Guidance

Place-based approaches for reducing health inequalities: foreword and executive summary

Updated 28 September 2021

Foreword

Everyone deserves the same opportunities to lead a healthy life, no matter where they live or who they are.

But in England today there is a 19 year gap in healthy life expectancy between the most and least affluent areas of the country. It is a stark symbol of social injustice that those living in the most deprived communities spend more years in ill health and die sooner.

Closing this gap is one of the biggest challenges we face so we must keep reinforcing the message that health is about much more than healthcare or the choices we make about our diet or whether we exercise, smoke or drink alcohol.

In fact, the best way of ensuring a long life in good health is to have a good start in life, a good education, a warm and loving home and an income sufficient to meet our needs.

To put it even more simply, a job, home and a friend are the things that matter most.

And because we understand that reducing health inequalities is about jobs that local people can get, decent housing and preventing people becoming isolated, it follows that we also recognise that places and communities have the most critical role to play.

If we all work together to get this right our neighbourhoods are more productive and prosperous, and we support and encourage people to use the NHS less and later in life, to stay well for longer, and when unwell to stay in their home for longer, and to stay in work for longer. Health and wealth are truly 2 sides of the same coin.

To support this vital action at local level, we are delighted to introduce ‘Place-based approaches for health inequalities’ (PBA), developed by all 3 of our organisations: Public Health England, the Association of Directors of Public Health and the Local Government Association.

It has been informed by an extensive consultation with a wide range of stakeholders across the country, and PHE staff are available to local areas for those who would like assistance using any of the tools included.

We hope the information, tools and resources will complement the excellent work already taking place at local level and support further co-ordinated action between local government, the NHS and the voluntary and community sector.

Duncan Selbie (Chief Executive, Public Health England)

Jeanelle De Gruchy (President of Association of Directors of Public Health)

Councillor Ian Hudspeth, (Chairman, LGA Community Wellbeing Board)

Executive summary

There is a 19-year gap in healthy life expectancy (years lived in good health) between the most and least deprived areas of England ^{[footnote 1]}. People living in the most deprived areas spend nearly a third of their lives in poor health, compared with only about a sixth for those in the least deprived areas ^{[footnote 2]}.

These health inequalities are unfair and avoidable. They cut people’s lives short; lead to avoidable years living with impaired health and wellbeing; and cost the NHS, local authorities and our national and local economies billions of pounds ^{[footnote 3] [footnote 4]}.

The aims of the ‘Place-based approaches for reducing health inequalities’ are to:

• reinforce a common understanding of the complex causes and costs of health inequalities
• provide a practical framework and tools for places to reduce health inequalities

How to use this resource

This work is intended for use by local parts of the healthcare and public health system including:

• local authorities (LA)
• Clinical Commissioning Groups (CCGs)
• sustainability and transformation partnerships (STPs)
• integrated care systems (ICSs)
• the voluntary, community and social enterprise (VCSE) sector

It recognises that there is a wealth of knowledge about health inequalities within these organisations and that, across the diverse range of actors working on inequalities, each will have different needs, knowledge, expertise and potential roles.

This resource is therefore not intended to be read cover to cover, but rather is modular, to allow readers from across the system to pick and choose the parts that are helpful to them at different points in time.

It is also designed to be a live and iterative suite of resources which improves and expands over time as it is tested and evaluated.

A summary of the main sections and messages of the PBA is outlined below:

Context and causes of health inequalities

Function

Describes what health inequalities are, why they matter, what is causing them and the current national landscape for action.

Main messages

The gap in healthy life expectancy in England between the most and least deprived areas is 19 years, and for life expectancy it is 9.4 years for males and 7.4 years for females (2015 to 2017) – the gap in life expectancy is growing ^{[footnote 5]}.

The extra cost to the NHS from health inequalities have been calculated as £4.8 billion a year in greater hospitalisations alone ^{[footnote 6]}.

Health inequalities reduce employment and productivity, which costs national and local economies ^{[footnote 7]} – acting on health inequalities is, therefore, an investment for England’s national and local economies.

The focus on health inequalities in the Industrial Strategy, the Department of Health and Social Care (DHSC) prevention green paper, and the NHS Long Term Plan all create welcome opportunities for ambitious, co-ordinated, action on health inequalities at a national and local level.

Health inequalities are not caused by one single issue, but a complex mix of environmental and social factors which play out in a local area, or place - this means that local areas have a critical role to play in reducing health inequalities.

Population Intervention Triangle: a framework for place-based action on health inequalities

Function

Provides a practical framework for acting on health inequalities which organises action around key assets by ‘place’, to enable population-level reductions in inequalities.

Main messages

Effective place-based action requires action on civic, service and community interventions, along with system leadership and planning ^{[footnote 8]}.

The combination of actions from all parts of this system are needed to reduce inequalities at population scale.

Civic interventions have the potential to impact a large number of people and therefore are an extremely powerful component of place-based action.

Services are able to achieve significant outcomes per person due to their direct impact with individuals.

They must be designed to reach at-need populations to effectively reduce inequalities.

It is important that all partners, including communities themselves, understand the potential of community contributions to reduce health inequalities (this includes the assets within communities, such as skills and knowledge, social networks, and community organisations, as building blocks for good health).

Joint working between the civic, service and community sectors is needed to enable the whole to become more than the sum of its parts.

Each local area will face different causes of health inequalities, have different assets available with different solutions already in place.

Acting on the different parts of the Population Intervention Triangle should therefore not be interpreted as a mutually exclusive list with every action required - instead, it is a useful map to identify potential areas to further strengthen existing action, that can be tailored to the circumstances in any place.

This model can also be applied flexibly to different sizes of place and types of community to fit local circumstances and need.

Supporting resources and annexes to aid implementation

These include:

• self-assessment guides to support place-based action on health inequalities - to be used through self-direction, a sector-led improvement approach, and workshops facilitated by PHE

• a summary slide set that explains the PBA and recommended interventions

• a live repository of case studies that shows existing good practise from across the country on health inequalities - by both Local Authorities and local parts of the NHS, to tackle the wider determinants of health

• a guide to using local health inequalities data to support local areas, to prioritise and plan action on health inequalities

PHE is available to support local areas to use the self-assessment guides, and to support their work programmes. Please contact health.equity@phe.gov.uk for further information about this support.

References

1. Office for National Statistics, ‘Health state life expectancies by national deprivation deciles, England and Wales: 2015 to 2017’ ↩

2. Public Health England. Health Profile for England. 2018. ↩

3. Marmot M. Fair society, healthy lives: the Marmot Review: strategic review of health inequalities in England post-2010. 2010. ↩

4. NHS England. NHS Long Term Plan. 2019. ↩

5. Public Health England. What’s new in the February 2019 PHOF update? 2019. ↩

6. Asaria M, Doran T, Cookson R. The costs of inequality: whole-population modelling study of lifetime inpatient hospital costs in the English National Health Service by level of neighbourhood deprivation. Journal of Epidemiology and Community Health. 2016;70(10):990. ↩

7. Marmot M. Fair society, healthy lives: the Marmot Review: strategic review of health inequalities in England post-2010. 2010. ↩

8. Public Health England. Reducing health inequalities: system, scale and sustainability. 2017. ↩