Health Inequalities – Kings Fund critiques Department of Health and offers actions for Joint Health & Wellbeing Strategies.

The Kings Fund report ‘Clustering of Unhealthy Behaviours over time’ builds on evidence from the Health Survey of England to present some useful ideas and actions on tackling health inequalities at a local and national level.

The report is essential reading for all local health leads – because of its critique of government policy and the actions that it proposes. It will help in the development of local Joint Health and Wellbeing Strategies.

In summary it says that:

• The overall proportion of the population that engages in 3 or 4 unhealthy behaviours has declined significantly from 33% of the population in 2003 to 25% by 2008.
• However, these reductions have been seen mainly among those in higher socio-economic and educational groups.
• People with no qualifications were more than 5 times as likely as those with higher education to engage in all 4 poor behaviours in 2008 compared with only 3 times as likely in 2003.

One of the dangers of a focus on healthy behaviours is that the policy priority becomes one of blaming the most disadvantaged and focussing on changing their behaviours rather than helping people change their socio-economic circumstances.

As the report acknowledges (page 17):

“our choice of lifestyles – and the cut-off points for what is termed ‘unhealthy’ behaviour are obviously subjective”

AND

“we do not know whether the effectiveness of strategies to change behaviour differs according to the comparative ease of change”

“how do large changes in income or wealth, moving in or out of employment .. impact on taking up multiple behaviours or reducing them?”

Behaviours as a way in to socio-economic issues.

Starting with behaviours always makes me feel uncomfortable – because I am clear that it is people’s socio-economic circumstances that are the biggest determinant of wellbeing. and Duncan Selbie the Chief Executive designate of Public Health England agrees – stating that the balance of factors that impact on wellness are:

• social and economic – education, employment, and violent crime, 40 per cent
• health behaviours – alcohol, tobacco and sexual behaviour, 30 per cent
• clinical – quality and access to health care, 20 per cent
• environmental – air and water quality and building design, 10 per cent

Nonetheless the report provides a useful way into this wider agenda and uses the population behaviour data to argue for a more coherent system level approach to addressing health inequalities.

It builds on a couple of useful reports. The first is a Department of Health one –  “Healthy Foundations – A segmentation model” which provides a helpful framework to make the case to commissioners for a model that is built around active citizens.

Grit your teeth if you don’t like being put in a box.

The Healthy Foundations model has two elements:

3 overaching dimensions collectively determine peoples ability to live healthily:

• Age/Life Stage
• Circumstances/Environments
• Attitudes/Beliefs towards health and health issues

It then identifies 4 further sub-segments that describe different ways we respond to our circumstances.

• Fighters – people living in negative environments who are standing above the norms and have a high level of motivation to look after their health (in the States they would be called Positive Deviants).
• Thrivers – people living in positive environments who have a high level of motivation in looking after their health.
• Survivors – people living in negative environments and who have a low level of motivation in looking after their health.
• Disengaged – people living in positive environments who for some reason have a low level of motivation in looking after their health.

The model is useful – because it recognises the importance of the circumstances we live in and the need to challenge cultural norms and it is simple enough for commissioners to understand. It provides a framework around which we can have a debate about where the balance of investment should be. Of course we need to argue that the definition of ‘Fighters’ encompasses activists who are championing greater citizen control for their communities.

The Kings Fund report makes a number of recommendations for action.

It starts off by providing conditional support for “Every Contact Counts” (p19) the governments soundbite policy on health improvement. While it calls for investment in training and support for staff to implement it presents a more thoughtful and nuanced view than that promoted by the Department and its Strategic Health Authorities. Noting that “successful intervention is likely to require coaching and structured decision making support to help people with multiple risk factors to focus on areas that motivate them and give them the confidence to change”.

This does not sound like “every contact counts” at all noting that “people are likely to require a more long term relationship rather than a series of one off interventions” it suggests that the policy would be better titled ‘every relationship counts’. This feels better particularly when combined with its next recommendation “Exploiting the potential of lay and peer support” (p20) recognising that “lay and peer support offers considerable potential for tackling multiple lifestyle risks… which offer tailored advice, motivation and practical support to people wanting to adopt healthier lifestyles delivered by staff who are representative of their communities”.

The report notes that “appropriately skilled health trainers and lay ‘health champions’ represent an under-used and ready made workforce to help drive the reduction of multiple lifestyle risks in the context of local joint health and wellbeing strategies. This role has a good fit with the ‘Fighter’ group described in the Healthy Foundations document mentioned earlier.

Local Wellness Systems

Finally, the report recognises the importance of system level approaches at a local level. A counterpoint to the failure of Government to offer joined up policies. It highlights the excellent briefing ‘From illness to wellness’ produced by the NHS Confederation in association with the Faculty of Public Health. Drawing attention to the integrated wellness service model – which provides a good basis for Joint Health and WellBeing Strategies.

Conclusion

This report and the links it makes provides a helpful addition to the toolkit for local champions who are arguing for a coherent system level focus on inequalities that places a greater emphasis on closer relationships with citizens.