Health data and its use in cities

A EUROCITIES peer review on health profiles in cities

Meeting of the EUROCITIES Working Group for Health and Well-Being

Liverpool, 25th November 2010

Contents

1. Introduction

2. Health profiles

3. Health profiles in cities

4. Conclusions

Annex A – contributions from the EUROCITIES working group health and wellbeing members to the Liverpool meeting

This publication is commissioned under the European Union Programme for Employment and Social Solidarity (2007-2013). This programme is managed by the Directorate-General for Employment, social affairs and equal opportunities of the European Commission. It was established to financially support the implementation of the objectives of the European Union in the employment and social affairs area, as set out in the Social Agenda, and thereby contribute to the achievement of the EUROPE 2020 goals in these fields.

For more information see: http://ec.europa.eu/progress.

The information contained in this publication does not necessarily reflect the position or opinion of the European Commission.

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1. Introduction 1.1 This report is the result of the EUROCITIES’ working group health and wellbeing meeting held in Liverpool on 25 November 2010. It summarises the discussions and consensus reached by the working group members regarding the use of health profiles by cities across Europe. It also provides some reflections from the external peer review which was undertaken at this time.

A ‘health profile’ is a snapshot of the wellness of an area compiled from information taken from health observatories or from statistical or administrative (i.e. hospital) data. It identifies trends and changes but does not provide an interpretation or explanation of these. They are designed to help local governments and health services identify problems in their areas and address them.

1.2 EUROCITIES believes that an integrated approach to fighting exclusion and poverty must address public health issues1. The working group’s goal is to raise awareness and improve strategies for health and well-being in cities. The working group’s objectives are to:

• increase the recognition of the important role that city administrations have in developing policies that promote health and well being;

• develop appropriate and effective policies and practices in cities in order to improve the life chances of everyone; and

• collaborate and co-operate in finding effective solutions to these problems through learning from one another.

1.3 The meeting in Liverpool followed on from a seminar in Ghent in June 2010 during which city representatives compared their approaches to tackling health inequalities. One of the key conclusions from that event was the importance of having a good evidence base for policy making. Participants stressed the vital role that cities play in this respect. The purpose of the Liverpool meeting was to review how health profiles are used to reduce health inequalities in the UK.

2. Health profiles 2.1 Health profiles provide a picture of the health of a population associated with a particular geographical area, for example, a municipal authority, city, region or country. They are a snapshot of the health of the area at that time.

2.2 Health profiles are made up of different indicators; they can include data on:

• population characteristics;

• health status, for example, life expectancy and mortality;

1 Key conclusions and recommendations from EUROCITIES campaign during the 2010 European Year for Combating Poverty and Social Exclusion.

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• risk factors for health, for example, smoking, drug and alcohol misuse;

• risk conditions for health, for example, poor housing, poor air quality; and

• protective factors for health, for example, social capital.

2.3 Figure 1 describes the broad range of indicator categories that can be included in a health profile.

Figure 1: Health profile indicator categories

Broad Indicator Categories

Population Health Status Health Determinants

Living and working conditions

Economic/employment conditions

Lifestyle factors

Biological factors (see population)

Ethnocultural structure

Population structure

Social and cultural indicators

Mortality

Morbidity and disability

Life expectancy

2.4 Health profiles enable comparisons to be made between different geographical areas, highlighting particular problems an area may have. However, the operational definitions of the indicators used need to be the same to make meaningful comparisons. In England, 32 indicators are used, enabling cities and other areas to compare the progress they are making to improve the health of their populations against national and local targets. Time series data also allows for the monitoring of health trends in a population.

2.5 There are still a number of limitations to using health profiling optimally. Firstly, although the accessibility and availability of comprehensive, routinely collected data is improving, there are gaps in the information being collected. For example, data for a social capital index or to measure job quality or the distribution of power are not routinely collected. Secondly, the opportunity to compare cities or even regions across Europe is limited because of data comparability issues; for example, definitions of different ethnic groups vary across Europe. Thirdly, health profiles still tend to be quite narrowly focussed on health outcomes and lifestyle indicators, and less so on health determinant indicators.

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3. Health profiles in cities 3.1 The Liverpool meeting involved reviewing different approaches to health profiling across Europe. Detailed presentations were given on health profiling in Liverpool, a survey of four cities (Amsterdam, Rotterdam, Utrecht and The Hague) and the European Urban Health Indicators System (URHIS) project2. In addition, prior to the meeting, EUROCITIES members sent brief overviews of their approaches to data collection and analysis for the rest of the group to read. The discussion during the meeting was aimed at sharing their experiences and exploring how the issues of data analysis and collection can be part of the working group’s work programme.

3.2 A recurring theme was the purpose for which the data is being collected. Depending on the objective of the data collection and monitoring, the results and any follow up actions vary. More specifically, the data can be used to monitor changes and to use them during the implementation of policies or programmes. In the first case, the information collected allows for monitoring changes in trends and thus discloses information on existing problems. At the practical level, however, finding out what causes these changes and problems requires additional research or evaluation of a given intervention. This is because the sets of indicators on their own are not enough to explain causal links between different events. In the second case, the data is collected to find out what impact a public intervention has.

3.3 Following from the above, the question on how data informs policy is crucial. Data can be used for setting priorities, to link the results of current work with policy. They can also be used to monitor the impact of implemented policies. In terms of priority setting, there were a number of issues raised, such as how and when data should be presented to policy makers.

In Rotterdam, the data collected in the Social Index (Sociale Index) provides insights into main trends and changes in the neighbourhoods and are starting point for further interventions. They can also be used to monitor the effects of policies.

In Stockholm, where districts have considerable responsibilities for data collection and analysis, it became clear that decisions need to be taken on whether particular data is relevant for those who decide on policies. While the figures are certainly informative, the information presented to the decision makers should already contain an analysis and interpretation.

In England, data is integrated in the management process. Local Strategic Partnerships (LSPs)3 make a collective decision on a given issue on the basis of available data.

3.4 It is difficult to show links between qualitative and quantitative data. Showing

2 European Urban Health Indicators System (URHIS) project’s website: www.urhis.eu. 3 Local Strategic Partnerships exist in nearly every local authority in England. They bring together representatives from the local statutory, voluntary, community and private sectors to address local problems, allocate funding, discuss strategies and initiatives. (Wikipedia).

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results of certain public policy interventions may not always be proven by using hard figures. In fact, in many cases, such as social and health programmes, the effects are often intangible, indirect or spread over time. It is therefore difficult to quantify the benefits of these programmes.

3.5 Since the social determinants of health are outside the health system, it is important to show how different policy areas impact on health. This can be done through such tools as Health Impact Assessment/Health Equity Impact Assessment and Health Equity Audit. These tools allow for the assessment of a given policy or programme on health (for example in housing or transport).

3.5 Lastly, a number of technical and methodological issues were identified that limit effective undertaking of monitoring and evaluation, particularly at an intra-European level. These included:

• data quality and validity, e.g.: in data collection. In Eindhoven, it is becoming more difficult to collect data for the neighbourhood profiles;

• comparability of indicators, e.g.: different operational definitions of indicators;

• accessibility and availability of data, e.g.: qualitative data;

• which units of analysis should be used: street, neighbourhood, district, etc; and

• administrative capacity to collect and analyse data in city administrations, especially in times of budget cuts.

4. Conclusions 4.1 The meeting provided a valuable opportunity to share experiences of how health profiling is used at city level to monitor and evaluate policy effectiveness.

4.2 The participants concluded that although there have been many improvements in health profiling at European and city levels over the last ten years or so (for example the European Community Health Indicators (ECHI) and URHIS), there are still significant development needs.

4.3 The meeting touched upon important questions of interest to the working group (WG). The crucial one is how can cities prove the effectiveness of policies and programmes at local level on the basis of the available data collection mechanisms. It implies not only comprehensive data collection but above all cooperation between different bodies to make sure that there are no overlaps and that the data can actually be shared. Furthermore, the working group’s focus on social determinants suggests that the data collected should also cover other areas than health.

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Annex A – contributions from the EUROCITIES working group health and wellbeing members to the Liverpool meeting

1. Summary of contributions

Health data and its use in cities

The annex presents key information on health data and its use in six cities: Belfast, Bologna, Eindhoven, Leeds, Rotterdam and Warsaw. Prior to the meeting in Liverpool they provided introductory reports about their approaches to collecting data on health in city neighbourhoods and the subsequent use of this information in policies to reduce health inequalities. What follows here is a brief summary of the work in these six cities, along the four questions the cities were asked to respond to:

• what are the main problems related to health inequalities in your city?;

• what are the key sources of information on health which you use in your city? (please mention also who and how collects the data);

• how do you use the data in the policy planning in your city? (Do the results of the research change the way a policy or a programme is delivered?);

• what are the key problems/issues that still need to be addressed in order to improve your approach to gathering and using data?

Main problems related to health inequalities in cities

The majority of the cities consider the significant differences in health outcomes between their affluent and deprived areas as the key problem to health inequalities. Almost uniformly, the cities see persistent and often widening gaps in life expectancy between areas of different affluence. Some cities indicated that infant mortality, poor lifestyle choices, obesity and mental health are more common or problematic in certain areas.

These inequalities are mainly linked to the socio-economic status of the inhabitants. Consistently, these neighbourhoods are also characterised by low educational and employment levels. Age plays in important role too. For example, the average age of people in the Polish capital Warsaw is above the national average, which impacts on the health care and needs of that city. In Bologna, the health problems are most acute amongst its most vulnerable social groups.

Rotterdam is the only city that indicated that its population’s health outcomes are statistically lower than the rest of the country. Yet, the health problems that it identifies as problematic are similar to those indicated by the other cities, with poor air quality playing a significant role.

Key sources of information on health used in cities

Each city has a system, a set of instruments or a method for gathering or identifying key

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information on health of its inhabitants.

Most cities follow the national statistical standards, and some collect additional information from either reports or through their own research. Not all reports were explicit about the level of data disaggregation, however it appears that each city collects data on an area or neighbourhood level, at least to some extent.

Both Leeds and Bologna indicated that a separate body or a team was established for the purpose of data gathering. In Eindhoven and Warsaw, the collection of data is the responsibility of the local governments.

Use of the data in policy planning in cities

All cities indicated that research and data is used to guide, at least to some degree, policy-making at the local level. This is mainly in terms of priority setting, strategic planning and resource allocation. Research also drives change, and results in adopting new approaches in planning and delivering health education, health promotion and health care services.

Key challenges ahead

The cities’ responses to this question varied significantly, however, some common themes are visible.

For Eindhoven, the number of people responding to surveys is decreasing to the point where it is becoming difficult or impossible to draw reliable conclusions. This is a key concern. In a similar vein, keeping databases up to date is one of the challenges in Bologna.

For Belfast, the main difficulty lies in the fact that there is no single model for data collection across different sectors. Moreover, the methods for collecting data are inconsistent amongst the many partners and stakeholders involved. This leads to difficulties in applying the data in policy processes, as “it is unclear what data is available, reliable, appropriate and most current”.

Belfast also indicated that key organisations fail to share information, which may lead to omissions and result in needs and problems remaining hidden. A similar problem occurs in Warsaw, where there is no cooperation between the seven bodies responsible for various out- and in-patient care units across the city. Only limited cooperation on new investments has occurred. Leeds indicated that data sharing has been identified as a “huge obstacle”, but this problem is already being addressed.

Moreover, Leeds reported that the process of linking information about the city with commissioners and policy makers is inconsistent and is not always part of the whole commissioning cycle. The main challenge for them is ensuring that key data is fully embedded into the existing partnership governance arrangements and aligned with planning and commissioning cycles.

Leeds also considers that it is critical “to supplement ‘hard data’ with the qualitative information that is sourced from the range of forums and networks” and to draw on this information in planning. The challenge lies in finding ways to effectively collate the

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qualitative information collected by various stakeholders so that it can be accessed and used by commissioners, area based representatives and other decision makers.

Finally, two cities identified some data gaps. Leeds requires more information in areas such as ethnicity, learning disabilities, mental health, children and maternity health, drugs, and housing and health. Bologna found that the effectiveness of evaluation and monitoring of the activities or interventions already implemented needs to be addressed.

2. Belfast, by Donna Gleek, Health & Wellbeing Co-ordinator, Belfast Health Development Unit

Main problems related to health inequalities

Eight of the ten most deprived areas in Northern Ireland (NI) are in Belfast. Research shows that health is largely determined by socioeconomic status, and that the higher the level of deprivation in an area, the less chance people have of living a long and healthy life. Despite investment in health, the health gap has not lessened in the city. People living in deprived areas continue to experience shorter life expectancy and higher levels of preventable illness than those living in more affluent areas.

Whilst there have been improvements in life expectancy, educational attainment and levels of unemployment, there is evidence of a widening gap, specifically:

• the number of smokers in manual and non manual occupations has increased;

• obesity is increasing amongst both adults and children;

• about 20% of people lead sedentary lifestyles and there has been an increase in the proportion drinking above safe alcohol limits;

• economic inactivity remains high, at about 30% in Belfast; and

• a large proportion of young people do not complete compulsory education.

The Department of Health, Social Services and Public Safety NI is the government department responsible for health.

The health minister recognises that the key determinants of health are income, employment and education and cannot be dealt with by a single government department or local authority, but rather by intersectoral collaboration, with community involvement at the core.

The government strategy for health ‘Investing for Health’ (IFH) aims to improve the health of the entire population of Northern Ireland and to reduce health inequalities. The strategy sets out a number of targets through which it can be evaluated against its goals and objectives. The main health providers across Northern Ireland (divided into North, South, East and West) formed a partnership to develop and implement the strategy. ‘Belfast Healthy Cities’, a citywide initiate to improve the health equity and wellbeing of Belfast’s residents, was commissioned to develop health and wellbeing indicators to monitor progress. This work has been endorsed by the Department of Health & Social Services and Public Safety and the Northern, Southern and Western IFH partnerships and is

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now the agreed regional monitoring tool.

However, since the strategy’s inception, the Review of Public Administration has led to many changes in Northern Ireland’s health service and the strategy itself is under review. Also, until recently, there has been no co-ordinated or integrated approach to implementing the strategy in the city, with each organisation setting its own priorities and using its own resources to tackle the health inequalities identified.

The Belfast Health Development Unit (BHDU) was established as a ministerial priority in March 2010, co-locating staff from The Public Health Agency (PHA), Belfast Health and Social Care Trust (BHSCT) and Belfast City Council (BCC). The Unit’s vision is:

“To be a driving force for city-wide collaboration to address health inequalities in Belfast - enabling people to live a good life in a fair society.”

The joint unit will have a key role in facilitating and driving the collaborative effort to tackle health inequalities. Throughout the BHDU Action Plan, complementary activities from other directorates and committees linked to the PHA, BHSCT and BCC are incorporated to achieve the strategic vision and address health inequalities in Belfast City Council Area. This enables the unit to maximise impact against strategic priorities and to capitalise on and add value to the full complement of health improvement resources across all three contributing organisations. Some of these activities will be taken up by BHDU staff, others will be the responsibility of staff assigned to partnerships such as the Eastern Drugs and Alcohol Coordination Team (EDACT), Eastern Physical Activity Coordination Group (EPACG), etc, who have developed specific skills and expertise in their area of responsibility.

The strategic priorities for the BHDU are:

• developing effective actions with those communities experiencing the sharpest inequalities in health;

• physical activity and obesity – an integrated ‘Active Belfast’ and open spaces strategy for the city;

• alcohol misuse – an integrated city-wide approach to tackling health and well-being issues associated with alcohol;

• mental health and well-being;

• children and young people;

• an integrated approach to planning and delivery of services for older people in the city; and

• an integrated city-wide approach to delivering effective and sustainable health and wellbeing outcomes for black and minority ethnic groups.

The underlying principle of the action plan is to maximise the extent to which the unit adds value to the health and social wellbeing landscape and key resources in Belfast City Council Area. The action plan presents an opportunity to give fresh impetus to priorities which have been developed over many years in response to community needs identified by communities throughout the Belfast City Council area. These priorities are now part of the corporate agendas for the three sponsoring organisations.

This action plan is a living document and will evolve organically as other exciting and

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strategic opportunities occur in the Belfast area, for example the development of a Strategic Health Improvement Partnership which when in place will set the strategic direction for the BHDU.

Key sources of information on health

DHSSPSNI – Information and analysis directorate is made up of five principal statisticians and a principal economist. It follows the UK statistic Authority’s Code of Practice for official statistics and collects information via the NISRA on health inequalities across three main indicators – morbidity, utilisation and access to health and social care services in NI. Results for each indicator for the bottom 20% (as per 2005 NISRA measures of deprivation) and the 20% most deprived rural areas are compared with the NI average. There is also a comparison between groups, as specified in Section 75 of the Northern Ireland Act, for areas in the bottom 20% in the whole of Northern Ireland.

Further resources

• NISRA (Northern Ireland Statistics and Research Agency) – Census data and yearly collection of information on health data at a neighbourhood level on www.ninis.nisra.gov.uk.

• Data from other statutory agencies e.g. Police Service NI and NI Housing Executive, Belfast City Council’s Citystats.

• Comparative data with WHO European Healthy Cities (Belfast Healthy Cities being a primary source) and the Urban Audit (European city level data; Metadata from Eurostat)

• Survey based data from various sources e.g. NISRA Continuous Household Survey; Social Health and Wellbeing Survey; School Leaver’s Survey; Resident’s Survey (Belfast City Council); Surveys conducted by the community and voluntary sector.

Use of data in policy planning

Data is used for evidence-based decision making, priority setting and policy making. For

example, the Belfast Health Development Unit was established as a ministerial priority

because the research showed that interagency, integrated working would maximise the

impact of health provision. The priorities were set in direct response to research

identifying the main health inequalities. In relation to policy, there is a drive for health

and health equity in all policies, again in direct response to the findings of the Commission

on the Social Determinants of Health (CSDH – led by Professor Marmot), data from WHO

Healthy Cities and the international evidence base from countries such as Australia.

Neighbourhood renewal has been driven by research into the needs of deprived

communities and has led to the development of Neighbourhood Renewal Boards, bringing

together all of the key stakeholders, in developing appropriate responses to community

needs and building the capacity of communities to be more self reliant and deal with

health needs where they arise. The thrust towards community planning and the adoption

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of a power of wellbeing are a direct response to the experience of other regions which

have adopted this as policy due to its efficacy in involving communities in decision making.

Research results do change the way a programme or policy is delivered. Perhaps the best

example of this in a Belfast context is the duty on all public bodies to have due regard to

the promotion of equality of opportunity and good relations. This has led to screening of

all policies for equality impact and the recognition in programme planning of the

increasingly diverse society in which we live and the needs in particular of minority ethnic

groups in our city. In turn, programmes addressing the specific health needs of minority

ethnic groups and the development of strategies such as the migrant health strategy were

recently developed by the Belfast Health Development Unit.

Key challenges ahead

The main difficulty is that there is no single consistent model for data collection across

sectors and therefore there is some variation in the years and geographical levels at which

data is presented and also in the actual data collected.

Many organisations have adopted their own methods of data collection, for example

Belfast City Council has developed a City Place model to ensure collection of information

and data (similar approach to NISRA Neighbourhood Super Output Areas) but other partner

organisations collect data differently, which leads to issues of validity, reliability and in

some instances, geographic responsibility or catchment. This can render the application of

the data in planning, priority setting and policy making difficult, as it’s unclear what data

is available, reliable, appropriate and most current.

Another difficulty is that, with the exception of the main public health strategy, Investing

for Health, organisations are using data to direct their own priorities and performance. If

data is not shared then some gaps in collection may occur and emerging or hidden need

could go unchecked. An example of this would be migrant health issues.

The establishment of a single health partnership for the city may help to overcome these

difficulties in data collection, management and use.

3. Bologna, by Marzia Bettocchi, Family Services Department, Municipality of Bologna

Main problems related to health inequalities

Generally speaking, there are many problems relating to health inequalities in the Bologna

area: social and urban environments, lifestyle, living and working conditions, accessibility

to and affordability of day-to-day essentials and accessibility to good quality health care

services, in particular for the most vulnerable social groups (minors, elderly people,

immigrants and for people who suffer from social exclusion) are all a concern.

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Key sources of information on health

The broad political context

The Permanent Committee for Social Services and Health Care (representing the mayors in the Emilia-Romagna region) plays the key role in developing and coordinating social and health planning. The committee outlays the strategic priorities for the plans which have to be developed at a district level, taking into account the community profile.

The city of Bologna then develops its three year health and social well-being plan based on this. The plan has to be approved by the municipal government through an ad hoc Local Steering Committee. This committee is composed of political representatives and directors of key departments of the municipality as well as representatives of the local health authority. The committee is supported by a technical unit set up within the Municipality of Bologna Department of Family Social Services.

The Community Profile (2009-2011)

This is a key instrument in identifying health and well-being needs of the local population. It also identifies critical aspects and priorities to be considered in planning local social, health and health care policies.

It is composed of quantitative and qualitative data and is divided into three main parts:

• the first part focuses on the local community and describes its demographic trends, birth-rate, death rate, life expectancy, environmental conditions, safety and safety perception, lifestyles, and a local socio-economic profile.

• the second part focuses on services relating to some expressed and satisfied needs in the health, social, health care, educational, socio-educational, training and occupational contexts as well as housing, in addition to some considerations on the social capital.

• the third part focuses on the main trends and the critical aspects resulting from the analysis of data described in the above mentioned sections It includes some reflections and final considerations to bear in mind for the local planning.

This document is developed by a multidisciplinary technical team from different departments in the city in association with its different ‘operational’ districts for the data collection and control.

The three-year Health and Social Well-being Plan of Bologna District (2009-2011):

This joint plan is the shared planning tool for social, health and healthcare by the Municipality of Bologna and the Local Health Authority. It is also the primary planning instrument for integrated social and healthcare interventions/projects combined with cross sector policies and actions within the municipality (e.g.: education, environment, etc.). It allows for the full participation of other stakeholders such as trade unions, private organisations and public institutions. In this way, the main social and healthcare strategies are contained in a single plan. This consolidated strategy encompasses all elements of society from children through to the elderly, families, disabled people, immigrants, people

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living in poverty and those with mental health disorders and chronic substance dependence problems.

The document gives a demographic overview of the community as well as an overview of social care and health and educational services. This community profile includes a comparative analysis between the Bologna District and the wider metropolitan area of the Province of Bologna (including many municipalities).

The data mentioned in the document was collected and compiled jointly by the local health authority and the municipality of Bologna.

The information and advice on social and health care services is available through social services offices that are established in each municipality district in Bologna (nine districts in total). The information covers the services provided by the municipality as well as, public and private institutions for adults, older and disabled people, minors and families in difficulty4.

Use of data in policy planning

Data and health profile information are vital in developing policy strategies and better tailor-made intervention programmes.

Key challenges ahead

The main challenges include the need to regularly update the databases as it is necessary to investigate and plan where social health care interventions are most needed. It is also important to carry out accurate evaluations and monitoring on the activities/interventions that are implemented. This can be supported by improving the gathering and use of data (for example in a new health profile).

4. Eindhoven, by Janine Cosijn, Public Health Policy Officer, Municipality of Eindhoven

Main problems related to health inequalities

The health inequalities in Eindhoven are mainly area based – that is to say that health status varies between neighbourhoods in Eindhoven. These inequalities are mainly socio economic ones. Neighbourhoods whose residents have a low socio economic status also display poorer health. Poor and ill health is linked with low educational levels, low income, social housing, low level of wellbeing, etc. Based on the health data, we can see that in these deprived areas there are no positive changes in the health situation, despite city efforts to improve it.

4 www.comune.bologna.it/sportellosociale.

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Key sources of information on health

Every municipality in the Netherlands is obliged by law (Public Health Act) to collect information on the health of their inhabitants every four years. The department of epidemiology of the Public Health Services in the region of South-East Brabant collects this though questionnaires. Some of the questions in these are asked in each Dutch region, so as to get a picture of the national health status. Other questions are asked in specific areas only.

There are four national health surveys and these are repeated every four years:

• Youth survey 0 – 11 years 2009

• Youth survey 11 -19 years 2007

• Adult survey 19 – 64 years 2009

• Senior citizens survey (aged 65 years and older) 2010

Based on the information returned by these surveys, city as well as neighbourhood health profiles are established.

Use of data in policy planning

The collected survey data forms the basis of Eindhoven’s health strategy. The city has collected this information for many years and we have discovered that there are no big changes in the health make-up of the population. Our objective has changed from trying to improve the health situation of the deprived areas into preventing deterioration.

Key challenges ahead

The Public Health Services reports that the number of respondents to the surveys is getting low; for some neighbourhoods there are not enough respondents to draw reliable conclusions.

5. Leeds, by Dan Barnett, Joint Health Partnerships Manager, the Leeds Initiative

Main problems related to health inequalities

When taken as a whole city, Leeds is quite stable and is relatively prosperous. However, previous health reports and the Joint Strategic Needs Assessment (JSNA) show that these positive overall trends mask significant differences between the affluent and deprived areas of the city. For example:

• the gap in life expectancy between the most disadvantaged parts of Leeds and the rest of the city has remained at around ten years since the 1990s. Currently it is:

o 71 years for men living in the 10% most disadvantaged areas, compared to 80 years, 7 months in the ‘best’ areas of Leeds. Men in City and Hunslet (a deprived ward in inner South Leeds) have the equivalent health of men in England 25 years ago.

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o 78 years for females living in the 10% most disadvantaged areas compared to 84 years, 6 months in the ‘best’ areas of Leeds. To illustrate, women living in Adel and Wharfedale (an affluent ward in outer North West Leeds) have a life expectancy that the rest of England won’t achieve until 2021.

• infant mortality in Leeds for the years 2004 to 2006 was six for every 1000 live births compared to five for England. When we factor in disadvantage, infant mortality in deprived areas of Leeds was around eight in every 1000 in the same period.

• in 2007 the death rate for Leeds males (standardised mortality ratio) was 105 - 5% higher than in England as a whole, compared to only 1% higher for women.

• mortality from lung cancer and respiratory diseases is also higher both in Leeds as a whole, and, to an even greater degree in deprived areas.

• recent reports such as ‘Measuring the Gap – Tackling Health Inequalities in Leeds’ and the JSNA have shown how persistent the differences in health outcomes are between the richest and poorest parts of the city. This dimension of disadvantage continues to have a profound effect on the health both of people in Leeds and the country as a whole5.

Key sources of information on health

Our Joint Strategic Needs Assessment (JSNA) captures key data for the city. This was informed by a number of previous documents: The data pack draws heavily on the following key documents:

• Leeds Strategic Plan;

• NHS Leeds Strategic Plan;

• Measuring the Gap: Tackling Health Inequalities in Leeds;

• Director of Public Health’s Annual Report;

• Children’s Services: Joint Area Review;

• Baseline Needs Analysis for Older People;

• Local data on specific topics (e.g. lifestyle surveys commissioned at regional level around physical activity);

• LCC’s annual residents’ survey and quarterly Citizen’s Panel to give a richer, more qualitative picture; and

• We also draw on national measurements such as the Office of National Statistics and Index of Multiple Deprivation.

A Joint Information Group (JIG) was established to provide information support to Joint Commissioning in Leeds. It now meets every three months and is presently chaired by the Head of Information for NHS Leeds. The membership consists of the lead information staff from the key directorates within NHS Leeds (e.g. Public Health, Corporate Information Service, Children, Practice Based Commissioning), and Leeds City Council (Education,

5 For more information see: Health Profile for Leeds 2010.

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Housing, Neighbourhoods, Adult Social Services, Children, Safer Leeds). Its remit is:

• to provide information support for the joint commissioning sub groups;

• to enable skill transfer to support organisational /operational commissioning teams;

• to signpost to information resources;

• to provide a register of needs assessments;

• to provide technological support to the JSNA and the development of a portal/warehouse for information; and

• to update the JSNA data pack as required.

The partners within the JIG have access to a private members website, the Leeds Initiative extranet, where they can log in securely to add new information to the dataset.

In order to continue the partnership work started with the development of the 2009 JSNA, with regard to involvement, participation and engagement, a Strategic Involvement Group (SIG) was also formed. The group’s remit is to provide leadership and direction for involvement work across the city. Specifically it aims to:

• develop a shared mechanism to collate public and service user feedback and intelligence;

• to provide leadership across Leeds in relation to involvement work;

• develop a training package to support staff across all partner agencies in involvement work;

• support the Commissioning Partnerships Programme to develop a systematic integrated approach to involvement within commissioning processes;

• ensure best practice in relation to involvement is shared across partner agencies and learning is taken forward;

• develop capacity to undertake joint involvement work across organisational boundaries where appropriate; and

• ensure involvement is carried out in a manner in line with equality and diversity best practice guidelines and policy.

Use of data in policy planning

Data about the city does, in theory, change the way policy is developed and programmes are delivered. We are currently in the process of developing a new 20 year sustainable community strategy as well as four year city-wide partnership delivery plans. Data from our JSNA and from the ONS gave us the idea that a new community strategy was necessary in order to tackle challenges not perceived when the original strategy was drawn up in 2004. These included:

• climate change;

• recession; and

• significant demographic change.

In terms of setting our partnership priorities for the short term, the JIG have played a key role in informing the decisions that are made. The JSNA subgroup of this partnership

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identified the key health priorities as identified by the JSNA. These were:

• addressing the increasing incidence of circulatory diseases and strokes;

• tackling obesity and raising levels of activity across all ages, but particularly the young;

• improving sexual health and reducing rates of teenage conception;

• improving mental health and emotional wellbeing;

• improving the quality and responsiveness of services that provide care and support for people; and

• improving the safeguarding of children and adults.

These are being considered when developing the new health partnership plan 2011 to 2015.

Whilst the process of linking in the information about the city with commissioners and policy makers is starting to happen, it is perhaps inconsistent at present. The JIG is still relatively new and it will take them time to be able to establish themselves enough to be capable of influencing decision makers. This is starting to happen but it will take time before the group is able to fully prescribe what work it is that we do. The JIG needs to be part of the whole commissioning cycle so that priorities become based on evidence rather than the other way around. Commissioners need to be engaged on what the macro issues of the city are when often they are engaged on the micro.

Key challenges ahead

This first JSNA required and benefited from close working across Leeds City Council and NHS Leeds.

Looking ahead it is clear that this process must be fully embedded into the existing partnership governance arrangements and better aligned with emerging planning and commissioning cycles. Leeds considers the JSNA process to be the beginning of a journey that will, in time, be fully embedded into supporting the work of wider stakeholder organisations. The JSNA process has provided a vehicle for assimilating core data necessary to support the assessment of health and social care needs across the Leeds area. It is our clear intention to extend this approach to other sectors. Critical to this will be the need to supplement ‘hard data’ with the qualitative information that is sourced from the range of forums and networks that Leeds is able to draw on. The information from this will be better collated and held centrally.

Ultimately it is the intention that a web-based on-line database be available in the city which will enable a broad range of self-sufficient partner users to inform all aspects of the commissioning cycle as and when they tackle them.

One important aspect of JSNA has been to demonstrate how harnessing data, information and technology can build a profile, not just of Leeds as a whole, but also of defined localities. NHS Leeds and the City Council have used this process as a means of expanding the concept of locality planning. We have sought to use a full range of available data, beyond the core data required of the Leeds JSNA, to build a profile of a particular area. The ability to define the boundaries of a locality and use hard data to build a picture of it

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is an incredibly powerful tool which enables a range of organisations to pinpoint areas of particular need and to target resources accordingly. This area profiling is already being used in Leeds and is called the Neighbourhood Index. It provides the Council, its partners and potentially area committee leads, with robust information about each locality, and seeks to measure the impact of interventions in a local area relative to others.

It is clear that there is a wealth of information from which to draw using the range of networks and consultative mechanisms in place. An important issue identified for JSNA has been how to collate the qualitative information collected by various stakeholders to ensure that it sits alongside the core dataset so that it can be accessed and used by commissioners, area based representatives and other decision makers. One future answer is to build a citywide central database of the results from consultation and engagement.

One immediate option is to use the City Council ‘Talking Point’ system which is accessed through the City Council’s website and could be made readily available for consultations undertaken by NHS Leeds and potentially by other partners.

To ensure the JSNA data pack is comprehensive and up to date the Joint Information Group has already identified that it needs to collect further data on the following areas:

• ethnicity;

• learning disabilities;

• mental health;

• children – maternity health;

• drugs; and

• housing and health.

Work has already begun on collating these data sets.

The Joint Information Group has recently agreed to revisit city-wide information sharing agreements. It has been identified that data sharing can be a huge obstacle but there are pragmatic solutions. The group has also agreed to produce analytical standards for needs assessments. This came about as collating the JSNA highlighted the inconsistencies and levels of detail within pre existing needs assessments.

6. Rotterdam, by Pascal Bisscheroux MD MPH, Bianca Stam Msc, Municipal Public Health Service Rotterdam

Main problems related to health inequalities

The population of Rotterdam is very heterogeneous, not only from a socioeconomic but also from a cultural perspective. Within Rotterdam, one finds wealth and poverty, university students and youngsters without a school diploma, more than 100 different nationalities and large numbers of first, second and third generation immigrants, as well as orthodox-Christian Dutch natives.

Rotterdam’s men and women have a considerably lower life expectancy (1.3 to 1.6 years) and lower healthy life expectancy (0.9 to 1.0 years) than the Dutch population as a whole. They also have an unhealthier lifestyle (smoking, alcohol, overweight), and the city’s air

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quality is also lower than elsewhere in the Netherlands. These factors are together responsible for 21-29% of the shortfall in life expectancy (average age at death) and for 32-50% of the shortfall in healthy life expectancy (the number of years without chronic illness). Smoking and particulate matter (PM) have the greatest influence on the shortfall in life expectancy. Overweight, sedentary lifestyle and alcohol use have a smaller impact.

Differences in average educational attainment level and household income between Rotterdam and the Netherlands explain 30% - 50% of observed health differences. These differences are only partially explained by the unhealthier lifestyles of those with lower educational attainment levels and less disposable income.

Figure 1 – Life expectancy at birth in Rotterdam by neighbourhood, 2006

Figure 2 – Percentage perceived health (moderate to poor), age 16+

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Key sources of information on health

Every four years the Rotterdam Public Health Service conducts a health survey among its 600,000 inhabitants. In 2008 there were approximately 6,000 respondents. The health survey uses nationally standardised questions. Other sources to determine health inequalities are the Rotterdam youth monitor, vital statistics, domestic violence registration and registrations for specific health problems. Information on public health indicators is publicly available.

A study by Erasmus University Rotterdam indicated that policy measures should be directed towards three main areas: lifestyle, air quality, and income/education. With regard to lifestyle and air quality, six scenarios – each with a coherent set of policy steps and interventions – have been laid out. The scenarios with the greatest health benefits are ‘A healthy youth has a healthy future’, ‘Healthy adults are the best example’ and ‘Health policy through primary healthcare’. In the most realistic variants of these scenarios, women’s health differences between Rotterdam and the Netherlands can be reduced by 10-18% for life expectancy and by 16-39% for healthy life expectancy. The scenarios with smaller health benefits yield 3-10% improvements in life expectancy and 7-12% in estimated healthy life expectancy. Even greater health benefits can be obtained over the longer term by combining certain scenarios. Incidentally, this report makes no estimates of the likelihood that any given intervention or scenario will actually be implemented.

In the area of income and education, no quantitative predictions have been made of theoretically obtainable health benefits. The strong effect of income and education on health shortfalls nonetheless clearly indicates the importance of policy measures aimed at reducing unemployment and poverty. Interventions directed towards an increase in labour market participation can make a considerable contribution to the reduction of health differences between Rotterdam and the Netherlands.

Use of data in policy planning

Up to now in Rotterdam, several programmes run to address socioeconomic health inequalities like ‘Fit for Work’ (reintegration into employment) and ‘Ready for a Child’ (reduction of perinatal mortality). In 2004, the Public Health Service and the Erasmus MC, particularly its Department of Public Health, started the ‘Academic Collaboration Centres for Public Health’. One of their main challenges is to reduce health inequalities.

The newly elected municipal board and council decided to make the reduction of health inequalities one of their major policy targets. The public health service acts as the programme manager but many public and private stakeholders are involved.

In this programme health is not just a goal in itself but also a means to economic growth and increase of social quality: ‘Health is Wealth’.

The comprehensive programmatic approach will be developed in two deprived neighbourhoods. If successful, it will be implemented in other areas. In this approach the health and health literacy of risk groups is strengthened. This will stop the influx into the category of about 30,000 vulnerable people.

The municipal board will use improvement of perceived health as measured in surveys as a SMART target. The components of the programme are:

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• interconnecting current intervention and initiatives;

• cooperation between care sector and private sector is essential;

• promotion of a healthy lifestyle through primary care;

• comprehensive approach to reduce obesity;

• reduction of alcohol and drug use among vulnerable youth with low educational levels; and

• development of a healthy firm approach because we need our labour force more and longer.

Because of the intersectoral approach the success of this programme will heavily rely on connections with other city wide municipal programmes, for example those directed at:

• increasing educational levels;

• improving labour market and health workplace;

• increasing sports participation;

• sustainable environment;

• involvement of lower socioeconomic groups in urban development; and

• facilitating local initiatives.

References

• Ö. Erdem, C. Nanninga, R. Kiela, W.W.M. Klaus-Meijs. Gezondheid in kaart Rotterdam. GGD Rotterdam-Rijnmond. Rotterdam, 2010.

• A. Burdorf, C. van Hooijdonk, L. Veerman, J.P. Mackenbach. Schatting van de potentiële effecten van primaire preventieve interventies op de gezondheid van de Rotterdamse bevolking. Erasmus MC Rotterdam, 2008.

• Collegewerkprogramma Rotterdam 2010-2014. Werken aan talent en ondernemen. Rotterdam Municipality 2010.

7. Warsaw, by Ewa Olsinska, Head of Public Health Division, Warsaw City Hall

Main problems related to health inequalities

Warsaw is the capital city of Poland with over 1.7million inhabitants. The city is divided into 18 districts. Age structure varies across these. For example, Praga Północ, a deprived district with an elderly population, has the lowest life expectancy, health status, quality of life, education and access to employment for the city.

The main problems related to health inequalities in Warsaw concern mainly:

• ageing population: the Warsaw population is older than the Polish average. One in six Warsaw residents are over 65 years of age and 50% of the inhabitants are over 41 years old.

• premature mortality: More than one quarter of Varsovians die before the age of 65. The rate of premature deaths in Warsaw over the last five years decreased in comparison with the whole of Poland.

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• differences in life expectancy amongst districts: For example, residents in Praga Północ district have the shortest lifespan. In the years 2004-2008, the average life expectancy of men from this district was 65.7 years. This is up to 8.1 years less than the Warsaw average and 16.5 years shorter than that in the Wilanów district. However, life expectancy has improved over the last ten years.

• differences in the level of literacy and access to employment: According to the 2002 national population census, 23.4% of Varsovians have third level education and 26.4% have at least vocational education. Comparing two districts – Ursynów and Praga Północ, the percentage of inhabitants with higher or vocational education is as follows: for Ursynów 31.8% and 19.2% and for Praga Północ 13.4% and 38.8% accordingly. There is a strong relationship between the level of education and the unemployment rate.

• differences in health status among districts: Warsaw, like other European cities, sees cardiovascular diseases, cancers and external causes as the biggest challenges for health policy. Mortality indicators show that inhabitants of three districts - Praga Północ, Żoliborz and Ochota are at a higher risk of mortality than others. There is a strong link between the level of education, access to employment and health across all Warsaw’s districts. When analysing the problems, differences in the average age of inhabitants should be taken into account. In districts such as Żoliborz, Śródmieście, Wola and Ochota the percentage of people over 65 is the highest. This age group is particularly exposed to age-dependant diseases.

• other remarks: Other factors that have impact on health such as lifestyle, participation in disease prevention programmes, physical activity, addiction (especially alcohol), family habits, family income level and literacy should be considered.

Key sources of information on health

Health status analysis is the key source of information on the subject. It is published every four years. The most recent one covers the period 1999-2008/2009. It is made up of the most comprehensive health statistics for the last ten years. These publications include data on: demography, life expectancy and mortality causes, health analysis based on hospitalisation, circulatory diseases and metabolic disorders, cancers epidemiology, psychical disorders, health status of children and youth, prenatal care, tuberculosis and from other infectious diseases morbidity, occupational diseases, prospective consequences connected with ambient air pollution in Warsaw.

This information is the result of work of the team of researchers, specially appointed to carry out the data collection and analysis. The research team included scientific institutes (among others, National Institute for Public Health, Institute of Cardiology, Institute of Oncology, Institute for Mother and Child, Institute of Psychiatry and Neurology) in cities Warsaw and Łódź. The research was based on the information gathered by the above institutions and the National Population Census data collected by the National Statistical Office. Also patients’ disease documentation has been taken into consideration.

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Use of data in policy planning

Planning and health services for prevention, treatment and rehabilitation as well as such tasks like health education and health promotion, result from the analysis of health status of the city population. The results of this analysis provide the base for planning prevention programmes as well as other work connected with improving infrastructure, purchasing medical equipment and allotting financial resources for these tasks. It is also a helpful tool used at the stage of planning the strategy and development of health care. Moreover it is an essential and basic source of data required in the process of applying for European Union funds.

Information on the health status of inhabitants is also a base for planning prevention programmes. Subjects of the programmes are focused on the needs of the population and directed to all age groups.

Programmes for young people include oral, aural and vision checks, posture screening, health education and various programmes to assess predisposition to diseases.

There are specific programmes for mothers-to-be which includes health care and health education during pregnancy.

The elderly can receive flu vaccinations through a programme addressed to those aged 65+ and to those in long-term care units and health care for veterans.

Some programmes are open to all age groups and are carried out by non-governmental organisations (NGOs) such as a flu vaccination programme that targets people staying in night shelters.

NGOs are entitled to support programmes directed at the chronically and terminally ill (including their families) within the in-patient and palliative home care; supporting rehabilitation programmes; supporting health promotion and health education programmes.

The total amount spent on these in 2010 was 8 million EUR.

It is worth stressing that data on the health status of Varsovians concerns the population as a whole and in individual districts of the city. It helps in directing all the necessary activities to environments which need them the most. They are also a tool for everyday work of health professionals, public health officers, health policy analysts and planners and health care managers.

Research on health situation of the local population contributed to more rational distribution of funds allocated for health care in Warsaw. It also revealed the areas with adverse health situation in the city and pointed out to the need for cooperation between key departments of the City of Warsaw in order to diminish disparities between districts (e.g. the Department of Social Policy, the Department of Education or the City Employment Office). However, despite numerous efforts the health situation still falls short of expectations.

Key challenges ahead

Warsaw, as every city, is responsible for health and safety of its inhabitants. Health care units in Warsaw – out-patient and in-patient are subject to seven founding bodies. One of

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them is the Mayor of Warsaw. Each of these health care units is responsible for its providing good access to health services and a financial situation of the unit.

The problem is that there is no common ground for cooperation between the founding bodies, therefore, the flow of information between them is insufficient. To some extent, the Department for Public Health works with units responsible for in-patient care, hospital emergency duties and special areas connected with current needs, such as transplants, epidemiology, etc.

Data on the health status of the Warsaw population is gathered by the city’s self-government. These data are prepared as a publication and distributed among various institutions dealing with health management in Warsaw.

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