Health and Wellbeing Board	20^th March 2024
Report of the Director of Public Health

Update on Goal 6 of the Joint Health and Wellbeing Strategy 2022-2032: ‘Reduce health inequalities in specific groups’

Summary

1. This paper provides the Health and Wellbeing Board (HWBB) with an update on the implementation and delivery of one of the ten big goals within the Local Joint Health and Wellbeing Strategy 2022-2032. It also includes information on performance monitoring.

2. The Board are asked to note the report.

Background

3. At the January 2023 meeting of the Health and Wellbeing Board (HWBB) members of the Board agreed a framework for an action plan and a Population Health Outcomes Monitor for the new Joint Health and Wellbeing Strategy 2022-2032. This was followed by agreement at the March 2023 meeting of a populated action plan and a Population Health Outcomes Monitor.

4. At the September 2023 meeting of the HWBB updates were given on Goal 1 in the strategy, namely ‘reduce the gap in healthy life expectancy between the richest and poorest communities.’ This was followed by updates on Goals 2, 3 and 4 at the November 2023 meeting and Goal 5 at the January 2024 meeting.

5. This report sets out updates on the two actions associated with Goal 6, including a broader update on reducing health inequalities in specific groups along with updates on the agreed key performance indicators associated with the goal. Annexes A & B to this report provide a detailed score card and trend data.

6. The agreed actions cover the first 24 months of the strategy’s 10-year life span.

Goal 6: Reduce health inequalities in specific groups

7. Some of our communities in York experience radically poorer health outcomes than others. Sixty three percent of people with learning disabilities die before reaching the age of 65, compared to 15 percent in the general population, and in York you are four times more likely to die before the age of 75 if you have a severe mental illness.

8. There is good evidence that health inequalities can arise through geographic variances in health between e.g. less and more deprived areas, through demographic variances in health e.g. across protected characteristics such as age, disability, gender, but can also affect specific groups within society who typically experience marginalisation – sometimes termed ‘inclusion health’ groups.

9. Examples of these include people who are homeless or sleeping rough, those from an ethnic minority or a marginalised group, people living with substance misuse disorder, and migrants, refugees and asylum seekers.

10. We know that many of these groups experience radically worse health outcomes. The life expectancy of someone who is homeless is 47, and of someone who uses heroin is 52. Research from Aldridge et al (Lancet, 2018) suggests that socially excluded men have a mortality rate that is nearly eight times higher than the average for other men, and it is almost 12 times higher for excluded women:

11. We also know there are inequalities experienced in health and healthcare if you are from an ethnic minority in the city, and the health outcomes of people in marginalised groups within our community are worse too, for instance those from Gypsy, Roma or Traveller backgrounds, those who are new migrants, who are homeless or who use substances.

12. The following groups have been identified within our local CORE20PLU5 framework (an NHS framework for tackling inequalities in health outcome) as our ‘PLUS’ groups in York

13. Racially minoritized communities: Members of these communities often face higher rates of chronic illnesses, including diabetes, cardiovascular diseases, and certain cancers. Limited access to healthcare services, cultural and language barriers, and a healthcare system not designed for diversity contribute to delayed diagnoses and inadequate treatment.

Socio-economic factors such as lower income, employment opportunities, and educational attainment further exacerbate these health disparities. Additionally, ethnic minorities may experience higher levels of stress due to discrimination and social determinants, negatively impacting mental health. Variance in the distribution of risk factors (smoking and BMI) within these communities explain some, but not all, of these health outcomes.

14. People experiencing homelessness: in Quarter 1 of 2023/24 there were 73 households in temporary accommodation in York (including 28 households with dependent children). Health inequalities among individuals experiencing homelessness are profound and complicated. Homelessness is associated with higher rates of physical and mental health conditions due to exposure to harsh living conditions, limited access to healthcare, and challenges in maintaining a consistent and nutritious diet. Mental health concerns, including depression and substance abuse, are prevalent within the homeless population. Moreover, the stressors of homelessness contribute to a higher susceptibility to infectious diseases.

Structural determinants such as poverty, limited social support, and systemic discrimination further compound these health disparities. Addressing health inequalities in homelessness requires a comprehensive approach that combines healthcare outreach, housing stability programs, and social services to address the root causes and provide holistic support for this vulnerable population.

15. Drug and alcohol dependence: In 2022/23 there were 449 people in treatment for opiate dependence in York, 216 for non-opiate dependency, and 380 for alcohol dependence. Particularly with alcohol, this is likely to be a large underestimate of the true need for dependency treatment in the city. For Opiate and Crack dependence it is thought that only 6 in 10 people who need treatment are receiving treatment. For Alcohol dependence, it is thought that only 2 in 10 people who need treatment are receiving treatment.

16. Individuals struggling with drug and alcohol dependence face profound health inequalities rooted in both social and systemic factors. Stigmatisation often leads to marginalisation, making it challenging for these individuals to access quality healthcare and addiction treatment services. Socio-economic factors, including housing instability and employment challenges, further compound health disparities among this population:

· Of all people receiving treatment for drug and/or alcohol dependency in York, 25% are in paid work, 2% are volunteering, and 3% are in training or education. This is far less than the general adult population.

· In regard to housing, 12% are not in ‘stable and suitable’ accommodation.

· Mental health issues frequently coexist with substance dependence, creating a complex web of health needs. Focusing specifically on people with alcohol dependence in treatment in 2022-23 76% also had a mental health need, (and of this group, 84% were receiving mental health treatment, mainly through their GP). Focusing on people with drug dependence who are in treatment in 2022-23 64% also had a mental health need, (and of this group 67% were receiving mental health treatment, also mainly though their GP).  Limited resources and fragmented healthcare systems contribute to delays in intervention and hinder the development of comprehensive treatment plans.

17. Gypsy, Roma, and Traveller communities as an ethnic minority group, with distinct cultural practices and traditions, experience significantly poor health outcomes, highlighting the necessity to address their specific needs as a separate PLUS group. The communities have experienced a long history of systemic racial discrimination and as such, often do not state their ethnicity on official documents. Because of this, it is not clear how many live in York, especially those living in “bricks and mortar” houses or roadside. The Census 2021 reported 368 (0.2%) York residents identified as a Gypsy or Traveller.

Gypsies and Travellers face various challenges often due to discrimination and marginalisation. They have a significantly higher prevalence of long-term illness, health problems or disabilities which limit daily activities or work. Their health status is much poorer than that of the general population in similar economic circumstances, their health in their 60s being comparable to an average White British person in their 80s. Poor access to, and uptake of, health services is another major factor to health outcomes in this community- aside from experiencing discrimination, many could not register with their GPs if they had no fixed abode, or were unable to complete registration forms due to low literacy comprehension. Key inequalities identified by national and regional research include:

· Life expectancy is on average 10-25 years less than the general population

· Suicide prevalence is six times higher for Irish Traveller women than women in the general population, and seven times higher for Traveller men.

· Are more likely to experience pain, arthritis and respiratory problems

· 20 times more like to experience the death of a child

· Three times more likely to experience anxiety

· High levels of digital exclusion making it harder to access healthcare and benefits

· Low vaccine uptake with the exception of COVID-19 vaccines. This was largely due to information about the vaccines that was tailored specifically to the Gypsy & Traveller community.

18. Vulnerable migrants: Access to language resources poses a significant challenge to health for our vulnerable migrants, and lack of good communication around the local health system compounds these issues, making it difficult for migrants to navigate services and access timely and appropriate care. Geographical barriers, such as long distances to healthcare facilities, can impede regular medical check-ups and exacerbate health disparities. Financial constraints are heightened when housing services no longer cover transportation costs, such as taxis to routine appointments, placing an additional burden on vulnerable migrants.

Addressing health inequalities for this population requires not only linguistic and cultural sensitivity in healthcare services but also initiatives to improve health literacy, increase accessibility, and provide support for transportation barriers, fostering a more equitable healthcare environment for vulnerable migrants. In York, our migrant, refugee and asylum seeker population is growing, with a significant number of people coming to city under resettlement schemes from Afghanistan, Syria, Ukraine, and through our contingency accommodation for asylum seekers.

19. Sex workers: who are adults who receive money or goods for sexual services , either regularly or occasionally, including female, male, and transgendered sex workers. Sex workers are a health inclusion group that may experience stark inequalities in both access and outcomes in physical and mental health and are also at greatest risk of social exclusion and violence.

Based on health inequalities work being undertaken jointly through the York Place team and Nimbuscare providing GP outreach clinics to vulnerable women, we know that sex workers in York present with multiple needs varying from mental health conditions, leg wounds, gambling addiction, UTI symptoms and contraception. We know that working with vulnerable women, such as some sex workers, requires health and care professionals to build trust, a sense of security, stability and equal healthcare provision for a group that suffers negative health outcomes. Given the multiple complex needs that sex workers can present with, joint working with other agencies, such as Drug and Alcohol addiction services and gambling addiction services is essential.

20. Students: The 2017 York Student Health Needs Assessment stated that there were around 31,000 students currently attending the 4 Higher York institutions (University of York, York St John University, York College and Askham Bryan College). Health inequalities among students encompass a range of challenges, both physical and mental. Mental health issues, including stress, anxiety, and depression, are prevalent among students, often exacerbated by academic pressures and societal expectations. Additionally, disparities may arise in access to healthy food options, recreational facilities, and opportunities for physical activity.  Socio-economic backgrounds can influence students' ability to afford wellness resources, creating disparities in preventive care and health promotion. Tackling health inequalities for students requires a holistic approach, addressing both physical and mental health needs, and promoting accessible, affordable, and inclusive healthcare services within educational institutions.

21. Carers: the 2021 Census reports that there were 14,868 York residents who provided some unpaid care. Most carers don’t qualify for (or won’t necessarily want) help from CYC for care and will get assistance from the voluntary sector (for example, from York Carers’ Centre). Of the 230,000 patients registered to GP Practice in the City of York, 6,800 people are identified as being carers (i.e. fewer than half of all carers in York are known to primary care). Of these, 4.7% (327 people) live in IMD Deciles 1 & 2 (most deprived areas in England, representing the 'Core 20' population. 31% of Carers do not have a long term condition diagnosed in primary Care. 22% of carers have 1 long term condition, 21% have 2 long term conditions, 7% have 3 long term conditions and 19% of carers have 4+ long term conditions.

National statistics show that:

· Unpaid carers contribute £162bn per year to society, equivalent to a second NHS. (England and Wales).

· Nearly 1/3 of NHS staff are carers (31%).

· 1 in 7 people in the workplace are juggling work and care.

· There is increasing evidence that caring should be considered a social determinant of health (Public Health England, Caring as a Social Determinant of Health, 2021).

· Joseph Rowntree Foundation listed carers as one of the groups more likely to be in very deep poverty.

· 60% of carers report a long-term health condition or disability compared to 50% non-carers.

· Young carers are more likely to report severe psychological distress.

· Research in 2019 highlighted almost half 45% of Young Adult Carers report having a mental health condition (before pandemic) and seeing issues in Young Adult carers who have frailty scores of 65 yr olds.

22. Transgender and non-binary people face a number of well-known inequalities in access to healthcare, including cervical screening, where clinical systems are not set up to support patients once they transition; dealing with gender confirmation certificates and NHS number changes, and use of KLINIK-like triage systems which do not have gender dysphoria as an option.

Health inequalities which transgender and non-binaryindividuals face are often rooted in societal stigmatisation, discrimination, and inadequate healthcare policies. Access to gender-affirming healthcare, including hormone therapy and gender confirmation surgeries, is often limited, contributing to disparities in mental and physical health outcomes. Discrimination and lack of cultural competence in healthcare settings can deter transgender and non-binary individuals from seeking medical care, leading to delayed diagnoses and inadequate treatment.  Mental health challenges, such as higher rates of depression and anxiety, are prevalent due to societal prejudice and a lack of understanding. Additionally, transgender and non-binary individuals may encounter barriers to accessing routine healthcare services, including preventive screenings.

23.Veterans often face distinct health inequalities from various factors related to military service and post-deployment life. Mental health issues, including post-traumatic stress disorder (PTSD), depression, and anxiety, are prevalent among veterans and may be exacerbated by the challenges of transitioning to civilian life. Physical health concerns such as musculoskeletal injuries and chronic conditions are also prevalent, and veterans may encounter obstacles in accessing specialised healthcare services. Socio-economic factors, including unemployment and homelessness, further compound health disparities among veterans.

Update on Health and Wellbeing Strategy Actions

24. Action A14: Use Health Inequalities grants to fund targeted work including by local VCSE organisations to enable them to address health inequalities

Progress: The Director of Public Health and NHS Place Director for York have a delegated budget from the ICB Health Inequalities fund of around £270k per year to tackle health inequalities in our city. The tables below show the projects which have been funded or proposed to be funded so far.

Project	Summary
Maternal and Child Nutrition	Developing an Infant Feeding Strategy and delivery plan for the improvement of maternal and child health outcomes through better nutrition during preconception, pregnancy, and early childhood. The funding awarded in 2023/4 will also involve a £10k contribution to the York Hungry Minds campaign, specifically around enabling the pilot of breakfast club provision.
Asthma Friendly Schools	Aims to reduce health inequalities for children with Asthma by ensuring school staff have appropriate training, support, and awareness of Asthma through the employment of a respiratory nurse with a focus on health inequalities.
York Brain Health Café	An intervention targeting individuals on the waiting list for the memory service to embed personalised care approaches for people with cognitive decline and provide support to carers. A population health management approach is planned in 24/25 to ensure those experiencing health inequalities are supported to attend the café.
Mental health-related school absence	Supporting Children & Young People with anxiety related school absence, this project aims to reduce absences from school, improve educational outcomes and the social and emotional health and wellbeing of children and young people. The funding has been used to employ a project worker that can work directly with children, their families and schools to develop & implement reintegration plans.
Ways to Wellbeing Small Grants Programme	The programme funds projects which enhance community connections and improve health and address the causes of health inequalities, particularly in areas of deprivation or for those disadvantaged by inequality in the city.
Health Mela	To provide funding into York's second Health Mela (a south Asian festival who’s name in Hindi means ‘meeting’), a celebration of culture, diversity and health held in the city every September
GP Outreach at the Women's Centre	Weekly GP outreach clinic held at Women's Centre to provide healthcare for sex workers and other vulnerable women. Providing preventative health care and support with long term conditions. Current monitoring shows this project is having an impact and building trust and engagement with this community.
Wellbeing Activities for Asylum Seekers and refugees	Funding fortnightly health and wellbeing drop-in sessions, tailored sessions for individual groups, and wellbeing fund for individuals to apply for to assist with their health and wellbeing.
Raise York Family Hubs	Placing a paediatric advanced clinical practitioner role in the Family Hubs model that would deliver a range of interventions to build confidence and health literacy in families and help families access support to make best use of community assets.
Peasholme Homeless Clinic	Providing primary care services to residents at Peasholme and Robinson Court, who are amongst the most deprived population often presenting with complex physical and mental health needs. Providing preventative health care and support with long term conditions.
CAY advice in GP surgeries	Funding Citizens Advice York to deliver advice clinics and support in primary care settings, an evidence-based model which has identified over £1m in unclaimed benefits for recipients so far.

25. Action A15: Identify and address barriers to accessing appropriate health services by people experiencing poverty through the Poverty Truth Commission

Progress: York Poverty Truth Commission aims to bring together people who have experienced poverty, ‘Community Commissioners’, with City leaders who have the ability to influence change, ‘Civic Commissioners’.

In Autumn 2023, nine Community Commissioners were joined by 9 Civic Commissioners representing key organisations in the City, for example, leaders from City of York Council, the NHS, Joseph Rowntree Foundation, the police and justice system, housing and the voluntary, community and social enterprise sector.

The Commission has been meeting monthly to listen to the experiences and insights shared by Community Commissioners and to collectively identify the changes that are needed to benefit those experiencing poverty.

Through this process, the Commission have been able to identify three key priorities that the group will focus on as areas of action. These priorities are:

· To ensure people are treated with kindness, respect and understanding by organisations in York that they have to deal with

· To ensure any communication from organisations is timely, understandable and focused on helping people to find support and solutions

· To address the poverty related causes and consequences of digital exclusion

The Commission is now drawing on the combined knowledge and experience of its members to identify what actions are needed to embed new cultures and practices and deliver meaningful change for those experiencing poverty in our City.

The Commission will end in April 24 when there will be an event to share what actions and changes have taken place or will take place. 

26. Population Health Outcomes Monitor: this is linked to the ten big goals and is designed to provide board members with a holistic view of whether the strategy is making a difference to the health and wellbeing of York’s population, using outcome data rather than data on what health and care services are ‘doing’. Today’s updates at Annexes A & B to this report provide information on goal 6 of the strategy.

27. This goal does not lend itself easily to a large number of metrics collected in a robust and standardised way, hence the inclusion above of some narrative on inclusion health groups drawn from national local research in order to paint a picture of the broad health needs of inclusion health groups.

28. However we do collect a number of metrics on inequalities facing those in the city with a learning disability or severe mental illness. These are the metrics illustrated at annexes A and B.

Consultation and Engagement

29. As a high-level document setting out the strategic vision for health and wellbeing in the city, the new Local Joint Health and Wellbeing Strategy capitalised on existing consultation and engagement work undertaken on deeper and more specific projects in the city. Co-production is a principle that has been endorsed by the HWBB and will form a key part of the delivery, implementation, and evaluation of the strategy.

30. The actions in the action plan have been identified in consultation with HWBB member organisations and those leading on specific workstreams that impact the ten big goals.

31. The performance management framework has been developed by public health experts in conjunction with the Business Intelligence Team within the City of York Council.

Options

32. There are no specific options for the HWBB in relation to this report. HWBB members are asked to note the update and provide comment on the progress made.

Implications

33. It is important that the priorities in relation to the new Local Joint Health and Wellbeing Strategy are delivered. Members need to be assured that appropriate mechanisms are in place for delivery.

Recommendations

34. Health and Wellbeing Board are asked to note and comment on the updates provided within this report and its associated annexes.

Reason: To ensure that the Health and Wellbeing Board fulfils its statutory duty to deliver on their Joint Local Health and Wellbeing Strategy 2022-2032.

Contact Details

Author:	Chief Officer Responsible for the report:
Tracy Wallis Health and Wellbeing Partnerships Co-ordinator	Peter Roderick Director of Public Health
	Report Approved	ü	Date	08.03.2024
Specialist Implications Officer(s) None
Wards Affected:					All	ü
For further information please contact the author of the report

Annexes:

Annex A: HWBB Scorecard (for Goal 6)

Annex B: HWBB Trends (for Goal 6)