Nearly a quarter of local people live in one of the most deprived 20% of areas in England and more than 1 in 5 children in some boroughs live in poverty. People living in poverty experience poorer mental health, live in poorer quality housing and are less able to afford products and services than underpin good health. The recent pandemic and cost of living pressures bring additional challenges for our poorest residents and exacerbate existing health inequalities.
More than half of our population in NEL are from a minority ethnic background. The pandemic highlighted and widened inequalities between ethnic groups and evidence is clear that collecting ethnicity data, measuring and addressing ethnic disparities in healthcare access, experience and outcomes, and addressing racism and discrimination, are crucial to efforts to reduce health inequalities.
We estimate there are nearly 52,000 people in NEL with a learning disability. People with learning disabilities and autistic people have greater and more complex health needs and experience higher levels of unmet health need than the general population, and are more likely to face multiple barriers to accessing services. People with learning disabilities in NEL were 4.8 times more likely to die than those without during the first phase of the pandemic.
Housing is a key determinant of health, and homelessness and inadequate housing are significant and increasing problems across NEL. Mortality among people experiencing homelessness is around ten times higher than the rest of the population, yet many of these deaths are preventable. The homeless population face barriers to accessing health and social care services including stigma and discrimination and rigid eligibility criteria for accessing services. We need to ensure that the housing planned in NEL is of the mix and quality local people require to support better health outcomes and prevent further burden on our system.
We estimate that 17% of our population in NEL may provide informal care. Informal carers make a significant contribution to supporting the health of vulnerable people, yet evidence suggests that carers themselves are at risk of poor physical, mental and financial health outcomes.
NEL is the most deprived ICS area in London as well as one of the most deprived nationally. Deprivation is about more than poverty. It takes into account a range of factors in the population and environment including housing and education as well as income. Deprivation is associated with higher risk factors for poor health (for example poor diet and smoking) and poorer health outcomes.
Key areas for system action
- Applying a poverty lens to all our work. This includes paying particular attention to the health and social needs of people living in poverty, reviewing their access to and usage of services, tackling unmet need, and addressing the wider determinants through making every contact count and through our role as anchors.
- Ensure we are measuring and addressing ethnic disparities including in our waiting lists, a strong focus also on cultural competency, building trust and tackling racism as evidence tells us this will be key to tackling health inequalities.
- Support for carers running through all our priorities and wider transformation programmes.
- Ensure all services are accessible, appropriate and effective for people with learning disabilities and autism, increase the number and quality of annual health checks and vaccinations for COVID-19 and flu, reviewing deaths to ensure we have up to date data and action plans to address health inequalities and safeguarding.
- Collaborate to improve the quality of health and care services for people experiencing homelessness and reduce the mortality gap between people who are homeless and the rest of the population.
- Build our understanding and recognition of intersectionality.
- Review the impact of local place based partnerships in reducing health inequalities and accelerate and invest in scaling up good practice.
What success looks like
In addition to the specific health inequalities measures set out in relation to our four priorities:
- Across north east London we are reducing the difference in access, outcomes and experience particularly for people from ethnic minority communities, people with learning disabilities and autism, people who are homeless, people living in poverty or deprivation and for carers.
- Healthy life expectancy is improved across NEL and the gap between our most and least deprived areas / those living in poverty and the wealthiest is reduced.
- We routinely measure and address equity in NHS waiting lists supported by improved ethnicity data collection and recording across health and care services leading to delivery of more inclusive, culturally competent and trusted services to our population.
- We understand digital exclusion and ensure new innovations do not widen inequalities.
- We are committed to becoming an intentionally anti-racist system where we prioritise anti-racism, understand lived experience of staff and local people, grow inclusive leaders, act to tackle inequalities, and review our progress regularly.
More than 40% of children in NEL are overweight or obese. NEL has a higher proportion of adults who are physically inactive compared to London and England. Smoking prevalence in adults is higher than the England average in most NEL places, and 1 in 20 pregnant women smoke at time of delivery. All NEL places except Havering have worse screening rates for breast, bowel and cervical cancer than England, and vaccination rates tend to be lower with considerable variation between ethnic groups. Poverty and cost of living pressures are likely to make the situation more difficult with, for example, families not able to afford the costs associated with preventive dental care, travel for healthcare appointments, and maintaining a healthy diet.
Most NEL places have a higher prevalence of diabetes compared to the England average, and rates are increasing. For many conditions there are low recorded prevalence rates, while at the same time, most NEL places have a higher under-75 mortality rate compared to the England average. This suggests that there is significant unmet health and care need in our communities that is not being identified or effectively met by our current service offers.
Given the scale of the challenge around some of these risk factors and the population growth expected in NEL, our current services will be unsustainable unless we focus more, as a system, on prevention and early intervention.
Our ambition is to move beyond a medical model focused solely on needs towards a social model of health creation focused on strengths or assets where power is rebalanced, where local people and communities gain a sense of purpose, hope, and control over their own lives and environment and in doing so enhance their overall health and wellbeing.
Key areas for system action
- We will increase, over time, the proportion of our budget that is spent on prevention (both primary and secondary) and earlier intervention.
- We will ensure there is a greater focus for all partners on primary and secondary prevention, supported by Population Health Management. Places will lead on primary prevention while continuing to work with provider collaboratives (particularly in primary care) to improve secondary prevention. Provider collaboratives and their clinical networks will need to strengthen their focus on secondary and tertiary prevention.
- There will be a greater system role in tackling poverty and promoting social and economic development as major employers of local people and through procurement for social value as we address wider determinants of health as a network of anchor institutions.
- We will improve how we use the data we collect to identify and tackle unmet need, in particular among those living in poverty, people from ethnic minority backgrounds, and other priority groups.
- We will work with the voluntary and community sector to develop our understanding and support for building health creation in our communities.
What success looks like
In addition to the specific prevention measures set out in relation to our four priorities:
- We invest more in prevention as a system to reduce prevalence of long term conditions and mental ill health, equitably across all of our places.
- We identify and address unmet need including diagnosing more people early and increasing access to care and support, particularly for our most vulnerable or underserved groups.
- We invest in our community and voluntary sector to support prevention and early intervention in a range of ways to suit our diverse population.
- Through our role as ‘anchor’ institutions, we support social and economic development by employing local people furthest from the labour market and prioritising social value in procurement.
- We share and use data to identify the most vulnerable people living locally including those not using services and those frequently using services to provide more targeted and proactive support which better meets their needs.
- We routinely use Population Health Management data in planning and delivering our services.
Personalised care involves changes in the culture of how health and care is delivered. It means holistically focussing on what matters to people, considering their individual strengths and their individual needs. This approach is particularly important to the diverse and deprived populations of NEL, where health inequalities have been exacerbated by the pandemic and further compounded by the cost of living increase. Embedding personalised care approaches into clinical practice and care, which take into account the whole person and address all their needs holistically will ensure our most vulnerable communities are supported in the years ahead.
We have built a strong foundation for personalised care over the last three years as a system, with an early focus on social prescribing and personal health budgets. Our vision is to make personalised care central to local population health approaches.
As part of delivering greater personalised care, we want to explore how we can strengthen our understanding and delivery of trauma-informed care based on the principles of safety, trust, choice, collaboration, empowerment and cultural competence. This is particularly important in the context of the recent pandemic, the cost of living crisis and the ongoing poverty and health inequalities experienced by many underserved groups across NEL.
Key areas for system action
- All of our social prescribing teams will have access to digital templates in primary care. We will develop similar shared digital platforms and solutions for other personalised care interventions such as care plans.
- We will implement our personalised care minimum data-set initially in social prescribing teams and then in other personalised care interventions to evaluate impacts on wellbeing measures like ONS4 (Life satisfaction, Worthwhile, Happiness, Anxiety).
- We will work with primary care networks (PCNs) and place based partnerships to ensure the personalised care workforce – social prescribing link workers, care co-ordinators and health and wellbeing coaches are consistently supported with continuous professional development – including training plans, leadership development, peer support networks and supervision.
- We will work with PCNs and place-based partnerships to support targeted social prescribing for identified cohorts including vulnerable people, specifically building expertise in tackling inequalities through increasing access and support for particularly underserved groups.
- We will support the development of new specialist roles in response to local population health needs, such as children’s social prescribers and social prescribers with expertise in violence reduction/knife crime. We will facilitate developing social prescribing across acute, mental health and community providers.
- We will invest in social prescribing ‘community chests’ to increase resources in the community and voluntary sector locally, targeted at addressing local inequalities and providing social value to our communities where it is needed most.
- We will support our place-based partnerships to expand their personal health budget offer according to local need and in line with population health priorities.
What success looks like
- Staff have access to all the information they need in one place to enable them to provide seamless care to local people and can share this information safely through our IT systems.
- Local people including carers only need to tell their story once through their health and care journey.
- Local people are asked what matters to them in setting their treatment or care goals and can access a wide range of non-medical support in the community.
- Particularly vulnerable people and underserved groups are identified and given additional support to access services ensuring their experience and outcomes of care are equitable.
- Our staff are equipped to deliver trauma-informed care based on the principles of physical and psychological safety; trust; choice; collaboration; empowerment; and cultural competence.
- We will increase access to social prescribing including ensuring there is at least one PCN in each place with a children’s social prescribing service.
At the heart of our system is the shared commitment to co-production and meaningful participation with local people, communities and partners.
Our Working with People and Communities Strategy is a framework document which we are developing through ongoing engagement with local people and communities, building on the good and wide-ranging practice in place across NEL. The strategy was developed in collaboration with our partners and local people, including public forums and community and voluntary sector groups and sets out our vision to ensure participation is at the heart of everything we do. As it evolves, our strategy will set out in more depth our shared ambition which is firmly aligned to co-production and to the active leadership of local people, service users, carers and patients.
Central to our ambition is our continued commitment to the development of an effective voluntary, community and social enterprise alliance which will ensure that the sector is fully embedded in our ICS, on an equal footing with our provider collaboratives. We also recognise and value the important role of our eight local Healthwatch organisations in communicating the voice of local people and providing insight through our partnership work at place level and their formal place in our governance and decision-making arrangements.
We are committed to ensuring we have a diverse and population focused clinical and care professional leadership, who are focussed on driving change through working hand in hand with local people.
We are committed to taking an asset based approach to participation and engagement, which moves away from focusing solely on needs and problems but truly values the capacity, skills, knowledge and connections which exist within our communities and local people.
Asset based approaches emphasise the need to redress the balance between meetings the health needs of our local people whilst nurturing the collective strengths and resources which exist within our communities. By working with our local people and building on these assets we are better equipped to reduce health inequalities and effectively promote good health and wellbeing.
Key areas for system action
Our commitment to co-production is rooted in a set of co-designed principles for participation, which are grouped under five overarching themes:
- Commitment: we are committed to putting people participation at the heart of our work, from the design of services to participatory budgeting
- Collaboration: we will talk to each other and identify where we can work together to achieve a high standard of participation with the communities we serve, sharing information, learning, resources and building on best practice
- Insight and evidence: we will share insight and produce plans based on evidence and feedback from local people, continuing to strengthen use of the NEL community insight system as an open resource for all partners
- Accessibility: we will ensure participation is accessible to all local people, supported by the development of an Accessibility Champions Programme
- Responsiveness: we will be responsive to the local voice and develop an approach built on reciprocity and partnership
What success looks like
- We can evidence how decisions taken by our boards are informed by the views of local people.
- We have supported the establishment of a community and voluntary sector collaborative and actively support and resource its development.
- We have developed models of co-production, learning from and embedding best practice, and train a wide range of health and care staff in co-production and power sharing approaches.
- We have established a vibrant and diverse community leadership programme, to empower local people to work alongside us as partners.
- We can demonstrate how we have identified and engaged underserved groups and the full diversity of our local population.
- We use existing sources of insight from local people including carers to shape our strategies and plans at the earliest possible opportunity and resist repeatedly asking the same questions.
- We close the loop when we seek the views of carers and local people by feeding back.
Our health and care partnership inherits a legacy of competitive and sometimes adversarial relationships between organisations, which often do not serve local people well. This is based in part on an old financial and contractual regime that encouraged the defence of organisational interests rather than a shared view of how all partners best work together to drive improvements to health, wellbeing, and equity.
This was always at odds with the commitment of partners and staff to do what is right for the people of north east London. NEL partners have already come together to agree on our collective ambition for improving health, wellbeing and equity as well as four design principles for our system – improving quality and outcomes; deepening collaboration; creating value and securing greater equity. With the new health and care partnership, we have the opportunity to ensure that our new ways of working reflect this commitment across our whole system spanning local authorities, the community, voluntary faith and social enterprise sector and health.
This includes defining how place partnerships, provider collaboratives, and NHS NEL each contribute to delivering local ambitions with all parts of the system coming together as equal partners. It also means defining the interfaces between these key building blocks of our system, and the hand-offs between the types of care that they are responsible for, which our experience tells us is critical to effective delivery.
Alongside this, we need to build the environment of high trust that enables seamless delivery across pathways spanning social care, primary and community care and secondary care regardless of organisational or sector boundaries. We define this as an atmosphere of constructive and ambitious engagement, in which each stakeholder acts on the basis of trust in the motivations and capabilities of all other partners.
Only building this truly collaborative and high-trust culture will enable our new partnership to work for local people and within and across local partners; without it, our new structures will have limited impact on the people of north east London.
Place partnerships and provider collaboratives
We have seven place partnerships working to promote the wider determinants of health and to integrate local health and care services
- Barking and Dagenham, City and Hackney, Havering, Newham, Redbridge, Tower Hamlets, and Waltham Forest
We also have five provider collaboratives working across NEL to deliver improvements to care at scale, to tackle unwarranted variation, to promote equity, to share learning, and to provide a strong voice for their member organisations
- the acute provider collaborative; the community collaborative; the mental health, learning disabilities, and autism collaborative; the primary are collaborative; and the voluntary, community and social enterprise sector collaborative
Key areas for system action
- A mutual accountability framework is being co-designed to improve interactions and behaviours across the system. It will describe how place partnerships, provider collaboratives, and NHS NEL will work together to deliver for local people. It will set out common ambitions, expectations, and ways of working, describe what each part of the system is accountable for, and commit support to enable each part of the system to deliver.
- We will continue to invest in the cultural and behavioural development necessary to ensure that collectively we are making full use of the opportunities of the new partnership
- We will support development of our current and future clinical and care professional leadership as well as supporting inclusion and increasing diversity of our talent pipeline.
What success looks like
- Local people trust our services and advice because they feel that their voices are heard and our delivery is culturally competent.
- Partners feel actively engaged in and know how best to contribute to our partnership work. We are working towards our collective ambition and can demonstrate how our agreed design principles are shaping our approach.
- Our partnership work is undertaken in a spirit of constructive engagement and shared risk, guided by the aspirations and needs of local people, with issues tackled together without blame.
- All partners adopt an open-book approach to aspirations, challenges, risks, and finances.
- All partners continually critique how effectively they work together and seek to improve collaboration.
As a system, we are continuously looking for ways that we can improve the quality of care that local people receive. Many of our organisations have already invested in developing their quality improvement methodologies and competencies among staff. Equally we are developing a good understanding of the make-up of our population – demography, prevalence of diseases and where there is unmet need – but we do not yet use that information in a systematic way, for the benefit of our population.
Closer working and integration between partners provides an opportunity to improve how we work; to improve how we share data and information between ourselves; and to improve how we learn from each other and spread new and innovative ways of working. We are building from a strong base and have begun the work to share data, including creating linked datasets that bring together information held by different organisations (such NHS trusts, primary care and local authorities) to allow clinicians and planners to better understand the needs of our population, including the wider determinants of health, such as housing and education.
We are also leading pioneering research – at Barts Life Sciences, a partnership between Barts Health and Queen Mary’s University we are bringing together scientists and clinicians to create new innovations that benefit the local population, and wider NHS.
As we move forward we will build on these successes to embed research, innovation, continuous learning and quality improvement into all that we do.
Population Health (our responsibility)
A focus on improving physical and mental health outcomes, promoting wellbeing and reducing health inequalities across an entire population, including a specific focus on the wider determinants of health (such as housing, employment and education).
Population Health Management (our methodology)
A way of working to help frontline teams and system planners understand current health and care needs and predict what local people will need in the future.
It involves analysing data to identify population cohorts where interventions will add value, intervening, measuring the impact of interventions and incentivising those interventions that add value.
It also involves using the data to allocate resources optimally to population cohorts with the greatest need and to interventions that add most value.
Key areas for system action
- With patient consent, give patients, carers and clinicians involved in their care, better access to their care record.
- Improve data and insights, giving teams easier access to actionable population information, to support the identification of population cohorts for whom interventions will be most effective.
- Improve our evidence base to drive investment in the transformation of services and the deployment of interventions targeted at specific populations to improve health and care outcomes.
- Grow our analytical capacity and capability and ensure that analytics teams are collaborating effectively with clinical direction, including more consistent assessments of local population need across north east London (via JSNAs).
- Increase our appetite for innovation, and use evaluation to understand the impact we have to support scaling up rapidly where we see positive change.
- Ensure that every part of our system has a clear methodology for learning and improvement while working towards common approaches across the system as far as possible over time.
- Develop our research strategy to ensure that we are attracting more research in our system, that research is addressing the most important questions for our population, and that more local people can participate in research.
What success looks like
- We use data, evidence and insights to build our understanding of our population and to drive our priorities.
- All staff consider quality improvement a key part of their role and are continually striving to improve services and outcomes for local people.
- We have systematic processes to continually identify people that are underserved by our current care pathways and make changes based on our learning.
- We innovate and enable shared learning to accelerate adoption of innovation, research and best practice throughout our system.
- We support and encourage research that is focused on improving health and care for local people and involve more local people in research.