Agenda item

Joint report of Allison Duggal, Director of Public Health and Wellbeing and Rachel Chapman, Consultant Public Health

The Board received a presentation from Allison Cartwright on behalf of Rachel Chapman, Consultant Public Health who had provided a report on Coventry and Warwickshire Integrated Care System Health Inequalities Strategic Plan.

The Coventry and Warwickshire Integrated Care System (ICS) was required to provide a ‘Health Inequalities Strategic Plan’ to NHS England/Improvement (NHSE/I) by 28th April 2022.  The plan must set out a locally agreed strategic approach for addressing health inequalities based on a recognised model of health and must include the NHS health inequalities priorities, as set out in the NHS Long Term Plan.  The plan should be Place-based and should involve the local Director of Public Health.  It had to be owned by decision making bodies within the developing ICS.  A programme of engagement was underway with partners and key NHS workstreams to develop the plan.  The local plan would build on existing work which aimed to embed consideration of and action on, health inequalities in all areas and focus on working with local communities.

A programme of engagement with key partners to further shape the plan, based on the Core20+5 model and embedded within the wider population health management approach, was taking place between November 2021 to April 2022.  The draft Coventry and Warwickshire Health Inequalities Strategic Plan would be shared with NHS England/Improvement by 31st March 2022, who were expected to provide feedback prior to a final version being adopted locally from the end of April 2022.

In January 2022 the shadow Integrated Care Board (ICB) agreed 8 principles for the plan:

·  Addressing Inequalities was core to and not peripheral to the work of the C&W ICS

·  Strategic Plan would be based on the King’s Fund model of Population Health

·  Built around the Core20+5 health inequalities framework

·  Evidence-based approach

·  Encourage innovation

·  Community co-production

·  Embed reducing health inequalities across all ICS work

·  Reducing inequalities is key to decisions on the prioritisation and allocation of resources

The King’s Fund model of Population Health included the impact of the wider determinants, individual behaviours, places and communities as well as health and care on people’s health.  It was already embedded as an approach within the system, it was well recognised by partners and was the basis for the Health and Wellbeing Strategies for both Coventry and Warwickshire.  Use of this model prompted the system to consider the breadth of influences on inequalities and to act beyond the health and care domain to achieve sustainable impacts.

The Core20+5 framework had been developed by NHSE/I to support the reduction of health inequalities at a system level. 

·  “Core20” was the 20% most deprived areas as defined by Index of Multiple Deprivation nationally.

·  “Plus” was specific groups identified locally who experience poorer than average health outcomes but may not be captured within the Core20.  For Coventry and Warwickshire these were proposed to be transient and newly arrived populations, including homeless, gypsies and travellers, boaters, refugees, and asylum seekers.  In addition, for Coventry, people who were on long term sickness benefit would be considered as a Plus group.

·  “Five” Key clinical areas of health inequality:

1.  Maternity: continuity of care for women from Black and Minority Ethnic

(BAME) communities in the most deprived areas

2.  Early Cancer Diagnosis: 75% of cancers diagnosed at Stage 1 or 2 by 2028

3.  Severe Mental Illness (SMI): annual health checks for 60% of those living

with SMI

4.  Chronic Respiratory Disease: a focus on Chronic Obstructive Respiratory Disease (COPD), driving up uptake of COVID, Flu and Pneumonia vaccinations

5.  Hypertension Case-Finding: to allow for interventions to optimise blood

pressure (BP) and minimise the risk of myocardial infarctions and stroke.

Coventry suffered from high levels of deprivation, with 26% of residents living in areas in the 20% most deprived in England.  This equated to 96,654 of the city’s residents living in the most deprived areas.  As a Local Authority area, men and women in Coventry experience significantly lower life expectancy than the England average.  Whilst there were pockets of deprivation in all parts of the city, the areas with the highest levels of deprivation and lowest life expectancy were in the central and north-east of the city, with pockets in the south west and south east.

Health outcomes also vary between population groups.  Coventry had a long history of welcoming refugees and asylum seekers to the city.  However, due to the recent international situation, exacerbated by COVID-19, Coventry and Warwickshire had seen an unprecedented rise in numbers.  In April 2019 there were 569 asylum seekers accommodated in Coventry under the Home Office Asylum Dispersal arrangements.  The latest figures (December 2021) showed this number has risen to 2055 – 1592 in Serco run accommodation and 527 in initial accommodation (3 x local hotels).  This was an increase of 361% and was unprecedented locally and regionally.  In Coventry, there were 968 existing Syrian, Yemeni, Iraqi, Sudanese and Afghan refugees currently in the city, with a further 121 Afghans arriving into the city over the course of 2021.  In addition to the asylum seeker hotels outlined above, there was a further hotel in the city housing Afghan refugees who were seeing out their quarantine period before moving out of the city.  Asylum seekers and refugees could have complex health needs.  Common health challenges could include: poorly controlled chronic health conditions; untreated infectious diseases or missing vaccinations; poor mental health related to previous trauma and/or to isolation as a newly arrived resident; and women may have additional need ante- or post-natally, associated with late presentation to healthcare, previous trauma, malnutrition or poverty.  Despite these health needs there was no evidence of a disproportionate use of healthcare resources.  Asylum seekers and refugees often face barriers accessing services including, language and cultural barriers along with a lack of understanding of UK health systems.

Gypsies and travellers had the poorest self-reported health outcomes of all ethnic groups.  National research suggested life expectancy was reduced by 10-12 years compared with the settled community and remained one of the most socially excluded groups within the UK.  Higher infant mortality rates contributed to this gap in life expectancy and caused significant distress to individuals, families and communities.  Such inequalities arise due to a range of factors including discrimination, poor accommodation, poor health literacy, a lack of trust in health providers and barriers in accessing health services. In the 2011 Census, 57,680 people identified themselves as Gypsy or Irish Travellers across England and Wales, with 151 in Coventry (0.05% of the resident population).

In 2020/21, 16.6 per 1,000 households (2,503 in total) were owed a duty under the Homelessness Reduction Act in Coventry.  It was recognised that homeless populations had significantly worse physical and emotional health outcomes compared to the general population.  The following factors should be considered:

·  Reduced life expectancy

·  Physical health and accelerated ageing

·  Mental health and alcohol & drug use

·  Autism and learning disability

The physical and mental health impacts of being homeless, as well as barriers to accessing services, including digital exclusion, contribute towards premature

mortality for this cohort.

The 2010 Marmot Review concluded that being in good employment was usually protective of health while unemployment, particularly long-term unemployment, contributed significantly to poor health.  However, being in work was not an automatic step towards good health and wellbeing; employment could also be detrimental to health and wellbeing and a poor quality or stressful job could be more detrimental to health than being unemployed.  Unemployment and poor-quality work were major drivers of inequalities in physical and mental health. People who were long-term unemployed had a lower life expectancy and experienced worse health than those in work.  Employment was one of the most important determinants of physical and mental health. There was approximately 14,600 people in Coventry who were on long term sickness benefit.

The proposed governance arrangements were shown in diagram form in the report.  Responsibility for delivery of the strategic plan would be through the Integrated Care Partnership and the Integrated Care Board.  The Population Health, Inequalities and Prevention system group would oversee development, implementation, and monitoring.  Delivery would be through the Care Collaboratives, Primary Care Networks (PCNs) and specific identified workstreams. National accountability for delivery would be to NHSE/I and local accountability through Health Overview and Scrutiny.  The Health and Wellbeing Board had a key role to play in enabling delivery, in particular joining up the healthcare elements with the other quadrants of the Kings Fund model.

RESOLVED that the Health and Wellbeing Board:

1)  Note the requirement for a Coventry and Warwickshire Integrated Care System Health Inequalities Strategic Plan

2)  Support the recommended local priority population groups for the strategic plan (covering newly arrived and transient communities and people on long-term sickness benefits)