The role and value of asset based approaches to improving health outcomes for inclusion health groups especially vulnerable migrant groups.. Ranjit Senghera.

The role and value of asset based approaches to improving health outcomes for inclusion health groups especially

vulnerable migrant groups..

Ranjit Senghera

Senior Manager Equalities and Health Inequalities; Regional Link Midlands and East & National Lead for Inclusion Health. NHS England

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What I aim to cover?• NHS Five Year Forward View (October 2014) and

opportunities for asset based approaches.

• To provide an overview of currently legal and policy drivers policy and legal context from NHS England

• Meeting the needs of the poorest the fastest: Where are we with Inclusion health groups and tackling health inequalities?

• The role and value of asset based approaches to improving health outcomes for inclusion health groups especially vulnerable migrant groups.

• Examples and approaches

NHS Five Year Forward View (October 2014)

• Sets a clear direction for the NHS, showing why change is needs and what it will look like.

• Key challenges; increased patient need and expectations; new treatment options merging; less funding, quality variable, preventable illness widespread; health inequalities deep–rooted.

• Three key opportunities:

• Need for a radical upgrade in prevention and public health

• When people do need health services, patients will gain far greater control over their own care. E.g. shared budgets across health and social care; supporting carers; and NHS will become a better partner with voluntary organisations and local communities 3

NHS Five Year Forward View (October 2014)• Breaking down the barriers in how care is provided: New care

models, Co-Commissioning Agenda; Better Care Fund; from one size fits all to diversity of care models with radical new care delivery options i.e. Multispecialiality Community Provider; Integrated primary and acute care systems; redesign of A & E services:

• Key aim: To improve primary care through national leadership and meaningful local flexibility.

• The NHS as a social movement

• “None of these initiatives and commitments by themselves will be the difference between success and failure over the next five years. But collectively and cumulatively they and others like them will help shift power to patients and citizens, strengthen communities, improve health and well-being, and as a by-product – help moderate rising demands on the NHS”

• NHS Five Year Forward View (October 2014)

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Build on an asset based approach:

• Build on the existing assets within the community, where there is a strong voluntary sector and a large number of volunteers delivering good work in the community, particularly due to financial constraints.

• Include experience and understanding of migrants and community organisations in dialogue about health services to ensure commissioning in-line with local needs.

• Build the capacity of such organisations to increase their ability to be involved.

• Consider a central database locally to know which community organisations exist to enable access to them.

• Consider the myths and misinformation in media about migration and health use, and collective responsibility to address this information.

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Health Inequalities

Health Inequalities have been defined as:

“Differences in health status or in the distribution of health determinants between different population groups”

• Addressing Health inequalities forms a key part of NHS England’s vision and values and are in line with those of the NHS Constitution.

• Addressing Health inequalities is also crucial to tackling the key challenges across the domains, including preventing premature mortality, improving recovery from illness and enhancing quality of life for people with long-term conditions.

• We should work to ensure that NHS services are resourced, planned and commissioned, based on robust evidence, to address both barriers to healthcare and health inequalities.

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Legal Duties – First Ever• Health and Social care Act 2012

• NHS England and CCGs have duties to have regard to the need to reduce inequalities in access to health services and the outcomes achieved for patients.

• Secretary of State has a duty to have regard to the need to reduce inequalities covering his NHS and public health functions for the whole population.

• NHS England, CCGs and Monitor have further duties around integration of health services, health-related services or social care services where they consider this would reduce inequalities.

• Monitor can set licence conditions and may appoint a special administrator.

• The Act also contains duties around health inequalities on, variously, SofS, NHS England and CCGs concerning planning, reporting and assessment.7

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Duty to integrate health services with health-related or social care service

NHS England, Monitor and each CCG must exercise its functions with a view to securing that

the provision of health services is integrated with the provision of health-related services or social care services

where it considers that this would:

• reduce inequalities between persons with respect to their ability to access those services; or

• reduce inequalities between persons with respect to the outcomes achieved for them by the provision of those services.”

What Can We Do? 15-20% • Know them

• Wider social determinants - HWBB

• Primary and secondary prevention – 15-20% clinical and quality of care; Health behaviours account for 30% of influences (public health messages/screening)

• Commission – across population and knowing physical environment (10%)

• Socio-economic factors account for 30% of all influences – where you live, employment.

• Plan according to need – proportionate universalism (shifting the mean)

• Services that match need

• Community engagement & Co-production9

Health Inequalities – largely determined by social inequalities

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Source: Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute

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What can the NHS do about Health Inequalities?

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Source: Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute

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What can the NHS do about Health Inequalities?

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Current Priorities for the National Equalities & Health Inequalities Team

• Assurance within NHS England - governance, active awareness and application within decision making, capability of staff including a positive awareness of legal duties, reporting mechanisms, Equality & Diversity Council (EDC); 9 Strategic priorities and Deliverables (NHS England Board

Paper – Annex B);

• CCG development and assessment process including annual assessment against these duties

• Working with national commissioners (specialised and primary care) to promote equalities & reduce health inequalities

• Embedding in business of NHS England including Resource Allocation, Incentive Reviews, Quality Accounts etc.

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Delivery mechanisms• The Equality and Diversity Council provides visual leadership on equality and

health inequality across the NHS.

• The Equality Delivery System (EDS 2) is a facilitative tool that helps NHS organisations to promote equality and reduce health inequalities.

• Health inequalities subgroup of the commissioning assembly will work with CCGs on health inequalities and NHS England commissioners and will have a wide-ranging in its role as an ‘expert reference group’.

• National Programme Board on Promoting Equality and Tackling Health Inequalities (Internal NHS England) - lead on implementation and delivery of Business Area 8

• The NHS England Equality and Diversity Strategy Group design, implement and evaluate effectiveness of NHS England’s internal strategy for equality, diversity in the workplace.

• NHS Values Summits bring together diverse range of people and perspectives to understand how people’s differences can affect experiences of health and care.

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Equality & Health Inequalities Strategic Priorities and Deliverables

• NHS England as system leader and supports the NHS EDC

• Supports NHS organisations to improve equality performance & meet the public sector Equality Duty

• Robust data available to measure equality and health inequalities, determine priorities and drive improvement

• Create an NHS workforce & leadership that is reflective of communities we serve and free from discrimination

• Resource allocation supports duties on inequalities

• Incentives and prioritise improvements in primary care towards communities & groups who experience inequalities in healthcare & outcomes

• Embed equality and tackling health inequalities in CCG assurance regime

• Remove derogations

• Support reduction of mental illness inequalities through Parity of Esteem Programme.

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Meeting the needs of the poorest the

fastest: Where are we with Inclusion health

groups and tackling health inequalitiesNational Inclusion Health Programme & Board

4 Working groups:

Workforce & Leadership; Data & Research; Provn,

Prevention & promotion & Assurance &

Accountability

Inclusion Health Board & Working Groups

Key facts and concerns

Key issues

What works well?

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Marmot – Fairer society – how ?

• Marmot review highlighted,

• “reduce the steepness of the social gradient in health, [with] action [that is] universal, but with a scale and intensity that is proportionate to the level of disadvantage”.

• This is called “proportionate universalism”, which means that closing the gap in health inequalities requires outcomes for the most disadvantaged to improve faster than the most advantaged

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Marmot – Life Expectancy and Healthy LE

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The living reality of ‘Tri-morbidity’• Long term homelessness is characterised by ‘tri-morbidity’

(combination of mental ill-health, physical ill-health and drugs and alcohol misuse) complex health needs and premature death

• Rough sleepers experience stark health inequalities – rough sleepers life expectancy is 30 years shorter than average population; at 47 for men and 43 for women (Crisis, 2012)

• Costs to the NHS – Homeless people attended A&E 5 times as often as house population, are admitted 3.2 times as often and stay 3 times as long because they are 3 times as sick.

• Resulting in secondary care costs 8 times higher than average; costing estimated £330 million a year

• Source: McCormick, B, 201019

Inclusion Health Groups• Life expectancy is lower than national average

• Healthy life expectancy is poorer than national average, with poorer health outcomes, that are within the gift of the NHS.

• Data on inclusion health groups is poor

• Very little evidence on cost benefit of current models, place care services and providers at risk’

• Need better integrated and co-ordinated services for inclusion health groups

• Barriers to access GP services for all inclusion health groups

• Inappropriate discharges pathways and outcomes for inclusion health groups

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Experiences for Inclusion Health groups• Need support to access services

• Practical barriers in accessing appointments in primary care lead to person frequent fliers at A&E

• Negative experiences in primary care (registering with GPs, accessing timely appointments and attitudes of A&E staff,) and face stigma and discrimination versus treatment

• Poor communication; from staff to homeless patient; and homeless person expressing themselves, poor engagement skills, confidence

• Other barriers – Groups do not complain, even though face worse health outcomes

• All inclusion health groups DO NOT make complaints due to barriers of access to system, knowledge and to lack of confidence in navigating system21

Poor patient experience's for Inclusion Asylum seekers

• Asylum seekers and refugees – poor access to mental health problems; with rates of up to 5 times higher than in the general population

• There is evidence of late booking, poor antenatal care and poor pregnancy and maternal health outcomes

• Poor rates of registration with GP services and being turned away at least once from general practices in England (rate currently at 54% in London study)

• Source: London Health Observatory, 2013

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Reducing health inequalitiesInclusion Health - Improving health care pathways for vulnerable migrants

What we need to do?

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The NHS belongs to the people……that includes vulnerable

migrants and the homeless 24

We need integrated co-commissioning primary care models and services leading to

integrated provision for Inclusion health groups/patients25

Barriers to GPs registering vulnerable migrantsmust be removed

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General Practice–Improving access for patients from Inclusion health groups – Homeless, Gypsy Traveler,

Vulnerable migrants and sex workers Or new primary care services/models should be commissioned

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There are great examples of care provided outside general practice–they should be replicated across the country

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Where it works - London Pathway

Holistic approach

Lead GP in hospital

Specialist homeless nurse specialist

Ex-homeless care navigators

Cost – effective

Ave length of stay reduced by 3.2 days (12.7 – 9.5)

Reduction of 800 bed days (average 250 admissions per year)

Cost savings per stay (£500 / day = £4,750 / stay)

Annual savings £100,000 after costs of service29

Building on community assets - Community consultants, who know the migrant communities needs, issues, concerns and can work with the NHS to improve patient access, experiences and outcomes30

Migrant health work – going forward & Updates

• Equality and Health Inequalities Knowledge Hub:

• EDS 2 implementation & case studies on Goals 1 and 2: Better health outcomes for all and Improved patient access and experience

• Inclusion health reports, toolkits and good practice.

• Equality and Health Inequalities Knowledge Hub:

• http://www.england.nhs.uk/ourwork/gov/equality-hub/

• Developing Frequently asked questions (FAQ) briefing for all primary care professionals to improve access to registration and primary care services

• Working with DH on Charging policy and other migrant health policy areas

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Migrant health work – going forward• Developing national standards on Interpreting and

translation Services

• Working with regulators and commissioning bodies on workforce and quality of services – CQC, HEE, PHE, NDTA, DH, Faculty of Inclusion health

• Capturing and sharing the learning from Homeless Hospital Discharge Service models, in partnership with Homeless Link

• Developing Virtual network of migrant health groups

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Discussion

•Any Questions

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ContactRanjit Senghera

• Senior Manager: Regional Link for Equalities & Health Inequalities, Midlands and East Region &

• National Lead on Inclusion Health

• NHS England

• [email protected]

• Equality and Health Inequalities Knowledge Hub:

• http://www.england.nhs.uk/ourwork/gov/equality-hub/

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