The document discusses key equality issues for public health in Hertfordshire in 2013. It notes new opportunities like Healthwatch and duties to reduce health inequalities. It explains that health inequalities often express social inequalities and accumulate over the lifecourse. Factors from conception like birthweight through education and employment can influence later health outcomes. Reducing inequalities requires understanding diverse populations and ensuring equitable access to services. Hertfordshire faces challenges in preventing disease, managing illness, and changing social determinants of health over 15 years as its population, especially those over 65, grows substantially.

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Taking on Public Health in 2013:
key equality issues for HCC
Jim McManus, CPsychol, CSci, AFBPsS,
FFPH, FRSPH, MIHM
Director of Public Health, Hertfordshire

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The Challenge
The Challenge:
Creating conditions in which
individuals and
communities have control
over their health and lives
and participate fully in
society.
New Levers:
• Healthwatch – full engagement
• Health and Wellbeing structures
– local democratic engagement
• Public health transfer
• Health scrutiny function
• Duty to tackle health inequality
• NHS Outcomes Framework
• Public Health Outcomes
Framework
• EDS

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So what’s the Link between equality duty
and health inequalities?
Equalities
• Ensuring people are treated
and can access services on the
basis of their health need which
Health Inequalities
• A worse health outcome,
access or experience
compared with a chosen
“standard” population or
measure, usually across a
social gradient but can work by
ethnicity or gender or sexuality
or faith

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Key Points
• Most health inequalities express themselves
through social or other inequalities, and most
social or other inequalities can be associated
with health inequalities
• These are expressed cumulatively across the
Lifecourse
– Disabled people, employment and stress
from hate crime
– Lower education, earlier death?

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What does Lifecourse mean?
• From conception to grave, things influence our
health all the time
– Lower birth weight – disease in later life
– South Asian – genetic risk for diabetes
– Readiness for school

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Life course perspective
• A way of looking at life not as disconnected stages, but as
an integrated continuum
• Suggests that a complex interplay of
– biological,
– behavioral,
– psychological,
– and social protective and risk factors
contributes to health outcomes across the span of a
person’s life.
• The life course perspective conceptualizes birth outcomes as the
end product of not only the nine months of pregnancy, but the
entire life course of the mother leading up to the pregnancy.

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The Lifecourse impact of health

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Example: Gaps in school readiness at 3 and 5
years by family income: UK
Averagepercentilescore
Waldfogel & Washbrook 2008

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Key Issues
• Largely well population in Hertfordshire
• Inequalities masked by wellness
• Worst off die 7 years earlier than best off
• Inequalities expressed across lifecourse
• Protected characteristics can worsen life
experience and thus health, or access to health
services

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A reflection from self harm studies
• ALL the evidence suggests strongly it is NOT
intra-individual factors but societal factors too
which are important to address
• Healthy public policy and services plus access
to services plus skills and motivation are key
• It’s the same with equality – look at LGBT hate
crime
• The individual is neither the whole problem
nor the whole answer

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Self-harm case postcodes with Indices of Multiple Deprivation score in
Hertfordshire, by Middle Layer Super Output Area
Key IMD 2010
3 to 8.9
9 to 14.9
15 to 20.9
21 to 26.9
27 and over

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Smoking 10%
Diet/Exercise 10%
Alcohol use 5%
Poor sexual health
5%
Health
Behaviours
30%
Education 10%
Employment
10%
Income 10%
Family/Social
Support 5%
Community
Safety 5%
Socioeconomi
c Factors 40%
Access to care
10%
Quality of care
10%
Clinical Care
20%
Environmental
Quality 5%
Built Environment
5%
Built
Environment 10%
Source: Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute.
Used in US to rank counties by health status
While this is from a US context it does have significant resonance with UK Evidence, though I would
want to increase the contribution of housing to health outcomes from a UK perspective.

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• Best start in life – conception, weight, vaccs,
imms
• Readiness for school
• Good Housing
• Resilient Childhood, Resilient Adulthood
• Into employment and education
• Lifestyle in working age
• Self management in older age
Work for us all here!

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Increasing deprivation
Target health outcome
Amount of
intervention needed
to get everyone to
target level
Current level of
health outcome
High level of
deprivation
Low level of health
Low level of
deprivation
High level of health

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Years
0 1 5 10 15
Planning
Education
Vitamin
Supplements
Air Pollution
Decent
Homes
Jobs
Primary
Care
20
CVD
Events
Self Care
Vitamin D and TB
Rickets
CVD Events
Acute Bronchitis Admissions
Respiratory
Mental Health overcrowding educational attainment
Life Expectancy
Healthier space use Changing culture of activity
Life ExpectancyMental Health

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• A strong role for every agency
• A need to rethink what the specialists bits of
public health have done and what they do in
future
• A need to rethink how we transform ourselves
into public health agencies
• Everyone has a PH role

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Examples
Equalities
• Systematic review in West
Midlands of LGBT population
found
• New migrant populations are
not always good at accessing
health care services
Health Inequalities
• Young gay men self-harm at
ten times the rate of the rest of
the population
• Late maternity booking and
perinatal mortality among some
new migrant populations

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Perverse outcomes...
• Interventions designed to reduce Health
Inequalities but cause them
– Uptake of cancer screening varies by class,
so does smoking. Those most at risk access
screening least!
• Uptake of cancer screening
• Uptake of diabetic retinopathy screening
• Call and Recall for treatment

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The upshot of this unless we do something is that
2/3 of people will be in chronic ill health or disability
before age 68, the new retirement age

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And Hertfordshire shows the same pattern!

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Why lifestyle alone will not eliminate health
inequalities 1
• Lifestyle is not sufficient – environment, genetic, lifecourse
influences
• It’s too late for some people – those who have disease already –
while lifestyle will help manage disease and health they will need
treatment
• It will be ten to fifteen years before lifestyle effects sustained
population change. Meanwhile people will still need treatment
• Lifestyle is not enough for some people at high risk – other
treatments are needed to
• Some risks are not amenable to lifestyle interventions for (e.g.
immunosuppresion; infectious diseases which make up 16% of
Birmingham’s deaths)
Healthy lifestyle is necessary but not sufficient of itself for significant
Reduction of health inequalities

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What should HCC and HWBB do?
1. Understand the populations of identity and
geography and work to ensure their health
outcomes are understood
2. Commission and provide with knowledge of what
those populations seek for optimal care
3. Audit programmes for equity and inequality and
make adjustments
4. Consider whether any populations need specific
clinics/interventions

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The Big Tasks – a 15 year agenda
• Short term challenge of tertiary prevention
• Medium term problem of keeping the ill well
• Short term problem of stopping avoidable
events
• Long term problem of changing determinants of
health, health expectations, behaviour and
culture

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2011 Census – Hertfordshire Projected Population Change

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Hertfordshire percentage projected population change
2010 to 2035
Age Group Percentage Change
All persons - 0-4 6.89
All persons - 5-9 21.27 21.27
All persons - 10-14 24.04
All persons - 15-19 18.36
All persons - 20-24 13.32
All persons - 25-29 13.56
All persons - 30-34 11.68
All persons - 35-39 8.35
All persons - 40-44 9.49
All persons - 45-49 11.91
All persons - 50-54 20.83
All persons - 55-59 25.24
All persons - 60-64 20.16
All persons - 65-69 59.04
All persons - 70-74 69.54
All persons - 75-79 51.01
All persons - 80-84 53.82
All persons - 85-89 102.96
All persons - 90+ 231.33

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Thank you!
Jim.McManus@hertfordshire.gov.uk