This report will be divided into three sections. In section 1, I will be talking about the profile of the London borough of Enfield, health issue (Stroke as an issue), the social determinants of health and the relationship to health inequalities. Section 2 will cover a relevant stroke policy on the national level and what it suggests and what it does not address. In section 3, I will identify a relevant Public Health Provisions and how they address the health inequality in the borough. I will also talk about the gaps that I identified in health provision in the borough of Enfield.
Demographic Profile of Enfield
The borough had a population of 324,500 in 2014 with a large proportion of the population being 0-14s and older generation compared to the rest of London. Enfield is very diverse as it has communities from all over the world (Enfield Council, 2019).
Based on the 2017 Enfield Ethnicity estimates, residents from White British backgrounds make up 34.77% of Enfield’s inhabitants with other White groups at 25.23%, Other Ethnic Groups at 6.14%, Mixed Groups at 5.34%, Asian Groups at 10.24% and Black groups at 18.28% (Enfield Council, 2018).
Enfield is ranked as the 64
most deprived out of 326 local authorities in England. Deprivation is correlated with worse health, high morbidity and high mortality. The largest cause of death in Enfield is Cardiovascular Disease (stroke, coronary heart disease and heart failure) followed by cancer. (Enfield Council, 2014)
In the borough of Enfield, according to rank, the deprived wards are, Edmonton Green, Upper Edmonton, Lower Edmonton, Ponders End and Turkey Street. The three Edmonton wards are within the most deprived 10% of wards in England. Out of the borough’s 21 wards, twelve are among the most deprived 25% of wards in England (Enfield Council, 2019)
The health issue that I will be highlighting in this report is Stroke as deaths from circulatory diseases which includes ischaemic heart disease and strokes accounted for 32% of deaths in Enfield borough. Stroke occurs when there is no supply of blood to the brain and it can lead to brain cell damage or death. Strokes can occur as a result of blockages in arteries that give oxygen-rich blood to the brain (ischaemic strokes) or it can be caused when there is bleeding in the brain refers to as haemorrhagic strokes. There is also another type of stroke known as transient ischaemic attacks(TIA’s) which is a mini stroke caused by a temporary blockage of the artery (Enfield Council, 2017).
Who is affected? Health Inequalities
Health inequalities is a term used to explain the disparity in health status among and within people with similar social and economic status (Wistow, 2015).
The Marmot review came out on 11 February 2010 to address the issue of health inequalities in England. The report was based on addressing the social determinants of health. It states that people’s environment, work and age result to health inequalities. The report shows that housing, income, education, social isolation and disability have a have a negative effect on people’s health. It states that if someone’s social economic status is low, the person/s health is likely to be poor (Local Government Association, 2019).
Health inequalities can be tackled by a joint action across all the social determinants of health by closely looking at education, occupation, income, home and community. The report suggests that to reduce health inequalities there should be a joint action looking at the population health status and related inequalities in social status (Local Government Association, 2019).
In Enfield, circulatory diseases which includes stroke are the biggest causes of life expectancy gap that accounts for 26% of the male life expectancy gap and 29% of the female life expectancy gap. Those that are at highest risk of stroke in Enfield are older people (mostly over 65), people who live in Edmonton Green Ward, those of African and Caribbean ethnicity and those who have a family history of stroke or TIA (Enfield Council, 2011)
People need good income to access the resources that are needed for good health and well-being. In Enfield almost 35% of children were estimated to be living in poverty in 2009 and the income level in Enfield is low compared to other parts of London. The borough has the 7
highest percentage of children who live in workless households across the London boroughs (Enfield Council, 2012).
Social Determinants of health are interfering factors that affect people’s health status. These are conditions such as where people are born, grow, live, work and age and they are influenced by how money, power, resources at global, national and local levels are distributed. The social determinants of health is the reason for health inequalities around the world and also contributes to the unfair and differences in health status (W.H.O, 2019).
From April 2012 till March 2013 the employment rate in Enfield stands at 67%. This figure is the eleventh lowest in London and it is below the London average of 69.5% and the England average of 71.1%. The rate of those people who are economically active in Enfield was 74.7% which is the 10th lowest rate in London. This is a little below the London average of 76.4% and the England average of 77.3% (Enfield Council 2014).
The residents of Enfield experience greater levels of deprivation when compared to London as a whole. 29% of Enfield children live in household of worklessness which is the 7th highest among the London boroughs. Those adults who are of working age and who claim out of work benefits make the borough the 10th highest across the London boroughs (Enfield Council, 2012).
Health policy approach alludes to the collection of plans, laws, controls, choices, methods, practices and activities that are embraced by a society to improve the well-being of the people who live in that society. A large perspective of it is to do with improving the physical health of its inhabitants, for example giving people easy access to its public health clinics. However, some parts of health policy may not be directly linked to health (Ungvarsky, 2019).
In January 2019, NHS England made known its Long Term Plan, in which stroke has been named as a new national priority. It plans working with partners in order to improve stroke care from the onset of stroke to ongoing care. This plan incorporates avoidance, treatment and rehabilitation (NHS England, 2019).
The National Stroke Program has been created in agreement with the NHS England and the Stroke Association in discussion with clinical specialists and individuals that are affected by stroke. The programme will work in collaboration with local organisations on the best ways to prevent, treat and care for those 80,000 who have stroke in England each year and meet the desire for stroke as set out within the long term arrangement (NHS England, 2019).
The programme purposes to improve post-hospital stroke recovery models for stroke survivors. It plans to deliver a ten-fold increment within the context of patients who get a thrombectomy after stroke each year so as to enable 1,600 more individuals to be independent after their stroke. It also aims to train more clinic specialists to give mechanical thrombectomy and double the number of patients who receive clot-busting thrombolysis (Guaranteeing 20% of those who suffer from stroke get it by 2025). The plan also aims to enhance the Sentinel Stroke National Audit Programme (SSNAP) to recognise further need and drive improvements. The plan also aims to ensure that three times as many patients receive 6 month reviews of their recuperation and needs from the current 29% to 90% (NHS England, 2019).
According to the King’s Fund the national leaders should be giving credit for focusing on quantifiable improvements in health outcomes. Their commitments will spare lives make the lives of patients feel better. But there is a big question as to whether the plans can be delivered as the government has to increase staff, especially in the primary care. They should also need to invest in diagnostic equipment and leaders on the national level. The plan is committed to patients’ involvement in their own care but it does not talk about patient and public involvement in shaping health services and it has left out the role of communities in health care (The King’s Fund, 2019)
The Sentinel Stroke National Audit Programme (SSNAP) says the method to use thrombectomy has appeared in trials to see greater results in patients who qualified once it is performed within few hours of stroke. But, the required facilities for thrombectomy are accessible in a little number of centres and there is a deficiency of qualified staff to perform the procedure (NICE, 2019).
The aforementioned health policy has not addressed people’s income in Enfield borough and it’s main focus is the health issue directly. However, it has given access to services for those who suffer stroke.
Public health is the science and craftmanship of avoiding illness and ensuring that people’s lives are prolonged. It is about the joined efforts of the informed decisions of society as a whole including the public and private sectors, communities and individuals working together to promote well being (Winslow 1920 cited by Viseltear 1982).
Winslow acknowledges that it is not only the medical discoveries that contribute to how we feel but our social relationships, the environment where we dwell and our sense of purpose in life are some of the factors he looked at to be the arts of public health (Thompson, 2014).
Enfield at this present time does not have a dedicated stroke rehabilitation team with little access to generic rehabilitation. However, it has two services for patients that require rehabilitation. One is Generic community rehabilitation service that is run by Enfield Community Services and the second one is Out-patient rehabilitation provided by Barnet and Chase Farm Outreach team. These services are able to provide short term intervention following patients’ discharge from hospital. There is little provision for community rehabilitation and this is identified as a gap in Enfield Council. The services provide interventions in the area of assessments, education, clinical managements, home visiting services for household patients, limited neuro-physiotherapy service, limited adult speech and language support, assessment and provision of walking aids and simple communication aids plus telephone reviews and support (Enfield Council, 2011).
The stroke outreach provides limited therapy service to patients who have suffered a stroke post discharge. In 2009 to 2010, 101 referrals were made to the service and 67 that met the criteria of the outreach were accepted (Enfield Council, 2011).
Enfield provides support in the area of community re-integration and includes support for their relatives, carers so as to gain back a good quality of life and be able to live independently (Enfield Council, 2011).
Stroke survivors can have access to homecare, residential care and day care. Enfield provides psychological therapies for those who have mild to moderate needs and those individuals who have severe and prolonged mental health problems (Enfield Council, 2011).
In addition, The Voluntary and Community sector in Enfield provide a wide range of services that support people to maintain their independence and wellbeing (Enfield Council, 2011).
Also, they provide support for people who are unable to live in their homes because of stroke. They provide residential and nursing care placements at a cost to the Council. This is addressing the social determinants of health as the income level in Enfield is low in comparison to other parts of London (Enfield Council, 2011).
Total Healthcare and Stroke Action provide services named Social Stroke Support to 35 stroke survivors and their carers to avoid social exclusion (Enfield Council, 2011).
Enfield Council has addressed social determinant of Health by providing residential support for those who need it at a cost to the council. In addition to the provision of walking aids and simple communication aids to those who suffer from strokes.
In this report, I have looked at the profile of Enfield borough and highlighting stroke as an issue. I have also talked about the social determinants of health and its relationship to health inequalities. I have also looked at relevant stroke policy on the national level. I have also talked about a relevant Public Health Provisions in the borough, looking at whether or not it has addressed the issue of health inequality in the borough of Enfield.
In the light of all that I have discussed above, I believe that the government has a long way to go in addressing health inequalities in our society and until they start addressing the social determinants of health, the disparity in health care would continue to widen.
- Enfield Council (2011)
Enfield Joint Stroke Strategy 2011-2016
. Available at:
(Accessed: 13 July 2019).
- Enfield Council (2012)
Improving Health and Wellbeing in Enfield. The Annual Report of the Director of Public Health 2012
. Available at:
(Accessed: 2 July 2019)
- Enfield Council (2014)
Enfield Joint Health and Wellbeing Strategy 2014-2019:
Your Health and Wellbeing.
(Accessed: 10 June 2019).
- Enfield Council (2017)
The Health and Wellbeing of Adults.
(Accessed: 30 May 2019)
- Enfield Council (2018)
Enfield Borough Profile: Information and Research Team London Borough of Enfield
. Available at:
(Accessed: 2 June, 2019)
- Enfield Council (2019)
Borough and wards profiles
. Available at:
(Accessed: 15 June 2019).
- Enfield Council (2019)
(Accessed 5 June 2019)
- Local Government Association (2019)
Marmot Review report – ‘Fair Society, Healthy Lives
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(Accessed: 7 June 2019).
- NHS England (2019)
(Accessed: 20 June 2019).
- NICE: National Institute for Health and Care Excellence (2019)
(Accessed: 2 July 2019).
- The King’s Fund (2019)
The NHS long-term plan explained.
(Accessed: 10 June 2019).
- Whitehead, M. (2007) ‘A typology of actions to tackle social inequalities in health’,
Journal of Epidemiology and Community Health
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- W.H.O (2019)
Social determinants of health.
(Accessed: 10 June 2019).
- Wistow, J. (2015)
Studying Health Inequalities : An Applied Approach
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