: Friday 12th December 2008
1
DEVELOPING A STRATEGY FOR ADDRESSING HEALTH IN
WESTMINSTER
Discussion paper to explore issues and options for the strategy
Section 1: Introduction
‘Health inequalities’ is a term used to describe the unequal health outcomes
experienced by different people in a society. Health inequalities can be
demonstrated in a number of different ways, such as:



Differences in life expectancy of people within a society, where some people
may be living much shorter lives than others. In Westminster, there is
currently a difference of nearly 11 years between males born in Churchill
ward (life expectancy: 73. years) and the life expectancy of those born in
Lancaster Gate ward (life expectancy: 83.9 years).
Inequalities in people being able to access services to support them to lead
longer and healthier lives. In Westminster, only 40% of women with a
learning disability had had a cervical smear test and only 29% had had a
breast screening test. (Westminster survey).
Inequalities in morbidity. For example, diabetes does not impact upon
everyone in our society equally. Significant inequalities exist in the risk of
developing diabetes, in access to health services and the quality of those
services, and in health outcomes, particularly with regard to people with Type
2 diabetes.
Health inequalities are not only geographically based, but also amongst particular
groups in the population. Health inequalities in Westminster are described and
explored in detail in Westminster’s 2006/07 Public Health Annual Report.
Whilst prevalence of particular conditions is higher amongst particular population
groups, this is not the cause of the wider health inequalities that are experienced
in the borough. The reasons for the levels of health inequalities are complex and
relate to:
 Wider determinants of health (such as education, employment, housing,
community cohesion)
 Access to services
 Genetic predisposing
This is why a Health Inequalities Strategy for Westminster is being developed by
the Westminster City Partnership, as tackling inequalities will require action from
all partners’ for real and sustained impact.
Westminster PCT, Westminster City Council, and wider partners believe that
these health inequalities are not acceptable, and are committed to driving
positive change. However, tackling health inequalities is a complex issue.
Policies and services that seek to improve the health of the whole population can
have the potential to increase health inequalities, as those people who
2
experience good health are better able to take advantage of them – therefore
widening the gap. The development of the first Health Inequalities Strategy for
Westminster will consider carefully how all partners can systematically embed
policy and practice in all that we do to tackle health inequalities.
We have produced this discussion paper to consider the issues and options in
the development of this strategy. The aim of the paper is to prompt discussion
and debate around our current approach and our current services, where these
are working well and where there is potential for change. The paper is organised
into the following sections:





Background to the strategy development
Defining health inequalities and priorities for action
Action to address inequalities in the:
 Wider determinants of health
 Lifestyle determinants
 Access to services and care pathways
 Children and Young People
Our approach to addressing health inequalities
Your views
Each section provides a description of the issues and introduces areas for
discussion.
We are committed to talking to as many people as possible about these options
to make sure that we have a deliverable, but ambitious strategy for tackling
inequalities that we all share a commitment to. From the information gathered
through this, a strategy will be drafted, which will be issued for further
consultation in early 2009.
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Section 2: Background
The Public Health White Paper Choosing Health1 (2004) and the Health and
Social Care White Paper Our Health, Our Care, Our Say (2006) both build on the
Government’s programme: Tackling Health Inequalities: A Programme for Action
(2002) to confirm the national level commitment to reducing health inequalities.
A key element of the national strategy is the delivery of the national health
inequalities Public Service Agreement target: by 2010, to reduce inequalities in
health outcomes by 10% as measured by infant mortality and life expectancy at
birth. Progress on delivery of this strategy was recently published in Health
Inequalities: Progress and Next Steps2. This paper reports significant absolute
improvements in the health of people in disadvantaged groups and areas, but
that relative change (in terms of narrowing the gap) remains challenging as the
health of everyone in England continues to improve rapidly.
Locally, tackling health inequalities has been identified as a key priority for
Westminster, as outlined in the Westminster City Plan 2006/16. In 2005,
Westminster PCT and City Council published 2 strategies: A Programme for a
Healthier Westminster 2005-08 and the Westminster Health Promotion Strategy
2005/08. A Health Inequalities Strategy will build on the developments and
actions delivered as a result of these documents over the last 3 years, but will
increase the focus on reducing health inequalities in Westminster.
Westminster is ranked the 72nd most deprived local authority out of 354 local
authorities in England (Indices of Multiple Deprivation, 2007). Death rates are
lower in Westminster than in London and England. The main causes of death
and the main contributing factors to the health inequalities gap in Westminster for
both men and women were circulatory diseases, cancers and respiratory
diseases. The gap in life expectancy across wards in Westminster currently
stands at 11 years for men and 9 years for women.
Male Life expectancy at birth 2001-2005
1
2
Choosing Health: Making Healthy Choices Easier (2004) Department of Health.
Health Inequalities: Progress and Next Steps (2008) Department of Health
4
Section 3: Defining Health Inequalities and priority areas for action
We intend to develop an ambitious strategy that brings partners together to focus
on where we can make the greatest impact on reducing health inequalities in
Westminster in the short, medium and long term. Statutory sector agencies have
access to a range of information which signals to us what the current and future
health inequalities in our population are. We recognise though that a thorough
understanding of health inequalities and what we can do to support their
reduction goes beyond the statistics and also requires full engagement with
communities, individuals and the voluntary and community sector.
We propose that an overarching principle for the development of any strategy,
policy or services to support health and wellbeing in Westminster should be
designed with a primary objective of reducing health inequalities. The
Health Inequalities Strategy would confirm this policy position and provide
guidance to commissioners of services and people responsible for service
delivery of what this will mean in practice in relation to population needs
assessment, targeted community engagement, service location and design of
delivery.
Health inequalities exist across population groups and geographical areas.
Some health inequalities are clearly identifiable, such as premature mortality
rates in particular wards in Westminster or higher rates of particular long-term
conditions, such as diabetes, amongst particular ethnic groups.
Some inequalities however are more hidden. These could be inequalities
experienced at very small geographical levels, where small areas of deprivation
are found within affluent areas which is a particular feature of Westminster,
especially in the South of the Borough or they may be hidden as certain
inequalities may be specifically experienced by specific groups. An example of
this would be binge drinking level amongst younger white women who are not
otherwise considered as a group experiencing health inequalities or very small,
new communities in Westminster whose needs are not highlighted through data
routinely collected by health and care services.
The Health Inequalities Strategy Group proposes that public health intelligence,
coupled with community and other stakeholder feedback, is used to identify
groups that will be given high priority for action within the strategy. There will
however need to be a system for prioritising areas for action to ensure a focused
and strategic approach.
Issues for discussion:
1.
Do you agree with the principle that all services should be developed
with the primary objective of reducing health inequalities?
2.
Are there particular geographical areas or population groups that you
think might be, or are currently overlooked in our current approach to
addressing health inequalities?
3.
Do you have any views of prioritising areas for action to address
inequalities?
5
Section 4: Action to address health inequalities
This section will explore the potential themes within the Health Inequalities
Strategy.
It provides details about our existing understanding of health
inequalities under these themed areas and the position of current policy to
address them. We would welcome your views generally on our current
understanding of inequalities within these areas, any gaps in existing approaches
to addressing these inequalities and what our priorities should be for the future.
a)
Wider determinants of health
The wider determinants of health include:
 Income and employment
 Social and community networks
 Housing
 Education
 Crime and fear of crime
 Access to public services
 Physical environment, including access to
open spaces.
There is strong evidence for the links between these wider determinants and
health inequalities. Health inequalities are both a consequence of wider
inequalities and can also contribute to inequalities. For example, a person’s
health may impact on their ability to retain or gain employment, which in turn can
result in the person experiencing income inequalities. Equally, there may be a
cumulative effect of low income, affecting, for example, housing conditions, which
in turn results in an individual experiencing poor health. Westminster is not
unusual in that health outcomes for the population have a direct correlation with
indices of deprivation:
Indices of deprivation 2007
All age, all cause mortality 2001 -2005
Westminster’s Annual Public Health Report 2006/07 explores in detail
inequalities in Westminster which impact on the wider determinants of ill health.
6
Inequalities in the wider determinants outlined in the report are summarised as
follows:
Income & employment: Income is a key determinant and indicator of other
inequalities. The most deprived SOAs3 for the Income deprivation domain of the
IMD 2007 are found in the Queen’s Park ward. The highest numbers of benefits
claimants were in the Church Street ward; the highest number of benefits
claimants as a percentage of the working age population was found in the
Queen’s Park ward.
For income deprivation affecting children, one Queen’s Park SOA has received
the highest rank in England (Mozart Estate) and one SOA in Church Street has
been ranked the fourth highest in England, indicating the need for priority action
by all partners to tackle childhood poverty. The St James’s ward has the highest
rate of unemployment – high rates are also found in the Queen’s Park, Harrow
Road, Westbourne and Church Street wards.
Housing and homelessness: Poor housing (which may be overcrowding,
damp, hazards in the home or poor heating and insulation) can have
considerable impact on physical health as well as health and wellbeing more
broadly, and is therefore an important underlying determinant of health
inequalities. The Indices of Multiple Deprivation measure quality of the indoor
housing environment, and show deprivation in this domain focused in south and
mid Westminster: in the West End, St James’s, Churchill, Hyde Park, Warwick
and Lancaster Gate wards. There are particularly high percentages of
households living in overcrowded accommodation in the Bayswater, Hyde Park,
Lancaster Gate and Westbourne wards.
Education: Education has a major role in influencing inequalities in health.
Therefore the health of Westminster’s future adult population is to a large extent
indicated by the educational attainment of today’s children and young people.
This is because the level of educational attainment plays a large part in
determining socio-economic position, and consequently affects income, housing
and the ability to purchase other material goods. The level of educational
deprivation varies across the borough. Two SOAs are ranked within the 20%
most deprived SOAs in the country for education, skills and training for children
and young people. They are in Westbourne and Lancaster Gate wards.
Crime and fear of crime: Crime and fear of crime can have considerable
negative health impacts, including increased levels of stress and anxiety, fear of
going out alone, therefore impacting on levels of physical activity undertaken,
and loss of confidence, The areas most affected by crime are in the north of the
borough. However, areas with the highest crime levels sit alongside those with
the lowest, reflecting the complex nature of deprivation in Westminster and
hence the adoption of neighbourhood based approaches. People who live in the
Westbourne ward report feeling least safe - this corresponds with the higher
levels of reported crime in this ward.
3
Lower-level Super Output Areas (SOAs) are geographical units that include an average of 1,500 people.
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Our current approach to addressing health inequalities in the wider
determinants of health
To date, Westminster has largely led the programme to address inequalities in
the wider determinants of health through the Westminster City Partnership
(WCP). The WCP is a partnership between Westminster City Council, other
public sector agencies, including Westminster PCT, voluntary and community
sectors, local businesses, regeneration partnerships and residents’ groups.
The Westminster City Partnership’s approach is reflected in the Westminster City
Plan 2006-2016, which, in addition to having a specific health focus, recognises
health and wellbeing as a cross cutting theme for all the work programme areas.
In developing the strategy for tackling health inequalities, consideration needs to
be given to how it will build on the cross cutting elements of the City Plan, with a
specific focus on how partnership action can strengthen our approach to tackling
health inequalities.
Options for future action
Options for future action will build on the priorities identified within the
Westminster City Plan 2006/16 to secure agreement across partners for
sustained and long-term action to address the wider determinants of health
inequalities. Some options for how we might achieve this, which we would very
much welcome comment are:
 Reducing income inequalities by focusing partnership action on supporting
new and existing Incapacity Benefit claimants to secure training, volunteering
and ultimately employment through supporting condition management
programmes, advice services and personalised support.
 To work with small and medium sized business in Westminster to support the
health and wellbeing of their employees, enabling people experiencing ill
health to remain in employment.
 Childhood poverty is a significant challenge for Westminster. We propose
that we should strengthen our current partnership arrangements to increase
household income levels for families, particularly in the Queens Park, Church
Street, Westbourne and Harrow Road wards
Issues for discussion:
4.
5.
6.
7.
How can the Health Inequalities Strategy best complement existing
work programmes to address the wider determinants of health?
What should the priorities for the Health Inequalities strategy be in
relation to the wider determinants of health?
What specific programmes addressing wider determinants would
benefit from a more coordinated partnership approach?
How can we ensure impact on addressing health inequalities in all
business plans and strategies developed both by the PCT and those
which address the wider determinants of health?
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b)
Lifestyle determinants of health
The lifestyle choices people make can influence their health for better or worse
and make a major contribution to the health inequalities experienced in the
community across Westminster. Health improvement programmes need to be
targeted towards those experiencing the poorest health and need to take account
of the reasons why people are less likely to choose a healthy lifestyle.
Lifestyle choices are often made for complex reasons. Environmental factors
such as poor transport links, unsuitable housing, fear of crime and the pressures
of daily life: stress and lack of time can create barriers to healthier choices.
These environmental factors are also exacerbated by the support people have to
access appropriate information and advice in order to make informed choices
about a healthy lifestyle.
The White Paper Choosing Health, Making Healthier Choices Easier4 was
published in 2004 following the second health review by Derek Wanless and HM
Treasury5, which focussed on public health. The Wanless review predicted that it
would be unlikely, if trends in lifestyles and emerging problems such as obesity
and chronic diseases continued, that the NHS would be able to afford to finance
sufficient healthcare to meet demand by 2015. Wanless felt that the only way to
sustain current standards of care would be change at a population level. He
described this as the ‘fully engaged’ scenario where individuals and communities
were engaged in health improvement and disease prevention.
Choosing Health built on this work and set out a vision for moving towards this
fully engaged scenario. Three principles underpinned this document: informed
choice; personalisation of services and working together. A Health promotion
Strategy for Westminster 2005-2008 identified six lifestyle areas for priority action
that were consistent with those set out in Choosing Health, Making Healthier
Choices Easier:
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



Tobacco Control
Promoting Healthy Eating
Promoting Physical Activity
Promoting Sexual Health
Tackling Substance Misuse
Promoting Mental Health and Wellbeing
Westminster’s Annual Public Health Report 2006/2007 explores in detail health
inequalities in relation to the six lifestyle areas. Continuing to concentrate health
promotion efforts around these priority areas in a targeted way will support
statutory and voluntary agencies in Westminster to tackle the major causes of ill
health within the borough, including Cardiovascular Disease, Respiratory
Disease, Cancer, Diabetes and Mental Illness.
4
5
Choosing Health: Making Healthy Choices Easier (2004) Department of Health.
Wanless, D (2004) Securing Good Health for the Whole Population: Final Report .London: HM Treasury
9
Key lifestyle areas that a Health Inequalities strategy should consider, based on
information presented in the Public Health Annual Report are proposed as
follows:
Smoking is the principal cause of preventable illness and death in the UK and
the single biggest preventable cause of the socioeconomic gradient
in infant mortality and life expectancy. Reducing the smoking prevalence
in disadvantaged groups and pregnant women will therefore make the biggest
contribution to reducing these health inequalities, particularly in the short term.
Half of all smokers will die as a result of smoking6. Smoking is a known risk
factor for cancer and causes 1 in 3 cancer deaths and 90% of lung cancer cases.
It is also a risk factor for circulatory diseases and respiratory disease, such as
Chronic Obstructive Pulmonary Disease (COPD).
In Westminster it is estimated that 1 in 3 residents smoke, a higher proportion
than the English average – and that there were 690 smoking attributable deaths
in 2006. Smoking prevalence in Westminster varies considerably by ward, with
the more deprived wards having higher smoking rates than the English average.
Smoking rates also vary within wards - a recent survey of two estates within the
Queen’s Park ward found that smoking rates were approximately 36%, compared
to the overall prevalence for the ward of around 28%.
Estimated smoking prevalence by ward 2003-2005
Wards
Church Street, Little Venice
Churchill, Warwick
Queen's Park
Tachbrook, Vincent Square
Westbourne
Smoking prevalence %
28.8
28.9
28.4
28.4
30.8
Source: Healthy Lifestyle Estimates, Office for National Statistics (ONS) December 2007
There are significant variations in smoking prevalence between social and ethnic
groups and, despite an overall reduction in smoking since the 1970s, there has
been little change in smoking prevalence amongst lower socioeconomic groups.
Reducing the prevalence of smoking in these groups will contribute more to
reducing inequalities in health than any other public health measure7.
National figures suggest that men in Pakistani, Bangladeshi and Irish groups are
more likely to report that they smoke than men in the general population. For
women, smoking rates are lowest amongst Bangladeshi women (2%) and
highest among Irish women (26%) and Black Caribbean women (24%).
Healthy Eating: Healthy eating helps to protect against disease, contributes to
maintaining a healthy bodyweight and improves overall physical and emotional
6
7
Doll R, Peto, R Mortality in relationship to Smoking: 50 years. BMJ 1976. 4: 1525 36.
Aspinall PJ. London health Observatory Commissioning for Equity: Are London’s Stop Smoking Services Equitable?
10
wellbeing. Being overweight increases the chance of an individual developing
diabetes, joint problems, cardiovascular disease and high blood pressure. Diet is
a major contributor to obesity, which is itself a risk factor for hypertension, heart
disease, Type 2 diabetes and some cancers. Low fibre diets have been linked to
a higher risk of bowel cancer and other bowel disturbances.
Estimates of the proportion of the population who eat five or more portions of fruit
and vegetables per day by Middle Super Output Area (MSOA) suggest that the
majority of residents in Queens Park, Harrow Road, Westbourne and Church
Street wards in the north, and a large proportion of those in Churchill ward and
just under half in Warwick ward in the south of Westminster, consume less than
the recommended five portions of fruit and vegetables a day. Even in the wards
with the highest estimated consumption, fewer than half of Westminster residents
are estimated to eat the recommended five or more portions.
Physical activity: Physical activity has a significant impact on health and
wellbeing and regular physical activity is important in maintaining a healthy
weight and reduces the risk of cardiovascular disease, Type 2 diabetes,
hypertension, osteoporosis, back pain and osteoarthritis. There is also
compelling evidence that regular activity improves mental health and wellbeing.
Activity levels across the country are low - according to Sport England’s Active
People Survey (2006), only 21.0% of adults participate in sport or physical
activity for 30 minutes on three days each week.
Adult participation levels in Westminster were significantly higher at 25.1% - this
was the sixth highest of all boroughs in London. The average for London was
21.3%. Although Westminster is performing relatively well on this key measure,
almost 75% of adult residents in Westminster do not achieve the recommended
levels of participation - and nearly 45% of residents do no sport or physical
activity at all.
In London men are more likely to participate in regular physical activity than
women - 24% compared to 19%. Only 9% of people with a limiting longstanding
illness or disability regularly participate in physical activity compared to 23% of
people who do not have either a limiting longstanding illness or disability.
There are also variations between socio-economic groups with 15.1% those in
the lowest groups regularly partaking in physical activity compared to 25.8% in
the highest socio-economic group.
The Health Survey for England 1999, which took a particular focus on ethnicity,
showed that Pakistani, Bangladeshi and Chinese men and Indian, Pakistani and
Bangladeshi women undertake lower levels of exercise than the general
population.
Sexual health: Sexual ill-health disproportionately affects people in communities
who are already experiencing health inequalities, with the highest burden being
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borne by women, men who have sex with men, teenagers and young adults, and
some black and minority ethnic communities. A diagnosis of a Sexually
Transmitted Infection (STI), particularly HIV can compound existing health
inequalities for people who are already socially excluded or for whom the stigma
makes access to services and support difficult. Individuals and groups who find it
most difficult to access services include asylum seekers and refugees, sex
workers and their clients, the homeless and young people in, or leaving care.
A high rate of STI diagnoses per 100,000 resident population has been attributed
to Westminster compared to North West London as a whole. However, it should
be noted that not all diagnoses made in Westminster GUM clinics are for
Westminster residents.
Young people are more likely to experience poor sexual health, including
unwanted pregnancy, than the general population. The incidence of STIs is
highest amongst 16 to 19 year old women and 20 to 24 year old men. In
Westminster, during 2005, the proportion of diagnoses attributed to under 25s for
Chlamydia, Gonorrhoea and Herpes were 47%, 25% and 35% respectively.
Research suggests that as a group men who have sex with men experience one
of the highest rates of sexual ill health and are disproportionately affected by HIV,
Gonorrhoea and Syphilis8. Westminster sexual health data shows that 50% of
men diagnosed with Syphilis and 66% of men diagnosed with Gonorrhoea had
engaged in sex with other men.
Substance Misuse - Alcohol: Excessive consumption of alcohol is associated
with a number of health problems including injuries and accidents, chronic liver
disease, gastrointestinal problems, a number of cancers, and mental health
problems including anxiety, depression and suicide. The consumption of large
quantities of alcohol over a short period of time (binge drinking) may result in
acute alcohol poisoning. Excessive consumption of alcohol in pregnancy is
associated with fetal alcohol syndrome. Consumption is inversely related to age:
consumption levels and binge drinking were highest in those aged 16-24 years.
Substance Misuse - Drugs: Substance misuse is a concern for many
Londoners and self-reported drug use is higher in the capital than England as a
whole. While substance misuse causes less damage to health in absolute terms
than tobacco smoking or alcohol, it poses its own challenges with its association
to crime and anti-social behaviour.
In 2005/06 there were 264 recorded offences in Westminster for drug trafficking,
3627 offences for drug possession and 41 for other drug related offences,
making Westminster the borough with the highest number of drug offences in
London9.
8
9
B, McManus S, Prescott A, et al. National Survey of Sexual Attitudes and Lifestyles II. 2003
Source: Westminster Drug Intervention Programme
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Children whose parents or carers misuse drugs, young offenders, looked after
children and children excluded from school or who are truanting are most at risk
of developing substance misuse problems.
There are strong links between homelessness and drug use and a significant
proportion of people accessing drug treatment services in Westminster are
homeless or in hostel accommodation. This mirrors London trends in which over
60% of homeless people cited drug or alcohol use as the reason for first
becoming homeless. Homelessness may also shown exacerbate substance
misuse with many people reporting that they had started using at least one new
drug since becoming homeless10.
Promoting Mental Health and Wellbeing: Good mental health is vital for good
physical health and the association between mental illness and poor physical
health is well established. Mental illness is one of the most important
contributors to the global burden of disease and disability.
Mental health problems range from common mental illness such as anxiety and
depression (often termed neurosis) to less common psychotic disorders such as
schizophrenia (often termed psychosis).
The prevalence of mental illness varies within the population and is higher in
specific groups, such as refugees and asylum seekers and certain Black and
Minority Ethnic (BME) groups. The causality of this is unclear and likely to be
due to a combination of social and other factors.
The demographic profile of Westminster is one which features elements
associated with a higher prevalence of mental health issues, for example high
levels of deprivation, a relatively large BME population and a large homeless
population.
According to estimates derived from the Health Survey for England, the
prevalence of neurotic disorders is high across all Westminster’s wards (ranging
from 16.9% to 20.4%). The estimated prevalence rates in all but two wards were
in the top 10% in the country - the prevalence rates in the other two wards were
in the top 20%.
People who suffer from mental illness are disproportionately represented
amongst lower socioeconomic groups. People who are unemployed are twice as
likely to suffer from mental ill-health as people in employment11.
Options for future action
In order for health promotion initiatives to be effective they must be designed
with particular population or target groups in mind, such as older people, children
10
11
Greater London Alcohol and Drug Alliance. London: the Highs and the Lows 2, Greater London Authority. 2007.
Department of Health. National Service Framework for Mental Health. London: 2001
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and young people and vulnerable groups as opposed to a ‘one size fits all’
approach.
We propose that health promotion initiatives should be developed and
implemented in a variety of settings including schools, leisure and community
venues and workplaces.
Health promotion initiatives must seek to increase the ability of individuals and
communities to adopt healthy lifestyles, identifying barriers they face to making
healthy choices. We propose social marketing approaches will offer some insight
into identifying these issues and understanding perceptions and attitudes. We
also propose to explore the use of incentives, including financial incentives, to
encourage uptake of preventative services.
Issues for discussion:
8.
9.
10.
11.
12.
13.
14.
If we adopt a lifestyle approach are we at risk of overlooking some
areas of health inequalities such as oral health?
How do we prioritise locally? Should we focus on 2-3 lifestyle areas or
particular geographical areas for example where there are marked
health inequalities, for example, Local Area Renewal Partnership
Areas (LARPS)?
Are there particular health promotion initiatives that would make more
of a contribution to reducing health inequalities if they had a more
joined up/partnership approach?
How do we align the development of the Health Promotion Strategy
with the delivery of Local Area Agreement targets?
How could we better engage GP and practice staff and pharmacies in
health promotion activities? Should we consider a Local Enhanced
Scheme (LES)?
Do we need a focus on gender specific programmes and targets to
address the ‘gender gap’ in health?
What evidence is there for the use of incentives as a method
encouraging and motivating people to adopt healthier lifestyles, and
based on this, what approach should we develop in Westminster?
14
c)
Addressing Health Inequalities in Access to Care and Care Pathways
Timely access to health services, both preventative services, treatment and
support for self-care, contributes to health and wellbeing. Poor access to the
right healthcare services at the right time can also exacerbate the impact of other
factors on health inequalities, for example it can effect someone’s employment.
There is evidence to suggest that the same groups who experience poorer health
because of the impact of the wider determinants of health also experience both
barriers to access to healthcare and worse health outcomes from healthcare
interventions.
The results of health equity audits, analyses of hospital episode statistics and
surveys of patient experience suggest that there are differences in access
between ethnic groups and that people living in deprived wards may experience
inequitable access to services. Local evidence also suggests that the particular
barriers experienced by people with disabilities and older people may be
contributing to the poorer health experience of these sub-groups of the
population.

It is not clear, however, to what extent different factors are interacting to impact
on differential access to services in Westminster because there is a shortage of
data to measure this effectively.
We will seek to explore and identify action to address inequalities across the care
pathway within the Health Inequalities Strategy:
Preventative
services
Primary
Care
Selfcare
Community
Health
Services
Secondary
care
Palliative
care
To do this, we will need to explore in detail the nature of the inequality, who is
experiencing these inequalities and the factors that are influencing this.
Examples of inequalities across the care pathway that the Health Inequalities
Strategy may seek to address are:
Preventative services: Fewer men across all ethnic groups are accessing
programmes commissioned to support health and wellbeing, such as physical
activity and health eating sessions. A focus of the strategy could be to address
the appropriateness of current commissioning of preventative services, barriers
and motivations for uptake.
Primary care: Westminster and Kensington & Chelsea’s BME Health Forum’s
Report “Primary Concern” (2008) reported from their research that patients’
experience some difficulties in seeing the doctor of their choice and in getting
appointments in general. These difficulties were experienced by all BME groups
who took part in the research but more so by the non-fluent English speakers
15
and/or newly arrived. The strategy may wish to focus on ensuring equal and
equitable access to GP services across all groups in Westminster.
Self-care: the term ‘self care’ includes both self care and self management. Self
care is all about individuals taking responsibility for their own health and wellbeing. This includes: staying fit and healthy, both physically and mentally; taking
action to prevent illness and accidents; the better use of medicines; treatment of
minor ailments and better care of long term conditions. (Martyn, 2002) 12
An example of inequalities in self-care in Westminster is found with people with
diagnosed diabetes living in the most deprived areas of Westminster have poorer
diabetes control, as indicated by HbA1c levels, a blood test used to assess their
blood glucose control. This suggests that they may be receiving less equitable
access to services. However, there is very little difference in the proportion of
people with diabetes who are achieving recommended blood pressure levels by
area of deprivation, suggesting that there is in fact equitable access to services.
The achievement of good blood glucose control is influenced by patient factors to
a greater extent than the achievement of good blood pressure control – for
example their ability to follow recommended advice on dietary intake and
physical activity – self-care. The issues surrounding the barriers to effective selfcare need greater exploration, for example whether dietary advice as a method
for self-care is provided in a culturally appropriate way.
The strategy may also seek to address factors which impact on an individual and
how they engage in self-care as well as self-care programmes such as the
Expert Patients Programme, Direct Payments and Individual Budgets.
Community Health Services: Locally, information systems are not currently in
place to effectively monitor inequalities in access to or outcomes from community
health services such as district nursing, health visiting, physiotherapy etc.
Academic research suggests that inequalities in service provision in relation to
community health services do exist due to organisational, professional and
personal constraints. Research also highlights issues in access to community
health services with, for example, particular ethnic groups under-represented in
district nursing caseloads. The strategy will therefore seek to address gaps in
local intelligence in order to better identify and understand inequalities.
A local source of intelligence to measure equity and equality in relation to
community based health services is the research report from “Ask your patients
week survey 2008”, an annual programme of involvement activities to monitor
patient experience week across 34 directly provided health services. Whilst
overall satisfaction with directly provided services is consistently high, differences
in experience by different groups is reported. White or White British patients are
significantly more likely to rate their experience of using community health
services as being excellent (60%), compared to those of Arab, Asian and Black
origin (49%, 49% and 52% respectively). In relation to telephone contact,
patients with a disability are significantly more likely to state that it is difficult to
12
Department of Health (2006) : Supporting People with Long-term conditions to self-care
16
get through to healthcare services over the phone (7% compared to 5% average
from 2176 sample base).
Secondary care: There is a range of ways that health inequalities within a
secondary care setting might be experienced. Health inequalities might be
showed through over-representation of certain group in A&E services for
example, which could be a consequence of cultural factors where immigrants’
country of origin has no primary care model and people are used to being and
expect to be treated in a hospital, demonstrating a need for wider reaching health
education message for such communities. Other health inequalities within a
secondary care setting may relate to health outcomes. Research by Cancer
Research UK shows that cancer survival for adults in England and Wales is
generally lower among patients in more deprived groups, even after allowance is
made for the higher mortality from all causes of death in the more deprived
groups. In the development of the strategy, differences in local health outcomes
within a secondary care setting will be explored.
Palliative care: Palliative care is concerned with the suffering, the dignity, the
care needs and the quality of life of people at the end of their lives, and care and
support of their families. The health and socical care White Paper Our health,
our care, our say set outs a standard where patients and carers have choice and
control in planning their end of life care. However, a report by Help the Aged has
shown inequalities in choice of palliative care services, where the opportunities
for people to choose to go into a hospice declines with age. Fairness and equity
in Westminster’s end of life care services will need to be explored.
Issues for discussion:
15.
What are the key issues / current inequalities that a Health Inequalities
Strategy should consider in access, outcomes and experience across
the care pathway?
16.
What are the current barriers and challenges in access to appropriate
and responsive services for different groups?
17.
How should we be better designing services to reduce health
inequalities?
17
d)
Health Inequalities amongst Children and Young People
The single, strategic, overarching plan for all local services affecting children and
young people in Westminster is the Children and Young People’s Plan. This plan
sets out the strategy for delivering the following local priorities:
 Be healthy
 Stay safe
 Enjoy and achieve
 Make a positive contribution
 Achieve economic wellbeing
Tackling health inequalities amongst children and young people will require
sustained partnership action across these five priority areas.
There are some significant health inequalities amongst children and young
people in Westminster, which are described in detail in chapter six of the Annual
Public Health Report 2006/07. Key issues that this report highlights are as
follows:
Childhood poverty
Childhood poverty is a significant issue for Westminster. According to the Index
of Multiple Deprivation 2007, in 29 (24%) of the 120 Super Output Areas (SOAs)
in Westminster, more than 50% of children live in income-deprived households
and 42 (35%) of SOAs are in the 20% most deprived SOAs in the country - all of
the SOAs in the Church Street, Harrow Road, Queens Park and Westbourne
wards are in the 20% most income deprived SOAs nationally. In these 4 SOAs,
more than 90% of children live in income deprived families - one SOA in the
Queens Park ward has the highest proportion of children living in incomedeprived families (100%) in the country and in one SOA in Church Street, 99% of
children live in income deprived families (ranked the fourth most deprived in the
country).
Action to address childhood poverty in the long-term should be to focus on
supporting parents, particularly lone parents, into work and to provide access to
affordable childcare for families. In the short and medium term, action to address
issues associated with childhood poverty that the Health Inequalities strategy
could consider are, for example, ensuring access to affordable healthy foods,
physical activity.
Infant mortality
Nationally, a public service agreement target has been set that by 2010 the gap
in infant mortality between the routine and manual group and the population as a
whole will be reduced by at least 10% from the 1997-99 baseline. Although the
infant mortality rate in routine and manual groups has reduced, the gap between
these groups and the population has a whole has increased. In 2006 there were
15 infant deaths in Westminster, of which 11 were in babies aged less than one
month.
18
Tackling health inequalities: What works?13, identifies action that would be
expected to reduce inequalities in infant mortality within the target timescale of
2010. Priorities include:

Reducing smoking in pregnancy in disadvantaged groups, focussing also on
paternal smoking
 Improving nutrition in women in disadvantaged groups of childbearing age
 Reducing teenage pregnancy, which is strongly correlated with socioeconomic status
 Increasing breast-feeding initiation and duration rates in disadvantaged
groups
 Maintaining immunisation coverage and improving service planning for
increased uptake in disadvantaged groups
 Providing effective education about ways to promote health (eg immunisation)
focussing on disadvantaged groups
It is recommended that a Health Inequalities Strategy sets out local action
against these areas.
Promoting health and reducing health inequalities in young children
Key action to reduce health inequalities in young children is through:
 Increasing the number of women breastfeeding and the length of time they
breast feed
 Improving the health and nutrition of children
 Increasing immunisation uptake
 Providing quality and integrated services for children.
There is variation in breastfeeding levels across demographic groups, with high
levels of breastfeeding amongst women from managerial and professional
occupations. This suggests the need for targeted work for lower income groups,
building on successful models such as the Children’s Centre peer breast feeding
programmes.
Westminster school children have a significantly higher rate of dental decay than
the average for London and England; Westminster is amongst the 20% of
boroughs in the country with the highest rates of dental caries. Where information
has been collected for older children, rates are lower and compare more
favourably to those for both London and England. Oral health is subject to
significant inequalities - the mean number of decayed, missing or filled teeth
ranges from 5.4 in one primary school to 1.6 in another. This would therefore
indicate that targeted action should be taken to improve the oral health of
children under 5 years old through health visiting and other early year’s services.
Immunisation rates in Westminster fall below the national averages and fail to
reach target levels. A particular challenge in Westminster is the feature of a
highly mobile population, which makes it difficult to ensure that all children
receive their immunisations.
13
Tackling Health Inequalities: What works? Department of Health 2005
19
Safeguarding children
Safeguarding and promoting the welfare of children is the responsibility of the
local authority, working in partnership with other organisations. Westminster City
Council, and the Westminster City Partnership, are strengthening their approach
to safeguarding children through intensive and targeted support to families at
risk. The contribution that this will make to reducing health inequalities will need
to be considered within the strategy.
Improving life chances for children and young people
The Department of Health have set out actions to reduce inequalities and
improve the life chances of children and young people as follows:
 Narrowing the gap in educational attainment for young people from
disadvantaged backgrounds, including black and minority ethnic groups and
Looked After Children,
 Implementing the Healthy Schools programme, with a focus on those schools
in disadvantaged areas,
 Support for teenage parents and pregnant teenagers to help improve their
health, educational attainment and life chances.
The level of educational deprivation varies across the Westminster borough.
Two SOAs are ranked within the 20% most deprived SOAs in the country for
education, skills and training for children and young people. These are in the
Westbourne and Lancaster Gate wards. There is considerable variation in
educational attainment between schools, with the percentage of children
achieving five or more GCSEs at grades A* - C in 2007 ranging from 23% to
93%. Westminster also falls below the national average.
Looked after children
Specific health inequalities are experienced by looked after children, who have
increased health needs when compared to children from similar socio-economic
backgrounds, as well as poorer educational attainment and social outcomes.
Tackling teenage pregnancy
Teenage conceptions are more likely to occur amongst young girls who have
grown up in poverty, deprivation and social exclusion. There has been a
significant decline in Westminster in the rates of teenage conception from the
peak in 2000, although rates increased slightly in 2006. The most recent data
shows that the highest rate of pregnancies in 15-17 year olds were in the Hyde
Park ward, and rates were also high in Churchill and St James wards.
Childhood obesity
Childhood obesity is a major public health challenge as it set as a local priority
area in Westminster’s Local Area Agreement. As part of the National Child
Measurement Programme, the PCT is required to weigh and measure all children
20
in reception and Year 6. In 2006/07 a higher proportion of children attending
Westminster’s schools were classified as being overweigh and obese in Year 6.
Westminster was below London and National Averages at reception year. There
are distinct inequalities in obesity, with studies finding that children in semiroutine and routine households were nearly twice as likely to be obese when
compared with managerial and professional households. Inequalities in obesity
levels are also found between ethnic groups. The Health Survey for England
1999 showed that Black Caribbean, Indian and Pakistani boys had higher rates
of obesity than the general population and for girls, higher rates were
experienced by Afro-Caribbean and Pakistani groups.
Issues for discussion
18.
19.
20.
21.
Intelligence shows that health inequalities amongst children and young
people, particularly childhood poverty, are largely experienced in
particular wards – Queens Park, Church Street, Westbourne and
Harrow Road. How can we better coordinate action and partnerships
to coordinate action to make an impact on the inequalities experienced
in these areas?
How can we better support the health needs of looked after children?
What are the key action that we should set out to address poor oral
health amongst the under 5s in Westminster?
How can we enhance and strengthen our work with schools,
particularly in tackling childhood obesity?
21
Section 5: An Approach to Addressing Health Inequalities
This section of the Health Inequalities Strategy will set out the approach for
delivery of agreed priority areas. It is proposed that the following approaches to
addressing health inequalities are set out in this chapter:







Community engagement
Developing a targeted neighbourhood approach to services
Mainstreaming reducing health inequalities in our commissioning
processes
The role of the voluntary and community sector in addressing health
inequalities
Infrastructure to tackle health inequalities (use of intelligence in service
planning, developing evidence based programmes and approaching
evaluation).
Information, communication and signposting
Innovative approaches to addressing health inequalities
Community engagement: Understanding the needs of communities
experiencing health inequalities through community engagement and user
involvement is essential in understanding health inequalities experienced and
some of the solutions to overcoming them. Both Westminster PCT and
Westminster City Council have strategies and programmes in place for public
engagement, consultation and involvement. The Health Inequalities Strategy
should set out principles and standards for how seldom heard groups and people
experiencing health inequalities are prioritised within these programmes to
ensure it is the voice of people most in need of health services that is heard in
shaping them.
Developing a targeted neighbourhood approach to services: Both the
Primary Care Trust and the City Council make decisions about how to best
allocate resources available to meet the needs of their population. Often this
means targeting resources to areas or groups of people who need it most. Both
the Council and the PCT have been developing and strengthening their approach
to neighbourhood based services through the Local Area Renewal Partnerships.
Ward Budget allocations. The Health Inequalities Strategy will seek to set out a
strategic direction for the development of neighbourhood based approaches for
the future as a method of addressing health inequalities.
Mainstreaming reducing health inequalities
in our commissioning processes: At each
stage of the commissioning cycle there is an
opportunity to make and impact on reducing
health inequalities – robust identification of
health inequalities through public health and
community intelligence at the start of the
process, setting out expectations around
reduction in health inequalities in the service
specifications, making better use of service
22
level agreements to ensure expectations are met, and to support wider
determinants of health, for example setting expectations around employment of
local people within contracts and then effective monitoring and evaluation of
impact. The strategy will set out expectations for how the commissioning
process can be more effectively and systematically use to address health
inequalities.
The role of the voluntary and community sector in addressing health
inequalities: A recent study set up by Voluntary Action Westminster (VAW)
found that Westminster’s voluntary and community sector helped to reduce
health inequality in two main ways:

By promoting healthy living to groups of people who may not use
mainstream services (for example, by organising women-only exercise
classes as an alternative to mixed classes at a public leisure centre)

By supporting people in using mainstream services (for example, by
arranging for volunteers to accompany people to hospital clinics)
Some VCS organisations helped to improve access to education and
employment, which they saw as an important step in improving people’s health
status. The voluntary sector in Westminster plays an important role in promoting
healthy living, and encouraging wider use of mainstream services in excluded
communities. The study commissioned by VAW did highlight some areas for
action both for commissioners of services, for example providing access to
sustainable funding and providing on-going and tailored support, particularly for
grass-roots organizations who play an important role in meeting the most
excluded communities. Development needs were also identified for the voluntary
and community sector, particularly for organisations to improve their ability to
communicating to commissioners their role in supporting local health and
wellbeing strategy.
Infrastructure to tackle health inequalities: This section of the chapter will
seek to explore practice of the PCT and City Council in intelligence gathering,
use and dissemination, how we both use an evidence base for what works in
tackling health inequalities to shape the programmes that we commission and
how we are building our local evidence base of programmes through effective
monitoring and evaluation. This section of the chapter will also address
governance and performance management of the health inequalities programme.
Information, communication and signposting: Meeting the information needs
of people experiencing health inequalities, supporting effective communication
and signposting to services that people need is a complex but powerful way of
addressing health inequalities. The strategy will address both corporate
approaches to communication and information design for vulnerable groups as
well as the role of all front-line services in disseminating messages and taking
the responsibility for providing information to the public and making referrals to
appropriate services as necessary.
23
Innovative approaches to tackling health inequalities: The Health Inequalities
Strategy will explore a range of approaches to tackling health inequalities,
including new and innovative approaches such as social marketing approaches
and the use of incentives to motivate for behavior change.
Issues for discussion:
22.
23.
24.
25.
26.
27.
28.
What is our current track record of engaging with communities
experiencing health inequalities and how could it be improved?
How effectively is the health and wellbeing agenda engaging with
neighbourhood structures such as the Local Area Renewal
Partnerships? How could it be improved?
How can we improve communication with Westminster’s most
vulnerable communities? What are the best and most effective
methods of communication?
Are we currently making best use of our commissioning processes to
reduce health inequalities?
What are the opportunities for
strengthening this?
How are we currently making decisions about investing resources to
support health and wellbeing to reduce health inequalities? Is this
systematic?
Are we currently making best use of the voluntary and community
sector as part of our strategy to address health inequalities? How
could we strengthen this?
What innovative approaches should we be considering in delivery of
the health inequalities programme?
24
Section 5: Your views on the development of the Health Inequalities
Strategy
A steering group Chaired by Michael Scott, Westminster PCT Chief Executive, is
overseeing the development of the Health Inequalities Strategy. The steering
group plan to publish a draft strategy for reducing health inequalities in January
2009 for further consultation and a final version in April 2009.
This discussion papers seeks to gather early views and opinions of key
stakeholders to inform the development of the first draft of the strategy.
Questions and issues for discussion have been raised throughout the paper and
they are summarised below. Please do respond to any many questions as you
can and add any other comments as necessary.
Stakeholders are invited to respond to this discussion paper up until Friday 12th
December 2008 to:
Lisa Henschen
Head of Health Inequalities
Westminster PCT
15 Marylebone Road
London, NW1 5JD
[email protected]
We are also keen to talk to groups of local stakeholders as part of this
consultation. To arrange this, please contact Lisa Henschen by email or on 020
7150 8121.
Please include your name and contact details with your feedback so that we
keep you updated with the development of the strategy.
Thank you.
25
Developing a Strategy for Reducing Health Inequalities in Westminster
Discussion paper to explore issues and options for the strategy
Issues for discussion: response sheet.
Name:
Organisation
Address (post / email):
Issues for discussion:
1. Do you agree with the principle that all services should be developed with
the primary objective of reducing health inequalities?
2. Are there particular geographical areas or population groups that you think
might be, or are currently overlooked in our current approach to
addressing health inequalities?
3. Do you have any views of prioritising areas for action to address
inequalities?
4. How can the Health Inequalities Strategy best complement existing work
programmes to address the wider determinants of health?
5. What should the priorities for the Health Inequalities strategy be in relation
to the wider determinants of health?
6. What specific programmes addressing wider determinants would benefit
from a more coordinated partnership approach?
26
7. How can we ensure impact on addressing health inequalities in all
business plans and strategies developed both by the PCT and those
which address the wider determinants of health?
8. If we adopt a lifestyle approach are we at risk of overlooking some areas
of health inequalities such as oral health?
9. How do we prioritise locally? Should we focus on 2-3 lifestyle areas or
particular geographical areas for example where there are marked health
inequalities, for example, Local Area Renewal Partnership Areas
(LARPS)?
10. Are there particular health promotion initiatives that would make more of a
contribution to reducing health inequalities if they had a more joined
up/partnership approach?
11. How do we align the development of the Health Promotion Strategy with
the delivery of Local Area Agreement targets?
12. How could we better engage GP and practice staff and pharmacies in
health promotion activities? Should we consider a Local Enhanced
Scheme (LES)?
13. Do we need a focus on gender specific programmes and targets to
address the ‘gender gap’ in health?
14. What evidence is there for the use of incentives as a method encouraging
and motivating people to adopt healthier lifestyles, and based on this,
what approach should we develop in Westminster?
27
15. What are the key issues / current inequalities that a Health Inequalities
Strategy should consider in access, outcomes and experience across the
care pathway?
16. What are the current barriers and challenges in access to services for
different groups?
17. How should we be better designing services to reduce health inequalities?
18. Intelligence shows that health inequalities amongst children and young
people, particularly childhood poverty, are largely experienced in particular
wards – Queens Park, Church Street, Westbourne and Harrow Road.
How can we better coordinate action and partnerships to coordinate action
to make an impact on the inequalities experienced in these areas?
19. How can we better support the health needs of looked after children?
20. What are the key action that we should set out to improve the health and
wellbeing of younger children in Westminster, particularly in relation to oral
health and immunisations?
21. How can we enhance and strengthen our work with schools, particularly in
tackling childhood obesity?
28
22. What is our current track record of engaging with communities
experiencing health inequalities and how could it be improved?
23. How effectively is the health and wellbeing agenda engaging with
neighbourhood structures such as the Local Area Renewal Partnerships?
How could it be improved?
24. How can we improve communication with Westminster’s most vulnerable
communities? What are the best and most effective methods of
communication?
25. Are we currently making best use of our commissioning processes to
reduce health inequalities? What are the opportunities for strengthening
this?
26. How are we currently making decisions about investing resources to
support health and wellbeing to reduce health inequalities? Is this
systematic?
27. Are we currently making best use of the voluntary and community sector
as part of our strategy to address health inequalities? How could we
strengthen this?
29
28. What innovative approaches should we be considering in delivery of the
health inequalities programme?
Any other comments:
30