Issuu on Google+

Tackling inequalities in health outcomes in Greater Manchester

Prepared by The Oglesby Charitable Trust (OCT) Issue: March 2013


This paper provides the context for a health initiative of the Oglesby Charitable Trust to address inequalities in health outcomes in the Greater Manchester area. It was completed by Millar Consulting and is based on a combination of desktop research using published data and informal, unstructured conversations with public sector principals. It is intended to identify options for discussion with agencies and through those discussions build consensus and co-operation around an issue, approach and outcomes.

Extract In the 19th Century Marx and Engels looked out over Manchester from the window of Chetham Library1 contemplating the mix of economic and social forces shaping the city and the health and lives of its residents. They wrestled with profound questions of inequality, fairness and social justice and the conclusions they reached, for better or worse, shaped the world we live in today. If Disraeli is correct, and “what happens in Manchester today, happens in the rest of the world tomorrow2� then Manchester’s leaders must now come together to answer the question: what benefit does economic gain bring to a city, if it does not also improve the health and wellbeing of all its residents? The answer, if it can be found, will shape the lives of a generation. It may also change the world.

Tackling inequalities in health outcomes in Greater Manchester


Contents

02

Summary

03

Chairman’s foreword

04

The state we are in

06

The task at hand

08

A considered response

10

What now? What next?

12

Annex

14

References

16

Acknowledgements

Tackling inequalities in health outcomes in Greater Manchester |

01


Summary

The health of Manchester’s residents poses one of the biggest barriers to the city’s further economic growth and progress on the global stage. Hard work and some gains are being overwhelmed by strong negative health trends. The biggest determinants of health in Manchester – tobacco, drugs, alcohol and obesity – are closely associated with areas of deprivation in the city. Deprivation, worklessness and mental health are themselves linked.

It is increasingly clear that these lie beyond the reach of public services ‘tasked’ with preserving the health of the nation. They are hampered by a structure optimised for cure not prevention, drawing on different budgets, juggling different objectives and better suited for dealing with discrete hazards not complex, social pathways; reliant upon the help of other agencies and in truth, residents themselves. If changing behaviours, challenging attitudes and reversing social breakdown are at the heart of the challenge to improve health and wellbeing in the 21st Century – can they be changed? Are there any grounds for optimism? A combination of public spending constraints, structural public sector reforms, shifting political narratives, technological advances and the example of successful campaigns elsewhere is raising important questions about the traditional public sector approach. Questions are being asked about the sustainability of spending some 95% of health funding on ‘ambulances at the bottom of the cliff ’ and just 5% spent on prevention and ‘building fences at the top’. A change of approach, even philosophy of public service is not something that is familiar, nor is it comfortable. Although the medical model of public service, characterised by its find and fix approach works best responding to the consequences of ill health and isolated hazard, it is generally accepted that this does not tackle the root causes. The key advance will come from fostering greater personal responsibility for health, not just better public sector cooperation. Developing a narrative based on abilities and strengths is an important part of this, addressing connected issues of deprivation, worklessness, poor mental health and the determinants of health. It is encouraging that the language of working with people, the importance of work to personal health and wellbeing are now a key part of priorities of the Health and Wellbeing Board in Manchester and that the University has invested in a key research strand focused on prevention. In short, there is an intentional alignment of values, thinking, priorities, approaches and plans across the public sector that gives cause for cautious optimism. The health barriers are clear and so is the opportunity. The skills, willingness and capacity exist in Manchester. The way forward must focus on doing things with citizens, not to them or for them; on working with the grain of people and communities. So is the time right for a new public/private/community partnership? One that can frame difficult conversations about values with residents, and work with them to address the attitudes and behaviours that are harming their health and holding the city back?

02

| Tackling inequalities in health outcomes in Greater Manchester


Chairman’s foreword

The Oglesby Family set up their Charitable Trust to make a difference to the lives of people in the North West of England and its capital, Manchester. Trustees have been concerned for some time that despite the substantial amount of money given to worthy causes in recent years, much of it has essentially been palliative, offering help to ease problems, but not addressing the underlying issues within society. We are now endeavouring to shift this approach and focus on causes and prevention. Good health, although often taken for granted, is central to life and our experience of community. The growing disparity in health outcomes between and within different social groups and regions is of concern across the UK, indeed the world. Accordingly, the Trustees decided to examine what contribution they could make to this complex issue in Manchester. One of the most important lessons we have learnt as a charity is that the more time and the better the research one undertakes before embarking on a project the better the outcomes. The enclosed report was undertaken to identify the consensus view, if one existed, on the situation in Manchester. Leading practitioners from across public services in Manchester were questioned in some depth. This identified different perspectives and opportunities, but a consistency of views and concerns – and little that would come as a surprise to thinking

members of the wider community. For that reason, if nothing else, this report offers a simple summary and confirmation of these concerns and opportunities. It may also act as a provocation to those for whom health may not be their natural territory. While we consider that the report does make important, high-level recommendations about a narrative beyond inequalities, and an approach that works with the community, we deliberately did not seek to offer narrow conclusions or be prescriptive about a response. At the outset it appeared that there were three broad avenues open to the Trust. The report has done little to change this view. The Trust could concentrate on a particular ‘disease’ area such as alcoholism or smoking and with the help of others arrive at a plan for significant reduction and become involved in the program of implementation. Another option would be for the Trust to focus on the community within a relatively small geographic area and develop with them a program to improve the health outcomes in their area, with the aim of arriving at a blueprint for an approach which might be used in other parts of the city or further afield. Finally, the Trust could adopt a city-wide approach, working on one of the principal underlying issues within society associated with poor health outcomes, such as generational worklessness or education.

The process starts by sharing this document. Through the conversations we hope will follow, we will look to identify the most appropriate avenue for the Trust to pursue, the most effective contribution we can make to design and implementation stages, and the team and partnerships to achieve the selected goal.

Michael Oglesby CBE DL Chairman

Tackling inequalities in health outcomes in Greater Manchester |

03


The state we are in

The shock waves from the 2008 banking collapse are still being felt around the world. The global financial crisis that followed was a result of decades3 of over-spending, overborrowing and nations living beyond their means. It has seen economies depressed, governments fall and the humiliation of nations. In the UK, after nearly two decades of economic growth, the talk of political, business and financial leaders has turned from prosperity to austerity. The future is no longer a vision of unlimited growth and opportunity, but of a “perfect storm” in which economic recession, a funding crisis for public services and growing demands on public services are putting an unbearable strain on society. The consequences are unfolding of living beyond our means as a nation. The two cities, eight boroughs and some two and a half million residents of Greater Manchester have their own tale to tell. The nineties and noughties saw levels of economic growth unseen anywhere in the UK outside London. Manchester made a clear claim to being the UK’s second city and now sits comfortably alongside Barcelona, Frankfurt and other global cities. Its universities have a rich history and a reputation of innovation and excellence: together they form the largest student campus in Europe. Art and popular culture have also flourished. Arguably the Manchester

04

Commonwealth Games foreshadowed the successful 2012 Olympics4 and Manchester’s two biggest football teams sit on top of the most exciting football league in the world, playing to a weekly global audience of millions. In spite of this success, Manchester, the “original modern city”, struggles to understand itself, conflicted beyond a loyalty to teams playing in red and blue. Despite two decades of a rising tide of prosperity, and hundreds of millions invested in regeneration and cultural vibrancy, life remains a struggle and prospects are bleak for too many of its residents.

One city, two parts Commuters from the affluent southeastern fringes of Manchester approach the city centre along Upper Brook Street. On their left they pass the Manchester University campus where the new Alan Turing and Schuster buildings shine literally and metaphorically as symbols of progress and economic growth. However, across the road is Ardwick, an area characterised by profound social problems and disengagement from available public services5. Just as Disraeli observed of the nation in 1845, Manchester today is one city, but it comprises two distinct and separated parts. The millions spent on urban regeneration projects have helped secure corporate commitment,

| Tackling inequalities in health outcomes in Greater Manchester

brightened the cityscape and promise further growth, but these improvements have not translated into better outcomes for all. On the demand side, technology has created an ‘hourglass economy’ enabling a talented, mobile, connected and skilled workforce but reducing intermediate, skilled jobs that served as ladders of opportunity for the unskilled and the excluded6. But the ladders that remain are also moving out of reach. On the supply side, poor health outcomes, the underlying determinants of health7 (obesity, tobacco, substance abuse, worklessness) and associated factors such as inter-generational benefit dependence, poor mental health, family and social breakdown form a reinforcing cycle, resistant to the best efforts of public agencies8.

An unhealthy divide Health in Manchester and the UK has improved significantly since Victorian times. Nationally the picture is one of positive trends. In 2010, cancer mortality rates9 had fallen from 1997 levels, due in part to better diets and less smoking but also to earlier diagnoses and modern treatments10. Deaths from the three most common forms of cancer in men (prostate, bowel, lung) and women (breast, bowel, lung) showed significant reductions between 2001 and 201011. Manchester has also made good progress in these areas, as well as other health issues such


as a reduction in teenage pregnancy from 2005/7 levels, and increased vaccination and immunisation rates. However there is still much to be done. The gap in health outcomes between Manchester and the rest of the UK and Europe is growing. In 2008, Salford and Manchester ranked first and third respectively in incidence of malignant cancer in the country12. Manchester’s population is developing life threatening conditions such as diabetes, vascular, heart and respiratory disease, in their fifties, not sixties – a whole decade before peer groups in other parts of the UK. As David Regan, Director of Public Health in Manchester summed it up:

presenting statistically15 a twelve-year difference in life expectancy. With nearly one in ten working age residents of Manchester inactive in the labour market for health reasons16, it is no exaggeration to say that the health of Manchester’s residents has become critical to the economic wellbeing of the city.

“Most people in England continue to die from heart disease and cancer – they are just dying earlier in Manchester.” This fits with a bigger North South picture. At 75 years of age, a person is twenty per cent more likely to die in the North13. But even allowing for regional differentials, the contrast within the Greater Manchester area is just as shocking. Forty per cent14 of all registered patients with the life threatening but manageable condition, chronic obstructive pulmonary disease (COPD) live in just one locality of the city, Gorton and Levenshulme. Or consider two wards in Salford separated by less than ten miles but at opposite ends of the income scale and

Tackling inequalities in health outcomes in Greater Manchester |

05


The task at hand

A response is imperative, but so is the need to get under the skin of these overarching figures: what is determining the health outcomes for residents in Manchester? Are they different from the rest of the UK? Are there any patterns? Smoking, and specifically lung cancer, remains one of the biggest killers in England and Wales. But it is Manchester that leads the UK17. Figures show a long-term downward trend in deaths due to lung cancer amongst males and a small but real decrease in deaths in women between 2003/5, compared with the North West region18 however, as we dig beneath these averages, we find that death rates in the most deprived wards in the UK19, many of which are in Manchester, are three times higher than the least deprived wards in the UK. Abuse of alcohol in Manchester is prolific and entrenched, with an estimated 80,000 harmful drinkers20. Rates of alcohol consumption are amongst the highest in the UK, in part due to a large student population. Heavy drinkers will visit their GPs twice as often as non-drinkers, and up to 80 per cent of people attending Accident and Emergency (A&E) departments at peak times require treatment for alcohol related injuries. Harmful and ‘binge’ drinking is associated with less wealthy areas of Manchester, where alcohol related hospital admissions are greater and

06

some of its A&E “frequent flyers” present more than one hundred times a year21. The national picture is one of harm associated with high rates of alcohol consumption22. Behind closed doors, in the home, alcohol is strongly associated with domestic violence, child abuse and divorce. Alcohol is also strongly associated with petty crime (such as theft to pay for drink) while approximately two thirds of all homicides, stabbings and beatings involve alcohol and as many as onethird of all murder victims are under the influence of alcohol at the time of their death. Alcohol is thought to be a factor in up to a third of all accidents and is associated with risk taking behaviours such as unprotected sex. Unlike other forms of substance abuse, against which Manchester is making some progress, alcohol’s position as the last remaining ‘socially acceptable’ drug – there are no laws limiting the amount an adult can purchase or consume – is causing significant harm23. In 1990 the estimated cost of alcohol to the UK economy was £2.4Bn in lost productivity, health and criminal justice costs. By 2007 that figure had risen to nearly £20Bn. Obesity, often referred to as a public health “time bomb”, is already having huge cost implications for the health service and the economy. A wide range of health problems is associated with

| Tackling inequalities in health outcomes in Greater Manchester

excess weight including coronary heart disease, Type 2 diabetes, strokes, common cancers and high blood pressure24. This further impacts on attendance at work and performance. The number of obese adults in Manchester is expected to reach 137,000 by 2015 – a 50 per cent increase in ten years – while amongst children, obesity is in the words of one professional “one of the most worrying issues within Manchester and the UK”. Obese children are likely to remain obese as adults and as noted by the National Obesity Forum obese teenagers are twice as likely to die by the age of fifty25 with the onset of related adult conditions such as Type 2 diabetes. Once again, within Manchester, obesity is more likely in more deprived areas and worse than the rest of the country. Approximately 15 per cent of children in England were classed as obese in 2010 but in Manchester, obesity rates were approximately 20 per cent higher than national averages – and doubled between Reception and Year 626. Mental health has a significant impact on employment in Manchester, where Incapacity Benefit claimants form the largest proportion of out of work claimants. More than half of these claims are due to a mental health condition, compared to a national figure closer to 43 per cent27. In other words, almost one fifth more than the national average.


Mild to moderate mental health disorders such as stress, depression, anxiety, low self-esteem, OCD and panic disorders (excluding congenital and genetic conditions) are associated both with unemployment and recognised as a major barrier to employment. This is a complex area. Being unemployed can also become a barrier to employment. Poor mental health is also associated closely with the problems of alcohol, tobacco and low levels of physical activity noted previously28. Heavy drinking, for example, is often associated with neurotic disorders, and suicide attempts29. Once again the question is not straightforward: do people suffering from depression drink because they are depressed, or are they depressed because they drink? Or both? This kind of cyclical reinforcement is also present when links between mental health and areas of deprivation are examined: poor mental health is both a cause and a consequence of greater deprivation30.

Tackling inequalities in health outcomes in Greater Manchester |

07


A considered response

These issues are not new and awareness of the challenges is widespread. The hard work that is being done and the few gains being made are simply being overwhelmed by negative trends. It is one thing to note that changing behaviours, challenging attitudes and reversing social breakdown are at the heart of the challenge to improve health and wellbeing in the 21st century – but can they be changed? If so, what responses are working elsewhere? Are there any grounds for optimism? Is there hope? The key discussion lies in the response: where to start and what to do?

No small change The persistence and growth of social and health problems despite a massive growth in spending poses a question that goes beyond the arithmetic of budgets and the challenge of funding the public purse: what if these problems lie beyond the reach of traditional approaches to public services? What if funding cuts are not the problem and more money is not the answer? This is unsettling because it threatens reform of cherished traditions, familiar practices and established institutions. Even the problem – a cut of nearly £1 in every £4 of grant for the local authority and an effective freeze in NHS funding – may be difficult, but it is still familiar. On the other hand, a change of approach, let alone philosophy of public service is not familiar. Nor would it be

08 |

comfortable. However it is the focus of the debate that is forming within the two major parties, behind political frontlines dominated by traditional tax and spending rhetoric31.

Working with the grain The ‘medical model’ of public services, characterised by its ‘find and fix’ approach works best responding to the consequences of ill health and “isolated hazards”. The structures, treatment and funds for patching up someone admitted to A&E are very different to those needed to resolve drug and alcohol dependency, a chronic smoking habit, ill health through obesity or homelessness, or the underlying mental health problems that may be associated with any of these. There are real barriers to health – such as cost of transport, cost of heating, knowledge of and access to healthy diet, an abusive partner, fear of neighbours, cultural objections, language and learning but as one doctor, working in the poorest parts of the city commented: “My patients will often only come in when I call them personally. And that is only after the receptionist has texted them.” A doctor, nurse or health worker cannot provide a service to someone who simply is unable or unwilling to engage with it. In Ardwick for example, before the City Region Pilot, less than one-fifth of parents with children younger than

Tackling inequalities in health outcomes in Greater Manchester

five years had any contact with the local children’s centre32 – a figure that defied the need within an area of its socioeconomic profile, and one that poses real concerns for safeguarding. The answer to this is not centralised, national, top-down programs (see Annex). Neither are the barriers to this geographic or even financial. Rather they are formed largely from attitudes. These pose a much greater obstacle to improving health for the ‘hardest-tohelp’ groups. Efforts to work ‘with the grain’ of people and communities must focus on doing things with citizens, not to them or for them. Indeed, the central recommendation of Marmot’s Review was “to create the conditions for people to take control over their own lives33”.

Straws in the Wind It is encouraging then that the language of working with people and the importance of work for health and wellbeing are now appearing in the plans of key agencies across the city. The Manchester Health and Wellbeing Board has identified within its priorities34 to: “Educate, inform and involve the community in improving their own health and wellbeing… moving more health provision into the community… bringing people into employment and leading productive lives.” Likewise the aims of the Board are simply stated and focus firmly on


prevention by working more closely with residents: “We want to see a major shift in the focus of services towards prevention of problems and intervening early to prevent existing problems getting worse. And… a shift towards services provided closer to home35.” This is also the focus of work in the University, where behaviour change is central to the only all-encompassing prevention and screening programme in the UK.

national discussions about minimum pricing and a Home Office consultation to include “health as a new alcohol licensing objective for cumulative impacts so that licensing authorities can consider alcohol related health harms when managing the problems relating to the number of premises in their area”. These words are more than straws in the wind. They point to an intentional alignment of values, thinking, priorities, approaches and plans, giving cause for cautious optimism.

But changing behaviours is also tricky political territory. Behaviours and attitudes are built on values – and these do not always follow rational patterns. The liberal philosophy that recognises a freedom to act is now being challenged where that freedom of choice results in harm to oneself – or dealing with the consequences imposes an unbearable cost on others. This dilemma is evident in the different language used to describe drug and alcohol treatments. While the tone surrounding drugs treatment for adults in Manchester has hardened in recent years, emphasising recovery and abstinence rather than management of risk, alcohol based services avoid making values statements and do not embrace recovery. This may be changing however. A strong awareness of the problems amongst Manchester City’s councillors exists which is not out of step with current

Tackling inequalities in health outcomes in Greater Manchester |

09


What now? What next?

A broad consensus has developed that inequality in health outcomes is a serious problem in Manchester. Even this brief analysis has identified points for careful consideration in plotting a response. The key advance to be made is to help more residents to take more responsibility for their health. The public sector in Manchester has a track record of communication, collaboration and innovation in its response to problems. The Community Budget is an important development of the ‘total place’ approach and offers some hope through shared budgets and objectives – but better public agency coordination and collaboration will not be enough by itself. Underpinning greater personal ownership of health outcomes is a new narrative centred on the resident and strengths and abilities, not the system and the help that is available. Health shapes our sense of security, our self-image, the way others see us, the relationships we form, the work we do and our hopes for the future. It poses some of the most profound questions we ask: will my partner stand by me “in sickness and in health”? Can I provide for myself, or those who depend upon me? Can I have a future free from illness and enjoy a healthy old age? These are all things for which we can take responsibility to greater or lesser degree. Where we cannot, we can ask for help from others and from public agencies.

10 |

A focus on causes and not symptoms flows from this. The experience of falling crime rates in New York City illustrated36 that headline issues such as ‘health inequalities’ are very effective at drawing attention to problems, but defy simple causal explanations and bring little insight to plan a response. Deprivation, worklessness, mental health and key determinants of health are all linked and yet our current responses are disconnected, delivered by separate agencies, objectives and funding streams. A new narrative with the resident, not the support system, at its heart, offers the hope of better organisation. A further challenge is developing a truly community led response. Empowering communities within wards, framing issues at a neighbourhood or street level means relinquishing control over priorities, building community confidence and waiting for permission to act, where and when requested. This is completely counter to the traditional public sector modus operandi. It requires collaboration with effective voluntary groups and speaks more of “spread” than “scale” but it is at the heart of the most exciting political initiatives, citizen action and public-private-community partnerships, including family support, that are taking place across the UK. This may also point the way to a gradual but clear shift in funding. Some 95 per cent of health funding still goes on the “ambulances at the bottom of

Tackling inequalities in health outcomes in Greater Manchester

the cliff ” – with just 5 per cent spent on prevention and “building fences at the top”37. Effective initiatives should pave the way for decommissioning of mainstream programmes that are not working and a redirection of funding. In other words, initiatives must be set up to both validate impact and demonstrate a reduction in service demand. Technology may also have a role to play. Education has always been a significant barrier in homes where schools are treated with suspicion because of the parents’ own experience of schooling, and where reading in the home is limited to the television, food and product packaging or catalogues. What opportunities are there to use the increasing presence38 of mobile phones to deliver timely, relevant information to individuals? Can Manchester’s history of academic excellence and world leading research be applied to link principles of rapid prototyping with principles of community ownership – countering the more ponderous traditional approach to health-based learning through research, review and regulation? Will the psychological and behavioural components of the University’s research into prevention provide essential insights on delivering effective policy? Leadership and commitment will also prove essential. None of these steps are simple or short-term commitments. Five years may allow enough time to see a sustainable and real improvement


in an individual’s health, but it is barely time to establish a trend in reduced demands for services. It is enough time also to find and settle into a job, but only just time for a person to grow beyond infancy into school, and not time enough for a youth to navigate their teenage years. It is also barely enough time to shift the attitude or culture of a community from dependency and incapacity, to one of strength and ability. Finally, the problems of timescale, combined with the challenge of delivering difficult values based messages and the limited reach of the public services means this cannot be the sole responsibility of political administrations. There is an important role to be identified and played by third parties, from outside the public sector.

Carpe Diem – “seize the day” Looking out over Manchester today, more than a century after Marx and Engels, there is clear capacity and appetite for economic growth. Manchester has made its claim to being the UK’s second city and is a player on the global stage. But with another level comes another devil: the new challenge is to enable all its residents to have a share in the benefits of that growth. The opportunities are clear – but so are the health barriers. The skills, willingness and capacity exist for a new form of public-privatecommunity partnership in Manchester: potential partners able to speak difficult truths, working with agencies that can change ways of working and align operations and resources behind them. Reducing health inequalities remains “a matter of fairness and social justice39” but it is also an economic imperative. If Manchester is to once again lead the world, then its leaders must now come together to answer the question, what benefit does economic gain bring to a city, if it does not also improve the health and wellbeing of all its residents?

Tackling inequalities in health outcomes in Greater Manchester |

11


Annex: Note on effective campaigns

Progress through nationally delivered behaviour changing campaigns has been limited – as illustrated by tobacco40 – unless complemented by regional campaigns and personal support, that is, working with residents.

Every Breath campaign This was the UK’s first dedicated regional tobacco control programme.Targeted within the North East, it has reported a seven-fold increase in those quitting, compared to national figures. Information and education were an important part of this campaign. It is estimated that one third of COPD sufferers in the North East were undiagnosed, and a survey of five hundred smokers had revealed that they did not associate shortness of breath with the onset of COPD. Combining national legislation to frame local anti-smoking media campaigns, personally targeted education on symptoms and side effects, plus personal support for those wishing to stop has produced much better results41.

12 |

‘Stoptober’ campaign Other principles for targeting behaviours and attitudes include stigmatising the habit whilst affirming and offering encouragement to those trying to stop. This national campaign in October 2012 concluded with the message, that for those who had gone 28 days without smoking, they were now five times more likely to stop than those who did not42. Effective campaigns have also been explicit in recognising the role of family members and loved ones to help people stop – and in the case of children, the important role parents can play in preventing them from starting the habit43.

Drink Driving campaigns An analysis of anti-drink driving campaigns reveals a similar story: education and information is used to convey powerful messages that help change behaviours and shift attitudes between generations, but it is the personal support that transforms behaviours and breaks addictions.

Tackling inequalities in health outcomes in Greater Manchester


About Bruntwood and the Oglesby Charitable Trust Bruntwood is a part of the Manchester story. Since it was established in Manchester in the seventies, it has been shaping lives and places across the UK. Its strategy of focusing on regional cities, unlocking overlooked value and seeing the opportunity others have missed has been the underpinnings of a property portfolio worth almost £1Bn. A core aspect of the strategy has been recognition for the importance of people. As founder and Chairman Michael Oglesby says: “People hold the key to our success. And their life and health are of utmost importance”. A respect for the people who work within their offices, the society they are a part of, the wider community they live within and the places the business is helping to shape is clear. Staff volunteering is well established, as are annual donations of 10% of profits to a wide range of charities and the Arts directly from the company and through the Oglesby Charitable Trust.

Tackling inequalities in health outcomes in Greater Manchester |

13


References

1

http://www.chethams.org.uk/treasures/treasures_marx.html (retrieved January 14th 2013)

2

Quoted on Manchester Peace and Social Justice website, http://www.manchesterpeacetrail.org.uk/city/index.php (retrieved 28th January 2013)

3

The UK has run a surplus (before costs for bank bail-outs) just twice in the 21st century and in only twelve of the last 65 years, http://www.guardian.co.uk/news/datablog/2010/oct/18/deficit-debtgovernment-borrowing-data# (retrieved 28th January 2013)

4

Sir Richard Lees, Manchester Evening News, 16th July 2012, http://bit.ly/Su3uqh (retrieved 8th December 2012)

5

Ardwick City Region Pilot Delivery Plan Progress Report to Manchester City Council, Health and Wellbeing Scrutiny Committee, March 2011 http://www.manchester.gov.uk/egov_downloads/9._Ardwick_report_for _HWBOSC_March_2011.pdf (.PDF document, retrieved 14th December 2012)

6

7

8

9

neweconomy Manchester, People Monitor http://neweconomymanchester.com/stories/1433-people_monitor (retrieved 14th December 2012) The World Health Organisation has identified key ‘determinants of health’. See “European Strategies for Tackling Social Inequities in Health: Levelling Up” (Dahlgren and Whitehead, WHO, 2008) See page 20 onwards (especially Table 1, page 23) http://tinyurl.com/8z8n54j (retrieved 30th November 2012) Over a thousand studies in the last century have linked unemployment and poor mental and physical health outcomes. Cited in Report of the Director of Public Health to the Health and Wellbeing Overview & Scrutiny Committee, Manchester City Council, January 2012 (paragraph 2.1, page 41) Trend in mortality from all cancers (ICD10 C00-C97, ICD9 140-208), directly age-standardised rate, persons under 75, 1999-2001 to 20082010, per 100,000 European Standard Population, Public Health Observatory's Health Profile 2012, Early deaths cancer aggregate – trend, Office for National Statistics Crown Copyright 2012

10 “Improving Outcomes: A Strategy for Cancer”, NHS, January 2011, http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/docum ents/digitalasset/dh_123394.pdf (retrieved 28th January 2013) 11 Incidence in males fell from 229/10000 in 2001/3 to 204 in 2008/10; in females from 160 to 149 in same period. Note diagnoses increased during same period. Ibid

14 |

Tackling inequalities in health outcomes in Greater Manchester

12 Cancer incidence, persons, C00-C97 excl. C44: All malignant neoplasms (excl. non-melanoma skin cancer), 2006-2008, from National Cancer Intelligence Network's Cancer eAtlas 13 Ibid. 14 “Integration of Health and Social Care in Manchester”, a report of Liz Bruce to the Manchester City Health and Wellbeing Board, 4th July 2012, paragraph 3.6 “In Central Manchester 40% of patients registered with Chronic Obstructive Pulmonary Disease live in the Gorton and Levenshulme locality, and the area has the highest urgent care costs for COPD admissions; there were 218 admissions for COPD from this locality in 2010/11 costing £575,456.”, http://www.manchester.gov.uk/egov_downloads/10IntegrationHealthSo cialCare.pdf (retrieved 15th February 2013) 15 Comparison of life expectancy at birth for males (2005-09) Worsley and Boothstown with Kersal, Broughton and Irwell riverside neighbourhoods, http://www.partnersinsalford.org/documents/Death_rate_-_TABLE__Male_Life_Expectancy_by_MSOA_-_2005-2009.pdf (retrieved 28th January 2013) 16 Report of the Director of Public Health to the Health and Wellbeing Overview & Scrutiny Committee, Manchester City Council, January 2012 (paragraph 4.1, page 46) 17 362 smoking related deaths each year for every one hundred thousand residents, aged 35 and over “Statistics on Smoking: England, 2012”, page 83 18 “Lung Cancer in the North West”, North West Cancer Intelligence Service, November 2008, pages 13 and 15, http://www.nwcis.nhs.uk/documents/publications/Lung_Cancer_in_the_ North_West.pdf (retrieved 20th December 2012) 19 All facts available with primary data from: http://www.cancerresearchuk.org/cancerinfo/cancerstats/types/lung/mortality/uk-lung-cancer-mortality-statistics (retrieved 12th December 2012) 20 Private conversation with David Regan, Director of Public Health, Manchester, December 2012. 21 Private conversation with David Regan, Director of Public Health, Manchester, December 2012. 22 Cited in “Alcohol Misuse: Tackling the Epidemic”, BMA May 2009, page 11 http://bit.ly/PSajDw 23 “Alcohol”, North West Public Health Observatory, ca. 1997 (retrieved December 16th 2012)


24 “Manchester Healthy Weight Strategy: 2010 - 2013", February 2010 (Executive Summary) 25 Cited on http://www.positivehealth.com/article/weight-loss/childhoodobesity-and-food-advertisements (retrieved 21st December 2012 26 Manchester City Council JSNA statistic, recovered from http://www.manchester.gov.uk/info/500230/joint_strategic_needs_asses sment/5645/childhood_obesity/2, 21st December 2012 27 In February 2012 this figure was 840770 out of 1945890 IB claimants. See also “Health and Work”, a report of the Director of Public Health to the Health and Wellbeing Overview & Scrutiny Committee, Manchester City Council, January 2012 (Appendix 1, page 57) 28 “North West Mental Wellbeing Summary”, January 2010, paragraph 6.3.8, http://www.nwph.net/nwpho/Publications/NorthWestMentalWellbeing %20SurveySummary-2.pdf (retrieved 20th December 2012) 29 See for example, “Alcohol and Suicide”, Kendall R E, 1983 (abstract retrieved from http://www.ncbi.nlm.nih.gov/pubmed/6648755, 21st February 2013) 30 “North West Mental Wellbeing Summary”, January 2010 (paragraph 6.3.2) See also Figure 4 (c) which suggests the link between deprivation and mental wellbeing is neither linear, nor straightforward. While those in the most deprived areas are twice as likely to have poor mental health (20.2%) as those in the least deprived areas (11.4%), the difference between areas concerning good mental health is less marked (17.6% and 22.5% respectively).This along with the observation that roughly 60% of residents in both areas have moderate mental health suggests that the factors affecting good and poor mental health may be different (see Table 1, pages 30 to 33) and that they may not be reflected effectively within current measures of deprivation.

35 “Joint Health and Wellbeing Strategy”, report of the Director of Public Health to the Manchester Health and Wellbeing Board, 19th September 2012 (paragraph 3.1, retrieved from http://www.manchester.gov.uk/egov_downloads/JointHealthWellbeingSt rategy.pdf, 20th December 2012) 36 “Explanation for Contemporary Crime Drops...” An introduction to the reasons for a drop in crime rates in America, New York City and other places during the 1990s illustrates the complexity of tackling a single headline figure: http://tinyurl.com/c3y6ryr 37 “Mending Broken Britain” (working title), Centre for Social Justice, provisional publication summer 2013 38 The first mobile phones in the UK were introduced in Manchester in 1985. Ofcom figures (2008) show household dependence on mobile phones in the Greater Manchester area (i.e. no land/fixed line) was higher than anywhere else in England (28%) http://stakeholders.ofcom.org.uk/market-data-research/marketdata/communications-market-reports/cmrnr08/england/ (retrieved 28th January 213) 39 Marmot, 2010 40 “Statistics on Smoking for England, 2012”, page 20 41 Good evidence also exists that these sorts of approaches are ‘reversible’.This ‘gold standard’ of evidence demonstrates the fact that removing the new approach brings a return of the original outcomes, with the benefits of the new approach disappearing. 42 http://smokefree.nhs.uk/stoptober (retrieved 14th December 2012) 43 Parental monitoring of children’s media viewing may have an influence on smoking and drinking over non-media related behaviours: http://www.ncbi.nlm.nih.gov/pubmed/17079564?dopt=AbstractPlus (retrieved 14th December 2012)

31 “From Big Society to Good Society”, New Statesman, 23rd October 2012 http://www.newstatesman.com/politics/politics/2012/10/bigsociety-good-society (retrieved 14th December 2012) 32 Ardwick City Region Pilot Delivery Plan. 33 Sir Michael Marmot, “Fair Society, Healthy Lives”, 2010 (page 37, paragraph 1.1.3) 34 “Joint Health and Wellbeing Strategy”, report of the Director of Public Health to the Manchester Health and Wellbeing Board, 19th September 2012 (paragraph 4.1, retrieved from http://www.manchester.gov.uk/egov_downloads/JointHealthWellbeingSt rategy.pdf, 20th December 2012)

Tackling inequalities in health outcomes in Greater Manchester |

15


Acknowledgements

The Oglesby Charitable Trust would like to acknowledge the work of Millar Consulting in writing this paper and the time given by the following individuals and others, to discussing health inequalities in Manchester. Prof Iain Buchan Lead Centre for Health Informatics University of Manchester Mike Emmerich Chief Executive New Economy Manchester Sarah Henry Head of Research and Performance

Chief Executive's Office Manchester City Council Geoff Little Deputy Chief Executive Manchester City Council Steve Mycio Non-Executive Director Central Manchester and Manchester Children's Foundation Trust Sara Radcliffe Program Director for Integrating Care Central Manchester University Hospitals NHS Foundation Trust David Regan Director of Public Health for Manchester

16 |

Tackling inequalities in health outcomes in Greater Manchester


Š The Oglesby Charitable Trust The publication is copyright and no part of the document may be reproduced without prior permission. March 2013. The views expressed in this document are those of The Oglesby Charitable Trust and should not be attributed to any individual. The Oglesby Charitable Trust PO Box 336 Altrincham Cheshire WA14 3XD oglesbycharitabletrust@bruntwood.co.uk


OCT Tackling inequalities in health outcomes in Greater Manchester