health on the margins commissioning to tackle health inequalities in gypsy and traveller communities...

HEALTH ON THE MARGINS

Commissioning to tackle health inequalities in Gypsy and Traveller communities

Sponsored by:

Health on the margins

Chair’s welcome and introduction

Tom McCreadySponsored by:


Addressing the cost of health inequalities

Dr Jessica Allen, UCLSponsored by:

Addressing the Costs of Health Inequalities

Dr Jessica Allen

UCL Institute of Health Equity

26 February 2015

Gypsy Traveller health outcomes

0 10 20 30 40 50 60 70

Chest pain/discomfort

Possible angina

Chronic cough

Chronic sputum

Bronchitis

Asthma

Health - slide from Inclusion health data pack

A study by Parry and others2 compared self reported health status of 260 Gypsies and Travellers with a comparator group (matched for age and sex). They found that Gypsies and Travellers had poorer health, twice the number of Gypsies and Travellers believed their health status was poor. (30%>14%)

They also found, however, low levels of inequality with diabetes, stroke and cancer between the Gypsy Traveller population and the comparator group. They suggest that cancer levels were lower due to lower levels of screening, qualitative evidence suggests cancer is always seen as terminal within this group.

Contrary to the above evidence, Kearney and Kearney1 look at a group of Irish Traveller children and find lower levels of asthma than in a comparison (non-Traveller) group. They suggest that the travelling lifestyle is actually a protective factor.

%

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Health Summary – taken from Health Inclusion data pack• Gypsies and Travellers are a heterogeneous group that have different health

needs

• Poor health Gypsies and Travellers are twice as likely to have poor health than the rest of the population (30%>14%)

• Infant mortality is far higher:– Miscarriages are higher than a matched group 29% of women have had

one against 16%– Not including miscarriages 17.6% of women had lost a child against less

than 1% of a matched group

• Healthy life expectancy Health status deteriorates rapidly after 50.

• Mental health Gypsies and Travellers have high levels of mental health problems, over 3 times more likely to suffer anxiety and almost 3 times as likely to be depressed

• GP Access Gypsies and Travellers are less likely to be registered with a GP, visit a GP and even then often do not reveal that they are Gypsy Travellers

• Approximately a third cannot read or write

• Gypsies and Travellers have high unemployment rates

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Health inequalities

• Social justice – health inequality the worst inequality of all

• And economic costs to individuals, communities and society

Cost of Inaction• In England, dying prematurely each year as a result of

health inequalities, between 1.3 and 2.5 million extra years of life.

• Cost of doing nothing• Action taken to reduce health inequalities will benefit

society in many ways. It will have economic benefits in reducing losses from illness associated with health inequalities. Each year in England these account for:– productivity losses of £31-33B – reduced tax revenue and higher welfare payments of £20-32B

and – increased treatment costs well in excess of £5B.

Reducing Health inequalities

• The conditions in which we are born, grow, live, work and age

• Creating the conditions for people to have control of their lives

A. Give every child the best start in life

B. Enable all children, young people and adults to maximise their capabilities and have control over their lives

C. Create fair employment and good work for all

D. Ensure a healthy standard of living for all

E. Create and develop healthy and sustainable places and communities

F. Strengthen the role and impact of ill-health prevention

The Marmot Review : 6 Policy Objectives

Cited obstacles to further prioritisation and implementation – nationally and locally

• We don’t know what to do• It’s not our role and remit (health care sector,

national government role)• Investment is difficult, no money available• Difficult to prioritise – not high on the political or

public agenda• No clear accountability incentives, enforcements• Lack of data and information

To prioritise politically and ensure implementation

• Evidence• Practical• Cost efficacy• Public support• Measurement and monitoring • Accountability• Leadership

Costs

• Costs of health inequalities are high – Individuals and public purse

• ‘cost of doing nothing’

• Cost of doing something– Evidence is hard to come by and hard to collect– There is evidence, but often not precisely right– But enough to go on

• Need political and public support to lever investment

There are other ways

• Health inequalities legislation – all health sector

• Social Value Act – all public procurement bodies

Social Value – What is it?

The Social Value Act states that during procurement public bodies in England and Wales must consider:

“How what is being proposed to be procured might improve the economic, social and environmental well-being of the relevant area, and…

How, in conducting the process of procurement, it might act with a view to securing that improvement.”

Social Value is…• An opportunity to improve health and reduce inequalities

in social determinants– Locally AND nationally

• An opportunity to ‘work’ the economic power of public procurement. In 2012-13 over £230 billion spent on public sector procurement of goods and services.

• An opportunity to align with other priorities and obligations

• A legal obligation!

Health Inequalities legislation

• Legal duties to reduce health inequalities for the first time

• Platform for joining up health services, social care services and health-related services at local level

Opportunities

• Cost argument is important but there is evidence to support

• More needed, but sufficient to act

• Needs leadership, political support and public support

• And there are accountability mechanisms


Case study

Gypsy/Traveller community member

Sponsored by:


Bringing a Gypsy & Traveller voice into the NHS

Olivia Butterworth, NHS EnglandSponsored by:

www.england.nhs.uk

Citizen, Community and Public Participation

Olivia Butterworth

NHS England

The NHS is founded on a common set of principles

and values that bind together the

communities and people it serves – patients and

public – and the staff who work for it.

NHS Constitution

www.england.nhs.uk

Public Voice and Participation: Why?• Engaging and involving communities in the planning, design and

delivery of health and care service can lead to more joined-up, co-ordinated and efficient services that are more responsive to local community needs.

• Public participation can help to build partnerships with communities and identify areas for service improvement.

• Principle 7 of the NHS Constitution: “The NHS is accountable to the public, communities and patients that it serves” – NHS England needs a way of meeting this through direct and transparent engagement with the public.

• Participation for improvement: Insight gathered from the public helps to improve services and outcomes as well as potentially helping to spot failures.

www.england.nhs.uk

NHS England: 13G Duty as to reducing inequalities• The Board must, in the exercise of its functions, have regard to the

need to— • (a)reduce inequalities between patients with respect to their ability

to access health services, and• (b)reduce inequalities between patients with respect to the

outcomes achieved for them by the provision of health services.

Clinical Commissioning Groups: 14T Duties as to reducing inequalities• Each clinical commissioning group must, in the exercise of its

functions, have regard to the need to— • (a)reduce inequalities between patients with respect to their ability

to access health services, and• (b)reduce inequalities between patients with respect to the

outcomes achieved for them by the provision of health services.

Health Inequalities Duties

www.england.nhs.uk

• (2)The Board must make arrangements to secure that individuals to whom the services are being or may be provided are involved (whether by being consulted or provided with information or in other ways)—

• (a)in the planning of the commissioning arrangements by the Board,

• (b)in the development and consideration of proposals by the Board for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them, and

• (c)in decisions of the Board affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact.

• (3)The reference in subsection (2)(b) to the delivery of services is a reference to their delivery at the point when they are received by users.

Section 23 (13Q) of NHS Act 2006, amended by HSCA 2012:

“when people do need health services, patients will gain far greater control of their own care – including the option of shared budgets combining health and social care. The 1.4 million full time unpaid carers in England will get new support, and the NHS will become a better partner with voluntary organisations and local communities.”

www.england.nhs.uk

• Local democratic leadership on public health. Local authorities now have a statutory responsibility for improving the health of their people,

• Encouraging community volunteering. Volunteers are crucial in both health and social care. Three million volunteers already make a critical contribution to the provision of health and social care in England

• Supporting carers. Two thirds of patients admitted to hospital are over 65, and more than a quarter of hospital inpatients have dementia. The five and a half million carers in England make a critical and underappreciated contribution

• Stronger partnerships with charitable and voluntary sector organisations … these voluntary organisations often have an impact well beyond what statutory services alone can achieve.

The Five Year Forward View

www.england.nhs.uk

NHS Citizen

Citizen Journalism - Access Dorset

http://www.youtube.com/watch?v=JBQuKLrvdnY

www.england.nhs.uk

• Patient Participation Groups• Local Healthwatch• Community Groups • Support groups • Schools and pre-schools • Youth Clubs, Sports Clubs • Digital spaces and forums

• Places that people use in

their everyday lives?

Let’s not reinvent the wheel

Where are all the people?


Case study


Sponsored by:


The National Gypsy & Traveller Health Inclusion Project

Helen Jones, Leeds GATE

Zoe Matthews, FFTSponsored by:


Case study


Sponsored by:


Applying learning from commissioning for marginalised groups

Dr Ann Marie Connolly, Public Health England

Sponsored by:

Applying learning from commissioning for marginalised groups

Dr Ann Marie ConnollyDeputy Director, Health Equity and Place Public Health England

Overview

• Barriers and health experiences of Gypsies and Travellers

• Standards for commissioners and service providers

• Joint Strategic Needs Assessment and Health and Wellbeing Strategies

• Engaging with and winning the trust of hard to reach groups through the community and voluntary sector

• Overcoming data gaps with hidden population groups

• Improving access to primary care

• Public Health England support for commissioning for vulnerable groups

38Health on the Margins – Commissioning to tackle health inequalities in Gypsy and Traveller communities - 26 February 2015

Health outcomes of gypsies and travellers

• Low rates of GP registration

• Poorer general health

• High rates of limiting long term illness

• High smoking prevalence

• Poor birth outcomes and maternal health

• Low child immunisation rates


Barriers experienced by Gypsies and TravellersLess likely to receive effective, continuous healthcare due to:

• Inequalities in registration with GPs (as a results of discrimination, mismatch in expectations, ‘expensive patients’, reluctance of GPs to visit sites)

• Poor literacy

• A lack of ‘cultural awareness/competence’ amongst service providers


Standards for commissioners and service providersA set of minimum standards for planning, commissioning and providing health care for homeless people and other multiply excluded groups (including gypsies and travellers).

Part A outlines a strategy for improving health care for homeless people, Gypsies and Travellers, vulnerable migrants and sex workers.

Part B provides commissioning guidance to ensure high quality health services for these groups.

Part C presents generic standards for all services, followed by specific standard sets addressing a range of clinical settings considering specific excluded groups.


Standards for commissioners and service providers – Part B• specialist services are not the only solution,

enhanced access and outreach services are also important.

• Primary care providers – assessed for their willingness to register patients and refusal should robustly contested.

• Service delivery needs to be seamless and collaborative commissioning will be required.

• cultural beliefs strongly influence health and health-seeking behaviour – targeted culturally-appropriate services or specialist liaison workers may be needed


Joint Strategic Needs Assessment and Health and Wellbeing Board Strategy• Through the Joint Strategic Needs Assessment (JSNA) and the Health and

Wellbeing Board Strategy (HWBS) ensure that health inequalities remain at the top of the agenda

• JSNA and HWB have a crucial role to play in ensuring services meet the needs of all in the local community

• ‘Patient voice’ - service user involvement must be integral to commissioning and delivery.

• Data concerning vulnerable groups, their access to health care and health outcomes should be collated, and inform commissioning to address health inequalities.


Identifying key vulnerable groups in data collections• As with other hidden, vulnerable groups the gaps

in routine information sources on Gypsy / Irish Traveller health are notable.

• The data on where Gypsies / Irish Travellers live in the 2011 Census (caravans and bricks and mortar) would provides a basis for a population denominator

• Authorised sites for Gypsies / Travellers are assigned unique postcodes (although around one quarter of caravans in the annual caravan count are on unauthorised sites).


Engaging with the community and voluntary sectorNHS Newham Pacesetters project

• Delivered through a partnership between NHS Newham and Roma Support Group (RSG)

• Collaboration with RSG, who are known and trusted by the Roma community was central to the success of the project.

• Involvement of RSG helped support a level of access and engagement which would otherwise not have been possible


Improving access to primary careNewham Pacesetters example:

‘transitional terms of registration’ which enables people to register with a GP with a proof of ID rather than proof of residence.


Inclusion health case study 2: The Market Harborough Medical Practice, Leicestershire

Gypsy/Traveller engagement and costed into the design and delivery of services

Built confidence through a named “trusted” professional

GP contract levers used to deliver an enhanced care model

PHE action on vulnerable groups


• CQC’s inspection framework for GPs for vulnerable groups: contribution to the framework which included specific consideration of homeless and Gypsies and Travellers.

• Single homeless population healthcare project: supporting local public health teams to improve the local ‘system’ as experienced by single homeless people

• Homeless prevention, health & wellbeing: Homeless Link research into effective interventions (due 14/15)

• Health needs audit: Homeless Link updating their tool to better inform local commissioning

• The right home environment for TB treatment: resources for local areas to enable this

PHE action on vulnerable groups


• Alcohol identification and brief advice interventions in housing settings: feasibility study

• 3rd International Symposium - Homelessness, Social Exclusion & Health Inequalities 2015: e-learning resources

• Housing workforce contributing to public health outcomes: resources and evaluation

• In partnership with NHS England, regional workshops on health inequalities: aimed at Clinical Commissioning Groups and Local Authorities

• Series of briefings to support local action on health inequalities: of note, for vulnerable groups in particular, is a forthcoming publication on health literacy

Thank you for listening /

[Invitation for questions or comments on PHE support for improved health outcomes for Gypsies and Travellers?]



Q&As

followed by coffee

Sponsored by:


Influencing local commissioning

Dr Peter Ilves, GP

Sponsored by:

Influencing local

commissioning

Dr Peter Julien ILVESGP Wandsworth – singlehandedCCG and HWB Board member Lead for Self Management ServicesLocality commissioning Lead for CCG and Mental Health (West Wandsworth)Big White Wall Lead Consultant for Primary care and CommissioningQandA expert for Gurgle Magazine

Health on the MarginsConference

26th February 2015

Good to be transparent from the start!

90% of all medical consultations occur in primary care

1in 3 consultations (Av.) have a MH component

1,000,000 appointments happen in Primary care

From 10 years ago seeing patients twice as often

Increasing complexity being seen Physical + mental health – GP contract blocks cherrypicking – no criteria, no list blocking etc…

78% of all consultations are for people with 2 or more chronic conditions

By 2016 the constultation rate is predicted to rise another 12% - 396.7m/year

In England: 2009 70 GP FTE/100,000 – 2014 65.5 FTE/100,000

WE CAN'T DO IT ALONE……….

Some Primary Care Stats

A visual example: Fragmentation – Isolated communities and assets – silos – seldom heard

Primary care

Communities and families/carers/friends

Acute and Secondary care

Third sector

Community services

Know yourself/Know your needs

Understand the needs of your own population

Physical

Mental

Social

Environmental

Gather data/intelligenceQualitative – word of mouth and what you knowQuantitative – if possible with evidence

Opportunities Clinical commissioning groups

Public Health – Local and England

Local Authority – social care

Local commissioning teams – e.g. clinical reference groups, strategic and operational groups, schools/School nursing etc…

Joint Commissioning

Better care funds

Co-Commissioning

Five year look forward

London Health Commission recommendations

Technologies and connectivity – Big White Wall, Buddy app, patient access (accessible record…)

Know your commissioner Factually

Joint Strategic Needs Assessment Health and Wellbeing Board Strategy Individual strategies

Scrutinise their own strategies

Now their priorities and challenges Often similar to yours Their drivers Their targets National targets – driving documents (e.g. 5 year look forward)

Use their language

Turn their own priorities and targets 180

Add in yours and make it unavoidable – create the possible

Demonstrate "value" and mutual benefits – create the possible

Whose door to knock on Local "friends"

GPs – preferably sitting on the board or strategy group

Ask to join a group that is relevant to you as an "expert"

Community health and social workers – community outreach

Mental health workers – associate with MH trust, IAPT etc..

CCG leads

Specific condition domains

Locality or board members

PH leads – LA

Specific condition domains

Locality or board members

HWB partnership

LA leads

Local councillors

Officers

Third sector partners

Others: NHSE, Specialised commissioning, HEE, AHSN…

SPONSORS

Start local

The address book

Bringing it together

Educate and raise awareness of what you know Make your leaders visible

Share your knowledge

Influence local commissioning

Health Education England funding? – needs local sponsors?

Explore and create an offer(s) Individually

As a community

Collaboratively – local partners

Create the business case (remember end of year invest) You are the expert

Look for the key driver (use their language) – ask….. Mental health

AandE attendance

Length of stay

Supported early discharge

Children

Prevention

Lifestyle interventions

Self management

Sponsors/partners not adversaries

The offer and the business case

Asset Based Empowerment

Leader and community empowerment

Your communities as hubs

Connected

Educating

Delivering

Your "leaders"/others trained with skills

Connected

Educating

Delivering

Possible:

Psychology – psychological and wellbeing practitioners? IAPT, family therapy, dementia etc..

Youth work – engagement, empowerment, employment, drugs, alcohol, criminal justice, MH awareness, prevention and treatment, schooling and education etc..

Physical health – Cardiovascular, respiratory, other long term conditions

Community services – Linked in and connected, older people, isolation

Prevention and lifestyle intervention

Self management/resilience skills

Is it you or the commissioners who are at the margins?

Thank you all for bringing this commissioner in from the margins

I would like to Acknowledge the following people:Malik Gul

Wandsworth Community Empowerment Networkhttp://www.wandsworth.gov.uk/site/scripts/home_info.php?homepageID=149&recordID=46260

Lankelly Chase FoundationFunder of WCEN

AndIntroducing me to the wonderful Helen Jones - LeedsGATEhttp://www.lankellychase.org.uk/funded_projects/435_wandsworth_community_empowerment_network

Wandsworth CCGFor creating opportunities and training for me as a commissionerFor making me realise that it is people who can be the barrier and

not commissioning

http://www.wandsworth.gov.uk/site/scripts/home_info.php?homepageID=149&recordID=46260

http://www.wandsworth.gov.uk/site/scripts/home_info.php?homepageID=149&recordID=46260

http://www.lankellychase.org.uk/funded_projects/435_wandsworth_community_empowerment_network

http://www.lankellychase.org.uk/funded_projects/435_wandsworth_community_empowerment_network


Case study


Sponsored by:


Monitoring and evidence based commissioning

Zoe Matthews & Rachel Wemyss, FFT

Sponsored by:

Monitoring and evidence based commissioning

Friends, Families and TravellersZoe Matthews, Strategic Health Manager

Rachel Wemyss, Health Policy Officer

Poor ethnic monitoring leads to a lack of data on Gypsy Traveller

health inequalities

A focus on geographical health inequalities draws attention away

from inequalities between different ethnic groups

Gypsy Traveller health needs are not prioritised due to a lack of

local data

There is inadequate evidence for interventions to improve access to health services or health outcomes

for Gypsy Traveller communities due to a lack of ethnic monitoring

A Cycle of Exclusion

Health Inequality Duty• The health inequality duty is a general duty and

commissioners are responsible for identifying health inequalities locally taking a ‘whole population’ approach.

• The Health and Social Care Act 2012 conveys a legal duty on CCGs to reduce inequalities in ability to access health services and outcomes achieved

• “Publishing guidance or policies, or making decisions without demonstrating how you have paid due regard to the Duty leaves the organisation open to legal challenge.”

- NHS Guidance for NHS commissioners on equality and health inequalities legal duties

http://www.england.nhs.uk/wp-content/uploads/2014/12/hlth-inqual-guid-comms.pdf

2011 Census and the NHS Data Dictionary

• ‘Gypsy/Traveller’ was included in the 2011 Census for the first time

• The NHS Data dictionary has not yet been updated to include ‘Gypsy Traveller’

• This lack of inclusion significantly impedes the ability of CCGs to identify inequalities in access to services and health outcome

Ethnic Monitoring and Trust

• Improving ethnic monitoring takes more than including categories on forms

• An environment in which Gypsies and Travellers have the confidence to declare their ethnicity without fear of prejudice or discrimination must be fostered

• Investment in building cultural competency relationships of trust between professionals and Gypsy Traveller communities is crucial

Inclusive JSNAsAs a minimum a good JSNA should:

• Provide an accurate picture of the demographics of vulnerable groups

• Include health and social needs

• Describe how existing services meet needs and where there are any gaps in provision

• Use a range of qualitative and quantitative data

PopulationWider social

and economic determinants

Lifestyles and health

promotion

Health & Wellbeing

Status

Service Utilisation

Priorities for action

JSNAs should include information on Gypsy Traveller communities with reference to –

Gypsy Traveller People are experts in their own health

• Use peer interviews, focus groups and Gypsy Traveller forums to gather community insight.

• Engage with grassroots Gypsy Traveller organisations. The National Federation for Gypsy Traveller Liaison Groups has a list of members organised by region available here.

• Engage with local organisations that work with Gypsy Traveller people. FFT have a services directory of Traveller support services.

http://www.nationalgypsytravellerfederation.org/members.html

http://www.nationalgypsytravellerfederation.org/members.html

http://www.gypsy-traveller.org/directory/

Robust and inclusive JSNAs are conducted with Gypsy Traveller

communities. Key barriers to accessing health services and gaps in

provision are identified.

Commissioners recognise the inequalities in access and health outcomes local Gypsy Traveller

communities face

Services such as community outreach or health trainer programmes are

commissioned to link Gypsy Traveller communities into primary care and

signpost to support services

Outcomes of projects targeted at Gypsy Traveller communities are evaluated to inform future needs assessments and commissioning.

A cycle of Inclusion

CCG funded community engagement influencing commissioning

Following a survey into the use of urgent care services the recommendations were made and actioned – • 3 GP surgeries and the walk-in centre were given Gypsy Traveller

cultural awareness training• Information regarding duties to register patients with no fixed abode

and lack of utilities bill was provided to GP surgeries• A help card was produced and distributed to support access to GP

surgeries –


Q&As

followed by lunch.

(Parallel streams run after lunch)

Sponsored by:


Feedback

and final Q&As

Sponsored by:


Close of conferenceThank you, please hand in your

badges and feedback forms as you leave and have a safe onward journey.

Sponsored by:

health on the margins commissioning to tackle health inequalities in gypsy and traveller communities...

Documents

health summary

poorer health

margins health

mental health gypsies

result of health inequalities

self reported health

gypsy travellers

comparator group