THE JOINT HEALTH AND WELLBEING STRATEGY FOR HARROW 2013- 2016 FINAL
THE JOINT HEALTH AND WELLBEING STRATEGY
FOR HARROW 2013- 2016
FINAL
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1 INTRODUCTION
Harrow is a good place to live. People in Harrow are, in general, healthier
and live longer than the average for England and London. However, the
Joint Strategic Needs Assessment has shown that unacceptable inequalities
in health and wellbeing exist in Harrow as in the rest of the UK. People living in
different social circumstances experience differences in their health and
wellbeing and in the length of their life. People living in the poorest parts of
Harrow live on average 7 years less than those in the richest areas. These
differences are avoidable but can’t be addressed by health services alone.
Health inequalities occur because of inequalities in society – in the places
where we live, in education, access to employment and the sort of jobs we
do and the money we have to live on and the lifestyle choices we make as a
result.
The local Sustainable Communities Strategy1, has a vision that by 2020,
Harrow will be recognised for:
� Integrated and co-ordinated quality services, many of which focus on
preventing problems from arising, especially for vulnerable groups,
and all of which put users in control, offering access and choice;
� Environmental, economic and community sustainability, because we
actively manage our impact on the environment and have supported
inclusive communities which provide the jobs, homes, education,
healthcare, transport and other services all citizens need.
� Improving the quality of life, by reducing inequalities, empowering the
community voice, promoting respect and being the safest borough in
London.
1 Harrow’s Sustainable Communities Strategy 2009-2020.
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In order to achieve this vision, inequalities in health and wellbeing must be
addressed to improve the quality of life for all residents. Reducing health
inequalities and promoting wellbeing and independence for adults and older
people is a key goal in achieving the 2020 vision.
This strategy for health and wellbeing in Harrow sets out the strategic
direction for partners to work together to improve health and wellbeing,
reduce health inequalities and promote independence. The success of this
work will be guided and measured by the Health and Wellbeing Board.
2 PURPOSE
The purpose of this strategy is to improve health and well-being in Harrow by
guiding the commissioning intentions of the member organisations, primarily
the local authority and the clinical commissioning group. It is grounded on
the fundamental principles that what we do will:
• Improve the wellbeing and quality of life of the people of Harrow
• Reduce the health inequalities gap
• Have long term and sustainable impact
The Health and Wellbeing Board for Harrow was established in shadow form
late 2011. The Board has taken external advice and undergone a
development programme to establish the working relationships and role for
the Board. The Board have overseen the development of the Joint Strategic
Needs Assessment, which was then used by the Board to debate and agree
the principles underpinning this strategy and the priority areas for Harrow.
Our strategy aims to bring together the wide variety of areas that impact on
health and well-being by making those links explicit. As we enter a phase
where funding for public services is limited, partnership working and
maximising the benefits of preventing ill health will become even more
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important. To this end, we also recognise the need to build capacity to
deliver public health programmes in the voluntary/third sector and the
important contribution that front line staff working in both public and business
sectors have in delivering the health improvement vision.
This strategy is not about finding additional funding to make these
improvements. In the current financial climate, this is not possible. It is,
however, about getting the best value for the funding we have through
effective commissioning, by reducing duplication and by working closely
together to achieve more than any one agency could achieve on its own.
The London Health Improvement Board, which receives 3% of the total public
health budget for Harrow, will also be a partner in this strategy. The LHIB has
a number of priorities including childhood obesity, cancer prevention and
early detection and alcohol misuse.
As a result of this strategy we expect that future commissioning intentions and
service plans will change to meet these priorities. Our annual implementation
plans will identify what we want to achieve within the year and how we will
achieve it.
3 A SNAPSHOT OF HEALTH AND HEALTH INEQUALITIES IN HARROW
Harrow is generally a healthy place but like everywhere else, there are parts
of the borough or groups with our community who have poorer health.
Inequalities result from differences in health outcomes (i.e. mortality rates, life
expectancy, etc.) which occur as a consequence of differences in health
status (socio-economic, deprivation, life styles and behaviour). The Harrow
Joint Strategic Needs Assessment (JSNA) identifies a number of inequalities.
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Life expectancy within the Borough, at 81.2 for men and 84.6 for women, is
better than that of England as a whole. However, there are marked
geographical inequalities. Women in Pinner South can expect to live more
than 10 years longer than women in Wealdstone. Men in West Harrow can
expect to live for five and a half years longer than men in Greenhill ward. It is
clear from analysis of local data that effort needs to be made to address the
inequality gap in the more deprived parts of the borough.
The JSNA shows that the biggest impact on life expectancy could be made
by focusing on circulatory disease. If mortality rates from Coronary Heart
Disease in the most deprived parts of Harrow were to reduce to the rate seen
in the most affluent, life expectancy would increase by over a year in males
and over 9 months in females. Lung cancer in men, breast cancer in women
and COPD2 in both sexes are the other areas where significant gains in life
expectancy could be made.
The slope index of inequality (SII) is an indicator that demonstrates within-area
inequalities. This indicator shows the relative difference within an area. In an
area where there are few inequalities within the area the slope index will be
small. It is important that this indicator is not looked at in isolation as an area
where everyone is deprived or where everyone is affluent will have very
similar small SII.
The data for Harrow shows that the inequalities in women in Harrow have
decreased over the past six years but have worsened for men in Harrow over
the same period. The difference in life expectancy in women in the most
deprived deciles in Harrow was six years lower than in the most affluent areas
but this has decreased to only 4 years. In men, the gap started at less than
seven years but has widened to over 8 years.
2 Chronic obstructive pulmonary disease – lung diseases such as emphysema and chronic bronchitis which are largely caused
by smoking
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FIGURE 1 SLOPE INDEX OF INEQUALITY FOR MALES AND FEMALES IN HARROW 2001-5 TO 2006-2010
Source: Public Health Observatories of England
Smoking prevalence and teenage pregnancy are amongst the lowest in
England and mortality from heart disease and cancer are also lower than
those of England as a whole, although they remain the two highest causes of
death in Harrow. Diabetes rates and tuberculosis rates are higher than the
England average.
However, health and wellbeing is about how we live not just what we die
from and indicators of quality of life need to be taken into consideration.
Mental health is one such area. Mental Illness affects one in four people
nationally but also has an impact on the carers and families of those with
poor mental health – making them more likely to suffer from it too. Although
rates of common mental health problems as well as more severe mental
illness are lower in Harrow than they are nationally, there are still hundreds of
people at any time who are suffering from mental health problems. Other
indicators of quality of life include fear of crime, which is high in Harrow
despite the low crime rates in the borough, and the proportion of carers who
are able to have a break from caring.
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4 HEALTH IS EVERYONE’S BUSINESS Health improvement is everyone’s business. As health technologies become
more advanced and more successful so should our efforts in improving
health. A strategy for health improvement looks to engage both public
sector and private sector organisations in its task there-by making health
improvement part of mainstream systems for incentives, performance
management, regulation and inspection.
FIGURE 2 THE DETERMINANTS OF HEALTH
Source: Dahlgren G, Whitehead M. 19913.
No single person or agency determines a population’s health and well-being.
In Figure 2, we can see the multi-layered factors that determine our health
and wellbeing.
• Our age, gender and genetic makeup are something we can’t get
away from. Some diseases are more common in one gender; some
conditions increase with age; some people are genetically
predisposed to certain diseases.
3 Dahlgren G, Whitehead M. 1991. Policies and Strategies to Promote Social Equity in Health. Stockholm, Sweden: Institute for
Futures Studies.
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• The decisions we take about our lifestyle will influence our health. Do
we eat healthily, take enough exercise, smoke, drink alcohol, use
drugs, sunbathe, have unprotected sex, or engage in high risk
behaviours? All of these and more will have an impact on our health
and wellbeing
• Our family and social networks and the way we interact with society
around us also have an impact on our health. Our health habits are
shaped as children and many of our health behaviours are influenced
by our peers. Socially isolated people are more likely to have poorer
health – and people with poorer health can become socially isolated.
• Where we live, what we do, how much we earn, the quality of our
food, our water, our natural and built environment and what services
are available to us can make us more or less healthy. Health services
are only a small part of this whole picture. They are important in
responding to ill health and in promoting good health.
• Taxation policy, funding of public services, global warming, intra- or
international conflicts and economic recession are all issues that affect
health and wellbeing but which have to be dealt with at a national
and sometimes global level.
What the diagram doesn’t show is how much each of the different factors
affects our health. This is shown in Figure 3. Health care services main role is
in dealing with the consequences of ill health although the focus on disease
prevention is also important. They account for around a quarter of the
overall health status of the population. Our age and genes account for
around 15% of the overall health status of the population and the physical
environment in which we live accounts for a further 10%. The most important
factors by far are the social and economic determinants which account for
half of the overall health status of the population.
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FIGURE 3 ESTIMATED IMPACT OF DETERMINANTS ON THE HEALTH STATUS OF THE POPULATION
5 SETTING OUR PRIORITIES
The setting of priorities is based on the evidence presented in the Joint
Strategic Needs Assessment and the best available evidence4. This shows
that:
• There is a social gradient in health – the lower a person’s social position,
the worse his or her health. The focus on reducing the gradient in
health inequalities requires action across all the social determinants of
health.
• Focusing solely on the most disadvantaged will not reduce health
inequalities sufficiently. To reduce the steepness of the social gradient
4 Fair Society, Healthy Lives - Strategic Review of Health Inequalities in England post-2010. The Marmot Review, February
2010
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in health, actions must be universal, but with a scale and intensity that
is proportionate to the level of disadvantage.
• Action taken to reduce health inequalities will have economic benefits
in reducing losses from illness associated with health inequalities which
currently account for productivity losses, reduced tax revenue, higher
welfare payments and increased treatment costs.
• Effective local delivery requires empowerment of individuals and local
communities and will require a local partnership approach as well as
action by central government.
Reducing health inequalities will require action on six policy objectives:
• Give every child the best start in life
• Enable all children young people and adults to maximise their
capabilities and have control over their lives
• Create fair employment and good work for all
• Ensure healthy standard of living for all
• Create and develop healthy and sustainable places and communities
through effective planning and housing strategies
• Strengthen the role and impact of ill health prevention
The Health and Wellbeing Board has agreed that the priorities for Harrow
should reflect three important criteria:
• They affect the wellbeing and quality of life of the people of Harrow
• They will lead to a reduction in the health inequalities gap
• They will have long term impact
Bearing these in mind, seven local priority areas have been agreed.
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5.1 LONG TERM CONDITIONS (LTCS)5
Long term conditions is the umbrella term used to describe the health
conditions that have a long term or lifelong impact. For the purposes of this
strategy, we have initially agreed to focus on cardiovascular disease (heart
disease stroke and hypertension), respiratory disease and diabetes. These
were chosen because there is a significant impact on wellbeing and quality
of life of people with LTCs and their family and carers. LTCs are the major
drivers of the health inequalities gap - CVD is the highest and respiratory
disease the third highest cause of death in Harrow. Although Harrow has one
of the highest rates of diabetes in London, it is largely well managed and
many of the adverse consequences are avoided. However, action is needed
to prevent people developing diabetes in the future as the rates are
increasing and therefore the treatment costs will also increase putting
additional financial pressure on the system.
All of the LTCs chosen share some common risk factors such as smoking,
obesity, diet, physical activity and alcohol. All of these will need to be
addressed as there is clear evidence that effective prevention will have a
long term impact on the rate of LTCs.
LTCs fit with the policy objectives in that there is a significant role for ill health
prevention and early interventions are possible from pregnancy and
throughout life that affect long term outcomes. There are links to
employment issues for people with LTCs and impact of disease on local
economy. With the additional pressure on household finances, the standard
of living of people with LTCs and their carers is affected and the .
5 Long term conditions include cardiovascular disease, respiratory disease and diabetes
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5.2 CANCER
Cancer was chosen as a priority because it has a significant impact on
wellbeing and quality of life of people with cancer and their family and
carers. Although many cancers are treatable and have a good and
improving survival rate, cancer is the second highest cause of death in
Harrow. Lung cancer and breast cancer are two specific cancers that drive
the health inequalities gap. Effective prevention and early detection will
have a long term impact on incidence of some cancers and deaths from
other cancers.
As with long term conditions, there is a significant role for ill health prevention
and early detection and there are considerable employment issues for
people with LTCs and impact of disease on local economy. Standard of
living is affected impacting on the individual with the condition and their
family.
5.3 WORKLESSNESS
Employment underpins much of our wellbeing whether we consider the
standard of living and ability to make healthy choices or the impact on self-
esteem. It has a significant impact on inequalities and the impact of
unemployment can be a long term impact affecting children’s attitude and
aspirations and intergenerational umemployment.
In terms of the inequalities policy objectives, there is the obvious link to
creating fair employment and good work for all. However, there are also links
to education of children and training/retraining of young people and adults
to maximise their capabilities for future employment. Reducing worklessness
will have benefits for the local economy and will make it possible for people
to have a healthy standard of living which in turn will make them more able
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to make healthy lifestyle choices. There are obvious links between long term
worklessness and housing need.
5.4 POVERTY
Poverty has a major impact on health inequalities and affects wellbeing and
quality of life. It can have a long term impact on families. It is important to
look at poverty at the current time as the changes in the benefits system will
mean that some families in Harrow are adversely affected either by
increasing the pressure on them by reducing benefits or by a need to move
to housing that is under the benefit threshold. This could have impacts on
social cohesion and mental wellbeing as well as the increasing risk of physical
health problems associated with poverty.
Poverty has impact right through a person’s life: from a poor start as a child,
poorer educational attainment leading to lack of control over their lives,
lower paid and low grade work and a poor standard of living with poor
housing. It impacts on individuals, families and the community in which they
live. It makes it less likely that people can make healthy choices about their
lifestyle and the stress from having a lack of control over their lives impacts
considerably on mental health.
5.5 MENTAL HEALTH AND WELL-BEING
Our mental health affects our wellbeing and quality of life. It is a factor
common to many of the other priorities. People with long term conditions
can have poor mental health due to their illness but equally poor mental
health is related to poor physical health outcomes and is therefore related to
health inequalities. Has long term impact
Mental health links into a number of the inequalities policy objectives: post-
natal depression and coping can impact on a child’s start in life; bullying,
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stress and diagnosed mental health problems reduces people’s ability have
control over their lives or hold down a job. Our community and environment
impact on our mental health whether by our perceptions of crime or
reduced social cohesion and increased isolation. And of course, there is a
role for mental health promotion to reduce both the incidence and impact
of mental ill health.
5.6 SUPPORTING PARENTS AND THE COMMUNITY TO PROTECT CHILDREN AND
MAXIMISE THEIR LIFE CHANCES
Giving a child the best start in life is important to the individual child but also
to society in general. Parents and carers impact cannot be underestimated.
A child’s early life affects their wellbeing and quality of life not only during
their childhood but throughout their life – and indeed into the next
generation. It is vital that this part of the strategy picks up the
recommendations from the recent children's safeguarding and looked after
inspection.
This priority area directly impacts on the goals to give every child the best
start in life and enable all children young people and adults to maximise their
capabilities and have control over their lives It also relates to the healthy
standard of living for all and healthy and sustainable communities. As early
behaviours lay down the foundations for behaviour in later life, it is important
that we strengthen the role of primary prevention.
5.7 DEMENTIA
As our population ages and life expectancy increases, we expect that
dementia will become an increasingly pressing issue. Dementia affects the
not only the person’s wellbeing and quality of life but that of their family and
carers.
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Caring for someone with dementia, as with other long term conditions,
affects the carer’s ability to maintain their employment and their standard of
living. Keeping both physically and mentally active can prevent the onset
and the development of dementia and therefore there is a role for
promotion of healthy lifestyle choices.
6 OUR APPROACH TO ADDRESSING THE PRIORITIES
In order to address each of the priorities we will take a life course approach.
For each of the priorities we will consider the contribution of prevention, early
detection, intervention and services, reablement and end of life issues. Using
the model in Figure 4, we will look at each of the priorities and the actions
needed to improve health and reduce inequalities in each of the life course
blocks.
FIGURE 4 HARROW’S APPROACH TO DELIVERING THE HEALTH AND WELLBEING STRATEGY
6.1 PRIMARY PREVENTION: MATERNAL HEALTH AND EARLY INTERVENTION
Primary Prevention is concerned with the actions that can be taken to
reduce the likelihood of a disease starting to develop but can equally be
considered in terms of preventing poverty or unemployment. The first stage
of our delivery model is concerned with the actions that can be taken
before, during or after pregnancy and in childhood to improve health and
wellbeing.
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Examples might include reducing smoking in pregnancy; reducing teenage
pregnancy in order that we have improved maternal education which
impacts on the child’s health and life expectancy; increasing rates of breast
feeding. Child health interventions will include education, and development
of life skills and ambitions.
6.2 PRIMARY PREVENTION: LIFESTYLES AND COMMUNITY
The second element for primary prevention is around lifestyle issues and the
impact of community. The choices we make about how we live our lives has
a huge impact our future health and wellbeing. Important elements in the
lifestyles part of this section will include tobacco use, healthy eating, physical
activity, maintaining a healthy weight, alcohol use and substance (drug and
alcohol) misuse.
The community part of this section is about the social dimension of wellbeing
which encourages building relationships within the community and
contributing to the physical environment with the intention of the common
welfare of one's community. We know that socially isolated people are
more susceptible to illness and have a death rate that is higher than those
who are not socially isolated. People who maintain their social network and
support systems do better under stress and can create a good mood and
enhance self-esteem.
6.3 EARLY DETECTION
Finding a problem early means it is usually easier to deal with. This section will
cover the things we can do to identify problems early. It will include things
like cancer screening and NHS Health Checks. However, we will also look at
how we might need to target certain groups who are at higher risk or who
are particularly vulnerable e.g. young people at risk of future unemployment,
.
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6.4 SERVICES AND INTERVENTIONS
This section will involve the bulk of services that are provided by health and
the local authority. It will include what health, social care and other services
are available; how they are accessed; the pathways to follow to ensure
seamless care; and how we can use our resources effectively. It will also
include other issues affecting people accessing these services such as the
health of carers. This section will be closely linked to the service planning for
the Community Health and Wellbeing Directorate at the local authority and
to the commissioning strategy and Out of Hospital strategy of the Clinical
Commissioning Group.
6.5 SECONDARY PREVENTION: BREAKING THE CYCLE AND SUPPORTING
INDEPENDENCE
Once people have a problem, there are things that can be done to break
the cycle of poor health and help people back into independence. This will
include the different sorts of rehabilitation e.g. cardiac rehab or pulmonary
rehab; programmes that target people with early stage problems e.g
exercise on prescription for people with LTCs and interventions to stop people
being readmitted into hospital e.g. falls prevention. It will also include issues
like debt management or retraining for people who have lost their jobs.
6.6 DIGNITY AND CHOICE AT THE END OF LIFE
Overall, the consensus is that the majority of people wanted to be informed,
share their care planning and to die with dignity in their own surroundings, be
that home or nursing home. This section of the strategy will be about how we
can achieve this aim.
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7 AN EVIDENCE-BASED APPROACH
In developing this strategy we will use the best available evidence of what
works to improve health and wellbeing and reduce health inequalities. To
support our approach we will continue to use evidence of what works and
learn from others to adopt policies and interventions that will work in Harrow
and which are acceptable to our diverse population. We have a number of
policy drivers that will support us in implementing the strategy. We have
engaged with stakeholders and will continue to do so to ensure that our
understanding matches theirs and that we are working towards the same
goals without duplicating the effort unnecessarily. It is using this partnership
approach that will deliver the reduction in health inequalities that we are
seeking.
We have a range of tools and techniques that we will employ to support the
development of action and implementation plans that will support the
strategy.
7.1 EVIDENCE AND BEST PRACTICE
Using and promoting evidence based practice is key to the delivery of
effective health improving programmes. We will, wherever possible use the
best available evidence from a range of sources.
NICE provides a wide range of reviews of effectiveness of public health
programmes. However, not all of the topics we want to focus on or the
groups where we know there are health inequalities are covered by NICE
guidance. In these cases, we will use other evidence based reviews such as
those from the Cochrane Collaboration, the national Library for Public Health
and in published reviews in peer reviewed journals.
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Where evidence is not available we will use best practice guidelines to
develop programmes to address our priorities and ensure that there are
measures of effectiveness embedded in each programme as well as robust
evaluation.
7.2 NATIONAL POLICY DRIVERS
There is a wealth of evidence that shows that we need to shift the focus of
health and wellbeing. Our current model relies on providing services to
respond to health needs. The shift needs to move towards providing services
to reduce the likelihood of future ill health through prevention and early
intervention targeted at those with the greatest need as this will be the most
cost effective way forward.
7.3 TOOLS AND TECHNIQUES
There are a number of tools and techniques that will be used to deliver the
strategy and monitor its impact. These tools are considered best practice in
public health.
7.3.1 EQUITY AUDIT
Equity Audit is an important method for systematically assessing the
inequitable mismatch between the need of a population for services and
interventions and those that are being provided. Fundamental to this is an
understanding of the difference between Equality (where everyone gets the
same level of health care) and Equity (where people with higher need get
more). It begins with an equity profile but does not stop there. It must
include agreed recommendations and actions to address the inequities
identified and evaluation of the impact of the actions undertaken to reduce
the inequity.
7.3.2 HEALTH IMPACT ASSESSMENT
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Health Impact Assessment (HIA) is a technique to assess the positive and
negative impact of policies, plans and proposals. HIA will recommend how
the negative impacts on health can be minimized and positive ones
maximized. It can be undertaken at a variety of levels – a rapid stakeholder
appraisal to a full health impact assessment – which have different resource
implications. It can also be undertaken prospectively and retrospectively.
We have already developed and adopted a local tool for undertaking HIAs
on partnership policies.
7.3.3 NEEDS ASSESSMENT
Needs assessment is the process by which the needs relating to a particular
population group, disease topic or determinant are analysed and actions
required. Health needs assessments (HNAs) are worthwhile only if they result
on changes that will benefit the population and it is therefore it is essential
that adequate resources are available and the outcomes that are required
to be achieved are realistic unachievable. HNAs involve epidemiological
profiling the current and future needs, opinions of stakeholders (including
patients) and a comparison with other similar areas. It is underpinned by
robust evince of what works to address the needs that are identified. It will
include action plans and risk management or risk minimisation plans and
measuring the impact and reviewing the plan.
We will undertake a minimum of four health needs assessments per year on
the topics identified by health and wellbeing board.
7.3.4 SOCIAL MARKETING
As we have shown, there are many differences in the population across
Harrow. Targeting the right messages and delivering the right services to the
right population in a way that is acceptable to them and addresses their
needs is vital to achieving an effective and efficient health and well being
programme. The way to do this is to look at the population in greater detail
and rather than simply use geography or age or ethnicity, we look at
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characteristics and the preferences of different groups, their attitudes and
beliefs about health and other services and how best to communicate with
them. This is known as population segmentation. Harrow has a group of
locally specific Mosaic profiles or segments which are already being used
across the local authority, health and police services though the Joint
Analytical Group. This targeting of segments within the community is known
as social marketing and this approach will underpin the delivery of the
strategy.
8 CONSULTATION AND DEVELOPMENT OF IMPLEMENTATION PLANS
Consultation workshops and meetings will be held with stakeholders to discuss
the priorities; identify the main outcomes we want to achieve on each of the
priorities and develop the action plans for the priorities.
8.1 THE PRIORITIES
Stakeholders will be consulted on whether they agree with the priority topics
identified by the health and wellbeing board. If they don’t, they will be
asked which priority should be replaced.
8.2 OUTCOMES
Our strategy is outcome focussed. Stakeholders will be asked what outcomes
we should be striving for. It is important that we focus on the outcome for the
whole workstream although different elements may have process indicators
8.3 IMPLEMENTATION PLANS
In our implementation plans, we will identify:
• What we need to do
• What we have already do well and plan to continue
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• What we already have planned that will support the outcomes of the
strategy
• How we will address any inequalities issues
• Who is responsible for delivery
• How we will monitor the outcomes
These implementation plans will be monitored and reviewed annually. Each
priority area will be championed by at least one member of the Health and
Wellbeing Board.