Inequality and health inequality finding meaningful measures of progress

1. Inequality and health inequality � finding meaningful measures of progress Good afternoon. I�m delighted to be here today at this seminal event which aims to develop a strategic response to inequalities, and health inequalities in particular, in the Eastern Health and Social Services Board Region. I hope that each of you will get the chance today to formulate the links and find the common ground between the commitments made in the Lifetime Opportunities policy and those made in Investing for Health policy. Once this common ground is established I�m hopeful that it will prove fertile ground for planting the seeds of partnership working. I hope the already impressive record of this area in tackling health inequalities will be further strengthened and it gives me great pleasure that the Institute can contribute at this stage. Good afternoon. I�m delighted to be here today at this seminal event which aims to develop a strategic response to inequalities, and health inequalities in particular, in the Eastern Health and Social Services Board Region. I hope that each of you will get the chance today to formulate the links and find the common ground between the commitments made in the Lifetime Opportunities policy and those made in Investing for Health policy. Once this common ground is established I�m hopeful that it will prove fertile ground for planting the seeds of partnership working. I hope the already impressive record of this area in tackling health inequalities will be further strengthened and it gives me great pleasure that the Institute can contribute at this stage.

2. Monitoring progress Understanding the context & the urgency What we learnt from monitoring progress with NAPS Some thoughts on �early years� within Lifetime Opportunities and Investing for Health My presentation today will cover three main areas. Firstly, I would like to encourage you to reflect on how much we really understand about health inequalities � who�s health is most affected by poverty and social exclusion and how their health is affected. In what context are inequalities in the health experience of different social groups evolving? The second part of the presentation will provide some insights from the experience in the South. We are now in the last year of the 10 year National Anti-Poverty Strategy which was first published in 1997. What have we learnt? What might we have done differently in monitoring health inequalities within this context? The final section of the presentation will focus on a select aspect of the common early years agenda between Lifetime Opportunities and Investing for Health and , I hope, enthuse you in the importance of moving forward on this agenda at local level. My presentation today will cover three main areas. Firstly, I would like to encourage you to reflect on how much we really understand about health inequalities � who�s health is most affected by poverty and social exclusion and how their health is affected. In what context are inequalities in the health experience of different social groups evolving? The second part of the presentation will provide some insights from the experience in the South. We are now in the last year of the 10 year National Anti-Poverty Strategy which was first published in 1997. What have we learnt? What might we have done differently in monitoring health inequalities within this context? The final section of the presentation will focus on a select aspect of the common early years agenda between Lifetime Opportunities and Investing for Health and , I hope, enthuse you in the importance of moving forward on this agenda at local level.

3. Inequalities � the not-so-good old days Absolute poverty Sanitation & over-crowding Unemployment Lack of universal access to secondary education This image here from the Getty collection shows Belfast children living in slum conditions in the late 1920s. Social history tells us that these girls would consider simple necessities such as footwear and home heating a real luxury. For these girls the risk of infectious disease and poor nutrition were high with long-term effects on their own health and that of their future children. We know that global events such as economic slumps and World War went on to effect the welfare of these girl�s families through rationing, parental unemployment and so on. With the end of the war, bold new policy changes such as the extension of universal access to education and health-care and the construction of better housing and employment prospects, politicians were at least hopeful that some of these health inequalities would dissipate. What would have been our key indicators of success in tackling health inequalities at this time? How would this differ from today � this is the importance of context. This image here from the Getty collection shows Belfast children living in slum conditions in the late 1920s. Social history tells us that these girls would consider simple necessities such as footwear and home heating a real luxury. For these girls the risk of infectious disease and poor nutrition were high with long-term effects on their own health and that of their future children. We know that global events such as economic slumps and World War went on to effect the welfare of these girl�s families through rationing, parental unemployment and so on. With the end of the war, bold new policy changes such as the extension of universal access to education and health-care and the construction of better housing and employment prospects, politicians were at least hopeful that some of these health inequalities would dissipate. What would have been our key indicators of success in tackling health inequalities at this time? How would this differ from today � this is the importance of context.

4. Inequalities � a new context As overall health improves, inequalities are widening Significant interaction between poverty and ill-health epidemics Significant interaction between poverty and demographic change However, time has taught us that health inequalities are stubbornly persistent. The nature and context has indeed changed but the fundamental inequality persists. For example, despite universal access to primary and secondary school education, children from more disadvantaged communities are still more likely to leave school early and not achieve their academic potential. Although we have a lot of difficulty monitoring how much these differences are changing over time, many other European countries are finding that while overall health improves, the degree of inequality is getting worse. For example, while less people are dying of heart disease overall, these improvements are not being shared equally across the social classes. We are also facing into a number of epidemics � most notably obesity and mental illness. These epidemics seem to be having an excessive effect on people who are living with less financial resources. Also, as Ireland�s population changes with an increasing number of older people and increasing numbers of ethnic minorities, so will the landscape of poverty and it�s health impacts. So this is the new context in which an unprecedented degree of consideration, and indeed investment, must be directed to tackle this persistent inequality in society. However, time has taught us that health inequalities are stubbornly persistent. The nature and context has indeed changed but the fundamental inequality persists. For example, despite universal access to primary and secondary school education, children from more disadvantaged communities are still more likely to leave school early and not achieve their academic potential. Although we have a lot of difficulty monitoring how much these differences are changing over time, many other European countries are finding that while overall health improves, the degree of inequality is getting worse. For example, while less people are dying of heart disease overall, these improvements are not being shared equally across the social classes. We are also facing into a number of epidemics � most notably obesity and mental illness. These epidemics seem to be having an excessive effect on people who are living with less financial resources. Also, as Ireland�s population changes with an increasing number of older people and increasing numbers of ethnic minorities, so will the landscape of poverty and it�s health impacts. So this is the new context in which an unprecedented degree of consideration, and indeed investment, must be directed to tackle this persistent inequality in society.

5. National Anti-Poverty Strategy1997-2007 NAPS and Health Working Group 2001 Quality and Fairness 2001 National Action Plans against Poverty and Social Exclusion National Action Plan For Social Inclusion 2007-2016 I�m now going to move you from this wider context to the issue of policy responses in the south of Ireland. In contrast to Northern Ireland, there has been a governmental policy to tackle poverty in existence since 1997. The Institute has been intimately involved in supporting the Department of Health to formulate responses to health inequalities within the context of the National Anti-Poverty Strategy. Some of the recommendations formed by the Department of Health�s Working Group on NAPS and Health were subsequently enshrined in the national health strategy, Quality and Fairness. This lead, in part, to the prioritisation of health inequalities in a number of subsequent health policies such as the specific strategies relating to cancer, breastfeeding and obesity and the publication of the Travellers Health Strategy. Over time, the initial NAPS strategy has been replaced with National Action Plans, initially short-term 2 year plans and now a final 9 year plan listed at the bottom of this slide. I do have some concerns that the health inequalities agenda has been diluted somewhat in this sort of policy progression. I�m now going to move you from this wider context to the issue of policy responses in the south of Ireland. In contrast to Northern Ireland, there has been a governmental policy to tackle poverty in existence since 1997. The Institute has been intimately involved in supporting the Department of Health to formulate responses to health inequalities within the context of the National Anti-Poverty Strategy. Some of the recommendations formed by the Department of Health�s Working Group on NAPS and Health were subsequently enshrined in the national health strategy, Quality and Fairness. This lead, in part, to the prioritisation of health inequalities in a number of subsequent health policies such as the specific strategies relating to cancer, breastfeeding and obesity and the publication of the Travellers Health Strategy. Over time, the initial NAPS strategy has been replaced with National Action Plans, initially short-term 2 year plans and now a final 9 year plan listed at the bottom of this slide. I do have some concerns that the health inequalities agenda has been diluted somewhat in this sort of policy progression.

6. What we learnt from monitoring health inequalities within NAPS Importance of health inequality targets in and of themselves Initial targets were beginning of process, need refined and developed Major statistical issues to be addressed TARGETSTARGETS

7. What we learnt� Need to preserve and develop health inequality focus within �shifting sands� of anti-poverty policy Need to integrate health inequality targets with wider targets set as part of NAPS Health Inequality within NAPSHealth Inequality within NAPS

8. What we learnt� Need a robust well-resourced monitoring system Need to refresh our understanding of �who are the poor� in a health inequality sense Need to integrate learning on health inequality within wider knowledge of social determinants of health Delay in roll-out of inter-linked strategies �negative effects The work already done on the Investing for Health indicators by the EHSSB should avoid many of the pitfalls that were faced in monitoring the NAPS indicators in the South. The work already done on the Investing for Health indicators by the EHSSB should avoid many of the pitfalls that were faced in monitoring the NAPS indicators in the South.

9. CPA conference Dec 06 High-level outcome targets must be underpinned by specific intermediate goals and actions. A structure to take responsibility for those goals and actions from central to local level must be put in place. The development, revision and monitoring of targets and actions must involve the meaningful participation of people affected by poverty and health inequalities.

10. Being effective.. Development of the Evidence-Base About the Social Determinants of Health (WHO, 2006) Conceptual model Map �entry points� Best evidence should be defined on the basis of its fitness for purpose & its connectedness to the research question

11. Early years �Lying side by side in hospital wards, not yet a day old, babies already have very different chances of doing well at school, of getting a well-paid job, being healthy or ill, or going to university or to prison� (Fabian Society, 2007) Lifetime Opportunities - �Our goal is to ensure that every child should have a chance to develop their full potential in infancy regardless of social background� Investing for Health indicators- LBW incidence, childcare places, uptake of pre-school education, dental health, breastfeeding