To present the 2019 director of public health annual report and to seek the support of the board in implementing the recommendations.

The chairperson asked the director of public health to present the annual report, the key points of the presentation are summarised below:

a.         The consultant in public health and the intelligence team were thanked for their support in producing the annual report.

b.         This report focussed on rural Herefordshire and the often hidden levels of ill health and inequality in rural areas.

c.         Herefordshire was one of England’s most sparsely populated counties, with 42% of residents living in areas officially classified as ‘rural village and dispersed’ and 25% living in ‘very sparse’ areas.

d.         The population age distribution showed that there was a higher proportion of 45 to 79 year olds living in rural areas.

e.         The ageing population profiles in coming years would create significant demand on services, with opportunities but also challenges for people living in rural areas.

f.          It was important to reflect on the wider determinants of health and wellbeing, including housing conditions.

g.         The health and wellbeing of Herefordshire’s rural population was, on average, slightly better than those living in urban areas for many indicators, with the exception of the proportion of households in fuel poverty.  However, there were significant pockets of deprivation and poor health outcomes in rural areas.

h.         A comparison with all the local authorities in England illustrated that Herefordshire was particularly deprived in relation to ‘living environment’ and ‘barriers to housing and services’.

i.           Comparison of the types of deprivation showed that ‘indoor living environment’ and ‘access to services’ were higher in rural areas compared to urban areas of Herefordshire, and were amongst the most deprived in England.

j.           An overview was provided of the housing stock in Herefordshire, and significant challenges were noted in terms of thermal efficiency, affordability and social mobility.

k.         In view of the access times for residents to reach GP surgeries, further consideration was needed on the ways in which people would be able to access services in the future.

l.           The strengths of rural communities and the benefits of the natural environment for health and wellbeing were outlined.

m.        Road safety concerns could be a barrier to people walking and keeping active.

n.         Gypsies and Irish Travellers were represented more in rural areas than in urban areas, were more likely to experience the effects of rural inequality, and had poor outcomes in key areas such as health and education.  It was anticipated that the Talk Community programme would help to reach people more at risk of inequality.

o.         It was emphasised that the report did not capture everything that was happening to support the health and wellbeing of people living in rural areas but an overview was provided of some examples, including Herefordshire Council’s new County Plan, the Children and Young People’s Partnership Plan, Talk Community, the NHS Long Term Plan and Primary Care Networks, the Keep Herefordshire Warm scheme, the Fastershire Broadband Project, and the review of the Housing Strategy.

The chairperson welcomed the annual report.  As a general point to report authors, it was suggested that charts should include not just percentages but also absolute numbers where appropriate.  Questions and comments were invited from board members, the principal points included:

1.         The chair of Healthwatch Herefordshire commented on the value of the report and advised that Healthwatch Herefordshire was considering potential projects for the year, including health and wellbeing issues for the farming community.

2.         The cabinet member – children and families considered the report to be informative and, in particular, expressed concern about the disadvantages for Gypsies, Travellers and Roma, and about dependency on the large number of people providing unpaid care for family members or friends.

The director for public health commented on the potential for Talk Community to engage with diverse communities.  The assistant director all ages commissioning made a number of points, including: the request to bring commissioning plans to the board was welcomed in the interests of transparency; the annual report would be used to inform a thematic approach to commissioning, working jointly with system partners, to ensure that decisions did not have unintended consequences for other groups of people; the council was in the top quartile in terms of payments to care providers; there was the potential for employers to be carer friendly employers; and the system would be difficult to sustain without unpaid carers and this would be taken into account as part of the commissioning agenda.

3.         The vice-chairperson also welcomed the annual report and made a number of observations, including: reflecting the potential focus on early help for children, it was suggested that consideration be given to communities of disadvantage; the needs of Gypsies, Travellers and Roma were significant, in terms of both health and wellbeing; and there was a need for close working with these communities and their representatives to understand and address the issues collectively.

4.         The non-executive director of Gloucestershire Health and Care NHS Foundation Trust said that the annual report had brought together many causes of deprivation in the county but noted that it raised more questions.  He suggested that there was a need to consider how to cut across silos of government in a coordinated way to tackle issues such as housing affordability and transport.

The director for public health said that Herefordshire was the worst area in the West Midlands for housing affordability and, in bringing the intelligence together in the annual report, the system was in a better place to lobby nationally to highlight the costs and challenges of providing services in rural areas.

5.         The managing director of NHS Herefordshire Clinical Commissioning Group considered the report fascinating and, drawing attention to the rural – urban based inequalities, noted the protective factors associated with living in rural localities.  In terms of access to healthcare, reference was made to the investment in Primary Care Networks and the potential of digital solutions to reduce the number of face-to-face appointments.

6.         The cabinet member - children and families, noting the issues with the existing housing stock, considered that sub-standard housing was still being built.  It was emphasised that better quality housing would be beneficial to health and to long term affordability.

The chairperson noted that the new County Plan recognised the need to improve the energy efficiency and build standards for new housing.

7.         The director for adults and communities said that the board should be able to hold to account the system and responsible bodies.  He added that there was a need to be mindful of not pricing people on low incomes out of the housing market.

8.         The managing director of Wye Valley NHS Trust commented that a challenging aspect of the annual report was that people were healthier in rural areas than in urban areas, and questioned whether the focus should be on those people who had significantly worse outcomes.  The importance of ‘healthy’ life expectancy was emphasised.  Reflecting the strapline of the new board priorities of ‘helping you to help yourself’, it was suggested that there was a need to consider how to build upon existing social and community connections, and to share learning with other communities.

The director of public health acknowledged that living in rural areas could be good for health and wellbeing but, with pockets of deprivation and an ageing population, there were also added challenges.  The potential of the Talk Community approach to connect communities and share good practice was outlined.

The vice-chairperson commented that, due to the level of scale, to be from a disadvantaged community in Herefordshire could be more difficult than in other settings.  The director of public health referred to access to transport to attend an interview as an example of hidden inequality for people in rural areas.

9.         The Leader of the Council drew attention to the overview of housing stock and the high proportion of larger, older detached houses and questioned what could be done to improve living environments.

The director of public health noted that some people were capital rich but revenue poor, and suggested that further understanding was perhaps needed on the barriers to improving homes and the role of planning approaches in this regard.

The chairperson invited the board to consider the recommendations, further observations of board members included:

i.           The managing director of Wye Valley NHS Trust reiterated that the annual report demonstrated that the bigger inequalities were in the urban communities.  The director of public health stressed that there were significant and often hidden inequalities in rural areas, especially in terms of housing and access to services.  She added that the system partners, especially as anchor organisations, needed to organise services which were accessible to rural communities. 

ii.         The vice-chairperson said that digital strategies could help to make services both more accessible and resource efficient, and inequalities and poor outcomes for some of the ethnic minorities in the county needed further exploration. 

iii.        In response to a comment by the non-executive director of Gloucestershire Health and Care NHS Foundation Trust, the director of public health confirmed that the annual report was not intended to be all encompassing but sought to improve understanding of the impact of living in rural areas on the health and wellbeing of communities and the challenges being faced.

In view of these further observations, the chairperson proposed an amendment to recommendation (b) to reflect the need to address inequalities faced by rural communities and the most deprived communities.

Resolved:  That the health and wellbeing board:

(a)      notes the findings of the annual report, and supports the identified strategies and actions to address the challenges of life in rural Herefordshire; and

(b)     will provide leadership in addressing inequalities faced by rural communities and the most deprived communities through recognition of the challenges, communicating the key messages of the report to constituent members, and identifying further actions that can be taken by constituent organisations and across the system.