Understanding the local context | Interviews DA There was a strong sense that awareness of the wider determinants in health and wellbeing in CS1 have been at the forefront of policy and healthcare for quite some time. The embedding of tackling health inequalities in all sectors was described in the DA and by interviewees. | Interviews DA Reporting of higher-than-average levels of death from alcohol, smoking and drug misuse. Also, an awareness that those from deprived areas of the region are more likely to be high users of healthcare in an unplanned way. | Interviews DA Deprivation and inadequate housing were reported to be factors in health inequalities. More lived stories and ‘person journeys’ was said to be vital to help understand the local context better. The COVID-19 pandemic had also impacted the ability to work with communities. | Interviews DA The diverse geographical spread of CS4 is recognised. Initiatives are in place to try and engage with communities and to embed co-production strategies into new services/interventions. |
Facilitators of how to tackle health inequalities and improve health and wellbeing | Interviews DA Many initiatives and strategies were discussed and reported. Major themes underpinning them were collaboration, systems working together and communities being at the heart. | Interviews DA CS2 appear to be aware of the need of a partnership/ whole system approach, and interviewees reported some good practices across sectors. However, in the DA, it is mostly described as a requirement for something to change in the future to help address health inequalities | Interviews DA A wide range of initiatives to support the local population were in place, with a strong VCSE sector. The findings from the DA report the use of community-based, targeted services. However, CS3 are facing several barriers to long-term planning/ solutions for the reduction of HIs. | Interviews DA A wide range of approaches to tackling health inequalities are described in the DA and by interviewees |
Looking forward | DA Opportunities were identified, for example, the commitment to Marmot principles was considered an opportunity to strengthen future funding bids and additional resource linked to CORE20PLUS5 | | | |
Addressing health inequalities | Interviews Major themes underpinning the addressing of health inequalities were collaboration working, systems working together and communities being at the heart. Interviewees spoke of staff training opportunities and programmes/ initiatives to work collaboratively and share good practice. | | | Interviews: implied in other themes such as ‘intervention facilitators’ and ‘whole system approach’ DA: identified as a subtheme |
Localised targeting of groups and specific health conditions | Interviews Reporting of collaboration between sectors and targeted campaigns with communities highlighted established practices | | | DA: identified as a subtheme in ‘understanding the local context’ |
Strong partnership /collaborative working | Interviews DA The importance of partnership and collaborative working across sectors was evident across all aspects of the data. The DA outline phrases such as ‘team approaches’ and ‘system strengths’. | | | Interviews Co-production between systems/the public is highlighted as an important aspect of service use/uptake evaluation. DA: implied in the ‘guiding principles’ theme |
Avoidable emergency admissions | | Interviews Interviewees acknowledged that the current A&E set-up/ access to services within the area was not ideal. Services across sectors were under increasing pressure leading to some people going to A&E as they were not able to access other services. Funding was also described as being a major issue, with most going to the hospital as opposed to other services. | Interviews Much work has been done to support high intensity users of A&E and to support those with addictions, multiple deprivation and homelessness with a safe discharge. | Interviews Interviewees described strategies in place to try and improve lifestyles, keep people well and cared for in their own homes to avoid AEAs. |
Neighbourhood/ community models | | Interviews Work has been ongoing with each neighbourhood developing their own objectives and outcomes based on an understanding of their own inequality issues | | |
Access to care/ services | | Interviews DA Many of the issues encountered, such as a large housing insecure population, and barriers to accessing healthcare were problematic pre-COVID-19, however health inequalities in communities post-COVID have been greatly exacerbated creating further challenges. It was acknowledged that CS2 had significant challenges with waiting lists and financial pressures. | Interviews DA Access to primary care services has been an ongoing challenge and there is an awareness that many communities/ groups have an unequal access to care and services. The CS3 area is challenged with a significant financial deficit and increasing demand on services. | Interviews Access to services for many was challenging due to geographical location, rurality and deprivation. Work is ongoing to determine why services might be inaccessible and how they can be addressed |
Workforce | Interviews DA The main focus was on the workforce being ‘assets’ and the good provision of training and support for staff (especially in the areas of reducing health inequalities). Staff capacity, recruitment and retention were also highlighted. | Interviews DA Main issues highlighted were around staff shortages, recruitment and retention. | Interviews DA Main issues highlighted were around staff shortages and recruitment challenges | Interviews Main issues highlighted were around staff shortages, recruitment and retention. Also of concern is the capacity of staff to support the increasing ageing population |
System processes | | Interviews A lack of staff capacity, access to follow-up services and financial pressures are impacting the process of the system. A ‘clogging’ of the system was described. | | |
Implications of COVID-19 pandemic | | Interviews CS2 was described as being greatly impacted by the COVID-19 pandemic, the effects of which were still being faced. However, despite the negatives, some system working practices improved/ were strengthened during the pandemic, which parts of the system are keen to continue. | Interviews Access to services post-COVID was challenging, it was reported that people were using A&E as a primary care service to compensate for not being able to access the appropriate service. The ability to change practices overnight and the way people worked to accommodate need during COVID was reported as a positive aspect. | |
Data and evidence | Interviews Challenges around accessibility and analysis of data. Local areas to consider the challenges of data sharing across organisations. | Interviews DA Active intelligence community but data collection of ethnic diverse groups and qualitative data is lacking/challenging. | Interviews Data is not lacking but interpretation of data to business intelligence is challenging. Reluctance across some systems to share data. More qualitative/lived stories needed. | Interviews Subtheme in DA Community engagement/ involvement/ feedback was reported to be good in some sectors but lacking in others. More is needed to try and diversify the groups who contribute. Some sectors felt frustration at not being able to access certain data sets due to funding or system contract/set-ups. |
Voluntary, community and social enterprise | Interviews A ‘strong’ VCSE sector is reported but not highlighted as a main theme | Interviews A large VCSE sector who are described as being exemplary in tackling health inequalities and helping to ‘plug the gaps’ in health and social care. However, a serious lack of funding and investment means many VCSEs are struggling to recruit and maintain staff on short-term contracts and funding, leading to pressured teams and restricted services. | Interviews The VCSE sector is recognised as an equal partner within the system and plays a strong role within this case study in supporting communities at home. However, a lack of thinking and collaboration across some sectors was reported. | Acknowledged very briefly in interviews so not highlighted as a theme. Lack of knowledge of what VCSE services are available and where to find information about them. |
Future concerns | Interviews Main concerns were around increased demand on services, public confusion of changed healthcare pathways and capacity of workforce. | Interviews A lack of national priority of the addressing of preventative measures of health inequalities was reported; too much focus is placed on hospital concerns. Also of concern is the ongoing ‘workforce crisis’. | Interviews It was reported that expectations from national government is that CS3 will have recovered from the effects of COVID, however it is more likely to be 5–10 years. Finding new solutions going forward for the changed norm is needed rather than trying to ‘fix the current model’. | Interviews Future concerns included workforce in rural areas and worsening of health inequalities. |
Supporting local communities/ delivering services in the community | | | Interviews Work is ongoing to try and connect more with groups in their locality/ communities. Wellbeing hubs have been set up. A pilot scheme to increase local employment in the domiciliary sector is ongoing. | Interviews The main themes focussed on support, providing safe spaces and holistic thinking |
Systems working / whole system approach | | | Interviews Wellbeing hubs have been set up to connect the community, GPs and the VCSE sector. Some VCSE sectors feel that there is some disconnect between sharing of data and silo working. | Interviews There was disconnection described between some sectors which impacted on timely referrals/ patient progression and knowledge of other sectors/services. |
Personal responsibility | | | DA Findings from the DA placed an emphasis on personal responsibility around lifestyle, particularly around diet, alcohol and tobacco use. The system wants to empower people to manage their own symptoms and conditions. This was not identified as a theme in the interviews. | |
Guiding principles | | | | Interviews DA Guiding principles to tackle health inequalities focused on available assets and strengths within communities and families to support quality health and wellbeing for all |