Bath and North East Somerset

Health Improvement and Modernisation Programme

2002-2005

FINAL DRAFT

Contents

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Chapter 1 What is a Health Improvement and Modernisation

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Chapter 2 Key Issues and Challenges 8-11

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Chapter 3 How We Work Together 12-13

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Chapter 4 Planning and Priorities 14-15

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Chapter 5 Financial Resources 16-20

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Chapter 6 The Health of the Population in B&NES 21-23

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Chapter 7 Tackling Inequalities in Health 24-27

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Chapter 8 Improving Health

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Chapter 9 Health Promotion and Education

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Chapter 10 Saving Lives

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Chapter 11 Caring for Vulnerable People

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Chapter 12 Modern and Convenient Services

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Chapter 13 Resources

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Foreword

We are pleased to present this annual update to the Health Improvement and Modernisation Programme (HIMP) for Bath and North East Somerset (B&NES).

During 2001 the term modernisation was added to the HIMP from its previous title of Health Improvement Programme. This is an important development as it reinforces the purpose of the HIMP in that it is about developing health services as well as the health of people. The HIMP captures the objectives and key tasks that have been identified locally for tackling this agenda. This includes a focus on the modernisation of all aspects of health services such as workforce, IM&T, Estates and Finance, which have previously been dealt with separately. You will see that it is a challenging programme of work and there is a lot to do which will require the skills and efforts of many people working both in frontline services and behind the scenes.

Primary Care Trusts have been given the role of leading the development of HIMPs across the whole health and social community care. This means working together with all partners towards effective planning, organisational development and delivery of services. We need to have good collaboration with other Primary Care organisations and with the range of provider trusts such as the RUH, Avon Ambulance Trust, Avon and Wiltshire Partnership Trust and the Mineral Hospital. A great deal of the work done to improve health and health services involves social issues and social care, which is why the close partnership between health, social services and housing that this HIMP reflects is so important. We are putting our efforts into increasing the effectiveness of these links within all these organisations.

Involving the public in decision-making was given a high priority in the national NHS plan and we are committed to developing this further. Alongside this our work with the voluntary sector and other important partners continues to develop. Some good achievements have already been made but there is a lot more to do so that users of services themselves, their carers and the public at large can influence and access services that are more joined-up, easier to use and more suitable for the solutions that we know local people want.

Working towards these aims is complex and challenging and at present in B&NES, there are a number of significant pressures that will impact on how this agenda of change can be pursued. This Health Improvement and Modernisation Programme describes those pressures and the context within which we will all be working over the next three years. We cannot do everything but we can do a lot of things, which is demonstrated by the hard and dedicated work done by a great many people who are working towards delivering better health and social care services in B&NES. We would like to thank those people for their continuing commitment and efforts to provide good services for local people.

We hope you find the HIMP interesting and useful. We are interested in your views and welcome any comments.

If you would like this document in another format or would like to comment on its content or receive further information, please contact B&NES Primary Care Trust at St Martins Hospital Bath on 01225 831800.

THE CONTEXT

OF THE

HEALTH IMPROVEMENT

AND

MODERNISATION PROGRAMME

Chapter 1

What is a Health Improvement and Modernisation Programme?

Purpose

This chapter explains what a Health Improvement and Modernisation Programme is and gives its background and purpose.

Introduction

The Health Improvement and Modernisation Programme (HIMP) is a framework of how we will work together to modernise local health services and improve the health of local people in Bath & North East Somerset. Good health is important for everybody and access to responsive and good quality services, which enable people to experience healthier lives and to benefit from effective treatments and care when these are needed, is essential. Many people experience problems with their health or die prematurely from avoidable illness, accident or disease. The reasons for this are complex but to live productive lives that enable people to exercise choice and fulfil their potential must be a fundamental concern for all and must shape a society's activities in achieving both good individual health, good public health and good local systems that can meet a community's needs. It is this that has led to the development of Health Improvement and Modernisation Programmes.

Improving health

In 1998 the Government issued an important publication entitled `Saving Lives, Our Healthier Nation' from which Health Improvement and Modernisation Programmes first emerged. Our Healthier Nation outlined two key national aims:

Both of these issues are placed into a local context and explained further in our sections on the health of the population in B&NES and Tackling Inequalities at pages 31-32.

Our Healthier Nation identified four of the most urgent areas where positive action could reduce illness and death, these were:

While these are accepted as essential areas where change needs to happen, there are of course numerous other threats to health and a wide range of treatments and services that need to be provided to enable a healthy and productive population.

Modernising services

Services need to be arranged and delivered efficiently and in such a way that they make the best use of resources and can deliver good professional practice in line with modern expectations. The NHS Plan, released in June 2000, set out a 10-year national vision for how this modernisation was to be achieved. It involves working together, doing things in new ways and putting patients and service users at the centre, of services.

The Bath and North East Somerset Health Improvement Programme is our local framework for delivering this modernisation agenda, for improving services, improving health and achieving positive change.

How the HIMP works

The HIMP is a three-year programme that shows a snapshot of the key tasks we will work to deliver this year, as well as some of our future aims for the next two years. It is a snapshot because it describes a framework for health improvement and modernisation that identifies the main elements of much wider and more detailed plans that direct the activity of partner organisations in B&NES in working towards improved health and improved services. These more detailed plans are referenced within each section of the HIMP so that readers are signposted to further information where requested. The HIMP also provides us with a framework of service development targets by which we can monitor progress and manage our performance.

The context within which we aim to deliver these health improvement and modernisation targets is a demanding one and raises a number of key issues and challenges. These are outlined within the following chapter.

Chapter 2

Key Issues and Challenges

Introduction

As explained in the preceding chapter the Health Improvement and Modernisation Programme covers a wide body of work across a range of programme areas. This section on key issues and challenges highlights some of the major emerging themes which will impact on delivering this work, identifies some of the risks and explains how we will monitor our progress.

Emerging Themes

Balancing priorities

The B&NES health and social care community are currently facing very significant financial constraints and are operating within the context of spending more money than we have available to deliver the services that we need. Money that is available may not be able to be used for new services, as we will need to use it to reduce the deficits that already exist. The detail of this and the reason for the overspends is explained further in the chapter on resources at page 59.

It is possible that the government will decide to invest more in health and social care or that they may earmark additional money particularly for certain services. Whatever level of investment does become available we will have to get better at jointly deciding how to share our understanding of government priorities, how to respond and how to agree what to do locally in terms of allocating resources in B&NES. This is described in more detail in the section on planning at pages 14-15.

At present national guidance to local health services is focusing on delivering key targets in the acute sector such as improving waiting times and emergency services. This emphasis is likely to continue. On the basis of work to date we know that the cost of meeting these challenging targets could be considerable and may further compromise our ability to invest in other areas. We have a complex agenda ahead of us and responding to all that we need to do within the financial picture we face will be an enormous challenge. It will involve working closely together and doing things differently.

Doing Things Differently

It is increasingly evident that the financial pressures we experience, along with the capacity of resource areas such as, Workforce, Estates and Facilities, and Information Management to deliver the programme of work the health and social care community needs are significant issues for us locally. For example, we experience difficulties in recruiting and retaining some staff groups and there is limited availability of land and premises for development.

This highlights the need for us to look not just at how we add new things in to existing services to improve them but also at how we use the existing resources we already have in new ways. We need to explore whether by doing things differently and approaching things differently we can realign resources create more capacity to improve and modernise our services and achieve better outcomes.

When we discussed this approach as part of our consultation process a number of issues were raised by partners and staff. Primarily these were that we should avoid crisis solutions and should concentrate our efforts in developing new systems within areas where it will make the most difference. In addition, we should work where we can to reconfigure services into primary and community care as well as recognise that the biggest asset we have for delivering change, which we need to protect and support is our existing workforce. The themes that follow build on this feedback.

Planning and Partnership

Our own local experience echoes the emphasis in the NHS plan, which shows that by working together partners can improve services more effectively. Some examples of this are the creation of systems to reduce hospital trolley waits or creating community teams that provide more intensive services at home for older people.

As mentioned above, it is also becoming clear that we need to do more joint planning in local health and social care "communities" where organisations and partners work together to create a coherent strategic framework.

These "communities" will be different depending on the service area we are looking at. For example, in mental health the key strategic partners are likely to be the PCT, AWP, Social Services and, to a lesser extent, acute hospitals. On acute secondary care, however, we would also need to work with other PCTs that use the same acute hospitals as us.

This makes planning a complex task and we need to develop better structures and processes for delivering it.

The PCT and the Local Authority have already said that we want to devolve much of the responsibility for planning and developing services to our emerging Service Development Groups. These are described more fully at pages 12-13. We also need to consider the remit of these groups and to extend their role to encompass monitoring how existing services are performing. All organisations that participate in the planning process need to develop a shared understanding of how the groups can work, how they can influence and, above all, how decisions are made. These groups are important; they need to be driving the local agenda and to be recognised as doing that. We need to do more work to help and support the groups in their role and we will need to identify a development programme that will enable them to achieve their leadership function more effectively.

Workforce

Consultation on the HIMP reinforced the view that our workforce is our most valuable and important resource.

We are changing traditional models of organisation and asking staff to be creative about doing things differently. As a local community we need to recognise this change and develop a more co-ordinated approach to staff training and development so that it complements our work on planning and partnership.

As we develop new arrangements for joint working we will be working across boundaries and in new ways. We need to be thinking about how we can involve all local staff in establishing these arrangements and how we will communicate effectively with them.

Putting People at the Centre

Finally, and most importantly, in all our work we must put patients, service users and carers at the heart of what we do.

The NHS plan makes this a key priority and the message is reinforced through the work we have done locally - for example, on the CHD patient survey, our PALS work, the stakeholder days we have held and our ongoing public involvement work.

All organisations are looking at this aspect of their work and progress is already underway but to really involve patients and carers a systematic approach is required that will deeply embed consultation and involvement within our culture. This will take management effort and investment to do properly. We have started on this and have some good early work in place but we will need to build on these foundations.

Risks

Looking across our ambitious programme and in the context of the issues outlined within this Health Improvement and Modernisation Programme we can identify a range of key risks. These can be broadly seen as follows:

Service Issues

There are two major service development programmes where not meeting increasingly challenging national targets and milestones has been identified as a major risk. Achieving access and emergency targets at both the RUH and UBHT not only requires more money than the health community currently has but will need more staff at a time of existing shortages. Additionally major changes in clinical practice and a concerted and coordinated effort by managers and clinicians in the local health and social community will be required.

The second area of significant risk is mental health services where plans to develop services and deliver NSF targets with additional investment of £2M over the next ten years are having to be revisited. Overspending against existing budgets has led to the need for a local recovery plan. In addition, there are concerns over the current and proposed future model of care. Priority is being given to revisiting the service plan for the B&NES locality and securing minimum standards of care, within the context of financial recovery over a period of 3 years.

Financial Resources

As explained earlier, the financial pressures facing us represent a real risk in our ability to implement the programme of development and change. Focus will continue to be placed on financial balance and recovering from deficit. This will inevitably reduce our capacity to invest in services.

Management & Leadership Capacity

Working on improving services requires skills and resources both in terms of people and time. Our management capacity is stretched and this will have an impact on the speed of change.

Workforce Recruitment and Retention

Our workforce is our biggest and most important resource without which change cannot happen and services cannot be provided. We do experience problems in recruiting some staff, for example nurses, which can mean that services are overstretched and the quality of care is reduced. We need to retain good staff and to support them well within their role. It is important that we approach this jointly and look at common approaches in terms of filling gaps and providing training and skills development.

Disengaging in Areas not identified as Priorities

We have already discussed the need to prioritise, and agree on local investment and this is further commented on in the section on planning at pages 14-15. The results of this prioritisation will mean that investment and capacity is focused on "must do" areas leaving other areas without investment or the resources they need for development. We will need to manage this carefully so that progress continues to be made, performance is carefully monitored and gaps identified. It will be important to continue clear and open communication with everybody about this.

Summary

In the above section we have explained that doing things differently will help us to modernise our approaches and to work towards achieving the outcomes we want but, in the light of the risks we have identified our capacity to do this will be limited and we may not be able to meet some of the targets indicated in this HIMP.

Performance Monitoring

Monitoring performance is the key to ensuring that we are accountable for what we do and can identify early on where there are pressures and difficulties and take action to address these. We need to aim for an integrated process where organisations can, where possible contribute to, and draw from, common systems. Our Health Improvement and Modernisation Programme action plans are monitored quarterly and, as explained above, we would want our Service Development Groups to take a greater lead in shaping and responding to this process.

Performance monitoring needs to be meaningful and effective, highlighting pressures and driving forward change. It needs to be constructed in a way that is compatible with the partnership working model that we are developing within the local health and social care community. We need to look at systems performance and not single organisations and to utilise performance monitoring methods which capture all the elements that impact upon a system such as finance, workforce, patient and staff satisfaction, leadership and clinical quality. Looking at reviews of themed areas such as older people may help us to do this.

Developing these systems will take time and resources. There is already a substantial requirement for reporting performance and any new developments will need to fit within the current statutory responsibilities of organisations.

The following chapters within the HIMP explain further the context of partnership working, planning, resource allocation and health issues within B&NES.

Chapter 3

How We Work Together

Purpose

This chapter describes the way in which we organise the planning work within the HIMP, how we are developing our partnership arrangements and how we are approaching involving the public in our work.

Developing our Health Improvement and Modernisation Framework

The areas within which we organise health and social care planning are wide and involve a number of key organisations - the PCT, B&NES Council, AWP, UBHT, the RUH, Primary Care general practices, RNHRD, North and West Wiltshire PCTs, Mendip PCT and a range of voluntary partners. Planning and developing services covers medical services in primary and secondary care, the social care services which promote quality of life and support independence, and the support services that sustain them. Work is going on all the time, within the resources that are available, to develop services that are better able to meet the needs of people in Bath and North East Somerset. The Health Improvement and Modernisation Programme is a part of this work and the key programmes of planning activity contained within it are led through a structure of Service Development Groups which cover the following areas:

There are also a range of important development programmes that cut across all these areas such as:

In addition, essential works that take place, both within and across organisations to enable them to deliver their work include:

All of these areas of focus and activity need to be approached in partnership with the key contributors and are now further described below.

Working in Partnership

No one agency can work in isolation regarding modernisation and the improvement of health. We are working hard in all our programme areas to develop multi-agency partnership and involvement across all the organisations that plan and provide health and social care services in Bath and North East Somerset. The aim is for the Service Development Groups to drive planning forward and these groups look to create a representative membership that draws from the health provider trusts, the Primary Care Trust, B&NES council, voluntary agencies and other partners as appropriate. Each of these individual group report in to the boards and committees of the member's own organisations, where the authority for decision making rests, but it is the groups themselves that have the remit for leading improvements in the delivery of services. The work they do is monitored via the Health Improvement Partnership Board that is itself a multi agency group with representation and involvement across the community. A diagram of how this structure is organised is included as Appendix 1.

Involving the Public

Everyone is a patient or a carer at some time or another and everyone has an interest in how his or her health and care is provided. Working more closely with the public so that they can influence service development and service change is an important area of modernisation and an action plan on how we intend to implement this is included later in this Health Improvement Programme.

The reason this is important is that it is increasingly recognised that public services need to be designed around the people who use them and to work hard to meet the public's needs. The Public Services can be intimidating and cumbersome for patients who may experience systems that are designed suit the organisations needs more than those of the patients. The NHS and its partner organisations need to listen to people and to be ready to change.

The Primary Care Trust is the newest Health Care Organisation locally and it has a key role in leading partnership working and public representation across the Health Improvement and Modernisation Programme. Lay members sit on both the Board and Executive Committee and, along with Social and Housing Services, a structure of devolved planning encourages users, carers and voluntary sector representatives to work with managers in influencing service change.

Listening to patients and the wider public, whilst important in itself is, of course, not enough - we have to learn from what we hear and assimilate this into our attitudes and plans. This has to take place within a complex environment of local service delivery where there are intense demands and limited resources. We continuously have to make judgements and decisions that are balanced towards the best and highest priority achievements that can be delivered within the available resources. In this sense our partnership with the public needs to be a mature and honest one. Together we cannot achieve everything everyone asks of us, and the public will understand that, but we can make progress towards health and care systems that work best for the people who need to use them and it is this aim which underpins the involvement of the public in the work of this Health Improvement and Modernisation programme.

The national priority context within which we aim to do this, and the planning framework within which we need to fit, is explained in the next section.

Chapter 4

Planning and Priorities

Purpose

This chapter talks about how the planning framework is created and what drives the local implementation plans which form this HIMP.

The NHS Plan

Increasingly, the delivery of local health and social care is led by national agendas that set the direction of travel and the goals that need to be achieved. The NHS plan was published in July 2000 and sets a 10-year programme for national change and modernisation across health and social care. It covers a very wide range of incentives and aims laying out targets by which the implementation must be delivered. The plan is the overarching framework, that currently drives the local agendas.

The National Frameworks

National Service Frameworks are models of service development, which local areas need to deliver. They set good practice and aim to establish standards of quality consistently throughout the country. The NSFs are specific and state clear targets to work towards. Currently, frameworks have been published for Coronary Heart Disease, Older People and Mental Health. Frameworks for Cancer, Children, Diabetes and Long Term Conditions are expected soon and others are on the way. The challenge for us is to respond to these national agendas and interpret them so that they can be delivered in a way that meets local need.

In addition to the priorities within the National Service Frameworks a range of other plans and guidance sets the agenda for modernising our services and improving the quality of care. Some examples of this policy framework are:

National Priorities

Each year a summary of overall planning is provided as National Priorities Guidance. This is a statement from the Department of Health that identifies the areas considered as most urgent or significant for the forthcoming year within which resources must be targeted. These are sometimes known as the "must do" areas.

For 2002/2003 the guidance supports the emphasis in the NHS Plan and identifies three major priorities:

· Delivering emergency services when and where they are needed.

· Reducing waiting times and delays throughout the system.

· Improving quality of service and outcomes in the clinical priority areas of cancer, heart disease, mental health and services for older people.

To deliver change the national framework and priorities guidance has, of course, to translate into local implementation, which involves decision making on setting and balancing local priorities.

Deciding on Local Priorities

Priorities need to be realistic within the context of the National Agenda but to also take account of local pressures. They need to be agreed as the most important issues for B&NES.

The HIMP should be the framework that drives planning across the health community of B&NES. We need a framework that gives direction to our planning across not only the first year but years 2 and 3 as well so that we know where we are going and we have prioritised the resources we need to get there. Once this framework is established it should simplify the annual planning process by which we agree detailed service changes and financial plans. The priorities will already be agreed and the annual process will concentrate on finalising the detail. We recognise however that the HIMP needs to develop as a better strategic planning tool to achieve this as this year we have not been able to set detailed priorities over the longer term or to fully agree a medium term investment framework. We aim to improve on this for the future.

To achieve this we will need to establish more shared ownership of the HIMP and to integrate our planning processes with the service providers within the B&NES health community. The Bath Clinical Area Partnership is a new forum in which B&NES PCT has come together with other service commissioners who use the same providers. It is expected to support collaborative working and to help ensure that different commissioners don't set conflicting priorities for providers. This forum will enable us to align our planning. We need to aim for a good process to achieve this, which engages everybody and leads to clear debate on balancing priorities and agreeing local investment over the longer period.

During 2001 we held a range of discussions with local partners that helped us to construct our proposals for this year. The debate that was held led us to conclude that our local position would need to follow the national approach of prioritising investment within the "must do" areas described above. This will inevitably mean that other areas will not receive the resources they may need to fulfil their development targets, which is why an approach of doing things differently will become so important. Additionally, as described in our chapter on key issues and challenges, the financial pressures we are facing will further limit our ability to invest in new areas. The message partners gave us was that they would want to see us responding to this efficiently and in a transparent and open way. They appreciated that choices would have to be made but felt strongly that this must not mean that resources were taken from clinical services. Partners agreed that should any additional investment become available it would need to be allocated against sound criteria that would address areas of highest risk and would make a difference.

While recognising that local investment in the "must do" areas will come first this does not mean that other areas are not important and development work will continue to take place across the board. This Health Improvement and Modernisation Programme sets out this work.

The following section details the resources we have available within which to do this.

Chapter 5

Financial Resources

Introduction

This section sets the financial context for planning within the B&NES Health and Social Care Community over the next 3 years. This is described in 4 parts:

Allocation of NHS Funds

The Government set out the allocation of resources for Health Services over the next five years in the NHS Plan. This envisaged that Health Services funding would increase by one half in cash terms or one third in real terms (i.e. after general inflation) over the five years from 2001-2 to 2005-6. Currently funds flow from the NHS Management Executive (NHSME) to Health Authorities who then allocate funds directly to Primary Care Trusts (PCT's). From 2003/4 funds will be allocated directly to PCT's by the NHSME, using a funding formula designed to provide, over time, each Health Community with a fair share of total NHS Resources.

How are Allocations Calculated?

Allocations to PCTs are calculated using a weighted capitation formula. This formula determines the way resources are shared out fairly amongst PCTs to enable them to purchase similar levels of healthcare for populations with similar health needs.

There are three components of the health budget: -

Each organisation's fair share of the total NHS budget is calculated based predominantly on the age and sex distribution of the PCT population, but also adjusted for other factors which research has demonstrated affect the needs of local people for health services. Account is also taken of unavoidable cost differences between geographical areas.

Factors used in the formula include:

· Long Term illness in under 75's.

· Pensioners living alone.

· Single carer household.

· Number of deaths under 75.

· Adjustment for the relative cost of pay, non-pay and the cost of land and buildings.

What Does This Mean Locally?

On the basis of 2002-3 figures, using this resource formula, the B&NES PCT's "fair share" of resource allocated to the Avon area is 16.72% or £137.2M. The actual allocation is based on historical spending patterns and the PCT currently receives £138.7M. This difference of £1.5M is termed "distance from target". With the move to a national allocation to PCTs and updating to the allocation formula, figures will change. Early indications are that the PCT will continue to be in an above target position.

The speed at which PCT's will receive additional resources to achieve their fair share is termed "pace of change" policy.

To protect existing services, which receive more than a fair share of NHS resources, allocations are seldom reduced. Progress towards achieving fair shares is usually made by differentially distributing new money.

Current Expenditure

Detailed below is a summary of 2002/3 allocations for the B&NES population.

Underlying Deficits within the Local Health System

A number of local healthcare providers are currently delivering health services which cost more than the allocations received by local commissioning organisations (PCTs).

Recovery plans are being agreed with each organisation, which will bring them into balance over a 4 year time period. In this interim period it is anticipated that strategic assistance funding - effectively a non-repayable temporary increase in funding - will be provided to support the local health community over this period.

Detail is provided in Appendix 2 and can briefly be summarised as:

Allocations 2002/3

Column 1 of Appendix 3 details actual allocations expected in 2002/3. It is important to note three factors:

Planning 2003/4 onwards

The amount of uncommitted money available to fund change and development in the future is dependent on a number of factors including:

i. Resource Availability

For the purpose of planning it has been assumed that:

ii. Expenditure

iii. Use of Unallocated Resource

The next stage in planning will be to review priorities for development using uncommitted resources. On the basis of the financial plan shown at Appendix 3, these will amount to between £2.8M and £4M per annum. This process of determining priorities for spend is supported by the existing advisory and service development groups. The priority setting work is also being revisited by all the partner members of the Bath Clinical Area Partnership (BCAP). This is with the aim of achieving agreement on the top priorities across the Bath Health Community, where coordinated action is necessary. Local priority setting may be impacted on by any national decisions to earmark funds for specific programmes.

Summary

The local health community faces significant financial challenges in the medium term. The delivery of the recovery plan will be key to our financial health. However, the plan also assumes a significant level of growth, which should enable the Health Community to achieve service improvements.

Social Services Position

Available Resources

The Council's funding is determined through a formula called the Standard Spending Assessment (SSA). This is similar to the weighted capitation formula funding for PCTs in that it is based on population numbers but with indicators such as:

The Council also receives revenue funding by charging for services, specific government grants and by increasing Council Tax.

The SSA for Social Services in 2002/3 is £25.9M. The Council's planned expenditure on Social Services is approximately £32.9M or 27% above SSA. This effectively means that the Council is funding Social Services by an additional £7M by subsidies from other Council services and increasing Council Tax. For the last two financial years Social Services has significantly overspent due to the costs of children's placements and Care in the Community.

In 2002/3 the Council will invest an extra £3.5M in Social Services in recognition of the pressure on independent sector fees and packages of care for children and adults. The Council receives a number of specific grants each year, including the Promoting Independence Grant, details of which are attached at Appendix 4. The Council has also received new specific grants from Central Government including the Building Care Capacity grant of approximately £1M, details of which are also set out in Appendix 4.

In the longer term Social Services is required to deliver a plan to reduce its spending above SSA as the current level of expenditure will not be sustainable.

Spending Plans

A summary of the main categories of expenditure including all charges for central support services, is detailed below:

Chapter 6

The Health of the Population in B&NES

Purpose

This chapter explains what we know about the health of local people and gives information on illness and death rates compared with other areas of the country and explains the differences that exist for different groups across the area.

How the health of local people compares

Overall people in B&NES enjoy good health compared with the rest of the UK. Table 1 shows two measures of health (or more accurately of illness) in B&NES, compared with Avon and with England and Wales as a whole. The first column compares the prevalence of "long term limiting illness" and the second column "all cause mortality". All of the figures have been "standardised" to take account of differences in age profile of different areas. Both measures show B&NES as being healthier than Avon as a whole, which in turn is healthier than England and Wales as a whole.

Table 1

_ Gathered from the census (or other surveys), it counts individuals who report they have a "limiting long

* The Standardised Illness Ratio compares the prevalence of illness in any given area with the England and

Wales average - which is given a "baseline" of 100

Areas of poorer health

There are substantial differences in health between groups within B&NES, in particular the health of those living in poorer areas, on average, is substantially worse than those who are materially better-off.

There are several standard ways that the level of material deprivation of an area can be measured. Additional information that explains this can be found on the following website:

http://www.avonhealth.org.uk/phealth/phinfo/interpreting.htm

One of these is the Townsend Index, which uses census data to rank areas according to measures associated with low income, such as the level of car ownership and of unemployment. Each of the areas can then be grouped into one of 5 "quintiles" (the poorest one fifth all together, the next poorest all together etc).

If we look at death rates from various diseases in each of the 5 groups there are marked differences. The first graph shows the differences in overall death rate for the population as a whole and for under 65s. Both show an increasing death rate with increasing deprivation (quintile 5 is the most deprived), however the difference between the poor and wealthy areas is much greater for the under 65 age group.

Most causes of death show the same social gradient, in particular deaths from lung cancer, suicide and premature deaths from cardiovascular disease (heart attacks, heart failure and strokes). These differences are shown in Graph 2. Although the total numbers of deaths from suicide is relatively small, there is an approximately 3-fold difference in suicide rate between the most deprived and least deprived quintile.

Not all causes of death follow the same pattern and the final graph shows examples where there is only a small difference (Diabetes), no difference (Colonic cancer) or a reverse gradient, where the least deprived areas have higher rates (Breast cancer).

Closing the Health Gap

These differences in health show that there are substantial differences in health between groups living within B&NES. These differences are important because they point to particular problems in particular groups, which are entirely related to the way society is organised and the lifestyles that we lead. Closing the gap offers enormous potential for health improvement. The steps needed to close the gap are simple to outline but very challenging to achieve because it requires co-ordinated action at all "levels" of society from national policy through local organisations to individual decisions. Co-ordinated action will need to take place within the health service and, most importantly, with other partners. B&NES PCT is well placed to work at a local level, with hospitals, primary and community services and with the local authority, voluntary groups, local business, statutory agencies and others.

This work is focused on in the next section, which discusses Tackling Inequalities in Health.

Chapter 7

Tackling Inequalities in Health

"What greater inequity can there be than to die younger and to suffer more illness throughout your life as a result of where you live, what job you do and how much your parents earned?"

Yvette Cooper

Parliamentary Under Secretary of State for Public Health

The current government places a strong emphasis on reducing inequalities in health and commissioned a report from a group chaired by Sir Donald Acheson¹, which brings together the research evidence setting out the main influences on health inequalities and the evidence of effectiveness of interventions. It sets out recommendations for central government to reduce health inequalities. The government's response to this report, Reducing Health Inequalities: An Action Report² and the white paper Saving Lives: Our Healthier Nation³, set out the government's commitment to `improving the health of the worst off in society'. They emphasise the importance of assessing locally what needs to be done to reduce health inequalities and the targets being set and outcomes identified at that level.

The factors that determine our health can be considered as a series of "layers", with our genetic makeup at the core which then is altered and modified by nutrition and environmental factors, including our upbringing, family relationships and educational opportunities. In adult life our work, housing, neighbourhood, lifestyle and social networks can act to keep us healthy or cause us to become ill. Similarly, many of the aspects of the environment that we tend to take for granted, such as safe food, clean water and air, are vital. Health care services are very important, particularly when we fall ill, but only play a small part in the whole picture.

The interplay of these "determinants of health" are shown in the following illustration:

Figure 1

Action for health and social care services

Health and social care services can help to reduce inequalities in health by ensuring:

Consideration of health inequalities needs to run through the planning and provision of all health and social care services, for this reason B&NES PCT is developing inequalities as a "cross-cutting" theme for all service development groups. Public health and information staff within the PCT will work with clinicians and others to carry out "equity audits" to monitor the uptake and health impact of existing services. Such information will help plan new service developments.

Working with partners

Evidence suggests that the most important determinants of health inequalities lie outside the health sector and, therefore, improvements in the underlying determinants of health such as poor housing or education, low income or unemployment are very powerful levers in bringing about a reduction in health inequality. A particularly important partnership is that between the PCT and the local unitary authority with its responsibilities for housing, social services, environmental health, education, leisure services and economic development. The Health Improvement Partnership is an important forum that brings together the local authority, health service, voluntary groups and others, with the broad aim of improving health. In April 2001 a subgroup - the Public Health Development Group - was set up with representatives from the PCT (public health, health promotion and health visiting) and from B&NES unitary authority (environmental health, health promotion, economic development and housing). The task of the group is, by April 2002, to:

One of the major challenges for the group is to fully understand the various threads of activity that are taking place across the health service, local authority, business and voluntary agencies. There is already a lot of innovative and effective co-operative work taking place under such initiatives as the communities partnership, community safety partnership and specific interagency strategy groups.

The determinants of health are wide-ranging and hence intervention can appear very daunting. However certain principles allow us to prioritise. Firstly, interventions in early life have a particular potential for long-term benefit, by improving an individual's life chances. These interventions will range from ensuring a healthy pregnancy, through to supporting families with child care and parenting skills, improving childhood nutrition, increasing the uptake of further education and reducing teenage pregnancy. Secondly, interventions have multiple benefits, so for example reducing smoking will reduce lung cancer deaths, chronic lung disease, heart disease, strokes and peripheral vascular disease.

Reducing smoking deserves particular mention for several reasons:

The Public Health Development Group completed its initial work in April 2002. This coincided with the abolition of Avon Health Authority and the further devolution of staff and responsibility to B&NES PCT. New staff at B&NES include a Director of Public Health, with support staff and the disaggregated Health Promotion staff from Health Promotion Services Avon. B&NES PCT is now well equipped to contribute fully to the co-operative effort to improve health and reduce inequalities in B&NES.

THE

HEALTH IMPROVEMENT

AND

MODERNISATION PROGRAMME

Key tasks for this year

Plans for the future

Progress towards the NHS Plan

Progress towards the Public Involvement developments in the NHS Plan is good.

Key documents for further information:

Public Involvement Action Plan 2002-2005

Involving Patients and the Public in Healthcare DOH Nov 2001: http://www.doh.gov.uk/involvingpatients/listening.pdf

Supporting the implementation of Patient advice and liaison services DOH 2002 http://www.doh.gov.uk/patientadviceandliaisonservices

The NHS Plan - A plan for investment, a plan for reform

http://www.doh.gov.uk/nhsplanimpprogramme/index.htm

Glossary of Terms

Key documents for further information:

Tackling Inequalities and Community Health Development

The Health of the Population 2001. Report of the Director of Public Health, Avon Health Authority.

http://www.avonhealth.org.uk/phealth/info.htm

Health Promotion Operational Plan 2001-2002

http://www.hpsa.org.uk/about_us/pub/opplan20012002/banesop.pdf

Local Public Health Partnership developing strategy

http://www.doh.gov.uk

Independent Inquiry into Inequalities in Health Acheson, 1998 London: The Stationary Office

Closing the Gap: setting local targets to reduce health inequalities HDA

(Reducing Inequalities: An Action Report 1999

Opportunity for all - Tackling Poverty and Social Exclusion. DSS 1999)

Drugs and Alcohol

Drug Action Team Treatment Plan

Drug Action Team Annual Return

Young People's Substance Misuse Plan 2002-2004

Bath and North East Somerset Community Safety Strategy 2002-2005

http://www.bathnes.gov.uk\communitysafety

Teenage Pregnancy

B&NES Local Teenage Pregnancy Strategy 2001-2010

Social Exclusion Unit/Teenage Pregnancy Strategy

http://www.teenagepregnancyunit.gov.uk

http://www.doh.gov.uk/healthinequalities

Injury Prevention

Avonsafe Injury Prevention Alliance Strategy 2001-2006

Avonsafe Operational Plan April 2002 - March 2003

Avonsafe Annual Report 2000-2001

Saving Lives: Our Healthier Nation (1999) Department of Health

Bath and North West Somerset Local Transport Plan (2000) and Road Safety Plan (2000)

Tomorrow's Roads: Safety for Everyone (2000) Department of the Environment, Transport and the Regions.

Smoking Cessation and Prevention

Tackling Smoking - strategy for tackling smoking by the Avon Health Community 2000 -2003 (Dec 2000)

Smoking Kills: a White Paper on Tobacco (1998) Secretary of State for Health. London: Stationary Office

http://www.official_documents.co.uk/document/cm41/4177/4177htm

NSF Coronary Heart Disease, London: Dept of Health (2000)

Food and Health

Reducing the risk of Coronary Heart Disease in B&NES - Action plans

National Service Framework for Coronary Heart Disease DoH ( 2000)

http://www.doh.gov.uk/nsf/coronary.htm

The NHS Plan - A plan for investment, a plan for reform

http://www.doh.gov.uk/nhsplanimpprogramme/index.htm

Sexual Health

Tackling Smoking - strategy for tackling smoking by the Avon Health Community 2000 -2003 (Dec 2000)

Smoking Kills: a White Paper on Tobacco (1998) Secretary of State for Health. London: Stationary Office

http://www.official_documents.co.uk/document/cm41/4177/4177htm

NSF Coronary Heart Disease, London: Dept of Health (2000)

Physical Activity

Reducing the risk of Coronary Heart Disease in B&NES - Action Plans

National Service Framework for CHD DoH ( 2000)

http://www.doh.gov.uk/nsf/coronary.htm

Saving Lives: Our Healthier Nation (1999) Department of Health

http://www.doh.gov.uk

Preventing Drugs Misuse

B&NES Young People's Substance Misuse Plan 2002 - 2004

Tackling Drugs to Build a Better Britain: The Government's Ten-Year Strategy for Tackling Drugs Misuse

http://www.archive.official-documents.co.uk/document/cm39/3945/3945.htm

Protecting Young People: Good Practice in Drug Education in schools and the youth service

Mental Health Promotion

Promoting Positive Mental Health in Bath and North East Somerset (draft)

National Service Framework for Mental Health DoH (1999)

http://www.doh.gov.uk/mentalhealth.htm

Making it Happen, DoH, 2001

http://www.doh.gov.uk/mentalhealthpromotion/nsfstd1.htm

Young People

Schools for Health (Local Programme accredited to National Healthy

School Standard)

National Healthy School Standard

http://www.wiredforhealth.gov.uk/healthy/healint.html

Children's National Service Framework (under consultation)

http://www.doh.gov.uk/nsf/children.htm

Cancer

Avon Cancer Local Modernisation Review (2001)

Department of Health (2000) The NHS Cancer Plan. http://www.doh.gov.uk/cancer/cancerplan.htm

National Cancer Programme (2000) Manual of Cancer Standards. http://www.doh.gov.uk/cancer/mcss.htm

Secretary of State for Health (1999) Saving Lives: Our Healthier Nation

The NHS Plan - A plan for investment, a plan for reform

http://www.doh.gov.uk/nhsplanimpprogramme/index.htm

Coronary Heart Disease

Coronary Heart Disease Local Implementation Plan (2000)

The NHS Plan - A plan for investment, a plan for reform

http://www.doh.gov.uk/nhsplanimpprogramme/index.htm

Secretary of State for Health (1999) Saving Lives: Our Healthier Nation

Department of Health (2000) National Service Framework for Coronary Heart Disease

Diabetes

Testing times: a review of diabetes services in England & Wales: London: Audit Commission

http://www.audit-commission.gov.uk

National Service Framework for Diabetes

http://www.doh.gov.uk/nsf/diabetes/index.htm

Mental Health

B&NES Mental Health Local Action Plan (October 2000)

National Service Framework for Mental Health

Mental Health Policy Implementation Guide (DOH Feb 2002)

Health Service Advisory Report (March 2002)

http://www.doh.gov.uk/nsf/mentalhealth.htm

Older People

Joint investment plan and health improvement plan for B&NES

National Service Framework for Older People

B&NES Strategy for Older People

http://www.doh.gov.uk/nsf/olderpeople.htm

Childrens Health

B&NES Action Plan for Childrens Health 2002/05

B&NES Childrens and Young Peoples Service Plan

Building a Strategy for Children and Young People (Children and Young People's Unit)

http://www.cypu.gov.uk/

Physical and Sensory Impairment

Physical and Sensory Impairment Services Work Programme/Action Plan 2002/2004

Welfare to Work JIP

The NHS Plan - Improving Health & Reducing Inequality, Chapter 13

http://www.doh.gov.uk/nhsplanimpprogramme/index.htm

Learning Difficulties

Bath & North East Somerset Joint Investment Plan - Service for Adults with a Learning Difficulty 2001-2004

Valuing People, a new strategy for Learning Disability for the 21^st century. March 2001.

http://www.doh.gov.uk/learningdisabilities/index.htm

Waiting Times for Treatment

Bath Clinical Area Partnership work programme

The NHS Plan - A plan for investment, a plan for reform

http://www.doh.gov.uk/nhsplanimpprogramme/index.htm

Emergency Care

Bath Clinical Area Partnership Work Programme

Reforming Emergency Care (Department of Health) http://www.doh.gov.uk/capacityplanning

The NHS Plan - A plan for investment, a plan for reform

http://www.doh.gov.uk/nhsplanimpprogramme/index.htm

Primary Care - Capacity and Access

Primary Care Collaborative Work Programme 2002

Walk In Centre Development Plan (Source - Walk In Centre Interface Group)

'More Than One Way to Skin a Cat' (The Centre for Innovation in Primary Care, 2001)

http://www.doh.gov.uk

Chief Nursing Officer's ten key roles for Nurses (Making a Difference, 1999)

http://www.doh.gov.uk

Primary Care - Professional Development

Primary Care Collaborative Work Programme 2002

Walk-in Centre Development Plan (Source - Walk-in Centre Interface Group)

'More Than One Way to Skin a Cat' (The Centre for Innovation in Primary Care, 2001)

http://www.doh.gov.uk

Chief Nursing Officer's ten key roles for Nurses (Making a Difference, 1999)

http://www.doh.gov.uk

Clinical Quality

Clinical Governance Development Plan

`Your Guide to the NHS'

http://www.nhs.uk/nhsguide

The NHS Plan - A plan for investment, a plan for reform

http://www.doh.gov.uk/nhsplanimpprogramme/index.htm

Organisation with a Memory (2000)

http://www.doh.gov.uk

A First Class Service - Quality in the New NHS (1998)

Public Involvement

Public Involvement Action Plan 2002-2005

Involving Patients and the Public in Healthcare DOH Nov 2001: http://www.doh.gov.uk/involvingpatients/listening.pdf

Supporting the implementation of Patient advice and liaison services DOH 2002 http://www.doh.gov.uk/patientadviceandliaisonservices

The NHS Plan - A plan for investment, a plan for reform

http://www.doh.gov.uk/nhsplanimpprogramme/index.htm

Information Management & Technology

Avon Local Implementation Strategy, April 2001

http://nww.avon.nhs.uk/imtconsortium/project_management/lis_descript/lis.htm

(Requires NHSnet access. B&NES specific version available through the PCT.)

Information for Health, September 1998

http://www.doh.gov.uk/ipu/strategy/index.htm

Building on Information Core, January 2001

http://www.doh.gov.uk/ipu/strategy/overview/index.htm

Information for Social Care, May 2001

http://www.doh.gov.uk/scg/infsoc/information.htm

Estates and Facilities

B&NES Local Plan - including minerals & waste policies (Deposit Draft 2002)

Developing an Estate Strategy - Modernising the NHS

http://www.nhsestates.gov.uk

Finance

Avonwide financial recovery programme

Resource allocation guidance 2002/03

The NHS Plan - A plan for investment, a plan for reform

http://www.doh.gov.uk/nhsplanimpprogramme/index.htm

Workforce/Tackling Diversity

Staffing Services Strategy 2001-03

The Vital Connection, An equalities framework for the NHS

Race Relations (Amendment) Act 2000

http://www.doh.gov.uk/race_equality

Improving Working Lives DOH

http://www.doh.gov.uk/iwl

Working Together DOH HSC1999/168

Developing the workforce